1. The sheer quantity of medical knowledge has grown to the point where no single person can keep up with it all. As a result, problem-solving and collaboration are becoming increasingly important competencies in medical professionals
The advances of medical science are far too expansive for any professional to master through rote learning alone, and this information is only increasing. Dr. Karl Koenig, director of the Integrated Practice Unit for Musculoskeletal Care at Dell Medical School in Austin, said that, at one point, everything that was known about orthopedic medicine was contained in a single textbook. Now, just a few generations later, the knowledge has expanded exponentially, and as such, the traditional idea that “the buck stops with the doctor” is simply untenable. Dr. Koenig instead considers himself to be the leader of a team, with many professionals each working to play the role that they know best. The ability to coordinate with other professionals, as a means of delivering care that is more comprehensive than one provider can manage alone, is an increasingly important capability for medical professionals.
Several different experts with whom we spoke similarly emphasized that no professional can keep up with the pace of new information. Virtually all of them, however, also emphasized that, thanks to technology, it has never been so easy to access such vast resources of medical knowledge in so little time. Because we have so many tools to help us “outsource” medical information, medical professionals’ expertise is best used not for memorization-based learning, but rather for the things that technology cannot do – critical thinking, careful decision-making, and effective communication with patients and collaborators throughout the care process.
2. Team-based care and learning require effective collaboration between doctors and a variety of professionals who are not physicians
There are additional reasons, beyond the sheer quantity of medical knowledge, that people are reconsidering the “one doctor-one patient” paradigm of care. Simply put, we heard extensive discussion that many of the most important aspects of care are best delivered by a professional other than a physician. Sometimes this is because of time constraints – we heard numerous references to the limited time a doctor has with each patient – but much of it actually stems from the fact that many patient needs are best addressed by a professional other than a doctor. For example, many behavioral specialists may be better suited to address matters of motivation and long-term adherence to lifestyle interventions. Occupational therapists and social workers can understand various aspects of everyday life that a physician may be less likely to recognize or address. Pharmacists can help patients navigate the details of medication regimens. Peer and community health-worker-based care has been increasingly embraced as an effective way to deliver culturally attentive health care. And the list goes on. The more that physicians work closely with a team of other health professionals – and the more that these various professions can both learn and collaborate together – the more comprehensive and continuous the patient care experience will be.
3. Cost effective team-based care involves multiple professionals all working at the “top of license”
Many experts noted that the relative lack of inter-professional collaboration is also the source of great inefficiency in an overburdened healthcare system. Countless professionals are not working at their highest level of expertise, and in many cases, they are trying to play roles that would better fit the expertise of another. For example, a physician, lacking a collaborator, might be tasked with trying to motivate and counsel a patient as part of an intensive lifestyle intervention, even though a behavior specialist might be a better, more appropriate provider of that intervention. The detriment, in a case like this, is threefold: 1) the physician is expected to spend time working in an area where they may not have the ideal expertise, 2) the behavioral specialist is not connected to the very patient who needs that support and expert attention, and 3) the patient receives suboptimal care both because they do not receive expert behavioral support and their physician’s time is divided. In an optimal health system, each professional would be working from the top of their expertise, and all of the collaborating professionals have an effective system of communication so that no aspect of the patient’s experience gets lost among them.
4. Many of the “silos” discussed in medicine are reflected in literal separations in the locations of different providers. Co-location, as a result, benefits collaboration
Quite often, the “silos” in the health field – so often talked about in metaphor – are also quite literal. As one expert put it, “Space is a highly coveted resource,” and the result is that the very professionals who should be working together end up divided into separate locations and practices. For example, Dr. Chantelle Rice, an Occupational Therapist (OT) at USC, described the challenges of building relationships with primary care physicians when the USC OT practice is in an entirely separate building from the clinics where physicians practice. Encouraging referrals from primary care to OT is hard enough thanks to the separation, and even when patients are referred, the need to schedule and attend an entirely separate visit adds an extra barrier. As a result, many of the patients who would benefit most from an OT-supported lifestyle intervention are lost to follow-up, or never encouraged to meet with a well-matched specialist in the first place. Health centers that house primary care physicians, behavioral specialists, and other varying specialists – all under the same roof – can better facilitate coordination of care.
