Taking team care from policy to practice

Amid disagreement on just about every aspect of the U.S. health care system today, there exists a close to universal belief that medicine, especially primary care, should be more of a team effort, with physicians, nurse practitioners, other clinicians and even nonmedical staff collaborating to provide patient care.

“The role of the physician is changing very much from the lone wolf that you're trained in medical school to being part of a team,” said Maryjoan D. Ladden, PhD, RN, senior program officer in the health care group of the Robert Wood Johnson Foundation, based in Princeton, N.J.

“We can't possibly address the primary care needs of the nation just through physicians,” agreed Sheldon M. Retchin, MD, FACP, CEO of Virginia Commonwealth University Health System in Richmond. “A helping hand and a more open dialogue is certainly called for.”

ACP recently advanced the dialogue among clinicians with a policy paper, “Principles Supporting Dynamic Clinical Care Teams,” published in the Nov. 5, 2013, Annals of Internal Medicine. Reactions to the paper, including accompanying editorials by clinicians, showed that while the principle of team care is agreed on, the specifics of how teams will work are not.

The most controversial issue is who should lead health care teams: only physicians, or also nurse practitioners (NPs) or other clinicians? For those actually trying to put teams into practice, determining team members' responsibilities and coordinating their work to provide optimal patient care may pose a bigger challenge, experts say.

No one has a definitive answer, but experts did have predictions and advice for the internists who will have to find solutions for their practices and their patients.

Leadership

The drive to form health care teams has emphasized differences in perspective between physicians and nurse practitioners about their respective roles.

For example, while the College's policy paper reaffirmed “the importance of patients having access to a personal physician who is trained in the care of the ‘whole person’ and has leadership responsibilities for a team of health professionals,” an accompanying editorial by the presidents of the American Association of Nurse Practitioners said, “Team leadership should not be defined by a particular professional nor by a regulatory or licensing body.”

A recent study found this difference of opinion mirrored among many practicing primary care clinicians. A survey of about 500 physicians and 500 NPs, published in the May 16, 2013, New England Journal of Medicine, revealed that 82.2% of the NPs thought their peers should be able to lead medical homes, while only 17.2% of physicians agreed.

“We were surprised not that there were differences, but by the magnitude of the differences,” said Karen Donelan, ScD, lead author of the study and senior scientist at the Mongan Institute for Health Policy in Boston.

She and her coauthors also looked at the day-to-day activities of the clinicians and found many fewer differences. “Both the physicians and the nurse practitioners say that they do similar kinds of work during the day,” said Dr. Donelan. “It doesn't really appear that the day-to-day work relationships are adversely impacted. The majority of the nurse practitioners we surveyed say that in their present setting they are working to the full extent of their training.”

In the real world

The gap between rhetoric and practice is good news for those worried about the conflict over who leads teams, experts said. “If you get down to actual practices, the nurse practitioners and the physicians work remarkably well together and those controversies [are] at more of a guild level in the physician groups or nurse practitioner groups,” said Scott Shipman, MD, MPH, director of primary care initiatives and workforce analysis at the Association of American Medical Colleges.

Team leadership is more fluid in practice than policy, with physicians “being a leader for the times that it makes sense,” said Dr. Ladden, who studied high-performing primary care teams for an article in the December 2013 Academic Medicine. “Sometimes it's the medical assistant who needs to lead the team huddles,” she said. “The roles often blend.”

Her observations confirmed the experience of Thomas G. Tape, MD, FACP, chair of the ACP committee that developed the clinical teams policy paper, professor of internal medicine at the University of Nebraska in Omaha, and an ACP Regent.

“There are many instances where my diabetes educator is really taking the lead in working with patients on their diabetic management. And there are other times when I'm assuming the lead role,” he said. “There's a difference between what I experience when I work as a member of a health care team with nurse practitioners and diabetes educators and clinical pharmacists and social workers and dietitians and what you read in editorials.”

That doesn't mean that dividing tasks among team members is easy. “How does one distinguish the role of the physician on the team, and the competencies of that physician that are distinct from the competencies of other team members?” asked Dr. Shipman. “There may be lots of different opinions out there, but there aren't any consensus guidelines or recommendations.”

In Dr. Tape's practice, division of responsibility has “evolved fairly organically,” he said. “Think of patients who are critically ill and may have multiple consulting services ... who is the attending physician versus who is the consulting physician may shift over time. That's the way I conceptualize these new types of teams that are multidisciplinary.”

On the other hand, the team-based practice of Nitin S. Damle, MD, FACP, chair of ACP's Medical Practice and Quality Committee and an internist in Wakefield, R.I., has developed protocols for dividing responsibilities.

