Principles Supporting Dynamic Clinical Care Teams: An American College of Physicians Position Paper
05 Nov 2013-Annals of Internal Medicine (American College of Physicians)-Vol. 159, Iss: 9, pp 620-626
TL;DR: The American College of Physicians offers principles, definitions, and examples to dissolve barriers that prevent movement toward dynamic clinical care teams, providing policy guidance that can be useful to clinical teams in organizing the care processes and clinician responsibilities consistent with professionalism.
Abstract: The U.S. health care system is undergoing a shift from individual clinical practice toward team-based care. This move toward team-based care requires fresh thinking about clinical leadership and responsibilities to ensure that the unique skills of each clinician are used to provide the best care for the patient as the patient's needs dictate, while the team as a whole must work together to ensure that all aspects of a patient's care are coordinated for the benefit of the patient. In this position paper, the American College of Physicians offers principles, definitions, and examples to dissolve barriers that prevent movement toward dynamic clinical care teams. These principles offer a framework for an evolving, updated approach to health care delivery, providing policy guidance that can be useful to clinical teams in organizing the care processes and clinician responsibilities consistent with professionalism.
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01 Jan 2005
TL;DR: The Medical Professionalism Project and its principal product, the Charter on Medical professionalism, appears in print for the first time in this issue of Annals and simultaneously in The Lancet, and everyone who is involved with health care should read the charter and ponder its meaning.
Abstract: To our readers: I write briefly to introduce the Medical Professionalism Project and its principal product, the Charter on Medical Professionalism. The charter appears in print for the first time in this issue of Annals and simultaneously in The Lancet. I hope that we will look back upon its publication as a watershed event in medicine. Everyone who is involved with health care should read the charter and ponder its meaning. The charter is the product of several years of work by leaders in the ABIM Foundation, the ACP–ASIM Foundation, and the European Federation of Internal Medicine. The charter consists of a brief introduction and rationale, three principles, and 10 commitments. The introduction contains the following premise: Changes in the health care delivery systems in countries throughout the industrialized world threaten the values of professionalism. The document conveys this message with chilling brevity. The authors apparently feel no need to defend this premise, perhaps because they believe that it is a universally held truth. The authors go further, stating that the conditions of medical practice are tempting physicians to abandon their commitment to the primacy of patient welfare. These are very strong words. Whether they are strictly true for the profession as a whole is almost beside the point. Each physician must decide if the circumstances of practice are threatening his or her adherence to the values that the medical profession has held dear for many millennia. Three Fundamental Principles set the stage for the heart of the charter, a set of commitments. One of the three principles, the principle of primacy of patient welfare, dates from ancient times. Another, the principle of patient autonomy, has a more recent history. Only in the later part of the past century have people begun to view the physician as an advisor, often one of many, to an autonomous patient. According to this view, the center of patient care is not in the physician’s office or the hospital. It is where people live their lives, in the home and the workplace. There, patients make the daily choices that determine their health. The principle of social justice is the last of the three principles. It calls upon the profession to promote a fair distribution of health care resources. There is reason to expect that physicians from every point on the globe will read the charter. Does this document represent the traditions of medicine in cultures other than those in the West, where the authors of the charter have practiced medicine? We hope that readers everywhere will engage in dialogue about the charter, and we offer our pages as a place for that dialogue to take place. If the traditions of medical practice throughout the world are not congruent with one another, at least we may make progress toward understanding how physicians in different cultures understand their commitments to patients and the public. Many physicians will recognize in the principles and commitments of the charter the ethical underpinning of their professional relationships, individually with their patients and collectively with the public. For them, the challenge will be to live by these precepts and to resist efforts to impose a corporate mentality on a profession of service to others. Forces that are largely beyond our control have brought us to circumstances that require a restatement of professional responsibility. The responsibility for acting on these principles and commitments lies squarely on our shoulders. —Harold C. Sox, MD, Editor
384 citations
TL;DR: This policy paper was drafted by the Health and Public Policy Committee of the American College of Physicians, which is charged with addressing issues that affect the health care of the U.S. public and the practice of internal medicine and its subspecialties.
Abstract: Social determinants of health are nonmedical factors that can affect a person's overall health and health outcomes. Where a person is born and the social conditions they are born into can affect their risk factors for premature death and their life expectancy. In this position paper, the American College of Physicians acknowledges the role of social determinants in health, examines the complexities associated with them, and offers recommendations on better integration of social determinants into the health care system while highlighting the need to address systemic issues hindering health equity.
346 citations
TL;DR: A PharmD-PCP collaborative MTM service was more effective in lowering BP than was usual care at 6 months in all patients and at 9 months in patients who continued to see the pharmacist, based on an intent-to-treat analysis.
106 citations
TL;DR: Findings identify specific policy changes that could help physicians feel more prepared, and highlight how providers of all types will need to become familiar with interpreting WGS results.
