SPECIAL FEATURE. Shared borders: Achieving the goals of interdisciplinary patient care

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1 SPECIAL FEATURE Interdisciplinary patient care Special Feature Shared borders: Achieving the goals of interdisciplinary patient care MAX D. RAY Abstract: Definitions and components of interdisciplinary care, as well as means of implementing, reasons for adopting, and barriers to interdisciplinary care, are presented. A health care discipline is an area of knowledge and research that is critical to patient care. In multidisciplinary practice, each member of a clinical group practices with an awareness and tolerance of other disciplines. In interdisciplinary practice, members of a team actively coordinate care across disciplines. In an ideal interdisciplinary health care team, decisions are made by consensus and each discipline has an equal opportunity for input into decisions. To make the transition from multidisciplinary to interdisciplinary practice, all disciplines, rather than representing freestanding silos, must have shared borders that represent a common professional interest and knowledge base. Such a practice model will lead to an increased level of trust among professions and a deeper level of understanding about what each profession can contribute. Barriers to interdisciplinary practice include historical factors such as different philosophies of practice and professional training, logistics of team implementation, and resource limitation. To facilitate interdisciplinary practice, pharmacists must be competent, understand what a team is, provide leadership, be prepared to help develop drug therapy outcome objectives, project self-confidence, and demonstrate a readiness for interdisciplinary practice. Interdisciplinary care must be applied in a cost-effective way. Interdisciplinary patient care must be taught in profes- sional schools and postgraduate training programs. Interdisciplinary patient care requires common values, a common vision, and an understanding of teamwork with the ultimate goal of serving the patient with wisdom. Index terms: Administration; Decision-making; Health care; Health professions; Patient-focused care; Pharmacists; Professional competence; Team Am J Health-Syst Pharm. 1998; 55: There has been growing interest over the past 50 years in interprofessional collaboration in patient care. This interest can be gauged, for example, by the number of papers in the health-professions literature on such topics as the health care team, multidisciplinary health care delivery, and interdisciplinary patient care. The accreditation standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) require that health systems seeking accreditation show evidence of interdisciplinary delivery of care. We have taught pharmacy students for the past 30 years that they should seek to become members of interdisciplinary health care teams, and we have been fairly successful, I think, in designing clerkship and residency experiences that emphasize that model. Yet, beyond the models created for the purpose of education and training, I wonder how firmly established interdisciplinary pharmacy practice has become. I would like to try to interest you in thinking with me about the following questions: In the context of health care delivery, what do we mean by a discipline? What do we mean by interdisciplinary patient care? Is there some intrinsic value in interdisciplinary patient care? If so, should one conclude that the more disciplines involved, the better the outcome will be? If not, which disciplines do we need? As new health care disciplines are created, do they MAX D. RAY, PHARM.D., M.S., is Professor of Pharmacy Practice and Director of the Center for Pharmacy Practice Research and Development, Western University of Health Sciences, Pomona, CA Presented on September 29, 1997, in connection with Dr. Ray s designation as the 13th John W. Webb Visiting Professor in Hospital Pharmacy by the Bouvé College of Pharmacy and Health Sciences, Northeastern University, Boston, MA. Copyright 1998, American Society of Health-System Pharmacists, Inc. All rights reserved /98/ $ Vol 55 Jul Am J Health-Syst Pharm 1369

2 Special Feature Interdisciplinary patient care The John W. Webb Visiting Professorship in Hospital Pharmacy was established in 1985 at the College of Pharmacy and Allied Health Professions at Northeastern University, Boston, Massachusetts. Webb was Director of Pharmacy at Massachusetts General Hospital from 1959 until his retirement in After receiving Bachelor of Science and Master of Science degrees from the Massachusetts College of Pharmacy in 1949 and 1951, respectively, Webb was Director of Pharmacy at Hartford Hospital and worked at the University of Connecticut before returning to Massachusetts General Hospital in 1956 to become Assistant Director. Webb also served as director of the graduate program in hospital pharmacy at Northeastern from its inception in 1964 until his retirement, and he is the author of numerous contributions to the pharmaceutical literature. A hospital pharmacy practitioner is appointed to the visiting professorship each year in recognition of his or her commitment to hospital practice, experience as a practitioner and educator, and dedication to publishing management-related articles. The visiting professor presents a lecture on excellence in management to students in the graduate program. automatically qualify for inclusion under the heading of interdisciplinary patient care? What do we mean by a health care team? What are the qualifications for an effective health care team? What effect will the current trend of increased reliance on primary care providers have on the demand for interdisciplinary teams? Terminology What is a discipline? According to one common definition, a discipline is a branch of knowledge or learning, usually involving research. In actual usage, the term seems to have been appropriated by different groups in subtly different ways. Discipline is used to describe a scientific field, such as physics or biology, or a branch of