How medical care teams can keep patients at the center of their work
■ What can practices do to ensure communication among physicians and nonphysicians?
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to firstname.lastname@example.org, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted July 29, 2013.
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Scenario Large medical care teams often spend time and energy managing team dynamics and personalities. How can a team of experts with different training and skills maximize attention to the patient?
Reply Dr. Francis Peabody's famous quote says “the secret of the care of the patient is in caring for the patient.” This helps to remind us that the purpose of the health care enterprise is to serve our patients and their loved ones. Serving our patients and their loved ones means understanding what is important — what matters most to them, what their fears are, what their hopes are, what they are hoping medical care can do for them. The only way to learn these central factors about our patients is to sit down and ask, and then to listen. This takes time and focused attention, something that is in ever-scarcer supply in modern medicine.
Amid the fragmentation, financial incentives and ever-increasing pressure to do more work in less time in our health care system, the concerns and needs of our patients are at risk of getting lost. Indeed, the No. 1 concern of families looking back after a loved one's death in the hospital was not having enough time with their doctors. Given that the average number of specialists seen by patients in their last six months of life exceeds 10 and that the number of individuals passing through an average patient's room in a 24-hour period exceeds 60, it is surprising and troubling that the time these specialists and professionals have available to spend with the patient instead of the computer seems to be rapidly declining.
The consequences of this rushed, fragmented and increasingly computer-driven practice of medicine are not good. The U.S. spends more of its gross domestic product on health care than any other country in the world, and 5% of the sickest and most vulnerable patients account for about half of all health spending. Some of this is appropriate and necessary — these are our sickest and most vulnerable patients, those most in need of medical care — but some of it is a consequence of everyone doing what's expedient — for example, ordering another imaging study (which takes 30 seconds) rather than sitting down for an honest conversation with our patients about what matters most to them and what medicine can realistically accomplish to help them achieve their goals (which takes 45 minutes).
We know that in another recent study none of the hemodialysis patients could recall ever having a conversation about what to expect in the future with their nephrologists, and this recall was confirmed by the nephrologists, only 3% of whom reported such a discussion with their patients. We know that patients and families who recall having a conversation with their doctor about what to expect in the future are much less likely to die in a hospital or ICU and are much more likely to have families report that care was of high quality during the dying process. In fact, the higher the health spending at the end of life, the lower the perception of the quality of that care by patients' families.
Time pressures hinder treatment
Among proposed solutions to the complexity, fragmentation and time pressures and their adverse impact on quality of care is a team approach. The hypothesis is that complex and seriously ill persons require more skills than any single professional discipline can provide. For example, a person contemplating a ventricular assist device as destination therapy for end-stage heart failure needs cardiologists, cardiac surgeons and social workers to assess the patient's family, financial and social context and his or her capacity for managing the device. That patient also needs nurses and nurse practitioners to provide continuity, coordination and teaching for the patient and family and physical therapists to help restore strength and independent function after the procedure.
How does a team this diverse and large avoid further fragmenting the patient's care? Just the amount of time required for a team of this size to stay in close communication with one another could result in even less time available to be with the patient. How do high-functioning teams avoid falling into this trap?
The key to keeping the patient at the center of a high-performing team is precisely the principle of communication with the patient, with the family and with one another. High-functioning teams engage in close and regular communication — teams meet at least daily to “run the list” and discuss and update one another on each patient in turn; division of labor, assigning discipline-specific tasks to the appropriate team member so as not to duplicate labor; and beginning and ending the team's work with reference to what matters most to the patient and the family — and every element of the care plan is developed with the patient and family priorities as the central organizing force.
The difference between a high-functioning team and the fragmentation caused by multiple specialists and disciplines is the recognition of and adherence to the structures and processes required for a team to improve care outcomes. These principles include role clarity; regular, respectful and open communication among all members; attention to quality metrics and quality improvement; and appropriate, ongoing training. A high-functioning team has no place for an intimidating or prima donna member, an adjustment that can be quite challenging for physicians trained in the doctor-knows-best era of medical education.
The growth in the last 10 years of hospital palliative care teams is the exemplar of this model of care — palliative care teams are now present at more than 90% of large hospitals in the U.S., where most of the seriously ill receive their care. Because of the multidimensional challenges faced by patients and families living with a serious and complex illness, palliative care teams typically require nurses and advance practice nurses, doctors, social workers and chaplains.
The medical literature demonstrates marked improvement in quality of life, length of life (survival), and family psychological well-being. As a result of this better quality of care and quality of life, sick patients and their overwhelmed families rely far less on emergency departments and hospitals for crises that are prevented from ever happening in the first place. This is the potential of high-functioning teams.
The future of quality care for our growing aging population, many of whom have multiple chronic conditions, functional dependencies and cognitive limitations and pose very high burdens on family caregivers, depends critically on our ability to work as a team — to talk to our patients and their families and find out what they think and need, and to talk to one another, a prerequisite for the kind of care we all will someday want for ourselves and our loved ones.
— Diane E. Meier, MD, professor of geriatrics and palliative medicine, Icahn School of Medicine at Mount Sinai, New York
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to email@example.com, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.