Abstract: Although the integration of whole genome sequencing (WGS) into standard medical practice is rapidly becoming feasible, physicians may be unprepared to use it. Primary care physicians (PCPs) and cardiologists enrolled in a randomized clinical trial of WGS received genomics education before completing semi-structured interviews. Themes about preparedness were identified in transcripts through team-based consensus-coding. Data from 11 PCPs and 9 cardiologists suggested that physicians enrolled in the trial primarily to prepare themselves for widespread use of WGS in the future. PCPs were concerned about their general genomic knowledge, while cardiologists were concerned about how to interpret specific types of results and secondary findings. Both cohorts anticipated preparing extensively before disclosing results to patients by using educational resources with which they were already familiar, and both cohorts anticipated making referrals to genetics specialists as needed. A lack of laboratory guidance, time pressures, and a lack of standards contributed to feeling unprepared. Physicians had specialty-specific concerns about their preparedness to use WGS. Findings identify specific policy changes that could help physicians feel more prepared, and highlight how providers of all types will need to become familiar with interpreting WGS results.
105 citations
Cites background from "Principles Supporting Dynamic Clini..."
...One solution to many of these concerns may be to encourage patient care approaches that distribute the demands of WGS among teams rather than individual physicians (43)....
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References
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TL;DR: Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.
Abstract: Crossing the Quality Chasm identifies and recommends improvements in six dimensions of health care in the U.S.: patient safety, care effectiveness, patient-centeredness, timeliness, care efficiency, and equity. Safety looks at reducing the likelihood that patients are harmed by medical errors. Effectiveness describes avoiding over and underuse of resources and services. Patient-centeredness relates both to customer service and to considering and accommodating individual patient needs when making care decisions. Timeliness emphasizes reducing wait times. Efficiency focuses on reducing waste and, as a result, total cost of care. Equity looks at closing racial and income gaps in health care.
15,046 citations
01 Jan 2002
TL;DR: The Charter on Medical Professionalism Project is the product of several years of work by leaders in the ABIM Foundation, the ACP‐ASIM Foundation, and the European Federation of Internal Medicine and consists of a brief introduction and rationale, three principles, and 10 commitments.
Abstract: Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine* To our readers: I write briefly to introduce the Medical Professionalism Project and its principal product, the Charter on Medical Professionalism. The charter appears in print for the first time in this issue of Annals and simultaneously in The Lancet .I hope that we will look back upon its publication as a watershed event in medicine. Everyone who is involved with health care should read the charter and ponder its meaning. The charter is the product of several years of work by leaders in the ABIM Foundation, the ACP‐ASIM Foundation, and the European Federation of Internal Medicine. The charter consists of a brief introduction and rationale, three principles, and 10 commitments. The introduction contains the following premise: Changes in the health care delivery systems in countries throughout the industrialized world threaten the values of professionalism. The document conveys this message with chilling brevity. The authors apparently feel no need to defend this premise, perhaps because they believe that it is a universally held truth. The authors go further, stating that the conditions of medical practice are tempting physicians to abandon their commitment to the primacy of patient welfare. These are very strong words. Whether they are strictly true for the profession as a whole is almost beside the point. Each physician must decide if the circumstances of practice are threatening his or her adherence to the values that the medical profession has held dear for many millennia. Three Fundamental Principles set the stage for the heart of the charter, a set of commitments. One of the three principles, the principle of primacy of patient welfare, dates from ancient times. Another, the principle of patient autonomy, has a more recent history. Only in the later part of the past century have people begun to view the physician as an advisor, often one of many, to an autonomous patient. According to this view, the center of patient care is not in the physician’s office or the hospital. It is where people live their lives, in the home and the workplace. There, patients make the daily choices that determine their health. The principle of social justice is the last of the three principles. It calls upon the profession to promote a fair distribution of health care resources. There is reason to expect that physicians from every point on the globe will read the charter. Does this document represent the traditions of medicine in cultures other than those in the West, where the authors of the charter have practiced medicine? We hope that readers everywhere will engage in dialogue about the charter, and we offer our pages as a place for that dialogue to take place. If the traditions of medical practice throughout the world are not congruent with one another, at least we may make progress toward understanding how physicians in different cultures understand their commitments to patients and the public. Many physicians will recognize in the principles and commitments of the charter the ethical underpinning of their professional relationships, individually with their patients and collectively with the public. For them, the challenge will be to live by these precepts and to resist efforts to impose a corporate mentality on a profession of service to others. Forces that are largely beyond our control have brought us to circumstances that require a restatement of professional responsibility. The responsibility for acting on these principles and commitments lies squarely on our shoulders.
1,014 citations
TL;DR: A Medline search for randomised controlled trials of team care using the MeSH heading “patient care team” considered the implications of these observations for the structure and functioning of patient care teams in primary care.
Abstract: > “In the gradual division of labor, by which civilization has emerged from barbarism, the doctor and nurse have been evolved”
>
> Sir William Osler (1891)
The delivery of health care by a coordinated team of individuals has always been assumed to be a good thing. Patients reap the benefits of more eyes and ears, the insights of different bodies of knowledge, and a wider range of skills. Thus team care has generally been embraced by most as a criterion for high quality care. Despite its appeal, team care, especially in the primary care setting, remains a source of confusion and some scepticism.1 Which disciplines are essential on the team? What do the team members other than the doctor do to support patient care?
