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FOR a number of conditions, team-based care is increasingly held up as the gold standard in management but while working in teams can have great benefits, we need to be vigilant that teams don’t become self-serving and inefficient.
A colleague and retired anaesthetist, Dr Jim Wilkinson, recently shared his thoughts, in the Australian Doctors Fund newsletter, on why he dislikes pain teams. His thoughts, which he has allowed me to use, illustrate why teams should only be involved if it improves patient care and outcomes.
He related the experience of a friend who presented to a public hospital in severe pain from an acute vertebral abscess on a Friday. She was fasted for surgery and analgesia was withheld. However, the operation was cancelled late in the day and she was left in pain. The pain team was summoned but messaged back that they would see her “next Monday”.
Acute surgical pain should be dead easy really, Dr Wilkinson wrote. “It also must be addressed now, not in 3 days. Patient-controlled analgesia is, truly, a 15-minute tutorial, not a whole textbook subject.”
Dr Wilkinson also told of a surgeon who had complained that the pain team had approached some of his postoperative patients and start changing and complicating his or his anaesthetist’s orders for analgesia, and charging the patient.
“Surgeons and anaesthetists deal daily with acute surgical pain”, Dr Wilkinson wrote “We do this expertly and at no extra charge to our patients.”
He does acknowledge that chronic pain is a mystery to him. “I know only one way to give aspirin or three ways to give paracetamol. If that fails — then and only then will I welcome the scrum from the pain department”, he wrote.
He also notes that such pain teams “cannot survive and do not exist in private hospitals … I wonder why?”
Dr Wilkinson’s insights can apply more broadly when it comes to teams. For me, it is aged care that provides examples of where teams may get in the way of good patient care.
My experience with Aged Care Assessment Teams (ACAT) is to see them pontificate on the future of a patient’s living arrangements with scant regard for the opinion of GPs and community carers who have been involved with the patient for many years.
Only last month, I was frustrated by a case of a man in his late 90s with terminal heart failure. The poor fellow cannot walk unassisted, is dependent on help for dressing and bathing, and frequently needs palliative oxygen therapy.
In its wisdom, the ACAT, which did not include a doctor, decided that because he was able to do up his buttons, he should be able to manage in a hostel, rather than the nursing home that his usual carers and I thought was best for him.
Psychogeriatric and general geriatric referrals via teams are often mired in paperwork. Referrals need to be sent ahead of time and a patient may have to see non-medical members of the team before they actually see the intended specialist.
This all adds up to treatment delays and added expense. In rural areas it can mean a lot of extra travel for very little gain.
Worse still, the team often insists on the referring doctor ordering a battery of tests — whether clinically indicated or not — before it makes contact with the patient. Not only is this a waste in many instances, but also transfers any risk of overservicing to the hapless GP.
Referring doctors should resist such demands unless it is a test the doctor believes is necessary for patient care. If you don’t think it is necessary, make the other doctor order it on his or her provider number.
Aren’t these teams meant to serve the patient and the referring doctor?
The simple solution is to ensure the GP is the captain and half-back of the team — we’ll feed the scrum in the way that’s best to score a try for our patients.
Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.
Sue Ieraci, thank you, but you’ve missed the point completely. What you’ve seen is not relevant to what I wrote, which is that “patient need” comes first; not being dead or alive or whatever according to some third party view, by teams, emergency care physicians or what have you, of what to do in any situation or bureaucratic choice. Dignity is determined by respect for the patient’s need and that is best communicated to doctors in whom the patient has established trust and who is prepared to advocate that the patient’s wish is legally acted upon and respected. Such an approach values patient Rights, is compassionate, appropriate and value based as well as supported by Law, namely the Medical Treatment Act 1988 (Vic.gov).
Pain teams are an important part of managing complex patients in hospital however they should have no role in the day to day care of most patients that pass through our institutions. Unfortunately they are a growing part of the anaesthetis department that seems to need to see every post op surgical patient. This unfortunately has several unintended complications. First it’s a waste of resources as most patients don’t need their services, second it deskills the junior doctors who often feel powerless in making these management decisions , at the very least they should be included in all pain team rounds so they can inform the pain team of the surgical teams management plan and expected outcomes. Finally they often arrive many hours or day to late. Acute pain is just that acute, it needs to be assessed acutely and assessed fully ie what’s the cause for the pain does the patient need to return to theatre ie compartment syndrome ? Often the pain the pain team just focuses on the pain
The pain team is a valuable part of Anaesthia department but a patient in pain needs to be seen and managed by their normal regular medical/surgical team with the pain team as a referral service to provide advice and help with the management of patients with difficult or complex problem
”Too many patients have died because teams not focussed on patient need are involved in the patient’s care and are headless in being run by nurses or doctors who are not patient appointed” And conversely, I’ve also seen the opposite – patients kept alive inappropriately because risk-aversion trumps human dignity.
Please see my piece under Scott Blackwell: Team challenge. Cleary, i agree. Patient feedback in a supportive environment is part of informed consent and essential to the doctor-patient relationship. Whether care is delivered in a team format or not is not the issue. Teams often fail because there is no leadership nor understanding of the patient’s condition, needs and goals. A bureaucratic push for teams is simply that. Appropriate and adequate care is determined by patient “happiness”, not team satisfaction or priority of agenda of any of the individuals on it, which is the dominating model in aged care and palliative care. Too many patients have died because teams not focussed on patient need are involved in the patient’s care and are headless in being run by nurses or doctors who are not patient appointed, i.e. someone in whom the patient has trust, who may be a specialist in or general practitioner involved at their level in their care.
A one-off bad experience with one pain team should not be used to tar all pain teams with the same brush. Many patients with acute pain these days have complex comorbidities including chronic pain and addiction disorders. A simplistic regimen of “one way to give aspirin or three ways to give paracetamol” will not go far at all. Anaesthetists these days MUST know something about chronic pain and addiction medicine in order to appropriately manage acute pain in these patients. Without the required knowledge/experience there may be inadequate recognition of the need and inadequate ability to tailor analgesia to each patient. There is also the risk of inappropriate opioid prescription, including at the time of discharge, potentially leading to patient harm and harm to others as well as opioid diversion. E.g. fentanyl patches are sometimes prescribed for acute pain management despite the fact that the peak effect will not be seen for days and despite risks involved to both patients and others (they are specifically contraindicated for the management of acute/postoperative pain). And if patient-controlled analgesia (PCA) is “truly, a 15-minute tutorial” and so easy for all anaesthetists, then why are patients still coming to harm from inappropriate PCA orders? Unfortunately, not all anaesthetists are experts in all aspects of acute pain medicine. Many tertiary teaching hospitals have different “teams” (pain medicine, palliative care, drug and alcohol). Most are are referred patients, so that any doctor who does not want his/her patient to be referred does not need to have the team see their patient. I would like to think that this would only be done if not consulting these teams would lead to the same quality of patient care.
I just could not agree with you more about the “Teams”. They grow like topsy and must cost a fortune to run.I recall a patient seeing the “Palliative Care Team” while I was away for a week. Every day a new person would see him and ask the same questions about his condition.
Not what you want to repeat constantly in your last few days.
He was glad to see me again – just because we could work positively with his limited time.
Anyway he had chosen me to be his doctor. He had not chosen all the members of the “team”.
He was comfortable with me visiting him in his home. He had not invited the “team” to be there.