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Trust, teamwork and transparency

Posted May 15 2012 8:21pm


Teams are a feature of healthcare, and nowhere more so than in pain management.  This is because, at least for chronic pain, no single profession can claim to have all the answers.  Many of us know we need to rely on one another to address patient/client concerns and to provide a consistent approach for the person to have some confidence in.

However (you knew this was coming!), teamwork isn’t easy and some groups of professionals appear to have a good deal of difficulty overcoming implicit attitudes and assumptions about other disciplines.  Now before I’m annihilated, I acknowledge that the attitudes and behaviours within every group of practitioners varies in a bell-shaped curve!

I had occasion, recently, to address a group of health practitioners who shall remain nameless.  This group were discussing sharing of health information, and an approach to inviting patients to be part of a programme of self management in which health information sharing is a component.  To my perplexion, I found that there were two major concerns about this approach. 

  1. That “all” health information would be shared by all team members rather than being selected by this group of clinicians (the risk being identified was that mental health and sexual health information would be shared along with cardiology, musculoskeletal, immunological and so on)
  2. That inclusion on this programme would not be “controlled” by this group of clinicians. 

In other words, that patients would be able to decide for themselves whether they wanted to participate, and that all their health information would be available to other clinicians was viewed with anxiety. I’m venturing to suggest that this reflects a lack of trust in both other health professionals, and in their patients, with the latter being a somewhat outdated paternalistic view, IMHO.

I took it upon myself to have a quick flick through the literature on health professionals attitudes towards one another, and there is a wealth of it! Unsurprisingly, studies about biomedical attitudes towards professionals of other persuasion dominate, so I’ll summarise just a couple and let you draw your own conclusions about how widely the findings might apply.

Moret, Rochedreux and colleagues (2008) found that while physicians delivered diagnosis and prognosis (and nurses agreed), nurses thought they provided additional explanations about diagnosis, information on investigations, and benefits and risks of treatment to what physicians provided, while physicians appeared unaware of the contribution of nurses.  Concerningly, more than 20% of patients were not satisfied with information on benefits and risks of investigations and treatments, and wanted more.  This report suggested that lack of physician-nurse collaboration affects the quality of patient care, and that both professions should recognise the contributions of each other.

Gaboury, Bujold et al (2009) examined the collaboration between medical doctors and “complementary and alternative medicine practitioners”.  (For the skeptics amongst us, these are the practitioners included: naturopathy, massage therapy, chiropractic, and traditional Chinese medicine, including acupuncture. Other practitioners coming from a biomedical healthcare background, such as nurse practitioners, physiotherapists or pharmacists were also eligible participants. I make no comment on whether these practitioners provide useful/helpful input, kthx).  They found that “awareness of one’s own limitations related to one’s healthcare paradigm and similarly limitations in colleagues’ abilities … affect[ed] the level of collaboration among the clinic staff.”; and that “capacity to acknowledge one’s own limits was identified as a major personality characteristic [my emphasis] that stimulates appropriate patient referral and safer care for the patient.”  They also state that  “comprehensive understanding and knowledge of colleagues’ healthcare abilities, and perspectives based on their healthcare paradigm appeared to be vital to the team cohesion.”   Sharing patient records was found to enhance collaboration, and patients were asked to agree to this.

However, relating directly to my experience regarding power relationships, this study identified that “…even though patients could self-refer and specifically request to see a CAM specialist in all of the five clinics visited, the designated entry practitioner for two clinics was the medical doctor. One manager interviewed depicted his clinic’s referral system as if the medical doctors were the orchestra conductors responsible for ensuring continuity of care and integrative care.”

There appears to me to be an easy assumption by the medical profession that they are at the top of a decision-making hierarchy in a healthcare team.  I’m not sure this is justified in all situations (I don’t mind if a doc decides for me if I have acute appendicitis!) – but it’s an attitude adopted very early in medical training.  A study of medical students by Weaver and Peters (2011) looked at factors contributing to medical students developing sense of professional identity.  They found two main elements could be identified : professional inclusivity and social exclusivity.  By professional inclusivity, they meant that as students participated in clinical placements and were treated as “members of the team”, and social exclusivity, they meant medical students tended to socialise with one another.  A commentary by Bleakley in the same journal suggests that “as medical students are drawn further into associating with those in medical culture, so other associations are denied or lost”, “as trainee doctors, medical students become ‘clinical reasoners’ and this, traditionally, identifies them and distinguishes them from others.” Bleakley says “Medicine has claimed a degree of autonomy that has progressively provoked its consumers – patients.” He goes on to say “When a student in the study … remarks that the medical profession is ‘something to look up to’, one wishes that this student had described it as ‘something to look forward to’. ‘Looking up to’ can so easily progress to ‘looking down on’, where meritocracy hardens into autocracy.

Bleakley writes strongly about the need to challenge medical students’ social exclusivity saying “The excluded ‘other’ (health care colleagues, patients, cultures other than medicine) should be a major focus for inclusion in medical education; otherwise students will continue to progress habits of exclusivity in their work as doctors, indicated by relatively poor communication with patients and colleagues”.

Really, I couldn’t say it better myself, so I’ll leave the last word to Bleakley:

Belonging to the medical team is an issue of professional identity, whereas belonging to the wider health care team is an issue of interprofessional identity.

 Applies to all of us, doesn’t it?

Bleakley, A. (2011). Professing medical identities in the liquid world of teams. Medical Education 45(12): 1167–1173

Gaboury, I., M. Bujold, et al. (2009). “Interprofessional collaboration within Canadian integrative healthcare clinics: Key components.” Social Science & Medicine 69(5): 707-715.

Moret, L., A. Rochedreux, et al. (2008). “Medical information delivered to patients: Discrepancies concerning roles as perceived by physicians and nurses set against patient satisfaction.” Patient Education and Counseling 70(1): 94-101.

 
Weaver R, Peters K, Koch J, & Wilson I (2011). ‘Part of the team’: professional identity and social exclusivity in medical students. Medical education, 45 (12), 1220-9 PMID: 21999250


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