Chapter 26 Multidisciplinary clinical decision making
Clinical decision making (CDM) often occurs in multidisciplinary modes, with collaboration among health professionals being required to make clinical decisions including diagnoses, treatment goals, management plans and evaluation of progress. A common context for multidisciplinary CDM is the healthcare team. The aim of this chapter is to consider: (a) the nature and place of multidisciplinary CDM in health care; (b) organizational parameters of decision making in multidisciplinary teams; and (c) interpersonal aspects required of health professionals participating in multidisciplinary CDM.
In this chapter we draw on the findings of two doctoral research projects (by the authors Anne Croker and Stephen Loftus) investigating multidisciplinary CDM using a phenomenological approach. The focus of the first project is collaboration in rehabilitation healthcare teams (Croker & Higgs 2005). Quotes below marked (AC) are derived from this research project. The second project (Loftus 2006; Loftus & Higgs 2004, 2005) involved a study of CDM in a multidisciplinary pain clinic.
The growing complexity of health care, involving escalating healthcare costs, rapid technological advances and the proliferation of highly accessible internet medical information, as well as the increasing incidence of co-morbidities and chronic conditions in ageing populations, have together resulted in increased opportunities for and reliance on multidisciplinary CDM. Two areas in particular where collaborative decision making is prominent are multidisciplinary pain centres and rehabilitation teams. There has been a dramatic increase in the number of multidisciplinary pain centres around the world in recent decades (Loeser et al 2001); this has been attributed to a growing realization that management of problems experienced by patients with chronic pain, such as physical deconditioning complicated by psychosocial issues, are beyond the capability of a single health professional and need a coordinated team approach to be adequately addressed. Rehabilitation teams, although not a recent phenomenon, are much in evidence in 21st century health care, for today they face challenges such as coping with economic restrictions and accountability, and dealing with issues of specialization alongside difficulties in recruiting team members for remote and rural workplaces (Australian Health Workforce Advisory Committee 2006, Gans 2003).
The term multidisciplinary CDM refers to the process in which individuals from different healthcare disciplines collaborate to diagnose problems and manage patients’ care. In this chapter, collaboration is understood to be the cooperative act of working with one another. Multidisciplinary CDM is collaborative in nature; however, we use the term multidisciplinary here to distinguish this process from collaborative decision making (as discussed in Chapter 4), where the focus is on direct collaboration between one or more practitioners and a patient and where the goal is to engage in participative decision making with the patient. The context of collaborative decision making is emancipatory practice. In multidisciplinary CDM, the patient may or may not be seen as a team member and the practice model may vary from biomedical to biopsychosocial to emancipatory approaches; the focus of multidisciplinary CDM is on collaboration among practitioners to make decisions that build on their various disciplinary strengths and expertise.
Multidisciplinary CDM is a complex process in which many factors must be coordinated, including the different skills and experience of a number of health professionals, in order to address the complexity of patients’ problems and organizational contexts. For example, an established team of experienced health professionals, with a clear understanding of disciplinary roles, responsibilities and communication styles, can plan and coordinate the clinical management of an uncomplicated patient condition with ease and familiarity, perhaps initially via a team meeting followed up by informal discussions and emails. Such collaboration may appear deceptively straightforward. However, even apparently straightforward collaboration for multidisciplinary CDM relies extensively on the participating health professionals’ prior experience of practice and collaboration, together with knowledge of self, other disciplines in the team, individuals in the team, team procedures and context. Collaborative processes may be more challenging when collaborating individuals are dealing with complex patient situations or are establishing their understanding of their discipline, self, others, team and context, or when the focus of the multidisciplinary CDM involves areas of conflict or territorial issues. In these situations, multidisciplinary CDM may require skilled communication and negotiation.
With the increasing specialization of health professions, job transferability and demand for coordination of healthcare services, health professionals may be required during their career to collaborate in a range of different types of teams in different organizational contexts. Multidisciplinary CDM commonly occurs in the context of healthcare teams. Teams of health professionals from different disciplines work in various contexts to provide a range of health service functions. A team is considered here in its broadest sense to be a collective of health professionals regularly collaborating for patient care. Accordingly, teams can take on different structures, memberships and modes of operation, such as:
Organizations have systems and processes that support (or at times inhibit) sharing of information, team structures, and departmental boundaries, all of which impact on multidisciplinary CDM. An understanding of different organizational features assists health professionals to adapt to and negotiate different processes of multidisciplinary CDM.