5. Co-location and collaboration are not the same thing. Technology can be a powerful tool to bridge the gap, especially when co-location isn’t an option
Even if professionals are working in the same space, or students are learning in the same space, they may not necessarily be collaborating with and learning from one another. Collaboration takes active engagement and communication, as well as shared decision-making. While patients may theoretically benefit by having more than one provider present in the same space, true team-based care means that multiple providers need to be actively applying their own expertise and working with other providers to achieve the best overall result for the patient’s needs.
Conversely, professionals don’t need to be in the same physical space to collaborate. Especially with the help of effective and affordable digital technology, inter-professional collaboration can increasingly be accomplished by collaborators who may even be thousands of miles apart.
6. Rewards, regulations, and assessments shape the way medical professionals perform their roles. Addressing these top-down factors is crucial to changing delivery models at scale
We were repeatedly reminded, by a wide variety of experts, that the healthcare system in the United States mainly offers incentives for services and actions, rather than overall results. This distinction is often referred to “fee-for-service” care, as opposed to “value-based” care. While different experts spoke to varied aspects of what constitutes “value” in care, they consistently emphasized that most health professionals, especially physicians, are given incentives not to provide overall “ownership” of a patient’s health, but rather to complete a particular service as efficiently as possible, often with little emphasis on the overall picture. The message that was made clear to us was this: to expect wide-scale changes in the way that care is delivered, there is dire need to provide top-down changes in incentives and reimbursement. In addition to moving to a healthcare system that values better health outcomes, as opposed to volume of services, future health care reimbursement should also account for the acuity and complexity of patients and populations, as to not discourage physicians from taking on highly complex or vulnerable cases. In the absence of such top-down, systemic change, healthcare providers who wish to provide comprehensive care may often do so at significant extra burdens.
7. Discontinuous care often means that no single health professional takes “ownership” of a patient’s health as a whole
Dr. Erin Kane, an emergency physician on faculty at Johns Hopkins, described to us what this endless cycle means in reality. A patient will go to see their primary care provide (PCP) for a particular reason, the PCP will refer the patient to a specialist or to the emergency room depending on the issue, and then the specialist or emergency room admitting team will discharge the patient to follow up with the PCP with regards to the exact challenge that led the patient to seek care in the first place. Dr. Kane gave this example to illustrate that each stakeholder in this cycle simply acts by filling their particular role in the health system, often with the goal of discharging or referring the patient as quickly and efficiently as possible. All too often, what this means is that no provider ever actually takes “ownership,” to borrow Dr. Kane’s word, over the patient’s health overall. There is no case manager, no one person accountable to make sure that patient receives the best care as a complete unit, meaning that the patient instead experiences a disjointed collection of care fragments.
Ownership certainly does not mean that any one health professional, or even any one practice, needs to be responsible for delivering all the care for a patient. Rather, it means that a patient needs someone to be accountable for ensuring that the various providers that a patient might see combine to meet the patient’s needs, rather than just checking their individual boxes and then passing the patient off. This idea of ownership is an individual-level display of the concept of value in care, ensuring that the ultimate outcome is not a series of services, but rather a complete and effective package for support for the patient.
Patient-centered care means that patients themselves should be equal participants in decisions made about their healthcare. Many experts shared the sentiment that there are two experts in every health interaction. One is the provider(s) who is an expert in the medical aspects of the disease and can communicate about risks, symptoms, and treatment options. The other, however, is the patient, who is the expert in their experience with the disease, and along with that their priorities, goals, and capabilities. Effective care is that in which the treatment options offered by providers align with, and are decided in conversation with, the patients and their priorities. Often, it may take many members of a care team to understand and support a patient’s priorities, and the physician may not always be the best suited to lead this conversation based on expertise and time limitations.
