One of the newest features from JBJS Reviews is the “Team Approach” article. Team Approach articles highlight the individual and collective importance of the multiple physician and nonphysician providers who are involved in the care of a patient. Determining how the multidisciplinary interactions and contributions are key to the understanding of a medical condition and its treatment can be essential to a successful musculoskeletal health process.
In the July 2016 issue of JBJS Reviews, Pinzur et al. describe the team approach to the treatment of diabetic foot ulcers. The authors note that an estimated 29.1 million people in the U.S. have diabetes and that, at any point in time, 3% to 4% have a foot ulcer, both of which are sobering statistics. Diabetic foot ulcers and their associated infections lead to >70,000 lower-extremity amputations yearly. Between one-third and one-half of diabetic patients undergoing major lower-extremity amputation will die within 2 years after the amputation. In order to most effectively deal with this devastating outcome, a team approach with multidisciplinary involvement is needed.
It is now accepted that the best-performing health systems are those that address challenges by developing a strategy of population management in which patients with resource-consuming medical conditions receive care across multiple medical disciplines. This strategy begins with the identification of modifiable risk factors. The most efficient patient-safety methodology for avoiding complications following surgery is to operate on healthier patients. Indeed, if we look at our orthopaedic trauma colleagues as an example, we see that survival rates and patient outcomes following hip fracture have improved since the development of systems that rapidly optimize patients prior to operative repair. This experience has taught us how important it is to have a hospitalist co-managing our orthopaedic patients. Similarly, our arthroplasty colleagues have learned that outcomes are worse and complications rates are increased in patients who have multiple medical comorbidities. Prior to urgent surgery, many of these medical conditions can be stabilized. Thus, the most proactive health systems are those that use interventions to identify and minimize health risk. When modifiable risk factors are improved, patient safety is improved.
Pinzur et al. reintroduce the concept of the so-called diabetic educator. The responsibilities of the modern diabetic educator have progressed from simple patient education on diet, glycemic control, and lifestyle change to using the educator-patient relationship to empower the educator to serve as a patient navigator/case manager. The diabetic educator and the physician also work closely with a certified pedorthist. This provider’s knowledge and skill of health maintenance through the use of therapeutic footwear are important in the prevention and treatment of diabetic foot ulcers. Patients are taught to self-examine their feet, and this level of empowerment becomes important from a psychosocial perspective.
The primary surgeon is the “captain of the ship,” and it is his or her responsibility to coordinate the management and the function of the multidisciplinary team. It is important to identify the roles of the consultants such as the certified pedorthist (who will provide guidelines on therapeutic footwear and prefabricate a custom foot orthosis as needed), the vascular surgeon (who will be needed for patients with a nonhealing foot ulcer and a nonpalpable pedal pulse), the radiologist (who will be essential for suggesting imaging modalities for understanding the disease and its progression), the infectious disease specialist (who will guide duration of therapy and monitor associated antibiotic-induced organ-system morbidity), and the plastic surgeon (who may have unique requirements for wound care and developing relationships in clinical-care algorithms).
The multidisciplinary team approach involves the use of a consistent strategy throughout the hospital or health system. This is the first step in an attempt to decrease the negative impact on quality of life and resource consumption and is essential to diabetic foot care.
Thomas A. Einhorn, MD
Editor, JBJS Reviews
The 9th annual Epocrates Future Physicians of America Survey from athenahealth polled more than 1,400 medical students about clinical teamwork, among other topics. A whopping 96% of respondents said that collaborating with “extended care teams”—members of which might include nurses, PAs, and medical staff—is important or very important to the delivery of high-quality care. Forty-three percent cited fragmented care as the number-one risk factor for compromised patient safety, with cost of care and medication non-compliance coming in a distant second and third, respectively. And, apparently aware of the shift toward financial incentives for better outcomes arising from team-based care, 67% rated care coordination as important or very important for a physician’s financial success.
However, 57% of respondents cited inadequate cross-team communication as the number-one barrier to coordinated care, with a lack of interoperability among current EHR systems cited by 42% as the primary hurdle. On a more positive note, the survey found that 86% of respondents felt that their medical training prepared them for patient-centered care, a model that stresses patient and family involvement in shared decision-making.
The survey also asked students about their awareness of accountable care organizations (ACOs). According to the American College of Physicians, “the core purpose of an Accountable Care Organization is to provide accessible, effective, team-based integrated care.” Yet, according to the survey, 65% of medical students feel they don’t know enough about ACOs. That’s down from 72% in last year’s survey, but it’s still a sizable proportion. Another 39% admitted that they are unsure about the purpose or structure of ACOs.
In two miscellaneous findings that reveal ambivalence among medical students regarding the personal versus technological in medical practice, 99% of respondents said they would prefer a face-to-face office visit over a virtual encounter for an initial patient interaction, while at the same time 97% said they would encourage patients to use remote monitoring devices such as those now available for tracking weight, physical-activity levels, blood sugar, and vital signs.