“Teamwork is the ability to work together toward a common vision—the ability to direct individual accomplishment toward organizational objectives. It is the fuel that allows common people to attain uncommon results.”
Health care is changing. The technologies available for diagnostics are improving. The methods of acquiring and sharing information are burgeoning with the advent of the electronic medical record and information technology. Care is expected to be patient-centered, ensuring that the patient and family understand the options available for treatment and are the decision-makers guiding care. In addition, health care is increasingly team-based. A broadly accepted definition of team-based health care is “the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated, high-quality care” (1).
“The high-performing team is now widely recognized as an essential tool for constructing a more patient-centered, coordinated, and effective health care delivery system” (2, p. 3). With the literature burgeoning with new research findings, and with the research evidence that serves as the metric for quality of care continually changing, no single physician can absorb all of this information. Physicians must rely on specialists in other fields. Patient consumers are frequent utilizers of physician services. For example, the “typical Medicare beneficiary visits two primary care clinicians and five specialists per year,” as well as utilizing the ancillary services of diagnostic radiology, laboratory testing, pharmacy, and other services (3). Individuals suffering from multiple chronic conditions receive care from even more providers. Effective communication and collaboration between these multiple providers is essential to provide the highest quality of care possible to patients and their families. Effective communication is also required to reduce the potential for errors that may occur with multiple provider systems (4).
Common electronic medical record systems have facilitated care by documenting the types of care provided to the patient, diagnoses, medications, and treatment plans. However, cultivation of optimally functioning interprofessional health care teams remains the gold standard for enhancing patient-care outcomes. The Institute of Medicine has stressed that psychiatrists and other health care providers have an “obligation to strive for perfection in the science and practice of interprofessional team-based health care” (2, p. 2).
As she reviewed the electronic medical record, Dr. Ying queried the resident that was working with her on the Psychiatry Consult service, “Did you meet with Mr. Thomas this morning?”
She was attempting to determine what had happened the night before that prompted the Psychiatry Consultation about treatment of agitation. The attending internist had told Dr. Ying that Mr. Thomas had a stroke, was in the ICU, and had become agitated in the night. The patient was confused but reportedly had agreed to a psychiatry consult.
“Yes, I met with him,” the resident replied. Dr. Ying glanced up quizzically, and the resident presented the case.
“Mr. Thomas is a 68-year-old man that was brought in by ambulance yesterday morning due to the acute onset of right-sided weakness, confusion, and difficulties speaking. CT scan demonstrated no acute bleed. The CVA protocol was followed by the medical team. Mr. Thomas seemed to be more oriented yesterday afternoon when his wife was with him. She provided a complete history, and then went home at the suggestion of the team. Last night, Mr. Thomas became agitated. The team gave him 1 mg of lorazepam i.v. to help with the agitation, and he seemed to calm. But he awakened several hours later and thought the nurse was trying to hurt him, and he may have been hallucinating. He received another 1 mg of lorazepam. His wife was at the bedside when I went in. She asked what we had done to make her husband so frightened and confused—he hadn’t been that way yesterday. She reported that Mr. Thomas is a biology teacher. He has no psychiatric history and no history of dementia. Ms. Thomas said her husband had a stroke, and he needed a neurologist, not a psychiatrist. I reassured her that we were part of the team trying to help him with his confusion. Mr. Thomas kept brushing off his arms, complaining that there were ‘bugs everywhere.’ I believe he is delirious.”
“What do you think caused the delirium?” Dr. Ying queried.
“Probably a combination of the CVA, the ICU setting, and the lorazepam,” the resident answered.
“That was a good synopsis,” Dr. Ying said by way of feedback to the resident. “Now let’s go see the patient.”
