Putting the patient on the health care team is one of the core principles for which the Foundation has advocated for many years. During our Geriatric Interdisciplinary Team Training initiative, when we tried to team up nurses, social workers, and physicians (the minimum geriatric team), we often raised the ante and reminded the grantees of the need to put the patient/family on the team.
But, in truth, I never really knew how I would know if anyone had succeeded in that leap. What does it mean to "put the patient on the team?" A couple of weeks ago I was at a briefing by the Center for Advancing Health, led by Jessie Gruman, PhD, that introduced their new framework for patient engagement in health care. Their Prepared Patient Forum website offers specifics on how patients can manage their own health care, including Communicate with Your Doctors, Organize Your Health Care, and Seek Knowledge about Your Health. While listening to the presentation, I realized that how and why you put patients on a health care team are the same as how and why you add a
member to any team. The business literature is replete with discussions of successful team creation, and I think most of the principles apply in health care.
Fundamentally, teams have to negotiate a common understanding of the problem they are working together to solve, and they have to be able to communicate effectively to share information and feedback as they work. Even in hierarchical work situations, consensus and open communications are essential if you want people to truly buy in to the team and its work. If formal role power is used to manufacture “consensus” and require “communication,” all you can reasonably expect is a sham of overt obedience coupled with covert apathy or worse.
Isn’t this the nature of the health care experience as well? For example, a few years ago my doctor (whom I did not know well) simply announced with no preamble or justification that I should eat no fat. With no connection to any of my goals and no opportunity to discuss the how or the why of this proposed rule, as you can imagine, I smiled, nodded, and proceeded to ignore the advice. Clearly the skills of actively eliciting patient goals, negotiating priorities, and motivational interviewing are critical. Creating true consensus takes time and significant facilitation skills at work and in health care.
Among health professionals, the question is often “who is the captain of the team?” This unfortunately unpacks into a discussion of the appropriate role of physicians on the team--“natural leader” versus a more nuanced discussion of skill sets and the needs of the team of professionals. Answering this question is easier if we think of the team as a battleship’s crew. I think the patient or family member should be the captain of the ship of health, and the better analogy for a health professional is “executive officer.” The executive officer brings detailed technical knowledge of the capabilities of a ship and its crew and is responsible for maintaining their readiness. The captain, however, makes the big decisions of who and when to fight, when to retreat, and when to surrender. A wise captain takes advice from his or her crew and counts on them for technical expertise, but knows at the end of the day it is the captain who is responsible for making sure the ship is sailing in the right direction.