Teams

By HL Admin posted 07-04-2016 20:06

  

December 5, 2015

|

John Brady, M.D.

I always get the current medical buzz phrase from the local hospital system when I listen to the radio. Gone is “patient-centered, doctor-directed” care. We have moved on to “expert, team-based care.” And why not? Proponents argue that doctors cannot possibly do everything themselves, so a team is necessary. As one physician described it to me, he likes to think of himself as the conductor of a medical symphony—the lead person organizing and orchestrating many talented individuals to uniformly share the music of health to his patients.

Though a beautiful vision, most of the time when I read about teams I cringe. Basic team dynamics and team theory oppose the notion that teams can be a panacea for medicine, and understanding these flaws can help shed light on why smaller practices by their very nature provide better care.[1]

Each added member of a team increases the number of lines of communication in a nonlinear fashion, so chaos and confusion quickly escalates with each new employee.[2] Unless great care is taken as the team enlarges, work will inevitably get dropped, lost, or ignored. There is also evidence that the larger the team, the worse the job satisfaction and the worse the motivation.[3] For example, a secretary informed me she was done answering the phone one morning because she had answered it 8 more times than the other secretary. Instead of being excited about the increased efficiencies she brought to her job, she considered it unfair that she had to do more work. This “race to the bottom” is a consistent finding of human nature amongst team members and the bigger the team, the more likely it is to occur. Finally, a study from Harvard showed that highly integrated teams are great for collecting data but are counter-productive in problem solving.[4] Though information collection is a huge component in the current push for quality metrics, the most important part of primary care involves problem solving with patients to overcome their numerous obstacles to health. Outsourcing this task to a team is destined to produce questionable outcomes.

Of course the way doctors are paid also plays into the dynamic of how teams work in medicine. Though medicine is moving quickly toward a quality based payment system, most doctors are still paid in a per visit manner. Unless a team member can bill for his/her services, each added employee becomes an albatross on the financial neck of the practice with each one requiring the doctor to see an additional 2-3 patients/day. Though unburdening the physician of nonessential administrative tasks (the oft-cited argument for additional employees) is always welcome, cramming more patients into an already packed schedule is analogous to running faster at the beginning of a marathon to try and improve the finish time. Though somewhat logical, the end result is more likely to be burning out with much more pain and suffering along the way (i.e hitting the wall) than a fantastic finish.

Given the overwhelming amount of peripheral activities (billing, quality reporting, prior authorizations, etc) prevalent in medicine today, teams are probably a necessary business construct. But before we rush into nonspecific team based care as the solution to what ails medicine, we should devote more effort to eliminating the unnecessary administrative burdens forcing offices to employ larger teams. We also need to tread cautiously with teams until we have good research evaluating the potential drawbacks of them, the possible implications to the fabric of family medicine, and how all this impacts our patients. Yes, great teams exist, but perhaps “perfection is achieved not when there is nothing left to add, but when there is nothing left to take away.”[5] My guess is if we follow that philosophy, many doctors will find being a virtuoso soloist, or even a member of a duet or a trio, far more practical, inexpensive, and uplifting than trying to run a symphony.

[1] http://www.commonwealthfund.org/publications/in-the-literature/2014/aug/small-primary-care-practices

[2] Number of lines of unidirectional communication = n(n-1) with n=number of employees. Ex: 5 member team=20 lines of communication, but a 10 member team=90 lines of communication

[3] Daft, Richard. Management. Thompson Higher Education, 2008. p. 602

[4] http://hbswk.hbs.edu/item/7505.html

[5] Antoine de Saint-Exupery

1 comment
148 views

Permalink

Comments

09-08-2016 15:59

I remain unconvinced that a team is better for everyone.  There are virtues: It offers more opportunities for different perspectives, more eyes to catch errors, less intense relationships with patients. Maybe it is cheaper. But in the end, the doctor/primary care provider is usually who the patient came to see.  The team dilutes that relationship and introduces opportunity for mis-communication and a whole new potential for errors. One may not be better than the other. I would suspect that different patients and different doctor have different preferences as well as different outcomes depending on the fit of the model.  I don't think that has been studied.  I have worked in both and prefer the high patient to doctor ratio, strong relationship model. At my office, I still have a "team" it is just very small: me, my medical partner and a part time nurse and part time manager/biller. As an introvert that borders on being a control freak, the idea of a larger team exhausts me. My outcomes are pretty good and my patients are pretty happy. So far NCQA has been happy with my small team.  Your thoughts? Avery