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For Top ACO or Team Care, Check Physician Egos at the Door

 |  By jcantlupe@healthleadersmedia.com  
   March 24, 2011

If accountable care organizations are the next big thing in healthcare, their cousin has been around longer, and probably has more staying power: Multidiscipline approaches of care. But those approaches may only be successful if physicians can leave their egos behind.

Klaus Thaler, MD, a minimally invasive surgery specialist for Hudson Valley Hospital Center in Cortlandt Manor, NY, is a prime advocate of multidisciplinary care at his hospital.  He also serves as a team "captain" to help other physicians work together under the framework of multidisciplinary care.

Thaler, who has been at Hudson Valley for about a year and a half, is excited about the growing focus on multiple disciplinary teams; whether it's bringing "multidisciplinary surgical and non-surgical disciplines" together, as he puts it, or radiation therapists working with other specialists to improve patient outcomes.

Thaler's specialties are in digestive and minimally invasive surgery, and he joined Hudson Valley Hospital Center in July 2010 to create a "center of excellence" in those specialties. Previously, he served at the University of Missouri as director of gastro-intestinal surgery and co-chair of the robotic surgery programs.  He is working in an emerging field of natural orifice surgery, aimed at reducing scarring and pain, and speeding recovery.

In a recent conversation, Thaler discussed the multidisciplinary approaches positively, and smoothly. And then I asked him about the process of putting teams of physicians together. Despite all the talk about hospitals moving in the direction of multidisciplinary teams, in reality, the process is extremely difficult, Thaler says.

 "It's a cultural change, it's a huge change," Thayer says, especially for the physicians. "It is a cultural change to accept the notion that you as a physician are not in the center of the care process. It's the patient and everything is being done that is necessary to optimize the patient's well-being."

So, multidisciplinary techniques are definitely part of the framework of care, but ego is part of the potential for disarray.

The physician conflicts that underlie the potential good of multidisciplinary approaches were addressed in a 2009 book by Atul Gawande, "The Checklist Manifesto – How to Get Things Right." Gawande is a physician and writer for The New Yorker.

"We in medicine continue to exist in a system created in the Master Builder era -- a system in which a Lone Master Physician with a prescription pad, an operating room, and a few people to follow his lead, plans and executes the entirety of care for a patient from diagnosis through treatment," Gawande writes.

"We've been slow to adapt to the reality that, for example, a third of patients have at least 10 specialist physicians actively involved in their care by their last year of life and probably a score more persons, ranging from nurse practioners and physician assistants to pharmacists and home medical aids, " Gawande adds. "And the evidence of how slow we've been to adapt is the extraordinarily high rate of which care for patients is duplicated or flawed or completely uncoordinated."

Obviously, there are no guarantees in the multidisciplinary approaches, and even the tiniest slips may occur, and could portend disaster. A few months ago, as I lay in bed waiting for an appendectomy, I saw a team of physicians approach patients to discuss what was anticipated during surgery. I could see and hear the team moving from one patient to another as they got closer to me.

Ah, I thought, multidisciplinary care at its best. The thought changed quickly. As the physicians reached the bed of a patient separated by a screen from mine, I heard the team of physicians explain what was expected, as they described the condition and details about the patient's condition and needs.

The only problem was they were talking about my condition, not the other patient's.

Oops, the physicians acknowledged: they realized they were speaking about my condition to the other patient. There were apologies all around.

The process is not without flaws, but as Thaler points out, the multidisciplinary approaches are the best way to improve patient care and minimize malfunctions. A physician trained in Austria, Thaler says he began embracing the multidisciplinary concept in the 1990s. A proper compensation plan to enhance the multidisciplinary work of physicians is essential, he says, and a physician's ego can be translated into something positive, delivering the "fortitude that makes it work"

Aside from the compensation, "it is most important to have a 'physician champion' who shares the vision and mission to do that," Thaler says. Such a leader is "an important factor to organize groups of physicians to develop their care plans, he says.

A physician champion is so important he or she should be specifically appointed within a hospital structure, according to Thaler. "If you don't have a clear appointment in such a position (that person) will most likely not be fully accepted," he says. The physician champion "should have the experience and knowledge and background that other physicians accept and look up to, and accept that person as an expert in the field," Thaler adds.

I thought of Thaler's comments about the need for proper protocols in establishing a physician team as I pondered the checklist phenomenon.

Perhaps the checklist idea should be expanded – something like a Physician Champion Checklist – to not only analyze clinical procedures, but to evaluate the attitudes of a physician team – so potential ego problems, for instance, can be checked at the door.

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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