Massachusetts Medical Society: Leading and Working in Teams: The New Care Paradigm

Leading and Working in Teams: The New Care Paradigm

MMS Introduces Physician-Led Team Legislation; Creates New Inter-professional Teams Task Force


As the health care system moves towards new models of care delivery and alternative ways of paying for that care, the idea of team-based care is gaining traction. Inter-professional teams, the thinking goes, can provide better-coordinated, higher quality care — physical and mental health — to individuals and populations. And thanks to increased collaboration, more attention can be paid to prevention and wellness, advocates say.

But who should lead those teams? What does leading a team mean exactly? And as inter-professional collaboration becomes increasingly common, do team members understand the capabilities of colleagues from other professions?

At Family Practice Group in Arlington, team-based care takes the form of the daily morning huddle when a physician or a physician assistant, a medical assistant, and an administrative assistant review the patients on that day’s schedule. In Dr. Hugh Taylor’s family practice in Hamilton, nurse practitioners team up with a physician and a medical assistant to care for a panel of patients. Lately, the medical assistants have taken on a critical piece of population management — making sure patients are up-to-date on their preventive measures.

But organizations that accredit medical homes, including the National Committee for Quality Assurance and the Joint Commission, do not require physician leadership in their criteria.

Many physicians, however, feel they should. MMS policy on accountable care organizations (ACOs) includes language endorsing doctors as team leaders, a preference that the Society hopes will become law in the next session of the state legislature, which begins in January. (See Vital Signs story, MMS to Propose Health Care Team Legislation.) The AMA recently approved policy to the same effect. Physicians are the obvious choice to lead teams because they have the most medical education and training and can take on the more complex, difficult, and unusual cases, argue supporters of physician-led teams.

MMS President-Elect Dennis Dimitri, M.D., said leadership can take different forms, and in some cases the operational head of a team may be a non-physician. But when it comes to ultimate

decision making about the “quality and direction of care, particularly for complex issues, patients need to know that there will be a physician who can take the lead,” he said.

Alternatives to Physicians as Team Leaders

That position, however, has bumped up against a long-time campaign by advance practice registered nurses (APRNs), such as nurse practitioners and clinical nurse specialists, to gain more practice autonomy from physicians. In many states, nurse practitioners are allowed to practice independently. And with an acute shortage of primary care physicians that just keeps getting worse, APRNs argue they are ideally suited to fill the gap.

“We’ve built up great relationships with our physician colleagues — including pulmonologists and cardiologists. If there is an issue that is beyond our scope, that we’re not comfortable with, we’ll reach out to our physician colleagues,” said Wendy Wright, the nurse practitioner who owns and heads up the eponymous Wright and Associates Family Healthcare in New Hampshire.

Wright believes that experienced NPs are capable of leading care teams not only because of their clinical expertise, but also because they are accustomed to working closely with other allied health professionals. In her office, a physical therapist, a phlebotomist, a diabetes specialist, and a nutritionist are onsite part-time to collaborate on patient care.

MMS Creates New Inter-professional Teams Task Force

Leadership issues aside, Dr. Dimitri believes that in this new world of team-based care, it’s incumbent upon health care professionals of every ilk to learn more about the training and capabilities of those they’re working with. He’s pleased that the MMS’s board of trustees recently approved a new task force on inter-professional health care.

“We need to create a better understanding on everyone’s part of what physicians and non-physicians bring to the care of our patients,” said Dr. Dimitri.

“And I’m not referring only to physicians, NPs, and PAs, he said. “We need to learn to work better and understand what pharmacists, social workers, and behavioral health specialists bring to the table as well.”

Third-year medical student and Delegate to the MMS House of Delegates, Aimie Zale, the prime mover behind the task force, is already well-versed in professional silos thanks to her clinical rotations and her work as a nurse’s aide prior to medical school. “I’ve talked to a lot of other professionals, whether midlevel providers, occupational therapists, hospital nutritionists or lactation specialists. They tell me that the referrals they get are often inappropriate or that they’re not being utilized to the full extent of their training and education,” she explained.

She gave the example of lactation experts: the best trained are International Board Certified Lactation Consultants. They must take 14 classes, have 90 hours of lactation-specific training, and work with patients between 500 and 1,000 hours before they are even allowed to sit for the exam. “Many pediatricians and residents have never heard of this,” she said. “As a medical student who will soon be a practicing physician, I want some guidance from my professional association about how best to use the many professionals I’ll be working with. I’m not getting that training in medical school and I’m not sure I will get it in residency either.”

Zale said she hopes the new task force spawns greater cooperation among different health care professionals on a more global scale as well. “I’d like the MMS to invite professional societies from other professions to talk to us about policy issues,” she said. “Let’s come to mutually satisfactory conclusions instead of arguing these issues at the statehouse.” Such efforts would also help counter the public perception that physicians are unduly concerned about protecting their turf, she added.

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