I have mixed feelings about the team concept. It annoys to me to no end when I have a doctor that can do something “simple” but yet farms it out. A couple years ago, I needed to have a stress test but instead of my PCP ordering it, I had to see a cardiologist first. Prior PCPs always ordered the stress test and if I needed to see a cardiologist after, I did. When my foot got infected, the doctor I saw at the first wound center wanted to play all the roles and I almost lost my leg. The next wound center had an infectious disease doctor – he specialized in bugs and made the decisions about the infections. They had a vascular surgeon and he helped with the circulation stuff if someone needed that. There are some things that really do need farmed out.
I agree, Peetie, when the “team” concept works, it works really well. Because then the team is talking about all aspects of “Mary” not just her foot or her blood sugar or her carbs. I agree with you, Natalie, that those of us who are proactive with our own care do better, but I think it is even more valuable to have the professionals talk with each other. In my own professional experience I’ve seen how much better a (co-located) team works than isolated professionals. For example I ran a program for senior women alcoholics many of whom were being given pain or anxiety meds from their doctors or psychiatrists which they admitted to me they abused. I contacted some of these doctors and they were close to rude because I wasn’t a medical professional (even though I was the expert on addiction, not them). When I worked in a colocated team each person was listened to for their own area of expertise, regardless of “status”. For example when I as CM brought my client to their Psychiatrist appointment, the psychiatrist would ask me before their appointment how they were doing in their group therapy and even about their living conditions.
On the personal level I had a bad experience when doctors were trying to stabilize my thyroid. I had an endo, a pcp, a nuclear medicine person and eventually a surgical team when they decided I needed thyroid surgery. The day before surgery an intern I believe asked me if I was on a certain med and I had never been told anything about it. Apparently it was very dangerous to have the surgery without it. My doctor hadn’t spoken to the surgeon and after postponing the surgery we found out that the nuclear medicine guy wanted to try a second dose of radiation before the extreme choice of surgery which did, in fact do the trick. These doctors were all located in the same large hospital clinic. But I doubt they would recognize each other in the hall. So co-location is no guarantee if they don’t work as a team.
My other big problem w/ the team thing is that it costs a lot of time, running back and forth to appointments. My boss/ employer are totally cool but I loathe being the guy w/ diabetes who has to go to the doctor/ lab/ dietician/ etc. all the time. IT should take one stop. Or they should talk to you together?
I don’t think it would work, AR, to have them talk to you together, because they all have different areas of expertise and emphasis. (Although in my Behavioral Health experience we did occasionally do “Wrap-around Meetings” where several different providers will meet for a two hour session with the client to brainstorm about how they can each help them deal with a crisis of some sort). But if it is a real Team, rather than just isolated providers, they would be located the same place and you could try and schedule your appointments back to back (not always possible, but sometimes). They would have discussed your situation in their staff meeting that week and/or the endo for example would have the dieticians notes in his chart and could say, “ah, I see you have changed this in your food regimen, are you doing well with matching insulin to the new eating program?” Or even, “In our meeting this week, we discussed these lab results and the dietician recommends more beer intake (LOL) and here is what I think would work in terms of covering your beer with insulin.”
In a well functioning team each member contributes their own strengths and special knowledge to produce an end result that is superior to the one that could have been produced by any team member on their own. In business a smoothly functioning team usually wins over a dysfunctional team because there is a score keeper in the form of the market.
From everyone’s comments smoothly functioning teams seem to be a rarity in medicine. In theory this could help stem the relentless inflation in health care costs, and produce better outcomes.
Whats needed is a paradigm shift. Unfortunately, the recent health care debate here in the US does not provide much reason for optimism. Old Ideas and entrenched interests fight any change tooth and nail.
At some point rising costs and an aging population will overwhelm the present system. It would be nice to fix things before a crisis but I’m not holding my breath.
“These doctors were all located in the same large hospital clinic. But I doubt they would recognize each other in the hall. So co-location is no guarantee if they don’t work as a team.”
Zoe, I had to laugh at that statement. A couple years ago, I wanted to see a neurologist in Pittsburgh. My insurance doesn’t require me to get referrals to specialists, but the neurologist would not see me without one. My PCP complained that I was going to Pittsburgh because it would be “easier” for him if I saw someone local. My thought was whether I see someone in Pittsburgh or 10 miles from his office, they will still communicate via phone, fax or email so what difference does it make! When I was in the hospital for a week in Pittsburgh, I had 4 different doctors coming in. They all came in different hours & they talked to each other by phone. They sometimes told me they called one of the others ones or planned on calling. The nurse told meone day Dr. K asked her to get Dr. C on the line and he was on a train to NY when they talked to him.
Except I am supposed to be their area of expertise. I would think they’d be more interested in coordinating their efforts? I guess a “wrap-around” seems like what I’m getting at but I wasn’t aware it would be an option.
Unfortunately, I don’t know that it is an option. The wrap-around is a concept used in Mental Health treatment. I’ve never heard the term or the idea used in reference to physical health. And it comes with its own challenges as the different disciplines have very different outlooks and sometimes seem to speak different languages. For example, I have had experience in both Substance Abuse and Mental Health but those two groups of professionals are very different and dont’ have a lot of respect for each other, so I often had to “translate” between them.
Perhaps one of the people who gets their care at one of the Diabetes Centers will share their experience. I’d be interested in hearing how those organizations work as a team.
Here in Britain, I’m pretty sure that dieticians know what is IN each food, but have little idea of what happens to it once inside the body.
I took a course in biochemitry as part of my agricultural microbiology degree [41 years ago] and I seem to have more understanding of the interactions of metabolic pathways than they do. Yes we studied human physiology as well as crops.
I think they just follow protocols laid down in their textbooks and ignore all evidence to the contrary.
Hana
The team approach:
I found this article on MedPage and it discusses, in part what you’ve been talking about in terms of medical cooperation:
Thanks for posting this, Natalie. I wish it had said more, though, about how the team approach functions. I’m still hoping someone who uses one of the Diabetes centers will tell us about how that team approach feels like from the inside.
In slightly more encouraging news, this is what I overheard a diabetes nurse telling gestational diabetes patients yesterday:
‘Don’t eat cereal in the morning, even whole grains. Most ladies find they can’t tolerate that much carb in the morning. You might think that All-Bran or Bran Flakes are healthy. But actually bacon and eggs will be better for your blood sugar in the morning!’
This was at an NHS hospital. I wanted to jump up and hug her!
To me this shows what happens when blood sugar targets are tightened as opposed to loosened. The tail is waging the dog when formulating targets for ordinary diabetics. They decide on a level of carbs they think is appropriate and then raise the targets to match, disregarding the resulting rise in complications. I think your anecdote shows the standard advice can’t last, cracks are already starting to form. It will eventually be replaced with a more pragmatic, results based, approach.