8 Principles to Start Building a Multidisciplinary Clinical Practice_
*I thank Gabriela Hernández and Dr. Alexander Krouham for their valuable comments for this article.
Many of the medical services that we see every day hint that they are “comprehensive” and many also use the word “multidisciplinary.” The reality is that Western medicine has always been comprehensive and multidisciplinary, but the model has come closer to a Shopping Center that “has everything you need”, and that assumes that the client knows what he needs, instead of a methodology that evolves in a reflective way to nurture the constant integration of distinct professional resources.
Many of the medical services that we see every day hint that they are “comprehensive” and many also use the word “multidisciplinary.” The reality is that Western medicine has always been comprehensive and multidisciplinary, but the model has come closer to a Shopping Center that “has everything you need”, and that assumes that the client knows what he needs, instead of a methodology that evolves in a reflective way to nurture the constant integration of distinct professional resources.
The interconsultation model (when one specialist refers you to another specialist to check, rectify or review a specific issue), has almost always been one-way. The patient, then, receives several opinions from different practitioners and is left to choose what to do with those. Seldom do we see many specialists in the same room talking about a specific patient, never do we see it happening in the same room where the patient is actually present.
(I am not interested here in exploring the underlying reasons that have led to this, but let me just say that this has to do with the idea that medicine, as a science, is an analytical methodology that separates and reduces to smaller parts what it wants to understand. In medicine this means that the endocrinologist does not get involved in the work of the cardiologist and the neurologist does not get involved in that of the gastroenterologist. Fortunately, the underlying philosophy that has maintained the conception of the body as separate systems — the most notorious being the separation of body and mind- is being increasingly questioned and great steps are being taken to have these analytical and practical principles revised)
What I want to propose are a few key points that we will have to address as health professionals, if we want to achieve a much more effective multidisciplinary clinical work for chronic patients without having to completely change the paradigmatic bases of medicine.
1. VISION
This is the most important and the most difficult.
It is impossible to have a multidisciplinary clinical practice if each discipline is not clear about the importance of working in close collaboration — not to say co-construction — with other health professionals.
There are thousands of analogies to explain this (from how to build soccer teams to enterprises), in which, if there is not a shared and clear vision of what you want to achieve as a team, it will be impossible to get there.
Health professionals were not trained to speak at length with their colleagues about each patient. Rather, they were trained to give their diagnosis from their perspective and are not “prepared” to talk about an aspect that they did not spend enough hours learning in school. For this reason, for example, even if the nutritionist has an intuition that the main source of the patient’s problem may be psychological, the nutritionist feels that he does not know how to help him and the best thing he can do is to give the patient a new dietary program and share the contact details of his cousin the psychologist.
The problem is that, at the family meal on the weekend, the nutritionist and the psychologist will not talk about the patient, not even during the week, and probably never. You will never be able to do multidisciplinary clinical work if the team you want to work with does not share the same vision.
2. PRIVACY
This brings us to the second point that needs to be addressed. If we continue to believe that each specialist can only have access to patient information directly (that is, through listening to the patient in the consultation room or by reviewing the clinical exams) and not through the insights of his colleagues, we are limiting a lot of the richness of a shared reading. If after 7 sessions a patient confesses to his psychologist that he has erection problems and that this is causing him to consume certain foods or drugs in excess, and this information remains in the hands of the psychologist without reaching the doctor, the nutritionist, or the coach, how long will it take for each specialist to be able to help from their own specific trench?
Privacy laws are good, but putting “the patient at the center” requires that this privacy goes beyond the patient-doctor relationship and becomes a patient-doctorS relationship issue.
(Which, incidentally, should also be a doctorS-patientS relationship. That is, the very stigma that this patient is having for not being able to talk about his problem with fellow patients, is brutally limiting his possibility of owning the problem to begin his journey out of it.)
We have to review those “privacy rules” and the “patient-doctor privilege” in order to be able to share more openly and regularly what is happening with each patient. Protecting the privacy of the patient is often detrimental to the patient.
3. COMMON MEDICAL RECORD
Like everyone else, healthcare professionals have busy lives. Sometimes a little more than average since their time is always on demand by patients. This is when the expanded and COMMON MEDICAL RECORD can be very helpful. Let us make medical records that allow “internal conversations”, that is, that it functions as a means for all members of the multidisciplinary team to go beyond the traditional inputs and works as a device to construct a more robust narrative of who the patient is and not only what he has (or suffers from). This can happen if the document is constantly shared, reviewed and expanded by the entire team on an ongoing basis.
Let’s sit down and design a file that works individually but also works for the group. Taking notes thinking about the other professionals who are going to read them and not only the notes that each separate specialist (or the regulatory authority) will need for his own use. We have to change our perspective of what a medical record can do.