the humanities, such as literature or philosophy; within these general fields we hear reference to specialized disciplines, such as particle physics, molecular biology, the writing of the American short story, and existentialism. And within each specialized discipline we hear of subspecialized disciplines. In health care circles, we seem to treat the term discipline as if it were interchangeable with profession (e.g., the discipline of medicine, the discipline of nursing, the discipline of pharmacy). In other instances, discipline is used to refer to a specialty or subspecialty level of practice within one particular profession. It is probably helpful to acknowledge that there is a distinction between the practice of a profession and the discipline (i.e., the knowledge and learning) on which that practice is based. But in doing so, we run into difficulty with some commonly used expressions such as interdisciplinary practice, interdisciplinary team, and interdisciplinary health care delivery. It seems to me that in each case the term interprofessional is more appropriate, but interdisciplinary seems to be so well entrenched that it is unlikely we will retreat from its use. It is fairly easy to reconcile this usage by presuming the knowledge and learning on which each profession participating in interdisciplinary activities is based. There is still an important question related to the concept of interdisciplinary practice: Do all members of a particular profession automatically qualify for inclusion in the discipline? What level of knowledge and learning is required (or presumed) of someone representing the discipline of pharmacy (or medicine or nursing) on an interdisciplinary practice team? Will one generic pharmacist do? Will one generic physician or nurse fit the bill? Is pharmacy, per se, a discipline? When we refer to the practice of pharmacy in an interdisciplinary setting, what do we mean? This begs the question, What is pharmacy practice? What are the qualifications that must be met for a practice? I raised this point in my Whitney lecture earlier this year. Do we intend to include all pharmacists within the purview of pharmacy practice or the discipline of pharmacy? (If so, the common denominator must be quite low, in my observation.) Or, do we intend to say that the discipline of pharmacy or the practice of pharmacy is reflected by what a majority of pharmacists do? Is it more helpful to think of the discipline of pharmacy as a field with differentiated parts, as described in the Millis Commission report 1? In that case, no single pharmacist would represent the discipline. It seems important that we agree on what we mean by the discipline of pharmacy if we are to have a serious inquiry into the interdisciplinary contributions of pharmacy practice. Let me belabor the issue of terminology just a little further. What do we mean by interdisciplinary? How is it different from multidisciplinary? One source distinguishes among unidisciplinary, multidisciplinary, interdisciplinary, and transdisciplinary approaches to patient care. 2 I think it might be helpful to include the term intradisciplinary here for the sake of completeness, although I have not seen the term in print. Unidisciplinary practice involves functioning in isolation from members of other disciplines. Intradisciplinary practice involves the contributions of different specialists within one discipline (such as physician consultations). Multidisciplinary practice refers to a clinical group whose members each practice with an awareness and toleration of other disciplines. Interdisciplinary practice is an integrated approach in which members of a clinical team actively coordinate care and services across disciplines. Transdisciplinary practice involves team members from different disciplines who share knowledge and skills; as a result, the traditional boundaries between professions become less rigid, allowing members of the team to work on problems not typically 1370 Am J Health-Syst Pharm Vol 55 Jul

3 Interdisciplinary patient care Special Feature encountered by or seen as the responsibility of their discipline. Finally, as previously mentioned, we hear the term interprofessional used more or less interchangeably with interdisciplinary. The interdisciplinary health care team Who are the players on an interdisciplinary health care team? A generic physician, a generic nurse, a generic pharmacist, and so on? Or, are there special stipulations in each case? I have concluded that an interdisciplinary team must be defined in terms of a specific patient care context. The requisite qualifications of the team members (i.e., of each discipline) depend on the situation. For example, the members of a surgical intensive care unit team, a diabetes clinic team, an inpatient psychiatric unit team, and an infant special care team would all be required to have different qualifications. I know of no teams in health care delivery whose members do not have other, non-team-related duties. Teams usually come together for some specific purpose, fulfill that purpose (one hopes), and then disband for the moment. Health care professionals, in fact, probably spend far more of their time engaged in unidisciplinary and multidisciplinary functions than in true interdisciplinary functions. Some common assumptions about interdisciplinary practice There is a considerable body of literature that asserts the value of interdisciplinary practice in health care. Certain assumptions seem to underlie the thinking of the proponents: Decisions are made by consensus; each discipline has an equal voice in (equal opportunity for input into) decisions; and unless each discipline (from among those who are expected to be involved) participates in a decision, that decision is potentially invalid. This set of assumptions seems to fit with the generally accepted characteristics of a health care team. Others make different assumptions: Most treatment decisions are made by one individual (usually a physician), with solicited or unsolicited input from other disciplines; decision-making authority of each discipline is defined in advance (e.g., through credentialing processes or organizational policies); and decisions do not require consensus the ultimate decision-maker (again, usually a physician) may freely override advice or recommendations from others (notwithstanding the legal implications). This set of assumptions seems to fit with the characteristics of a multidisciplinary team. Some basic questions about the premise of interdisciplinary practice Before proceeding, let me raise some questions that are intended to hold our feet to the fire in our thinking about interdisciplinary practice: 1. Is the term discipline overused in health care? 2. Is it realistic to think that major health care treatment decisions can be made by a group? Does the concept of interdisciplinary practice illustrate the old saying that when everyone s in charge, no one s in charge? 