Brian Goldman, MD, is a veteran emergency physician, bestselling author, and host of CBC Radio’s podcasts “White Coat,” “Black Art,” and “The Dose.” His new book is The Power of Teamwork: How We Can All Work Better Together.
When I first started working nights in the ER decades ago, I was pretty much a solo act. It’s not like I worked all by myself; The emergency room has always been staffed with excellent nurses and other healthcare providers. I’m talking about a mindset.
For eons of time, training and cultural reinforcement have forced physicians to figure out how to diagnose and treat a patient themselves. But this model is outdated. Today, more than ever, physicians are taking a more integrative approach that involves the patient and their caregivers.
The key is teamwork – for doctors this means going the professional and existential path from “I” to “We”. Today I work in the emergency room with a team of nurses and physician assistants. Nurse Practitioners have an independent practice approaching that of a general practitioner and they consult with me on diagnosis and treatment. Physician assistants do many of the things that NPs and MDs do, except work under the direct supervision of physicians.
As a team, we discuss diagnosis and treatment together. It’s uncanny how each person’s approach to a patient enriches the perspective of the team as a whole.
For example, when an elderly woman comes into the emergency room with trouble breathing, I think she has heart failure because the diagnosis is common and because she looks just like thousands of other patients I’ve treated. The nurse believes the patient has chronic obstructive pulmonary disease because she purses her lips in a way that helps reduce the work of breathing. A resident believes the patient has pulmonary fibrosis or scarring of the lungs because she read the old medical record and learned that the patient once worked in an asbestos mine and may have an undiagnosed case of silicosis.
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The diagnosis we make as a team is more detailed and accurate than the one I make alone. Human factors engineering, a discipline that studies how people interact with systems, tools, and machines, has a term for this type of collaboration: “Team Cognition”. Experts believe team cognition and diagnosis are effective ways to reduce diagnostic medical errors. like dr Pat Croskerry, a retired emergency medicine physician and father of cognitive psychology related to emergency medicine, writes, “It is imperative to view the diagnostic process as a team effort.”
There are other reasons why teamwork is a necessity in healthcare. Medicine has become much more complicated. Today, patients come into the emergency department with six or seven different diagnoses, for which they may be on a dozen or more medications. No single healthcare provider can accommodate all of these details. Complexity requires a team.
Depending on the patient, this team may consist of a respiratory therapist, social worker, physical therapist, occupational therapist, pharmacist, geriatrician, or even a nurse specializing in the increasingly complex needs of frail seniors. And the healthcare team of 2022 would work even better if patients and their loved ones participated as equal members.
However, COVID-19 has been a strong deterrent to family contribution. The pandemic prompted hospitals and nursing homes to implement strict visitor policies that prohibited loved ones from accompanying patients throughout their stay. The idea behind this ban on visits was to curb the spread of the corona virus on the wards. This rule, well-intentioned as it is, made the mistake of lumping family and friends who provide necessary care into the same category as the general hospital-going population.
A paper published by the Ontario COVID-19 Science Advisory Table states that family members and other key caregivers are important advocates for patients. They feed them and help with mobility. They calm down relatives with dementia and overcome language barriers. And they help patients get through difficult times, including the end of life.
This approach also applies in other contexts: commercial airlines, for example, recognize the role of passengers in providing better and safer service.
“When I’m flying, I can’t see my engines from where I’m seated,” Niall Downey, a former heart and chest surgeon who now flies for Aer Lingus, told me. “A passenger might be able to tell me something is dripping from the bottom of the engine before I realize there’s a problem.”
Hospitals have been reluctant to relax visitor guidelines, but that can and must change as the pandemic recedes. We need to understand that more, not less, input from patients and their families paves the way to better and safer care. We must welcome these patients and their families as full members of the healthcare team.
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