Interdisciplinary Health Care Team
An Introduction from Gerald P. Whelan, MD, FACEP, Director of ECFMG’s Acculturation Program
Dear Resident:
I am pleased to introduce the Interdisciplinary Health Care Team and would like to take this opportunity to provide some context for this new resource.
In the earlier days of American medicine, the Interdisciplinary Health Care Team did not exist. Doctors managed patients and gave instructions to nurses who provided most of the practical hands-on care. Doctors, occasionally in consultation with other doctors, were the sole repositories of medical knowledge and the solitary decision makers. They were never questioned – not by nurses, not by patients.
Things have certainly changed! The model of unchallenged physician autonomy has been replaced by a patient care model in which scores of specialized medical professionals provide knowledge, skills, and services in a collegial and collaborative practice environment. The concept of the team now is so central to health care and to medical education that several references to it are included in the Accreditation Council for Graduate Medical Education (ACGME) Core Competencies developed as guides to graduate medical education (GME). What brought about this change?
One cause of this change is a veritable explosion in medical knowledge. The growth in the amount of medical information available to diagnose and treat a host of diseases and conditions, many of which were not even recognized only a few years ago, has been exponential. New professions have arisen or evolved including a range of therapists: physical, occupational, respiratory, speech and language, and others. New ways of delivering care have given rise to alternate caregiver models including nurse practitioners, physician assistants, certified registered nurse anesthetists, midwives, and others. Recognition of the importance of the patient’s social and spiritual well-being, especially as they affect physical and mental health, has highlighted the need for professional medical social workers and chaplains. A host of other professionals provide support, consultation and special services in the hospital – dietitians, health information managers, hospital executives, and so many more. Even within the field of nursing, registered nurses have diversified into numerous areas of specialization and practice venues, some requiring advanced degrees or specialized certification. Navigating through the hospital system has become so complex that care managers have become an indispensable resource to patients by coordinating their continued care. With so many diverse “players” on the team it can be very difficult to keep track of them all, let alone understand how their unique knowledge and skills are best coordinated and applied to patient care.
The Physician Team
In discussing any team, one of the first questions to arise is who leads it? One way to define the leadership role is to determine who has ultimate responsibility for the operation of the team and its outcomes. In the case of the Health Care Team, the outcome is patient care, and the person who is most directly responsible for the patient’s overall medical care is the physician. In the GME setting, this physician is part of a physician team.
Residents just entering training initially have very little autonomy but instead work in coordination with a team of physicians. At the head of this team is the physician of record – the attending physician – who has ultimate responsibility for the care delivered on his or her service. This physician also has a primary teaching role and may be referred to as a faculty physician as well. It is the attending physician’s responsibility to see that all the physicians-in-training on the team receive appropriate instruction and have the opportunity to practice medicine under appropriate supervision.
The attending physician is responsible for setting the tone for his or her service with respect to quality of care, professionalism, and patient safety, as well as for fostering a collegial environment that supports teaching and learning. The attending must be aware of all patients on the service, their diagnoses and problems, their treatment and diagnostic plans, and must be apprised of all study results and other developments on a daily basis.
Although the role of the attending physician is fairly standard across U.S. hospital settings, the ways in which individual attendings function can vary considerably. While some may be physically available in the hospital for extended periods every day and others may only round for a short period each morning, all are required to write a note on each patient each day. Some want to be involved in almost all management decisions, while others may permit their residents more autonomy in patient management. Some are superb bedside teachers who make extensive teaching rounds, while others are more inclined to take a supervisory role and defer most teaching to chief or senior residents on the team. Some attendings are relaxed, approachable, and informal, while others may be more formal and less approachable. Aside from observation and experience, the best way to learn an individual attending’s style and preferences is to ask the more senior residents who have worked with that physician in the past.
