Interdisciplinary? Or serial monotherapy?

Teamwork can be a mixed blessing. Knowing that other members of the team are working alongside you is wonderful but a team that’s not functioning well can be a destructive animal that can tear itself apart.

I’ll begin with some definitions:

Monotherapy means having a single type of intervention. This is useful for acute problems, or very simple problems. For example, if I sprain my ankle, I might need to see a physiotherapist to improve my mobility. In New Zealand, the ACC-funded Psychological Pain Management sessions are a good example.

Multidisciplinary means more than one discipline working with an individual, but not necessarily working with one another. This is useful where coordination is difficult, such as in a busy Emergency Department, or where the problem doesn’t need collaboration, for example possible neuropathic pain post-deQuervains release where the patient needs physiotherapy, medication and help to return to work. In New Zealand, a good number of the ACC-funded Activity Focused Programmes run this way.

There may be a physiotherapist, occupational therapist and psychologist working with the same patient, and although they may share notes their interventions remain focused on their individual disciplinary contributions. The way the disciplines conceptualise the patient’s problems remains within the individual professional’s model. So the physiotherapist might focus on biomechanics and strength, the occupational therapist may consider how the individual manages his or her driving and work tasks, while the psychologist may consider the person’s thoughts and beliefs about pain. Although the disciplines acknowledge one another’s contribution, clinicians focus on their own intervention and clinical reasoning with little reference in their own sessions to anything another clinician has looked at.

Interdisciplinary means professionals from a variety of disciplines working together in an integrated way with joint goals and ongoing communication. A common model is used, joint goals developed, clinicians contribute in the area/s most needed by the patient/client, share session content and communicate regularly so other team members can provide the same message in their sessions. This might mean the physiotherapist uses cognitive reframing during exercises, the occupational therapist discusses medications and side-effects during activity planning sessions, the psychologist talks about exercise timing and intensity during a session using biofeedback.

The popularity of interdisciplinary pain management has waned somewhat since the days of the mid-1980’s to late 1990’s. Health administrators look askance at large teams because they seem expensive, time is tied up in meetings, there are turf wars, people talk about role conflict and role confusion, time is needed for induction, and there’s always a suspicion that having a team leads to over-servicing and too many cooks spoiling the broth. I’ve watched the integrated interdisciplinary approach gradually being replaced by a multidisciplinary approach, although the language may not have caught up with this!

Teams are a complex beast. To understand teams we need to draw on cognitive psychology, social psychology, rehabilitation research, general systems theory and, dare I say it, management theory.  Not only do clinicians in an interdisciplinary team need to know their profession’s contributions, they must also communicate effectively as individuals, have learned how to collaborate, and the team must be supported in a structural way to do its job well.

What does this mean in practical terms?

There must be effective selection and induction process for new team members – members need to be chosen for teams on the basis not only of their proficiency in their individual discipline, but also on what they can contribute individually to a team. Personally I don’t think a decision to appoint an individual to a team should occur without the team being involved in the selection process.  Induction needs to involve not only where the first aid kit is, but more importantly, the team’s philosophy and clinical model, sharing what each individual member can contribute to the team – especially when a new member is appointed, how decisions are made, how disputes are resolved, and the team’s values.

Time must be set aside for team development and that hackneyed term “team building”. This is an ongoing need – because trusting one another is critical to effective teamwork. This means learning about other clinician’s contributions – enough to be able to provide the same kind of input within your own clinical session, so a consistent message reaches the patient.

Communication must be pretty robust at times! What I mean by this is that it’s vital to be able to disagree, challenge one another’s viewpoint and take the time to reach alignment, if not agreement. A team that can’t or won’t openly disagree with one another is likely to hold onto disputes, souring the relationships and creating distrust. Over time, the team’s effectiveness is lost as patients/clients can tell where the weakest links lie.

Develop a structure for presenting information
–Optimum amount of information – 3-7 from each person
–Most likely to be forgotten – presented first
–Lowest prestige – presented early
–Share unique information rather than shared
–Use a timer to limit discussion – egg timer?
–Consider using delphi, or other structured decision process (nominal group technique, SWOT, decisional balance, cognitive mapping)
Identify functional roles as well as clinical roles in a team, support these roles – this means some people are the “organisers” in the team, some are the “comforters”, some are “rule makers”, some are “enforcers”. These interpersonal roles are as important as clinical roles because they facilitate team functioning. And the professions traditionally expected to “lead” or “organise” may not be the best individuals to do so in a particular team.
Develop a process for resolving differences – this might mean sitting and thrashing a problem out in discussion, or it might mean bringing another person in to mediate/arbitrate, or it could mean giving a decision-making role to one individual within the team, though this can mean developing a hierarchy and this is less positive within an interdisciplinary team.
Managers must recognise that interdisciplinary teams need time to learn to work together, that teams are less effective when team membership changes, that members of teams often know what they need and who they need as members and that external managers or even clinicians working outside a team may have little knowledge either of how the team works, or of what the team needs to be effective.
Are interdisciplinary teams effective?
This is a slightly difficult question to answer, but overall the indications are that interdisciplinary teams are effective in terms of patient outcomes, and they are also better for the individuals involved in them. This report, somewhat old now but still relevant, found that IDTs are better for mental health of members and there is lower staff turnover.  This report, from 2013, finds that the data are not yet clear about cost effectiveness.
What seems evident is that the more complex a patient’s problems, and the more chronic, the greater the need for interdisciplinary teams, and the more cost effective the outcomes.
Human Resources for Health provides this summary – 10 Principles of Good Interdisciplinary Team Work
I love working in a team. I love being able to trust the other members of the team to provide seamless integration of the things I contribute, and I love being able to support the other clinicians in their approach. I know it’s not easy to develop good teamwork, but there’s enough information available from research to know what can help. What I definitely know is that defining what one profession will do without also considering both the other professional’s contribution AND the personal strengths and vulnerabilities of the individuals involved is likely to lead to subversive behaviour, dissention and ultimately failure for the person at the centre of it: the client/patient.

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