3. Do we really know the prevailing attitude of medicine toward interdisciplinary practice? Do physicians, in supporting the concept, mean that they view other disciplines as equals, or do they mean that they welcome input from other disciplines to help them make decisions? 4. Is the current interest in interdisciplinary practice driven by a need to determine the ideal skill mix for patient care, or is it more of an effort to make room for each of the existing professional groups? 5. Are there any educational models in health care that are constructed to teach the concept of interdisciplinary practice not just having students take courses in the same classroom, but teaching them how to work together as a team? Getting from multidisciplinary to interdisciplinary A considerable amount of health care delivery today probably most is provided through unidisciplinary, intradisciplinary, and multidisciplinary models. Although more than one profession may be involved in meeting the needs of a given patient in a unidisciplinary model, there is no coordination or communication among those professions; they operate strictly in silos. Physicians may refer patients to other disciplines, but there is no plan for coordinating the care provided by the physician and the other professional. In an intradisciplinary model, a primary care physician either makes a decision based on input from another physician or refers a patient to another physician no other professions are involved. In a multidisciplinary model, the various professions operate in their individual silos, but there is some communication between them. Either the silos are noncontiguous or, if they touch each other, they do so at only one point. To make the transition from multidisciplinary to interdisciplinary practice requires that the various disciplines have some basis for understanding each other. This requires a different visual image. Instead of freestanding silos or tangential circles, I imagine two boxes (or polyhedrons with an indeterminate number of faces) with one face in common. This is a shared border between the two boxes. Each of the two boxes in turn has other faces that are shared with other boxes. These boxes with shared borders represent an interdisciplinary practice model. It has been said that the boundaries between the health professions are becoming blurred. The blurred borders may be thought of as the shared borders between two professions. In this indistinct area, both professions have a common knowledge base, a common professional interest, and a shared instinct. To use Vol 55 Jul Am J Health-Syst Pharm 1371

4 Special Feature Interdisciplinary patient care yet another metaphor, this is the area in which synapse between the two professions occurs. It may seem somewhat paradoxical to say, on the one hand, that knowledge domains have to be continually subdivided in order for practitioners to keep up and, on the other, that the boundaries between the professions are becoming blurred. How can we have overlapping areas of knowledge with other professions while the knowledge in our individual disciplines (professional fields) is exploding? I believe the answer lies in modern information technology, which makes information on virtually any subject area available to any of us on demand. Reasons for adopting interdisciplinary patient care Reason 1. Complex human needs such as health care often exceed the capacity (both actual and potential) of any individual. Meeting these needs usually requires the combined knowledge and skills of individuals from two or more domains or disciplines. Disciplines may have some degree of overlap at a specialized level but no substantial overlap at the generalist level. For example, a physician and a pharmacist may be equally knowledgeable in certain areas of pharmacotherapy, but neither would have a very broad knowledge about the other s overall discipline or domain. One discipline can become specialized and subspecialized, but it may never broaden itself sufficiently to embrace another domain. (Or, if it does, a long time is required.) Thus, no single health care discipline, regardless of its number of specialized divisions, can be self-sufficient. Reason 2. We need a structure for coordinating the efforts of independent disciplines. To the extent that the various disciplines operate in silos, there is no effective means of coordinating their efforts, and the single efforts of each discipline may fail. Interdisciplinary practice includes the notion that the contributions of the various disciplines will be coordinated. However, there must be a structured plan for coordinating the services provided by the various disciplines; they won t simply fall in place by accident. Reason 3. It seems likely that a true interdisciplinary practice model will lead to an increased level of trust among the various professions and to a deeper level of understanding about what the members of each profession can contribute. In the process, physicians may begin to become more comfortable with the notion that pharmacists could manage patients drug therapy (to use one example). This would free physicians from having to spend so much time trying to keep abreast of new drugs, drug-use guidelines, the subtleties of therapeutic niches for various drugs, and so on. Reason 4. In addition to the pooling of knowledge and skills on behalf of the patient, the involvement of various disciplines will also likely result in a sharing of attitudes and values. Barriers to interdisciplinary practice Health care sociologists tell us that interdisciplinary team practice is not the norm and not even a common form of practice. According to a report issued by the University of Colorado Health Sciences Center in 1996, major barriers to an interdisciplinary approach include historical factors such as different philosophies of practice and professional training, logistics of team implementation, and resource limitations. 