EDITORIAL

Teamwork in family medicine: another myth to expose?

John Yaphe*

*Associate Professor, Community Health, University of Minho

Endereço para correspondência | Dirección para correspondencia | Correspondence

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Teamwork has become a sacred term in family medicine. One wonders if this is just another myth that needs to be exposed, like the benefits of tight control in diabetes and hypertension, some cancer screening, ritualistic measurement in maternal and child health, and routine assessment of family function. To avoid tossing out the good with the bad, we need to examine the evidence for the va-lue of teamwork, to clarify its place in twenty-first century primary care and guide future research.

As the task of medicine becomes more complex, new structures and methods are required in primary care as well as at other levels of care. We will always need compassionate, knowledgeable, skilled physicians to attend to the health needs of patients and their families. However, when we look at the needs of large communities and consider the resources we have at our disposal to meet them, teamwork seems like a good idea.

A look at the earliest reports of the value of teamwork supports this. There is evidence that there is better achievement of health targets and higher patient satisfaction associated with team-based care.¹ There appears to be a relationship between medical teamwork and patient safety.² Teamwork may also be one of the solutions to prevent, diagnose and treat professional burnout. An appreciation of teamwork and the leadership provided to the team were associated with lower scores on the Maslach Burnout Inventory, in a study from primary care in Barcelona.³ Closer to home, an external evaluation of primary health care reform in Portugal identified teamwork as a key feature in the success of the reform.⁴ What then is wrong with this picture?

Some evidence suggests that teamwork is the enemy of continuity of care, since bigger teams have lower continuity.⁵ When everyone is responsible, then no one is responsible. Defenders of teamwork argue for the benefits of continuity of the team and continuity of the medical record, beyond traditional, single-provider continuity. There is evidence that medical errors often creep in during handovers of patients from one team member to another.² Excellent communication and accurate records are necessary for this to work.

Teamwork also requires a sense of mission and vision. Mission statements are common features of corporate life where teams predominate. Their value lies not in the framed mission statement hanging on the wall but in the preparation of the document. When all teams members are involved in preparing the mission statement and feel a sense of ownership of the team’s purpose, they have a better chance to succeed.

Teamwork depends on characteristics of the team members and their leader. Teams with a strong sense of membership, with a commitment to change, and with support for their leaders had higher teamwork scores, in a study from Canada.⁶ This was independent of practice size and other organizational factors. Attention to the culture and climate of the team appears to be important for success.

An editorial board of a journal, like this one, is also a team. Our editor-in-chief has said that to work as a team you must be a team first. This requires careful attention to the needs of team members and to the relationships between them. Teamwork cannot be a myth or a ritual but must produce practical evidence of function, like consistently publishing good issues of a journal. Successful teamwork is complex, demanding and rigorous, according to our editor-in-chief, but worth the effort.

Another challenge to teamwork comes from turf wars. Battles between professional groups for ownership of a procedure, type of patient, or body of know-ledge tend to work against the goals of a team and the interests of the patient. In functioning teams the roles of team members are well defined. Some tasks are best done by one type of member. Team members with equivalent skills may share other tasks like booking an appointment, changing a dressing, or discussing laboratory results. When a doctor says: “That is a nursing job or a secretarial job and I won’t do it”, patients may suffer. Recent research in Portugal suggests that there is dissatisfaction with overlapping roles when there are insufficient resources to perform the wide variety of tasks needed in primary care.⁷ Does serving the patient’s interests come before serving personal and professional needs? Is that more important than teamwork? Does effective teamwork solve this problem? All these questions are worth discussing in healthy, functioning teams.

Leadership is also an important component of teamwork.⁸ There are many styles of leadership, just as there are many styles of teamwork. However there are clear differences between a leader in a health care team and a boss. There is a difference between giving orders and guiding the work of others, between citing examples and providing a personal example, and between poli-cing the work of team members and promoting their individual growth and development. There is no “I” in teamwork.⁹ Leaders may be judged by the number of times they use the word “we” and mean it.

If teamwork is important, how can we teach this to our students, trainees and colleagues? The most important teaching method is personal example. There are also structured interventions that can promote teamwork. Devens¹⁰ showed how a brief 15-minute weekly intervention with a group of trainees in the inpatient setting helped them to learn the essential elements of teamwork including principles of leadership, communication, situation monitoring, and mutual support in teams. This intervention helped to reduce trainee stress and perhaps prevented burnout.

Improving inter-professional communication may also be a key to improving teamwork.¹¹ A surprising finding from the study by Chan was that empowering patients to take control of their care in chronic conditions was associated with improved teamwork of the professionals caring for them.