4. CONVERSATIONS
But the shared medical record is not enough. Professionals have to make time each week to meet with the entire team and talk about patients.
For example, a good initial conversation about a patient who has just arrived, and has already been seen by the entire multidisciplinary team, can help us a lot in answering more effectively the question that we all have in mind at the beginning: “I know all the things that need to be corrected for this patient, but where do I start?”
We are all running all the time, but constant conversations between professionals are essential and cannot be postponed. We have to put them on our calendar as if they are just another consultation with a patient. Many times, a conversation with our team helps us even more than seeing the patient for the fifth time.
These conversations help health professionals to think of themselves beyond “operators” (dealing with crises and the immediate future) and enables them to act together as “strategists” in the well-being journey of the patient.
5. ROLES AND PROCESSES
Health professionals are not engineers, they are not designers, they are not company directors. But multidisciplinary work requires new processes, new technologies, new paperwork and new administrative processes. In order to do multidisciplinary clinical work, it is not necessary to think that we have to do everything ourselves. There are other people who are not health professionals, but who are also part, precisely, of the multidisciplinary team. Let’s not be afraid to reach out to administrators, consultants, accountants. People who can help put together, operate and solve the minutiae and not so minutiae of an organization with multiple moving parts. If this is executed correctly, it won´t be an extra cost but a wise investment.
6. MONEY
This last paragraph has already ignited our quantifications mind: “I charge by the hour” some say, “I can’t waste my time at a table with 4 other professionals, I have to be with patients.” “I can put up to 5 patients per hour, while my colleague needs at least 1 hour with each one.” “How am I going to charge the patient for the hour of work with the multidisciplinary team?” “How will the patient be able to pay for consultations with 4 specialists on a recurring basis?”
All these questions are valid and come from a model that in some cases is excellent -as with acute diseases-, but that is not sustainable in a world of chronic conditions.
We have always had the Shopping Medical Center where you “find everything”, but with chronic conditions we cannot wait for the patient to put together his own puzzle choosing who to see and what to make out of the different opinions and treatment plans that he gets offered. Professionals are the ones who have to put it together with him and we have to find or invent the economic models that support it.
This question is not trivial at all, but it is not impossible to solve either. Each multidisciplinary team has to sit down with their spreadsheet and find ways to gauge the time they will spend alone with the patient and the time they will spend with the team addressing issues for that same patient. In the long run, a well-invented model makes consultations more efficient, shorter, and effective.
If the current model pays us for sickness, we are now inventing a model that will pay us for health, and this implies a paradigm shift that can take years. But I am convinced that no professional team will be dissatisfied when seeing their patients improve when they “sacrifice” their current economic model for a model that generates more health. In the long run, too, this model allows the team to see far more patients than they could see individually, and perhaps the equation shifts from charging per consultation to charging for results, or from charging per event to charging for memberships.
7. COACH
The coach is the new player in the world of clinical medicine and it seems to me that he is even more fundamental in multidisciplinary clinical work. If a large part of chronic health problems are linked to lifestyle and lifestyle is so linked to the story that each patient tells himself and how he lives his daily life, the coach is the one who accompanies the patient to create a new vision for himself. The coach motivates and educates the patient throughout his transformation journey. We all need a coach and we would like our doctor, our nutritionist, our psychologist to become our coaches, but maybe that is not going to happen. That is why the coach can act as the link between the patient and the team of professionals, the one who translates what some recommend into understandable and actionable habits, the one who is available for sporadic questions or the inevitable mini-crises that will happen. The coach acts as a secretary to the professionals and sometimes to the patient, acts as a translator and spokesperson, and even becomes friends with the patients.
8. EGO
I left the one we’ve all been thinking about for the final point. The famous, often-misunderstood and very present: E-G-O.
The ego is good. But sometimes it is bad. And that’s why I think we have to call EGO with his three letters so that we know when EGO is calling the shots. If we start to put together our multidisciplinary team and we make sure that we constantly bring the issue of ego to our conversations, we will attend to it in a better way than if we leave it there and it becomes, as always, the elephant in the room.
Let’s talk about the ego, let’s talk with our ego and observe that taking care of it is important, but taking care of it exclusively is detrimental to our health, that of our colleagues, that of our income, and yes, that of our patients.
Many believe that having the ego disappear completely is the only way health professionals can collaborate. I’m sorry to tell you that this is not going to happen. But what is happening is that professionals are realizing that too much ego is limiting and they are willing to re-learn and share their fears so that a collaborative solution can happen instead of a siloed ego-protecting response.
Conclusion
Multidisciplinary clinical work is not for everyone: It is not for all professionals, just as it is not for all patients, or for all health conditions. But there are many who are needing it. And there is no doubt that in 10 years this will be common practice.
When am I going to start?