2 The report also points out that the dominant cultural values in the United States tend to place greater importance on individual achievement than on cooperative group work and makes several points about barriers to interdisciplinary patient care: 1. The training of physicians (and dentists) emphasizes that they are in charge. They make independent decisions and take action. Patients expect their physicians to be decisive and may be more comfortable with a unidisciplinary delivery model than with an interdisciplinary model. 2. Traditional models of care are based on organ systems and on specialized knowledge and specialty practitioners. These models may not accommodate disciplines that are more oriented toward the total patient. 3. Frequently there are differences in expectations among the various disciplines regarding the goals and objectives of treatment. 4. Educational programs for the health professions do not teach interdisciplinary teamwork. 5. Interdisciplinary health care delivery is more costly than unidisciplinary care. 6. The requirements for effective teamwork are not generally understood. Recommendations regarding interdisciplinary practice I have a number of recommendations regarding interdisciplinary patient care. Some pertain specifically to pharmacy, and others are more general. Recommendations to pharmacy. We must be competent. We must set standards for our competence and be willing to be held accountable for meeting those standards. Competency standards should give appropriate reflection to knowledge, skills, attitudes, and values. We must keep centered on real needs. We should continually think about the unmet or undermet needs in patient care that pharmacists are qualified to fulfill. We must really understand what a team is. Being part of a team requires sublimating ego, operating with a broader good in mind, knowing when to lead and when to follow, and giving others credit for their knowledge. We must understand the medication-use process from the standpoint of sources of drug-related problems and from the standpoint of total quality management. We must be completely oriented to the safe, appropriate, and cost-effective use of drugs, recognizing that drugs may not always be the answer to a patient s needs Am J Health-Syst Pharm Vol 55 Jul

5 Interdisciplinary patient care Special Feature We must provide leadership without always being overt about it. The concept of a servant leader, which Robert Greenleaf 3 has described, comes to mind. We must be prepared to help in developing drug therapy outcome objectives, in cooperation with the patient and with other members of the health care team. We must project self-confidence. In my opinion, this requires more rigorous training than is typically achieved in Pharm.D. clerkships. A minimum of one year s postgraduate training as preparation for an interdisciplinary patient care role should be considered. I don t care how many arguments may be thrown up about extending the time required for training pharmacists (e.g., the added cost, the lack of residency training sites). The fact of the matter is that pharmacists are not ready to hold their own with well-trained clinicians (such as physicians) right out of school. Even if the pharmacist s knowledge base is adequate (a doubtful assumption), his or her self-confidence won t be any match for the physician s. We can t have it both ways in pharmacy: We can t produce turnkey practitioners right out of school and be viewed as major players in the clinical setting. We must demonstrate through our actions that we are ready for interdisciplinary practice. That means we must provide a consistent level of service. We must be there when needed. We must have cross-covers when necessary. We must be up to speed on the patient. We must be prepared to contribute. We must be able to use patient information and add useful information of our own. We must have a recognizable practice methodology. General recommendations. Each health care delivery organization should have a public board of directors that includes current and former patients. The board should help the professions resolve any ego problems they may have in working together. It should help all the professions understand what patients want out of the system. The board should help the system move from a disease care system to a health care system. We must all be aware that not every discipline needs to be involved in every patient s care. There seem to be a lot of turf arguments about this. In a market-driven economy, only those disciplines that are needed in a given situation will be tolerated. The will to make an interdisciplinary team work must be shared by all the disciplines involved. Pharmacy cannot make it happen alone. Neither can nursing, medicine, or any other single group. We mustn t make too big a deal of interdisciplinary care. We must apply it in a cost-effective way. The concept seems on the surface to be quite expensive. Benefits outweigh costs as a result (it would seem) of overall improvements in outcomes and cost avoidance. (Improved health care outcomes prevent subsequent morbidity and mortality and their associated costs.) We must know what qualifications are required for an effectively functioning team. Petrick and Quinn, 4 in Management Ethics, provide a useful discussion of teamwork in which they distinguish among pseudoteams, potential teams, real