After the attending physician in the hierarchy of the physician team is the chief resident (where one is designated) and/or the senior residents. While still physicians-in-training, these residents have one or more years experience in the program and have a great deal of practical information about the local systems and how best to get things accomplished. More importantly, they were not long ago exactly where the first-year residents are and can appreciate the confusion, uncertainty, and anxiety that come with that position. In U.S. GME, physicians at all levels are expected to teach, and some of the most valuable teaching new residents receive will come from their “near peers” – residents only a year or two ahead of them in training. It should also be noted that the physician team commonly includes medical students participating in clinical clerkships. Medical students will learn from attendings, chiefs and senior residents, but before long into the academic year should be learning from the first-year resident as well.
In the context of this physician team, the first-year resident will rarely be the physician in charge. Instead, the first-year resident will be learning, along with clinical medicine, the skills he or she will need to lead the larger Interdisciplinary Health Care Team in the future. Attendings and senior residents will serve as role models, teaching the first-year resident professional leadership skills necessary to coordinate, direct, and collaborate with the many other team professionals in providing optimal care for each patient.
The Interdisciplinary Health Care Team
In addition to the physician members of the Interdisciplinary Health Care Team, there are a variety of other professionals who contribute to a hospital’s smooth functioning and, ultimately, its patients’ health and well-being. The other members of the team possess varied specialized expertise and experience, and many will have far more contact with patients than physicians do. They are all professionals, many of whom have spent years in study and preparation and have had to undergo rigid testing to achieve their current status.
Physicians often interact with the other members of the team by being directive in ordering treatment or other services from them. At other times, physicians’ interactions will need to be more consultative, asking team members for their management advice rather than dictating treatment. Many of the interventions provided by team members who are not physicians are beyond the expertise of the physician, so it is appropriate to defer to their judgment in these situations. However, the physician still retains ultimate responsibility for the patient’s care. If the physician receives conflicting recommendations from different team members, he or she must gather the necessary evidence from each of them to make a sound decision regarding a patient’s medical care.
Those team members who work most directly with patients can be an important source of feedback to the physician, providing perspectives gained from more repeated and lengthy interactions with patients. In this regard, the input of nurses deserves special consideration. Nurses generally spend considerably more time with patients and their families than any other team members do, including physicians. Nurses may have practiced in a particular ward or unit for an extended period of time, giving them far more familiarity with procedures, policies, and protocols of that unit. Those professionals who practice in special hospital units (Intensive Care, Coronary Care, Emergency Departments, Operating Rooms, etc.) often have sophisticated knowledge regarding the types of patient conditions managed in those settings as well as the complex medical equipment associated with the needs of patients in those practice settings. These practitioners are an integral part of the team and the patient’s care and serve as a valuable source of learning for the new resident and are more than willing to take the time to teach, when asked. For example, a respiratory therapist can adjust the patient’s ventilator with the correct settings if requested to do so. However the astute resident may gain far more by asking the respiratory therapist to teach him or her how to correctly adjust the settings.
While a good leader will take the initiative in seeking the consultation or input of other team members, a different set of skills may be required when that input is unsolicited and the team member comes to the physician with suggestions, questions or, in some cases, even challenges to his or her judgment. The mature leader will not react defensively, feel threatened, or interpret the team member’s input as a challenge to his or her authority. Instead, the team leader will recognize that the team member has the patient’s best interest at heart and truly believes that his or her input is appropriate and valuable. If the input is relevant, it should be accepted and the team member thanked for the contribution. If it is not, the physician must make efforts to explain why. More importantly, the physician must acknowledge the team member’s contribution in a way that is neither demeaning nor dismissive, taking care not to discourage that team member from volunteering potentially vital input in the future.
Finally, the foregoing describes an ideal world of medicine. However, teams are made up of people and as such the degree to which the team concept is accepted and the level of teamwork actually in practice in any given hospital, department, or program may vary. Like so many other things that are new to the IMG coming from other countries and systems, it is best to observe carefully and learn from senior residents, attendings, and other hospital staff how the approach to team care is best accomplished in individuals settings.
I hope you find this new resource helpful.
Gerald P. Whelan, MD, FACEP
Director
ECFMG Acculturation Program