“We don't let a patient get seen by a physician extender more than 2 times for the same diagnosis without being seen by the internist,” said Dr. Damle, who is also an ACP Regent. “They would not see certain complex patients that we had been following for years ... and there are certain areas in which we would prefer they see patients: acute illness, upper respiratory infections.”

Top of your license

One general principle often proposed in descriptions of team care is that all team members should spend their time on the most challenging tasks they can handle. “We need everybody to practice to the top of what they can do,” said Dr. Ladden.

This concept makes sense from an efficiency standpoint, but putting it into practice could be complicated. “One way to do this is ... when you're sick, you go to the doctor. When you're a little less sick, you go to the nurse practitioner. That doesn't feel good to me,” said Arthur Garson Jr., MD, MPH, director of the Center for Health Policy at the University of Virginia in Charlottesville.

Or, “Some patients may say, my person is a nurse practitioner. When I get sicker, the nurse practitioner brings in the doc, and when I get even sicker, the heart failure doctor comes in to help the internist. That may work fine,” said Dr. Garson.

However, seeing only the sickest patients may not work well for all internists. “A drive toward more efficient use of a physician's time runs the risk of taking out of the physician's day-to-day activities some of the lower-level, lower-acuity or lower-complexity parts of care they may have really enjoyed,” said Dr. Shipman.

“During a very busy day of seeing 25 or 28 patients, we do enjoy once in a while just having a bronchitis or pharyngitis, which we can easily diagnose and then spend a little bit of time talking about something else,” confirmed Dr. Damle.

In Dr. Ladden's study, other clinicians reflected similar concerns about their role shifts. “Some of the nurses at the learning community [were] feeling like medical assistants are being upscaled to do many of the things that, in the past, we considered as nursing roles, like health coaching and patient education,” she said.

She found that these conflicts often worked themselves out as everyone settled into new roles, but Dr. Garson's solution is to revise the system for delegating tasks. “It has to start with ‘What does the internist want to do?’” he said. “What is it that we really want to do, have fun doing, and are really good for patients and ultimately the health care system [at doing]?”

Internists will have different answers to that question and develop different versions of team practice as a result, he said.

“That's going to be as variable as there are internists in the world,” he said. Some general internists will delegate more tasks to nurse practitioners (or other clinicians) and use the extra time to take on more complex care that could potentially be referred to specialists, while other internists will lean the other direction, he predicted.

Dr. Ladden agreed that team structures may be individualized, although she thinks more of the focus should be on patient needs and preferences.

“It starts with getting to know who you're working with, what their skills and expertise are, what their education and experience is, then sorting out what are the real needs of the patient and family,” she said. “The conversation among these practices has changed from ‘Let's try to take the load off the physicians and try to make them happier’ to ‘Let's try to figure out what's best for the patient.’”

Eventually, as models of team care are piloted and proven, the variation in practice should diminish, according to Dr. Garson. “Probably the evolution is for the next 5 to 10 years, as the roles get redefined,” he said.

Challenges and rewards

Over that time, internists will also be working on the other challenges of team care. Communication, for example, risks “going down the tubes” when several clinicians are each handling different aspects of a patient's care, said Dr. Shipman.

The patient-physician relationship may also change. “If patients are asked to think about the team as their provider, the physician may feel less like the person to whom the patient is most strongly bonded,” said Dr. Shipman.

But the complexities of modern health care require internists and patients to deal with this transition. “It's just no longer feasible for physicians to be responsible for every last element of a patient's needs,” concluded Dr. Shipman.

Internists who have been using the team model say there are enough rewards to outweigh the challenges. “Overall, it makes our job much more satisfying,” said Dr. Damle.

“The team model makes my life so much easier,” added Dr. Tape. “In the traditional primary care setting, there are so many things that I'm doing that someone with a different background, training and skill set is so much better equipped to do ... like providing detailed diabetes education or dietary counseling.”

Medical training, as well as the education of other types of clinicians, should also be modified to support team care, the experts agreed. “The majority of people who are doing it got on-the-job training, but we can't really sustain that for much longer, I don't think,” said Dr. Ladden.

“Without question, there needs to be active incorporation of the skills of working in a team in health care into the earliest levels of training,” said Dr. Shipman. “We have historically done a pretty poor job of ever meaningfully exposing the health care professions to one another.”

New competency requirements for medical schools, more use of team models in resident clinics, and the new National Center for Interprofessional Practice and Education, which opened in 2012 at the University of Minnesota, should help improve this aspect of training, the experts said.

And as those in practice already experiment with team models and new clinicians are trained in it, this form of practice should get easier.

“I don't think I have a clear enough crystal ball to predict if and when all of those issues are going to be ironed out,” Dr. Tape said. “But I do think as time goes forward and people get more used to delivering health care as a team, some of these issues will just naturally drop away.”