Aniello Iannuzzi: Tackling teams

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.