By Wendell Kellum, CCHP Healthcare Hotspotting Fellow

Healthcare is now a team sport. The complexity of available technology, knowledge and services makes effective collaboration between primary care clinicians, specialists, hospitals and ancillary care services essential. The paradigm of a lone doctor providing all needed care can’t support the complexity of modern medicine.

In contrast to being the “do everything” generalist, the role of the PCP is increasingly shifting toward coordination of care and preventative services. We help patients understand and navigate increasingly complex medical systems and treatments. There is also a shift in primary care toward population health management – trying to help patients be and stay healthy in the community before they come into the office. These new roles of primary care need a team.

Early in my fellowship with the Camden Coalition, Dr. Brenner said one line to me that shifted my paradigm about a doctor’s role. I was mourning the loss of the doctor-patient relationship, as it seems to be crowded out of primary care. Dr. Brenner responded, “A caring family doctor for every patient is a numerical impossibility.” He agreed that medical care needs to be translated to patients in caring relationships, but challenged my idea that the relationship needed to be with a doctor.

How does working in teams look in a primary care office?

I had the privilege of working in team based care team in my last practice. This is a typical sample of what it looks like for a single patient.

STEP 1 • Mr. Rodriguez comes to my practice for a routine follow-up of diabetes.

STEP 2 • The clerical assistant sees that he hasn’t had a recent eye exam and generates a referral to ophthalmology with a standing order protocol.

STEP 3 • The medical assistant checks his vital signs and asks him to take his shoes off since he is due for a foot exam.

STEP 4 • The diabetes educator comes in and reviews his last labs and his home glucose log. His sugars have been running high and the diabetes educator presents several options for increasing his medicines that we discussed in the morning huddle, including the option to start daily insulin. Mr. Rodriguez agrees to give the insulin a try, so he is taught to use the insulin pen before I come see him.

STEP 5 • After hearing briefly from the diabetes educator about the outcome of her meeting with the patient, I review the plan for medication changes with the patient and address other concerns that he has today.

STEP 6 • A behavioral health consultant meets with the patient after me to talk about goals that he has set for weight loss and some family stressors that make food control difficult right now.

STEP 7 • At the end of his visit, the clerical assistant schedules Mr. Rodriguez’s next follow up and reminds him to bring all his medicines to the next appointment.

Working in this team structure, Mr. Rodriguez’s visit was segmented into 7 separate actions. My direct interaction with the patient as a physician only took place during one of those steps. My role as physician involved not only my relationship with my patient, but participation and leadership in a clinical care team.

Information technology bringing overload or empowerment?

Adding computerized tracking and reminders about the ever growing list of preventative services and chronic-disease management recommendations into a traditional “doctor does is all” paradigm of primary care is basically proficient tracking of unrealistic expectations. Adding the same information technologies into a team paradigm has the potential to empower nurses and other care team members in their work.

If a computer algorithm can recognize an evidence-based recommendation for a patient, we should create a standing order protocol so that a nurse, medical assistant or clerical team member can effectively complete the task. This would remove it from the agenda of the doctor-patient visit. Evidence-based practices such as mammography, vaccination and colon cancer screening should not need a physicians’ direct input in day-to-day care. Standing order protocols for routine blood pressure or diabetes medication titration could also greatly expand the role of diabetes educators, nurses or clinical pharmacists in the treatment of these common conditions. Information technologies that seem to magnify the impossibility of getting everything done in traditional model of physician-driven care can become powerful agents of empowerment in team-based primary care.

Is it perfect?

I actually believe ideal care will often take place in patients’ homes or in community settings rather than a doctor’s office and will have a much greater role of non-physician caregivers on the front lines with patients, but the team approach will be critical. Shifting our mental paradigms of patient care to team-based models is one of the most practical things that we can do today to take steps toward the ideal primary care of the future.

Team-based care isn’t just about being able to get more done. It is also about doing what we do better. In the team-based care described in my last practice, I experienced first-hand (repeatedly) instances where a behavioral specialist, a medical assistance, nurse or clerical assistant made a connection with a patient that seemed much more significant to the overall well-being of that patient than what I as the doctor had contributed that day. The more we are able to appreciate, utilize, and empower all members of our primary care teams, the better our care of patients can become.

Wendell Kellum is one of the Healthcare Hotspotting and Super-Utilizer Fellows working with CCHP and the Crozer Keystone Family Medicine Residency. The year-long fellowship provides an opportunity for family doctors to learn and work in population health management and healthcare system redesign. Prior to this fellowship, Wendell worked for 7 years as a primary care doctor with Esperanza Health Center, a faith-based community health center serving the predominately Latino population of North Philadelphia. One of his particular interests is in community development for impoverished neighborhoods. He is hoping this fellowship will equip him to work more on a systems-level for strategic planning of healthcare delivery and health promotion that supports the holistic health of patients and their communities.

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