teams, and high-performance teams. They define a real team as a small number of people with complementary skills who are equally committed to a common purpose, goals, and working approach for which they hold themselves mutually accountable. Their definition of a high-performance team is a team that meets all the requirements of a real team and whose members are also deeply committed to one another s personal growth and success. Joseph Jaworski, 5 in Synchronicity: The Inner Path of Leadership, described a state that some teams are able to achieve when members work in close harmony, which he (and Carl Jung before him) referred to as synchronicity. String quartets and athletic teams frequently achieve this state. One might hope for such a level of harmony among the members of health care teams. We must know how to come together quickly as a team and then disband as soon as our purpose has been achieved. Team members must agree on the role or roles of each other member and respect those roles. In most instances, the members of a potential interdisciplinary team need some team-building training. However, from my own experience, some of the training programs in this area are very superficial. Teams need to operate with a team culture that is sufficient to withstand the loss of team members and the assimilation of new members. We need to teach interdisciplinary patient care in our professional schools and postgraduate training programs. This cannot be accomplished simply by putting students from different professional schools together in the same classroom. The students have to learn from each other to understand what each other s role is and how they can collaborate on behalf of the patient. Most medical students probably still do not get any formal training in this concept. It probably doesn t have to be obvious to patients that we do function as a team, but it will be obvious to patients if we don t. We need a long-range plan in health care that takes into account the impact of shared borders on the traditional professions. What will be the impact of the information explosion? The half-life of scientific knowledge is continually being shortened. All sciencebased professions will have to develop coping mechanisms to keep up. How much thinking and decision-making will be done by machines in the future? If the dispensing and information roles of pharmacy are filled by technology, will there continue to be a need for pharmacy? We must keep in mind that acquiring knowledge requires a higher mental capacity than providing information and that wisdom is superior to knowledge. Can we make a go of it at the knowledge and wisdom levels? Shouldn t all the pro- Vol 55 Jul Am J Health-Syst Pharm 1373

6 Special Feature Interdisciplinary patient care fessions concentrate at these levels? What will it take to get us there? Summary I return now to my opening questions, with the hope that we have explored them in sufficient detail to provide meaningful answers. Perhaps it is useful to think of a health care discipline as an area of knowledge and research that is critical to patient care, recognizing that each patient care situation is potentially different from all others. I hope you will agree with me that true interdisciplinary health care delivery requires more than simply the side-by-side collaboration of various groups of professionals, and more than the interdigitation of those professionals; it requires common values, a common vision, and an intuitive understanding of teamwork. It seems reasonable to say that interdisciplinary practice, per se, has no intrinsic value; its value lies in the results it produces. The division and organization of knowledge under the labels of disciplines is highly arbitrary; the fact that a new health-related discipline comes to be recognized in certain professional circles does not automatically mean the new discipline has to be incorporated into interdisciplinary practice. A health care team is a very valuable organizational structure, but it usually exists for an ad hoc purpose. To be effective, a team must be composed of individuals who are competent, who are willing to be held accountable by each other, who are each committed to the same goal (outcome objective), who value and respect each other, and who readily defer to each other as the need arises. There are probably very few effective teams. One might expect that increased reliance on primary care physicians and midlevel practitioners will lead to an increased need for and reliance on interdisciplinary practice. This remains to be seen. The basis for interdisciplinary practice is the fact that the traditional boundaries between professions, which have been established in large measure by the unique body of knowledge mastered by those in each profession, are becoming less rigid. Scientific and technical information flows between and among the various health care professions today at an unprecedented rate. In the process, we have begun sharing borders with each other. My thinking about this subject has led me to one principal conclusion: Those professions that view the provision of information as their principal role will probably not survive indefinitely. Those, however, who learn to use information to acquire knowledge, and who are eventually able to apply that knowledge with wisdom, will be in great demand. The ultimate goal of interdisciplinary patient care, then, is to serve the patient with wisdom. And I leave it to each of you to decide if our profession has yet distinguished itself in that area. References 1. Pharmacists for the future: the report of the Study Commission on Pharmacy. Ann Arbor, MI: Health Administration Press; Professional perspectives for health care practitioners: interdisciplinary program (fall 1996). Supplemental material. Denver: University of Colorado Health Sciences Center; Greenleaf RK. Servant leadership. New York: Paulist Press; Petrick JA, Quinn JF. Management ethics. Thousand Oaks, CA: Sage; Jaworski J. Synchronicity: the inner path of leadership. San Francisco: Berrett-Koehler; Am J Health-Syst Pharm Vol 55 Jul