- Donna Kaminski [forum discussion]

According to several polls, between 60 to 82% of the United States public believes that our health system needs fundamental change. ^(1,2) When we take a closer look at our current system, it would seem that the public would have a basis for this assertion. Our system of care is by far the most costly in the industrialized world, absorbing 15% of our gross domestic product (GDP), a figure that continues to rise. It is expected to reach 19.2 % by the year 2017. ^(3,4) Despite the large amount of funds we invest in our care, the United States ranked 37^th in overall performance and 72^nd in overall level of health, when evaluated among 191 countries by the World Health Organization (WHO).^(6,7). Part of this discrepancy between cost and care may be explained by inefficiency. According to the National Academy of Engineering, between 30 and 40% of U.S. health care spending is associated with failures, such as poor communication or duplication. ⁽⁸⁾ However, beyond failures, our health care system suffers from an approach that is less focused on overall patient health, and at times overuses technology. For example, while in the U.S. the MRI-to-person ratio is ten times that of Canada’s, each year, many children will go unvaccinated. In addition, despite spending as much as we do on health care, 16 out of every 100 Americans continue to go uninsured, and another 10 are underinsured. ^(1). These statistics suggest what the American public has been sharing from their dining room tables to the many polls that have been taken, we as a country are in dire need of health care reform.

In its’ document “Building Upon the Cornerstones”, the Mayo Clinic outlines four areas of focus in recommends as being key considerations in health care reform. These cornerstones ask that the system be transformed to 1) Create Value, such that patient health outcomes and satisfaction with U.S. health care would be improved, and medical errors, costs, and waste would be decreased; 2) Coordinate Care, such that patient care services would be coordinated across people, function, activities, location and time, increasing the value of health care service provision. To do so, the cornerstones suggest that patients must be active participants; 3) Reform the Payment System, such that providers are paid based on value, using a payment system that provides incentives for providers to coordinate care, improve care, and support informed patient decision-making; and 4) Provide Health Insurance for All, such that all individuals are given choice, control, and peace of mind. ^(7). If embraced, these four tenets have the potential to transform our existing health care system into one that embodies a high-value team approach to coordinated, patient-centered health care.

The reconstruction of our current health care system into one that provides this coordinated, patient-centered health care will require a multi-faceted approach. In a recent discussion on this topic in JAMA, Patrick Conway and Carolyn Clancy suggest that a transformation should include the development of patient-centered quality measures, a payment system that is pay-for-performance and strays away from volume or unit-based imbursement, health information technology tools that capture quality measures, on-going measures of efficacy that compare quality of care, and the establishment of quality improvement collaborative and learning networks. ^(2). In that same issue of JAMA, Kaveh Shojania and Wendy Levinson assert that academic medical centers begin to incorporate quality improvement into the research and education they provide, so as to create an environment where practitioners work together to provide a standard of care that is constantly improving and adapting to meet the needs of its patients. ^(8). Therefore, a high value, coordinated, patient-centered health care system will require is the development of a multidisciplinary team that works together to together provide and constantly re-evaluate the integrative health care that is served. It will redefine health care that is provided more so as a bundle or a whole, and less so a series of individual units of care, that is much greater than the sum of its individual parts. In short, it will require teamwork, the ability to use the talents and skills of providers of all disciplines to work together to address the health needs of our population, one that is often times facing chronic health issues.

A team approach will require the development of team building skills. While traditionally our healthcare system has focused on the “patient-physician team”, coordinated patient-centered health care includes a large array of health care professionals that include the nurse, pharmacist, nutritionist, physical and occupational therapists, physicians, and other providers as equal team members, with the patient at its center.  Together, these professionals would work not as separate units, but together as a collective whole, or a team. A process that embodies this concept of a team must be integrated into our health care education system. Currently, our system of medical education does not emphasize a team-building approach, even in its preclinical education arena. Most curriculums focus on individual growth and learning. Students are often busy trying to achieve the highest scores in an effort to later have competitive residency applications. However, it is imperative that tenets of team-building are incorporated early on in medical education. As Katharine Treadway, MD stated during a roundtable discussion for the New England Journal of Medicine, “it must begin on Day 1 of medical school and continue in residency training.” ⁽⁹⁾ This begins with the introduction of teamwork early on, and building on that concept throughout the four year curriculum.

So where do we begin? How can medical school curricula that are already overloaded integrate team-building into their programs? This starts with a simple concept: helping students understand that helping each other will ultimately help patients. To do this, schools can employ a wide variety of teaching techniques, such as simulator sessions, small-group learning, and pairing trainees with senior faculty. Other ideas include a clinical skills laboratory using a clinical instruction model with a bank of patient volunteers, standardized patients, and the use of a bank of patient videotapes.⁽¹²⁾ Given that many students are grade driven, these exercises should offer collective grades, where the greater the collaborative effort represented by all members of the team, the greater the grade is for each person in the team. This approach would help future physicians to see themselves as equals and peers, and seek ways to integrate each person’s strengths and talent-sets. It is a good place for many institutions to begin.

