Are internists team leaders or orchestra conductors?

The concept of teams in health care delivery has taken on particular focus in recent years. As we try to implement team-based care, I ask myself: Are our teams constructed and functioning in the most efficient ways?

I joined my first medical team as a third-year medical student. The team consisted of an attending, a resident, two interns, and two third-year students. In the “team” concept, we worked with a common purpose, to manage and help our patients. We shared necessary tasks. We helped each other. We understood we had different levels of knowledge and experience, and so there was a natural and logical hierarchy. With appropriate respect and clearly delineated responsibilities, all of us worked smoothly with a sense of coordinated accomplishment.

Those teams on which I trained were homogeneous. We were all doctors or in training, and we all knew that the team leader, typically the attending, had done or could do everything that we could. We had one very thorough skill set: doctoring.

Today, younger physicians have more “interdisciplinary” training, working with a wide variety of individuals with complementary skill sets: advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, nutritionists, certified diabetes educators, care coordinators, and other health care professionals. It is not just doctors, and so through training, there is a broader exposure to these paraprofessionals, their areas of expertise, and the specific roles they have to play in patient care.

We internists develop expertise at knowing when we can manage issues and when we need to involve and coordinate care with specialists and other caregivers. Our experience gained during residency training alongside so many other specialists- and subspecialists-in-training gives us a deep understanding of the work done by all these other roles. We internal medicine specialists become uniquely qualified to serve as the conductor of this patient care orchestra.

I had opportunity at the European Congress of Internal Medicine meeting in August to attend the opening session, where a speaker made this analogy. A conductor leading an orchestra is quite similar to an internist coordinating and aligning the work of multiple different clinicians and team members in the delivery of care to a patient. Delivering patient care is not just reading the music—an algorithm—and pointing at different instrument sections at certain times in the piece. It is knowing the audience—having a trusting patient-physician relationship—that helps us to decide in which key each instrument should join, and at what volume (for example, a patient might still be processing a new diagnosis and may not yet be ready to accept a new medication or directed education or referral).

This more nuanced analogy of an orchestra making music might be better than that of a team working together toward a shared goal.

While the inpatient teams on the wards of teaching hospitals have been part of our health care culture for a long time, it is a more recent concept in the outpatient world.

ACP started talking about teams in a 2006 policy paper, “The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care.” Things haven't changed since we stated, “Trusting, intimate relationships with patients have suffered, as physicians and patients struggle with the financial and bureaucratic complexities of public and private insurance coverage issues, which can cause substantial stress within patient-physician relationships.”

ACP further stated, “The advanced medical home acknowledges that the best quality of care is provided not in episodic, illness-oriented, complaint-based care—but through patient-centered, physician-guided, cost-efficient, longitudinal care … promotion of continuous healing relationships through delivery of care in a variety of care settings according to the needs of the patient. … In the advanced medical home model, patients will have a personal physician working with a team of health care professionals in a practice.”

We must acknowledge that since 2006, there has been an ever-increasing work burden to deliver comprehensive care to medically complex patients and to manage recommended preventive care and health maintenance. All those internists also wearing “primary care” hats know this well. Some of this burden is related to information technology, as there is simply too much data to track. And much is related to decades of rapid progress in medical knowledge and care. We now have so many things to do: diagnostic and screening tests of many varieties, conditions to treat with medications, lab tests to monitor the many medications we prescribe, and communication of all that information to patients. It is simply too much for one person to do.

So physicians need help. And patients need help. An individual physician cannot do it all. Without using paraprofessionals, we are missing out on the expertise and support they can contribute.

Even with resources and guidance from entities like the Patient-Centered Primary Care Collaborative, why are efficiently functioning teams not in every office practice by now? Clearly, there is a need for resources to pay for the added personnel, but our payment models have not changed widely enough to enable this.

ACP further described a vision of teams in its 2013 policy paper “Principles Supporting Dynamic Clinical Care Teams” as the imperative for team-based care was becoming even more compelling.

There was recognition that “The movement to team-based health care delivery has generated confusion among the public, policymakers, physicians, and other health disciplines on how to organize teams to achieve the best possible outcomes for patients … to dissolve the barriers that hinder the evolution toward dynamic clinical care teams and nimble, adaptable partnerships that encourage teamwork, collaboration, and smooth transitions of responsibility to ensure that the health care system meets patient needs.”

Teams involve relationships, and relationships require trust that the team members have the skills to fulfill their roles and that they will then fulfill their responsibility. In this 2013 paper, a clinical care team was defined as “[consisting] of the health professionals—physicians, advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals—with the training and skills needed to provide high-quality, coordinated care specific to the patient's clinical needs and circumstances.”

The leader needs to set the direction of the team by having a broad view, thoroughly understanding the mission and goals, and coordinating the roles of the members of the team to achieve them. And here shines the expertise of the internist as an orchestra conductor.

In this 2013 paper, ACP stated that “Although physicians have extensive education, skills, and training that make them uniquely qualified to exercise advanced clinical responsibilities within teams, well-functioning teams will assign responsibilities to … [various] health care professionals for specific dimensions of care commensurate with their training and skills to most effectively serve the needs of the patient.”

Trying to fulfill multiple roles and manage all the data is burning out too many physicians. The National Academy of Medicine developed a paper in September 2018 on which the first author was ACP's Vice President for Clinical Education, Daisy Smith, MD, FACP. The paper, “Implementing Optimal Team-Based Care to Reduce Clinician Burnout,” articulates how “Team-based care … presents a unique opportunity to achieve key aims of a high-quality health system. Successful teams have the capacity to improve patient outcomes, the efficiency of care, and the satisfaction and well-being of health care clinicians.”

Our everyday challenges as physicians continue: taking good care of our patients and taking good care of ourselves. Our expertise as internists provides us with many responsibilities and with many opportunities. There are countless nuanced judgments and decisions we make in caring for patients based on constantly changing variables. We don't know how to play every instrument in the orchestra, but we understand how they fit together and how to coordinate them with the larger goal of caring for the patient.

So yes, we are “team leaders” in the current lexicon, but we might more accurately think of ourselves as conductors of the orchestra. Go forth, maestro.