Total Patient Care: Just A Dream?

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By Judith Philipps Otto

It's a popular concept--so popular that it's hard to find a dissenting voice. Total patient care, in the form of a cooperative multidisciplinary team approach to treating each patient's specific needs, is an idea universally and enthusiastically embraced. And the concept is not a new one. Why, then, over these decades of discussion and approbation since the notion first emerged more than half a century ago, hasn't the idea been successfully implemented on a broader, grander scale? What's the holdup?

It's a popular concept--so popular that it's hard to find a dissenting voice. Total patient care, in the form of a cooperative multidisciplinary team approach to treating each patient's specific needs, is an idea universally and enthusiastically embraced. And the concept is not a new one.   Why, then, over these decades of discussion and approbation since the notion first emerged more than half a century ago, hasn't the idea been successfully implemented on a broader, grander scale? What's the holdup?

Joan E. Edelstein, MA, PT, FISPO, a senior research scientist in New York University's Department of Prosthetics & Orthotics from 1961 through the program's close in 1991, briefly explored the history of the team concept:

"The clinic team, which is where the total patient care concept originated, was really introduced after World War II in order to treat people who had amputations. It consisted of the physician, the prosthetist, and the physical therapist; this was an insight which appeared very early, when the whole concept of rehabilitation was developed. At NYU, I worked with this concept from Day One--it was certainly an integral part of our teaching and our educational philosophy, not only for prosthetists, but also for physicians and therapists. I had a central role in educating people about this."

Tom Colburn, CO, FAAOP, CPed, director, prosthetics & orthotics, Tufts-New England Medical Center Hospital, Boston, Massachusetts, and a member of the American Academy of Orthotists & Prosthetists (AAOP) Board of Directors, has worked at the hospital for 20 years, Before that, he was a young scoliosis patient at the same hospital. Describing the team concept at work in his practice setting, Colburn sees the hospital as a medical community, "where we see patients together using the team approach." He continued, "With the full-service hospital, you have all the different specialties which can work together collectively for the best care for the patient. You don't have one individual seeing a patient in a vacuum; instead, we're actually physically seeing patients with the orthopedic surgeon and with the physiatrist, who have offices next to each other. If we have a complex case, we're readily available to touch base with each other and preserve the continuity of care.

Joan E. Edelstein, MA, PT, FISPO
Joan E. Edelstein, MA, PT, FISPO

"The team approach is really a mindset in that you're never looking at the patients just from your perspective--you're always cognizant that you're just one of the members of the team seeing this patient," Colburn said. "If there's another issue that you feel is not really your specialty, you speak with the other team members or direct the parent or the patient to another team member for the best interest of the patient."

Since the team concept took off after World War II, what went wrong?

"I think in part it is a matter of the numbers of professionals in each of the occupations that I mentioned," Edelstein reflected. "There are many more physicians and many more therapists, as compared with prosthetists. That was certainly an issue in terms of education. Many people will look to problems of funding--of reimbursement. That is certainly a pertinent issue, but I'm not so sure it's the main issue. Maybe it is in terms of everybody's desire to treat patients, to have them return as quickly as possible to their customary activities; and the timeframe is certainly part of reimbursement, so in a sense, maybe money is part of the issue."

Edelstein raised another relevant concern. "I think also there is a certain lack of clarity as to what professional roles are: specifically, what it is reasonable to expect from a physical therapist with regard to professional responsibilities and professional education. And when that is misunderstood, there's uncertainty on everybody's part, and then the patient suffers."

Who should be part of the team?

Kevin Carroll, MS, CP, FAAOP
Kevin Carroll, MS, CP, FAAOP

The core team, Edelstein believes, remains physician-prosthetist-therapist, regardless of what other specialists might occasionally be required to participate on a case-by-case basis.

Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics, Hanger Prosthetics & Orthotics Inc., Bethesda, Maryland, believes that it's also a matter of identifying the various professions that might be potential team members. "I counted them up one time and there might be as many as 30 people on a patient care team--from nutritionists, dieticians, social workers, case managers, certified rehab counselors, and more."

How would an O&P practitioner locate or develop such a team, where this medical-center team situation doesn't exist?

"My suggestion to the clinicians reading this article is to take it upon themselves to go out and build relationships with the various team members, from all the rehab people to all the primary care physicians, physical therapists, physiatrists, anyone they can recognize as a team member--and build those relationships," said Carroll. "The stronger the relationship, the more widely we can spread the work and share the various tasks."

