Collaborative teams offer chance to improve patient care, workload

Medical Post
Helping Hand Column, May 25, 2007

Despite growing pains, it’s best to embrace change to help shape system

I recently attended an amazing conference, Strengthening the Bond: Collaborating for Optimal Care, on collaborative practices in health care, in Banff. This was Alberta’s first tri-profession conference, bringing together more than 800 doctors, nurses and pharmacists to explore ways in which we can collaborate to improve health care. It got me thinking more about this development in health care, and how it will be part of the new landscape of how we practise medicine in Canada.

The medical news is full of such developments—pharmacists assuming the authority to prescribe medications, nurse anesthesia assistants and family health teams. There is a lot of discussion, resistance and defensiveness. The Canadian Medical Association has identified collaborative care as a topic for discussion at the annual meeting in Vancouver in August.

In 2003, Health Canada defined a collaborative patient-centred practice as one that is designed to promote the active participation of several health-care disciplines and professions. It would enhance patient, family and community-centred goals and values, provide mechanisms for continuous communication among health-care providers, optimize staff participation in clinical decision-making and foster respect for the contributions of all providers.

While this sounds wonderful in theory, there are many barriers to collaborative care in medicine. There is a common history and similar goals of patient care; yet each discipline has a different culture and training, and so addresses issues from differing points of view.

As doctors, our personality traits can hinder collaboration. We are perfectionistic, and can be rigid and inflexible. We have a need to be in control, and so have difficulty delegating to others or changing how we have done things in the past. These uncertainties can add to our concerns about the blurring of roles and responsibilities, and can have a negative impact on patient safety and care. Additionally, this new way of practice requires training and time, when time is at a premium.

I wonder if some of this uncertainty results from an earlier type of “collaboration” with doctors and midwives. This had a turbulent start, as midwives were seen as anti-doctor and took control of a birth situation, often outside of a hospital with little resources available, and only called the doctor when there was serious trouble. Who wants to come into a clinical situation in a crisis? The reality is this was uncommon, and when it occurred it was not really collaboration; rather, it was two professions working independently. Better examples of collaboration would be case room nurses and doctors, and how doctors and midwives have learned to work comfortably together, communicate well, respect their own and others’ limitations, and ask for help.

Regardless of how we feel about this, collaboration in medicine is happening. We may as well be proactive and help shape this into a positive situation. It is essential to include people in the process, get input and set mutual goals. It is harder to make a change and enforce it after the fact—a situation I see occurring now that the Ontario Ministry of Health announced the creation of anesthesia care teams in March to reduce wait times, but did not include the anesthesiologists in this decision-making process.

It helps to remember what is good about collaboration. There are now fewer resources in medicine, with cutbacks and less manpower. Working with other health-care professionals with increased scope of duties may prevent provider burnout, free up time for doctors, and allow increased access to appropriate, timely care for patients.

Teams work well with attention to seven key aspects—clear goals and purpose; clear roles and responsibilities; clear and regular communication; mutual respect and trust; defined processes for tasks; effective leadership; and an effective organizational structure with regular meetings, preferably face-to-face.

All members of the health-care team will benefit from specific training as a team. This can assist in setting and clarifying roles and responsibilities, and providing reassurance that this is not substitution but a realignment of the system to make it work better. Doctors are usually relieved to know they are not legally responsible for the clinical work of another regulated health professional. On a team, they are only directly legally responsible for their own clinical work and patient care, for communicating about patients as they hand over care, and for enforcing policies and procedures if they are an administrative leader.

While teams need leaders—and doctors are not the only ones who can lead—doctors do make effective leaders as it is a role in which they often have training, comfort and experience. A team leader can play a key role in facilitating the recognition of the value of all team members. Trust within a medical team is built as one profession can see and value what the other is doing to provide better care to the patient. We all feel a personal responsibility to our patient and cannot hand him over to just anyone. Regular communication is crucial, especially in the early stages of setting up a team.

As doctors, we have all the skills to make a team work. It is crucial to approach this with an open attitude, and remember that we have a common goal of providing the best possible care to our patients. Many doctors say once they have worked on a team, they cannot imagine how they ever did it without the team, and they would never go back to the old way.

The Banff conference offered many outstanding speakers and points of view, and impetus to move forward in this process. One comment I keep remembering is Rex Murphy’s stark description of the paucity of medical care in rural Canada just 50 years ago, and how far we have come since then. He helped me recognize that our current problems are a result of our past successes; that we have created overwhelming expectations from our patients because we have done such a great job to date. Collaborative care allows us to add support to an overburdened system, and to share energies, ethics, values and concerns to meet the increasing needs of patients.

Mamta Gautam is an Ottawa psychiatrist who specializes in treating physician patients. If you have a question you would like addressed in this column, please contact Dr. Gautam at mgautam@rogers.com. Please include “Helping Hand” in the subject line. All inquiries will be confidential. Your questions will not be replied to, but may be selected to be answered in this column, which is intended to be educational, not therapeutic.