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Total Patient Care: Just A Dream?
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.
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Joan E. Edelstein, MA, PT, FISPO |
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"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?
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Kevin Carroll, MS, CP, FAAOP |
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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 
Table Of Contents - December 2003
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