Colburn offered an example: "When our orthopedic surgeon, Dr. Sally Rudicel, considered coming to work at this hospital, I was stunned that she set up a separate interview with me, as director of orthotics and prosthetics here. She also set one up with the head of the cast techs; she set up interviews with a number of different people within the hospital in order to assess the team she was considering joining. She wanted to make sure that the team collectively was strong enough in all areas to support what her needs were to provide the vision of patient care that she had."

Colburn continued, "As an orthotist, I would talk to the person who is interviewing and inquire about their team approach; but more importantly, I would spend a few hours, if possible, in the clinical setting as a visitor to that lab to see how they interact, because many people talk about the team approach and have the best of intentions, but physically the reality is not conducive to working within a team environment.

"I guess a lot of it is education--we need to have educational opportunities for all team members and have cross-training to understand what the physical therapists are doing--not so that we will provide that care, but so often an understanding of what they're doing is helpful," Colburn reflected.

But how does an orthotist or prosthetist explore the team presence or potential when considering a new position and location? It's not likely he'll be able to interview potential teammates.

When Colburn considers potential clinical employees, he not only goes through the usual screening interview process, but also offers them the opportunity to come and spend a couple of hours observing. "I want them to see how we interact with patients in a clinical setting, and to have a clear understanding of how clinical care is done within this facility. Conversely, if I were an interviewee, and the process had reached a serious point where an offer might be made, I would request spending a couple of hours as a visitor--not interacting necessarily with the other professionals, but as a visitor to observe the dynamics of how patient care is run."

Sally Rudicel, MD, orthopedic surgeon at Tufts-New England Medical Center Hospital, advised physicians who want to establish a team relationship with O&P practitioners to contact the national organizations to locate certified orthotists/prosthetists in their area. (Editor's note: To locate orthotists and/or prosthetists certified by the American Board for Certification in Orthotics & Prosthetics [ABC], visit www.abcop.org. To locate orthotists and/or prosthetists certified by the Board for Orthotist/Prosthetist Certification [BOC], visit www.bocusa.org)

"The main thing from both a medical and an O&P perspective would be to find out who in your area would be qualified to help you and establish a relationship," Rudicel said, adding, "It has to be financially worth their while to do it--certainly for the orthotists [and prosthetists]--so they have to have the volume of patients."

"That's another reason why a medical center makes the most sense--because there aren't a huge number of patients in a small area, people come from miles around to go to the medical center for better care," she noted.

How might we achieve better progress toward total patient care?

"I would say progress could be achieved through improving the quality of professional education--and I think also greater collegiality amongst the professions," Edelstein said, adding, "Implicit to improving education is a better understanding of what each profession does. I think there is some misunderstanding as to what physical therapists do customarily. PTs do not construct permanent, definitive prostheses, and it's misleading to imply that they do. It may be that better dialogue is needed."

Are we likely to make progress toward more total patient care situations any time soon?

"I think that one of the barriers is insurance company and government reimbursements," Colburn reflected. "And with reimbursements going lower and lower, it becomes more challenging for the regional centers of excellence nationwide to stay financially solvent and to provide this level of care.

"I personally think it's more expensive for the insurance companies and the government to provide inferior healthcare," Colburn said. "I think that it's cost-effective for them to provide comprehensive healthcare within a team environment. In the long term, it's very cost-effective in that there are fewer complications and better outcomes. Despite the current economic climate, there are a lot of committed professionals who frankly make many personal sacrifices in order to maintain that vision of quality care."

Looking at the future, Colburn said, "Existing regional centers of excellence will still proliferate, because they're driven by committed professionals and by patients who individually and collectively recognize the difference in quality of care in a team environment, and who support these kinds of centers.

"I guess I choose not to be pessimistic about the overall future," Colburn continued, "because I see such a dramatic difference in the quality of care with patient-centered team approach to patient care. Despite the challenges of the economic times and the challenges of the insurance constraints, I believe that those professionals who are driving this and the patients who are receiving the benefits will be able to continue this vision."

More research showing improved outcomes with the team approach is needed, Colburn believes. "Research is something that is unfortunately pretty difficult to do, with everybody's time constraints and financial constraints. But increasing the amount of research on outcomes needs to be a priority. If the outcomes do prove this to be cost-effective--not just altruistically the best way to do patient care--then I think that this will become the paradigm that the insurance companies will follow."

Colburn concluded, "Good research doesn't happen overnight--yes, it will take time."

Judith Philipps Otto is a freelance writer who has also assisted with marketing and public relations for various clients within the O&P industry. A graduate of the University of Missouri School of Journalism, she has been a newspaper writer and editor and