Brian Goldman, MD, is a veteran emergency room physician, best-selling author and host of CBC Radio’s White Coat, Black Art, and The Dose podcast. His new book is The Power of Teamwork: How We Can All Work Better Together.
When I started working nights in the ER decades ago, I was pretty much a solo act. It’s not that I worked entirely alone; the ER has always been staffed by excellent nurses and other health care providers. I’m talking about a mindset.
For eons, training and cultural reinforcement have compelled physicians to figure out how to diagnose and treat a patient on their own. But that model has become outdated. Now, more than ever, physicians are embracing a more inclusive approach that incorporates the patient and their caregivers.
The key is teamwork – for doctors, this means making a professional and existential journey from “me” to “we.” These days, I work in the ER alongside a team that includes nurse practitioners and physician assistants. Nurse practitioners have an independent scope of practice approaching that of a family doctor, and they confer with me regarding diagnosis and treatment. Physician assistants do many of the things NPs and MDs do, except they work under the direct supervision of physicians.
As a team, we talk through diagnosis and treatment together. It’s uncanny how each person’s approach to a patient enriches the team’s perspective as a whole.
For example, when an older woman arrives in the ER with trouble breathing, I think she has heart failure because the diagnosis is common and because she looks just like a thousand other patients I’ve treated. The nurse practitioner thinks the patient has chronic obstructive pulmonary disease, because she’s pursing her lips in a way that helps reduce the work of breathing. A resident thinks the patient has pulmonary fibrosis or scarring of the lungs, because she’s read the old chart and has learned that the patient once worked in an asbestos mine and might have an undiagnosed case of silicosis.
The diagnosis we come up with as a team is richer in detail and more accurate than what I come up with by myself. Human-factors engineering, a discipline that studies how humans interact with systems, tools and machines, has a term for this type of collaboration: “team cognition.” Experts believe that team cognition and diagnosis are powerful ways to reduce diagnostic medical errors. As Dr. Pat Croskerry, a retired ER physician and the father of cognitive psychology as it applies to emergency medicine, writes: “There is an imperative to view the diagnostic process as a team endeavor.”
There are other reasons why teamwork in health care is a necessity. Medicine has become far more complicated. Today, patients arrive in the ER with six or seven distinct diagnoses for which they might take a dozen or more medications. No singular health care provider can keep all those details in mind. Complexity demands a team.
Depending on the patient, this team could include a respiratory therapist, social worker, physiotherapist, occupational therapist, pharmacist, geriatrician or even a nurse who specializes in the increasingly complex needs of frail seniors. And the health care team of 2022 would function even better if patients and their loved ones participated as equal members.
COVID-19, however, has been a powerful deterrent to the input of families. The pandemic led hospitals and long-term care homes to introduce strict visitor policies that barred loved ones from accompanying patients throughout their stay. The idea behind these no-visitor policies was to reduce the spread of coronavirus on the wards. That rule, however well-intentioned, made the mistake of lumping family and friends who provide essential care in with the general hospital-visitor population.
A paper published by the Ontario COVID-19 Science Advisory Table says family members and other essential caregivers are key advocates for patients. They feed them and help with mobility. They soothe loved ones with dementia and overcome language barriers. And they help patients get through difficult times, including the end of life.
This approach applies in other contexts as well: Commercial airlines, for example, recognize the role passengers play in better and safer service.
“When I’m flying, I can’t see my engines from where I sit,” Niall Downey, a former heart and chest surgeon who now pilots for Aer Lingus, told me. “A passenger might be able to report to me that there’s something dripping out the bottom of the engine before I’m aware that there’s a problem.”
Hospitals have been reluctant to relax visitor policies, 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 need to welcome these patients and their loved ones as full-fledged members of the health care team.
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