After interviewing the patient, confirming that he was, in fact delirious, Dr. Ying and the resident talked to Mr. and Ms. Thomas about why they thought he was having these frightening symptoms—and how that they would likely resolve. They discussed a recommendation for a very low dosage of antipsychotic medication if he continued to be frightened and to hallucinate, and noted the risks and benefits. The psychiatrists wrote recommendations in the medical record about medications, suggestions to help Mr. Thomas with orientation, and allowing his wife to stay with him overnight. They discussed these recommendations with the attending and nurse, and were leaving the floor when the intern on the case approached them.
“Do you think that you could round with us tomorrow to discuss your recommendations?” he asked tentatively. “I don’t know much about treating agitation. Also, the resident on the case doesn’t agree with having the wife stay. Ms. Thomas has been very critical of the team and questions everything we do”.
“We would be happy to round with you,” the psychiatry resident replied. “Ms. Thomas is actually very reasonable once you listen to her concerns. She is just worried about her husband. He is much calmer when she is there. Would you like me to talk to the resident about it today?”
Dr. Ying smiled. She felt proud of the psychiatry resident for being skilled in engaging Mr. Thomas and his wife and explaining the recommendations in a practical way to the intern on the case. She was pleased that the intern had asked for their help in learning about the treatment of agitation and working with his team. Then she shook her head, contemplatively. “We still have a ways to go to understand and practice optimal interdisciplinary collaboration and patient-centered care,” she mused.
Interprofessional teams are becoming the norm for health care delivery, whether these services are hospital-based, in the outpatient Medical Home, or in community-based health and mental health care systems. It is therefore increasingly important for every physician to be skilled in interpersonal and communication skills required to work collaboratively in teams, as well as to work individually with the patient. The Institute of Medicine (2, p. 6) has elaborated five principles of team-based health care delivery. They include:
Shared goals: The team—including the patient and, where appropriate, family members or other support persons—works to establish shared goals that reflect patient and family priorities, and can be clearly articulated, understood, and supported by all team members.
Clear roles: There are clear expectations for each team member’s functions, responsibilities, and accountabilities, which optimize the team’s efficiency and often make it possible for the team to take advantage of division of labor, thereby accomplishing more than the sum of its parts.
Mutual trust: Team members earn each other’s trust, creating strong norms of reciprocity and greater opportunities for shared achievement.
Effective communication: The team prioritizes and continuously refines its communication skills. It has consistent channels for candid and complete communication, which are accessed and used by all team members across all settings.
Measurable processes and outcomes: The team agrees on and implements reliable and timely feedback on successes and failures in both the functioning of the team and achievement of the team’s goals. These are used to track and improve performance immediately and over time.
A well-functioning team ensures that communication is active, accurate, and rapid to inform optimal health care decisions. In the digital age, communication may (and generally should) take multiple forms: in-person, such as in team meetings, progress notes and electronic health records, telephone conversations, e-mail, text messages, faxes, web-based information sharing, or even “snail mail.” The channels of communication used should be those that may be expected to optimize the functioning of the health care team (5).
Effective communication requires incorporation of the values underlying effective teams: honesty, reliability, curiosity, humility, and creativity. It is often helpful to articulate these values and expectations when the team is organized. However, teams may be fluid in membership, as trainees, attending physicians, or other health/mental health professionals rotate on and off of a service. It is the responsibility of all team members to give honest and accurate information; to be reliable in their follow-up and team attendance; and to model the value of lifelong learning. The team member that presents as overly confident and self-aggrandizing may dismiss important information, in addition to his/her communication style having a damaging effect on optimal team functioning. Team members need to address this team member’s behavior promptly, respectfully, but firmly, to maintain the team as a safe place in which to communicate and work. It is the responsibility of all team members to be open to and encouraging of new or creative solutions to patient care problems (2).
Some individuals communicate effortlessly and effectively with patients, families, and colleagues and are frequently the ones to facilitate the team discussion. However, effective communication is a teachable skill that can be developed by each member of the team and by the team as a whole. Teams may choose to alternate facilitators to encourage leadership development in all of the members.
Whether the facilitator, consultant, or supportive professional to the patient and family, general guidelines that may enhance effective team participation include the following (2, 5, 6):