Topic of the Month

Topic of the Month, May 2001

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Teamwork in Health Care and Professional Training

One of the most significant transformations in health care during the managed care era has been the emphasis on systems approaches to delivering care. Solo practitioners have joined groups, and groups have joined networks. Informal and ad hoc processes and relationships have given way to protocols, pathways, and contracts. A related development is greater collaboration among professionals and a reliance on teams of practitioners to care for patients. Still, the benefits of teams have yet to be fully realized. In this month's piece we review recent calls for training physicians and others in teamwork and collaborative care.

In March 2001 the Institute of Medicine's Committee on the Quality of Health Care in America released its second report, Crossing the Quality Chasm: A New Health System for the 21st Century. This report is an exceptionally strong statement on the need for fundamental change and improvement in our health care system. A major theme throughout the report is the importance of teams in delivering care to patients and populations. Among the report's six major challenges to establishing and maintaining organized systems of care that are responsive to patient needs is the following:

A fifth challenge is to continually advance the effectiveness of teams. Team practice is common, but the training of health care professionals is still typically isolated by discipline. Making the necessary changes in medical training is often slowed or stymied by institutional, labor, and financial structures, and by law and custom. (Executive Summary, p. 12)

The report recognizes that the training of health professionals must be changed.

As more care is provided by teams, more opportunities for multidisciplinary training should be offered. People should be trained in the kinds of teams in which they will provide care, starting with initial professional training and continuing through graduate training and ongoing professional development. Multidisciplinary training is difficult to implement because of professional boundaries, the traditional hierarchical structure of health care, clinical specialization, faculty experience, and educational isolation. Changing the situation will require an examination of clinical curricula, funding for education, and faculty preparation. Although there was great interest and innovation in multidisciplinary training during the 1960s, little lasting change resulted. The ability to plan care and practice effectively using multidisciplinary teams takes on increasing importance as the proportion of the population with chronic conditions grows, requiring the provision of a mix of services over time and across settings. (Chapter 9, Preparing the Workforce, pp. 223-224)

The IOM's report joins several other major statements on curriculum reform in medical education that also call for increased attention to teams and multidisciplinary collaboration.

The Accreditation Council for Graduate Medical Education (ACGME) now calls upon residency programs to require its residents to develop competencies in six areas. Specific objectives within three of these areas refer to this theme, e.g. "residents are expected … to work with health care professionals, including those from other disciplines, to provide patient-focused care … to work effectively with others as a member or leader of a health care team … to understand how their patient care and other professional practices affect other health care professionals … and to know how to partner with health care managers and health care providers to assess, coordinate, and improve health care."
The Association of American Medical Colleges' new Graduate Medical Education Core Curriculum (AAMC) includes objectives that "residents should demonstrate the ability to work in team settings by identifying roles and assignments, planning and prioritizing, accepting responsibilities, and assisting others;" and "demonstrate skills of conflict resolution including: listening and explaining, feedback, respect, trust, and consensus development."
The Council on Graduate Medical Education (COGME) in its 1997 Resource Paper, Preparing Learners for Practice in a Managed Care Environment, identifies as a necessary competency: "promoting teamwork and organizational change," including knowledge of group behavior and processes; familiarity with the concept of organizational culture; and strategies for promoting change.
The Pew Health Professions Commission, in its 1998 report, Recreating Health Professional Practice for a New Century, defines "twenty-one competencies for the twenty-first century." One of the competencies is working in interdisciplinary teams. The report states:
Researchers are beginning to confirm what many caregivers have suspected intuitively for a long time: the coordinated efforts of practitioners from many disciplines provide the best outcomes for the sickest patients. The future of medicine will call on all health professions - doctors, dentists, nurses, pharmacists, allied professionals, and public health and social workers - to work together in more focused ways. Comprehensive care of individuals and populations require a wide range of knowledge and skills and involves a variety of delivery settings. To assure effective and efficient coordination of care, health professionals must work interdependently in carrying out their roles and responsibilities, conveying mutual respect, trust, support and appreciation of each discipline's unique contributions to health care.

The report recommends that all health professional training programs incoporate planned interdisciplinary experiences in the curriculum. They should also model effective interdisciplnary collaboration and team integration in teaching, research, and clinical practice.
The national demonstration project Undergraduate Medical Education for the 21st Century (UME-21) defines nine curriculum domains, including "leadership and interdisciplinary teamwork." The learning objective is to "promote effective working relationships with other healthcare professionals to foster teamwork and organization change."

Here at Tufts Health Care Institute we have developed a curriculum framework comprised of five content categories and ten domains. Within the category of Practice Management, we include the domain of Teamwork and Leadership. Topics and content in all the domains are described in the Curriculum Framework pages of this website.

References

Accreditation Council for Graduate Medical Education. ACGME Outcome Project. www.acgme.org
Association of American Medical Colleges (AAMC), Core Curriculum Working Group. Graduate Medical Education Core Curriculum. Washington, DC: AAMC, 2000.
Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine, 2001. www4.nas.edu/onpi/webextra.nsf/web/chasm?OpenDocument
Council on Graduate Medical Education (COGME). Resource Paper, Preparing Learners for Practice in a Managed Care Environment, Rockville, MD: Health Resources and Services Administration, 1997.
O'Neil EH and the Pew Health Professions Commission. Recreating Health Professional Practice for a New Century. The Fourth Report of the Pew Health Professions Commission. Pew Health Professions Commission, December 1998. futurehealth.ucsf.edu/compubs.html
Undergraduate Medical Education for the 21st Century (UME-21): A National Demonstration of Curriculum Innovations to Keep Pace with a Changing Health Care Environment, 1997 - 2002. Health Resources and Services Administration and American Association of Colleges of Osteopathic Medicine, 1999. Washington, DC. www.aacom.org/UME/