Attention to teamwork was important to the success of a quality improvement program in primary care in Canada.¹² Hilts found that the clear definition of roles and a flattening of the hierarchy by empowering team members were necessary for establishing and maintaining a quality culture in practice.

Our Americans colleagues have recognized the importance of teamwork in their “new” concept of the patient-centered medical home.¹³ While this concept is familiar in Portugal following primary care reform, and is probably familiar to all family physicians working in health systems with a strong primary care orientation, we can give our trans-Atlantic colleagues credit for finally adopting this model and promoting its development. We hope they continue to test its effectiveness in their setting. Their educational agenda includes teaching trainees to act as productive team members and team leaders. They focus on inter-professional communication skills as an expression of teamwork. Markova¹⁴ has described how teaching team-based care can meet educational as well as clinical needs in the new model.

In order to understand the role of teamwork in primary care in Portugal, we need more empiric research that assesses the state of teamwork here and tests its association with high-quality care. Lurie’s reliable 5-question tool for assessing teamwork may be useful for this effort.¹⁵ We need to know if improving teamwork improves patient outcomes or if it is just another hollow myth. Reports of research of this nature will certainly be welcome on these pages.

 

REFERENCES

1. Yodfat Y. A new method of teamwork in family medicine in Israel with the participation of nurses as physician's assistants. Am J Public Health. 1972;62(7):953-6.         [ Links ]

2. Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand. 2009;53(2):143-51. doi: 10.1111/j.1399-6576.2008.01717.x.         [ Links ]

3. Vilà Falgueras M, Cruzate Muñoz C, Orfila Pernas F, Creixell Sureda J, González López MP, Davins Miralles J. Burnout and teamwork in primary care teams. Aten Primaria. 2014 Jun 4. pii: S0212-6567(14)00149-8. doi:10.1016/j.aprim.2014.01.008. [Epub ahead of print]         [ Links ]

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5. Kristjansson E, Hogg W, Dahrouge S, Tuna M, Mayo-Bruinsma L, Gebremichael G. Predictors of relational continuity in primary care: patient, provider and practice factors. BMC Fam Pract. 2013;14:72. doi: 10.1186/1471-2296-14-72.         [ Links ]

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7. Granja M, Ponte C, Cavadas LF. What keeps family physicians busy in Portugal? A multicentre observational study of work other than direct patient contacts. BMJ Open. 2014;4(6):e005026. doi: 10.1136/bmjopen-2014-005026.         [ Links ]

8. Dine CJ, Kahn JM, Abella BS, Asch DA, Shea JA. Key elements of clinical physician leadership at an academic medical center. J Grad Med Educ. 2011;3(1):31-6. doi: 10.4300/JGME-D-10-00017.1.         [ Links ]

9. Leasure EL, Jones RR, Meade LB, Sanger MI, Thomas KG, Tilden VP, et al. There is no "i" in teamwork in the patient-centered medical home: defining teamwork competencies for academic practice. Acad Med. 2013;88(5):585-92. doi: 10.1097/ACM.0b013e31828b0289.         [ Links ]

10. Devens M, Hasnain M, Dudkiewicz B, Connell KJ. Facilitating resident well-being: a pilot intervention to address stress and teamwork issues on an inpatient service. Fam Med. 2012;44(4):265-8.         [ Links ]

11. Chan BC, Perkins D, Wan Q, Zwar N, Daniel C, Crookes P, et al. Finding common ground? Evaluating an intervention to improve teamwork among primary health-care professionals. Int J Qual Health Care. 2010;22(6):519-24. doi: 10.1093/intqhc/mzq057.         [ Links ]

12. Hilts L, Howard M, Price D, Risdon C, Agarwal G, Childs A. Helping primary care teams emerge through a quality improvement program. Fam Pract. 2013;30(2):204-11. doi: 10.1093/fampra/cms056.         [ Links ]

13. Chang A, Bowen JL, Buranosky RA, Frankel RM, Ghosh N, Rosenblum MJ, et al. Transforming primary care training: patient-centered medical home entrustable professional activities for internal medicine residents. J Gen Intern Med. 2013;28(6):801-9. doi: 10.1007/s11606-012-2193-3.         [ Links ]

14. Markova T, Mateo M, Roth LM. Implementing teams in a patient-centered medical home residency practice: lessons learned. J Am Board Fam Med. 2012;25(2):224-31. doi: 10.3122/jabfm.2012.02.110181.         [ Links ]

15. Lurie SJ, Schultz SH, Lamanna G. Assessing teamwork: a reliable five-question survey. Fam Med. 2011;43(10):731-4.         [ Links ]

 

Endereço para correspondência | Dirección para correspondencia | Correspondence

E-mail: yonahyaphe@hotmail.com

 

Conflict of interest

None reported.