What stands in the way?

Yesterday I wrote about the benefits of a multidisciplinary team approach to care.  Given that this approach results in better medical decisions, and in treating patients more like human beings, why doesn’t everyone do it?  At our roundtable meeting, we discussed a variety of barriers to establishing this approach everywhere, and felt, generally, that they fall into three categories:  systems issues, provider issues, and patient issues.

Systems issues:  Most institutions and businesses develop practices that are remarkably resistant to change.  At some point, good people with best intentions hold on to ways of doing things simply because that is what they always have done.  Creating a treatment approach that is truly patient focused requires a change in organizational culture, and this isn’t easy.  Everyone in the organization, from the leadership to the line staff, must commit to the importance of this new approach.  This takes vision, commitment, and work.  More pragmatically, someone must answer this question:  who pays for it?  If a treatment team sits together in a room to discuss patients one at a time, who covers those costs?  You can’t bill insurance for this.  You can’t charge the patient.  Ironically, if the team gets together they can make better (and more efficient) decisions about care.  Ultimately this approach should cost less and result in better outcomes.  But if you can’t pay for it, it won’t happen. And, even if you can change the culture and find a way to pay, for some people getting a team together is a major challenge.  If you live in a rural community two hours away from the nearest town, finding a treatment team won’t be easy.  For many patients, the only oncologist and only surgeon to whom they have access are essentially generalists.  For them, meeting with the “team” may simply mean sitting down and having a good talk with themselves.

Provider issues:  Doctors may not embrace a multidisciplinary team approach simply because it takes them out of their comfort zone.  This is natural; we are all more comfortable with what is familiar to us.  Physicians trained in one specialty sees patients through the lens of their training.  A surgeon is more comfortable with cutting.  An oncologist is more comfortable with chemotherapy.   Collaboration is one thing—the doctor has the opportunity to share his or her expertise with others.  Sitting down at a table with physicians from other disciplines—not to mention with nurses, social workers, and others—to debate treatment approaches is much more threatening.  Providers need a compelling reason to move outside this comfort zone, and so far we have not done a good job of “selling” how significant a shift to a multidisciplinary approach can be.

Patient issues:  Some patients embrace the adage that “the doctor knows best” and go through treatment passively.  This approach provides some comfort and is relatively easy.  Simply do what you are told and hope for the best.  Sadly, this is something akin to flipping a coin to decide if you will get better or get sicker.  Other patients become almost manic in their pursuit of understanding (and, I suspect, of control over their lives).  If you type the words “colorectal cancer” into the search bar of Google, you get over 11 million hits.  I think some patients have read them all, just trying to get a handle on the disease.  This later is the kind of patient who is much more likely to demand a multidisciplinary team approach.  If they have to change the system and push doctors out of their comfort zone, then so be it.  These patients will, by all that is good and right, fight tooth and nail until their treatment team is working together to develop the best options.  As in most things, the key is balance.  Enough orneriness to demand the best care, but enough trust to commit to that care and follow it through.  Until more patients abandon the role of passive victim and embrace some self-advocacy, we will not likely see significant change in approaches to care.

So how do we fix this?  Stay tuned….