The further development of a team approach is one that extends far beyond the student physician base to include practitioners from all disciplines. Therefore, it is critical that medical and other health professionals intimately learn the details of other disciplines, and have opportunities to work collaboratively with them as a team. Exercises that bring together nursing, dental, physical and occupational therapists, social workers, nutritionists, pharmacists, and clergy are critical in developing a mutually-supportive and respectful environment in which students learn to work together as a team. ^(9). Many institutions host a variety of health professional programs on the same campus, creating a perfect opportunity for such team-building. By working collaboratively, instructors can provide routine opportunities for students from various programs work together on case studies and scenarios, where they are required to utilize each others’ toolsets.  This type of integrative training has already begun to be used in some residency training programs. For example, the Mercy Health System of Southeast Pennsylvania in Philadelphia described a system-based practice program it introduced to its first-year internal medical residents. The Residency Director developed a two week systems-based practice for first-year residents, where they had first-hand experience with delivery of health care in home care, hospice, pharmacy, laboratory, utilization, and nutritional services. The use of pre-and post-surveys showed that after the two week interval, residents reported deeper theoretical understanding and a greater knowledge of specific policies around these health services.^(10). A plan such as this one is a good first step towards a multi-disciplinary team model. Further exercises could be developed where residents work collaboratively with multiple disciplines on specific patient cases, where the team consists of a larger number of health professionals based on individual patient needs.

While the above study documents attempts made within some residency programs, as Katharine Treadway suggests, there is an imperative need to establish competencies within medical school programs that help establish collaborative, patient-centered health care. In 2001, the Department of Health Policy of Johns Hopkins University School of Medicine conducted two studies. In the first they randomly sampled U.S. physicians that see patients with chronic illness for at least 20 hours a week. The results were astounding. Of those surveyed, 61% felt that their medical training did not prepare them to develop team work with non-physician care providers. 63% of the physicians also felt that their training had not prepared them to educate patients with chronic conditions, coordinate in-home and community services, provide end-of-life care, manage geriatric syndromes, manage psychological and social aspects of chronic care, manage chronic pain, assess care-giver and family needs, provide nutritional advice, or develop team-work with non-physician care providers. Today, chronic care is a major cause of disability and use of health care services, totaling 80% of all health care expenditures. This study suggests that many physicians feel both insufficiently trained to address the complex aspects of chronic disease, and difficulty in developing the necessary multidisciplinary team needed to address those needs. Another study done by the same group surveyed 70 directors of required clerkships and courses of 16 US medical schools. In the survey, they asked the directors to rate the importance of 49 different skills or practices deemed relevant to the management of chronic disease. Only 29 of the 49 skills were rated as moderately important, and none were rated to be essential. ^(11,12) This suggests that in order to create a system of health care that can effectively treat and manage chronic disease, we must begin by teaching our medical students to develop the skills necessary to manage the complex needs of chronic disease, which includes the development of team-building skills across multiple medical and nonmedical disciplines.

The transformation of our health system into one that offers our patients care with a high value that meets the multifaceted and diverse needs will require efforts from every corner of our current system. Our government will need to work with various sectors of our health system to restructure our current payment and administration system. Current providers will need to work together to modify the current way care is administered. Most critically, future health providers have the exciting opportunity from the first day of their medical training to develop the ability to work and think collaboratively, to invite their colleagues from other disciplines and health professions to work together as a whole, creating a true multidisciplinary team. It is through the greater development of a collaborative team model that as a country, we can effectively shape a model of care that defines not as an individual unit of service rendered, but rather a host of various services that work together collectively. Through a multi-disciplinary team approach, we may better be equipped to attain better patient outcomes, greater patient and physician satisfaction and reduced health care costs.^(11). And ultimately, through a multi-disciplinary team approach, our health care system may be able to place at its’ center the most important component: the patient.

References:

1. Moody J. “Health Care Reform: The Debate Ahead”. The Journal of Nuclear Medicine. 36(4). 1995:22N,38N.
2. Conway PH, Clancy C. “Transformation of Health Care at the Front Line”. JAMA. 301(7) 2009:763-765.
3. “National Health Expenditure Data: NHE Fact Sheet”. Centers for Medicare and Medicaid Services.
4. Keehan S, Sisko A, Truffer C, Smith S, Cowan C, Poisal J, Clemens MK, and the National Health Expenditure Accounts Projections Team, “Health Spending Projections Through 2017: The Baby-Boom Generation Is Coming To Medicare”, Health Affairs.
5. “World Health Organization assesses the world’s health system“. Press Release WHO/44 21 June 2000.
6. Health system attainment and performance in all Member States, ranked by eight measures, estimates for 1997, World Health Organization. http://www.who.int/whr/2000/en/annex01_en.pdf. Accessed on March 16, 2009.
7. “Building Upon the Cornerstones”. Mayo Clinic Health Policy Center Power Point. http://www.mayoclinic.org/healthpolicycenter/pdfs/building-cornerstones-final.pdf. Accessed March 16, 2009.
8. Shojania KG, Levinson W. “Clinicians in Quality Improvement”. JAMA 301(7). 2009:766-8.
9. Bodenhaimer T, Starfield B, Treadway K, Goroll AH, Lee TH. “The Future of Primary Care- The Community Responds”. New England Journal of Medicine. 359:25. 2008. 2636-2639.
10. Eiser AR, Connaughton-Storey J. Experiential learning of systems-based practice: a hands-on experience for first-year medical residents. Academic Medicine. 83(10. 2008: 915-23.
11. Holman HR. “The inadequacy of medical education” Chronic Illness 5. 2009: 18-20.
12. Pols, RG. “Chronic condition self-management support: proposed competencies for medical students”. Chronic Illness. 5. 2009:7-14.