8. There is increasing emphasis on the importance of understanding how the daily life of a patient impacts their health and healthcare
A crucial underlying reason for shared decision-making described above centers around the seemingly straightforward concept that a treatment plan can only be effective if a patient can actually integrate that plan in their life. A medication or other therapy or intervention may be effective in principle, but the impact it may have demonstrated in clinical trials and other patients will not be seen if a patient is unable to adhere to the regimen. While a host of factors can impact medical adherence, the experts emphasized the need to understand how the everyday aspects of a patient’s life affect the ease or difficulty of a given therapy. For example, work schedules may conflict with a medication regimen or a recommendation for physical activity, or transportation issues may be a barrier that causes a patient not to follow through on a follow-up with a behavioral specialist, etc. For health professionals, the more able they are to understand the obstacles in individual patients’ everyday lives, the more likely they will be to provide treatment options that patients can actually sustain.
9. Patients have knowledge, understanding, and power. Patients should be a part of the medical education process from day one
Many medical educators expressed to us their desire to see medical students and other health professionals-in-training learn about the aspects of a patient’s experience with health and illness outside of the healthcare setting. For example, what is it like for a person with diabetes to go to work, or to shop for food? What is it like for a person to store and take medication in their home, or exercise on a regular basis? Many of the educators who raised this subject with us emphasized that the training of health professionals should involve, from the very beginning, engaging patients from the community as “teachers” about the many facets of the patient experience. Some specialties, such as occupational therapy, are more accustomed to focusing on these everyday aspects of life, but many people with whom we spoke emphasized that health professionals would benefit from increased training on how to better focus on these daily life factors.
10. Medical education is increasingly emphasizing the social determinants of health, but much more needs to be done
In addition to the individual factors of daily life that shape a patient’s experience, we also heard repeatedly about the need for increased emphasis on the social determinants of health – community and society-level factors that influence health outcomes. Consideration of social determinants is not new to health; it has long been a central focus of public health, for example, and it is certainly not a new concept among medical professionals either. However, our interviews were filled with repeated calls for the healthcare professionals to be involved in increased learning about the social factors that drive health outcomes.
We heard from experts such as Deans Sue Cox and Clay Johnston of Dell Medical School, who spoke about encouraging medical students to get involved in the local community to build a fuller understanding of how community factors influence outcomes. Dr. Sarah Kim, an endocrinologist at UCSF, said she hoped medical students could learn about diabetes from experts on poverty and socioeconomic inequality as a way of understanding a critical factor underlying the burden of chronic disease. Others expressed their own variations, but the theme remained the same: medical professionals will benefit if they can understand the social and economic factors that drive health, disease, and the ways that illness is experienced.
11. Learning in medicine is lifelong, and professionals will benefit from structures that support this
Dr. Bon Ku of the Sidney Kimmel Medical College at Jefferson University offered us an analogy: elite professional athletes, even when at the very top of their sport, receive feedback and coaching virtually every day. There is constant opportunity for continued learning and improvement, and constant need for someone with a different perspective to comment on one’s strengths, weaknesses, and opportunities to improve. Why then, Dr. Ku asked, do we assess physicians with a multiple-choice exam (the Boards) once every ten years or so, and almost never in between? Here Dr. Ku highlighted that feedback is rare among experienced medical professions. Yet feedback – from peers, patients, and supervisors – is a valuable way for any professional to continuously learn and improve in an ever-adapting clinical setting. Many experts shared with us the importance of introducing regular, effective feedback into health professions from the very beginning, and reiterated that this should be a career-long piece of the profession.
Beyond just receiving feedback, health professionals need the chance to continue learning throughout their careers. In some ways, this already exists in the form of continuing medical education (CME), or a comparable equivalent. However, several people to whom we spoke noted that CME is both incomplete and underemphasized in the health professional’s role. Dr. Kunal Patel, who works on digital learning platforms for medical professionals, suggested that health professionals should have, on average, 2-4 hours per week of “protected learning time,” such that development of both clinical skills and medical knowledge becomes a constant, emphasized aspect of health careers. In addition, several experts emphasized to us that standard CME, much of which is conference-based, fails to address many of the most valuable aspects of medical careers, such as inter-professional collaboration and communication with patients. To truly build the healthcare workforce of the future, we not only need to be training health professionals with a variety of important competencies as they enter their careers, but also deliberately making frequent, ongoing learning an important part of their role throughout their careers.