With the ageing of the population and the advances in the treatment of chronic diseases, teamwork in the context of chronic diseases needs to be re-examined. Successful chronic disease interventions usually involve a coordinated multidisciplinary care team.2–5
In this article I consider the implications of these observations for the structure and functioning of patient care teams in primary care. My work is rooted in US health care, and the references and roles described largely reflect that perspective. I performed a Medline search for randomised controlled trials of team care using the MeSH heading “patient care team.”
#### Summary points
Effective chronic illness interventions generally rely on multidisciplinary care teams
Successful teams often include nurses and pharmacists with clinical and behavioural skills
Such teams ensure that critical elements of care that doctors may not have the training or time to do well are competently performed
These elements include population management, protocol based regulation of medication, self management support, and intensive follow up
The participation of medical specialists in consultative and educational roles outside conventional referrals may contribute to …
1,004 citations
"Principles Supporting Dynamic Clini..." refers background in this paper
...In a well-functioning team that is providing primary care, collaboration among all team members, using the full range of skills and abilities among primary care clinicians, may help to reduce unnecessary referrals and escalation of care to non–primary care specialists, thereby enhancing access to these specialties for patients who need such services (15)....
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01 Jan 2005
TL;DR: The Medical Professionalism Project and its principal product, the Charter on Medical professionalism, appears in print for the first time in this issue of Annals and simultaneously in The Lancet, and everyone who is involved with health care should read the charter and ponder its meaning.
Abstract: To our readers: I write briefly to introduce the Medical Professionalism Project and its principal product, the Charter on Medical Professionalism. The charter appears in print for the first time in this issue of Annals and simultaneously in The Lancet. I hope that we will look back upon its publication as a watershed event in medicine. Everyone who is involved with health care should read the charter and ponder its meaning. The charter is the product of several years of work by leaders in the ABIM Foundation, the ACP–ASIM Foundation, and the European Federation of Internal Medicine. The charter consists of a brief introduction and rationale, three principles, and 10 commitments. The introduction contains the following premise: Changes in the health care delivery systems in countries throughout the industrialized world threaten the values of professionalism. The document conveys this message with chilling brevity. The authors apparently feel no need to defend this premise, perhaps because they believe that it is a universally held truth. The authors go further, stating that the conditions of medical practice are tempting physicians to abandon their commitment to the primacy of patient welfare. These are very strong words. Whether they are strictly true for the profession as a whole is almost beside the point. Each physician must decide if the circumstances of practice are threatening his or her adherence to the values that the medical profession has held dear for many millennia. Three Fundamental Principles set the stage for the heart of the charter, a set of commitments. One of the three principles, the principle of primacy of patient welfare, dates from ancient times. Another, the principle of patient autonomy, has a more recent history. Only in the later part of the past century have people begun to view the physician as an advisor, often one of many, to an autonomous patient. According to this view, the center of patient care is not in the physician’s office or the hospital. It is where people live their lives, in the home and the workplace. There, patients make the daily choices that determine their health. The principle of social justice is the last of the three principles. It calls upon the profession to promote a fair distribution of health care resources. There is reason to expect that physicians from every point on the globe will read the charter. Does this document represent the traditions of medicine in cultures other than those in the West, where the authors of the charter have practiced medicine? We hope that readers everywhere will engage in dialogue about the charter, and we offer our pages as a place for that dialogue to take place. If the traditions of medical practice throughout the world are not congruent with one another, at least we may make progress toward understanding how physicians in different cultures understand their commitments to patients and the public. Many physicians will recognize in the principles and commitments of the charter the ethical underpinning of their professional relationships, individually with their patients and collectively with the public. For them, the challenge will be to live by these precepts and to resist efforts to impose a corporate mentality on a profession of service to others. Forces that are largely beyond our control have brought us to circumstances that require a restatement of professional responsibility. The responsibility for acting on these principles and commitments lies squarely on our shoulders. —Harold C. Sox, MD, Editor
384 citations
02 Oct 2012
TL;DR: This discussion paper aims to help inform and stimulate discussion in the field of regenerative medicine by exploring the role of immune checkpoints in the development of central nervous system disease.
Abstract: The views expressed in this discussion paper are those of the authors and not necessarily of the authors' organizations or of the Institute of Medicine. The paper is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine and is not a report of the Institute of Medicine or of the National Research Council.
369 citations
"Principles Supporting Dynamic Clini..." refers background in this paper
...Improved measurement will enable teams to grow in their capacity to fulfill the principles, facilitate the spread, improve the research, and refine evaluation of the highvalue elements of team-based care” (3)....
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...Efforts should be made to address the “deficiency in the availability of validated measures with strong theoretical underpinnings for team-based health care” (3)....
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...Research should be directed at “determining the specific practices that achieve the best outcomes and cost savings for particular patients in a given setting” (3)....
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...This frankness allows the team to inventory the discipline-specific assets of team members and ensure that they are creatively aligned with the team’s shared goals” (3)....
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...Optimal effectiveness of clinical care teams requires a culture of trust; shared goals; effective communication; and mutual respect for the distinct skills, contributions, and roles of each member (3)....
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