Multidisciplinary CDM requires effective use of available communication processes and procedures. Sharing of information between collaborating health professionals is a basic requirement of multidisciplinary CDM. The means by which information is formally and informally shared within an organization may depend on available resources, employer and employee preferences, and ethical and legal obligations. For example, assessments, diagnostic reports, progress reports, discharge reports and referrals are different formal written systems that fulfil the dual purpose of information sharing and organization or discipline accountability (McAllister et al 2005). Case conferences and team meetings are formal processes for verbal information sharing, and facilitate face-to-face concurrent multidisciplinary CDM.
Informal communication systems are also used to share information and build relationships between disciplines; these include phone, email, shared work spaces and opportunities for socializing. For example, Cook et al (2001) reported that geographical proximity of a shared open-plan office enhanced timely sharing of information between members of a community health team, and Ellingson (2003) highlighted the importance of ‘backstage communication’ in building collegial relationships in a geriatric oncology team. Informal communication systems also provide a more flexible means of communication than formal case conferences and can facilitate micro-negotiations between team members (Ellingson 2003). There can also be a purposefully opportunistic element in informal communications systems, as evidenced by a rehabilitation team member’s comment: ‘I guess in terms of interaction with the other team members it would be more be bumping into each other and having a quick chat about things.’ (AC)
Underpinning multidisciplinary CDM is a range of factors supporting communication which need to be understood and mastered. One of these is the structure of the team itself. Structures are commonly either distributed (e.g. horizontal) or hierarchical. The decision-making power within a team is more evenly spread when the team’s structure is horizontal and supportive of egalitarian, cooperative teamwork compared with a hierarchical structure with bureaucratic channels of decision making controlled by higher status professionals (Cook et al 2001, Cott 1998). A rehabilitation doctor described decision making at a team meeting as follows, providing an example of shared control for team decision making: ‘We all have an understanding of what everyone else’s thoughts and approach are to a patient, and what our individual goals are, so that we can all sit down and work out together what our overall goals are, to incorporate that together as a joint approach, and get the best outcome for a patient.’ (AC)
Acute care hospital teams tend to work within a more task-oriented hierarchical structure in which the primary CDM control is commonly held by medical staff. Research into collaborative decision making in acute care situations has predominantly focused on intensive care situations. For example, Baggs & Schmitt (1997, p. 76) reported that medical residents in an acute medical intensive care unit saw themselves as the primary decision makers, one saying: ‘The ultimate responsibility, legally and, you know, emotionally lies with the house officer’. Other researchers have reported low levels of collaboration between nurses and physicians, with collaboration tending to be the exception rather than the dominant practice, and with nurses providing input into physicians’ decisions rather than collaborating in the decision-making process (Chaboyer & Patterson 2001, Higgins 1999, Kennard et al 1996, Thomas et al 2003).
Low levels of collaboration for decision making can also be found in rehabilitation teams. In Anne’s study a rehabilitation specialist reported, ‘I can remember distinctly, when I was an intern, the consultant telling the therapists exactly what was going to happen.’ However, his experience in another team was different: ‘the therapists ran the whole [meeting], the consultant gave advice when requested’, and he subsequently preferred ‘the unobtrusive approach, the consultant that sits there and is willing to listen more than talk’. (AC)
Power differences between professions within a hierarchical structure have been identified as contributing to low levels of collaboration between medical and nursing staff, and medical and social work staff in acute care settings (Abramson & Mizahi 2003, Baggs & Schmitt 1997). However, such power differences are not necessarily consistent across professions. Abramson & Mizahi found that, although not the dominant pattern, some physicians in metropolitan hospitals did share responsibility and decision making with other professional groups. An awareness of power differences within a team and the implications of these differences for decision making, enables team members to understand their ‘allocated’ role in multidisciplinary CDM, and may provide the basis for negotiation of decision-making roles within the team.
Team supervision or management can influence decision making in teams (Hyrkas & Appelqvist-Schidlechner 2003). There does not appear to be one ideal team management structure for enhancing decision making for all teams. For example, Cook et al (2001) noted that community primary health teams demonstrated an evenness of power distribution in decision making when the teams moved from a nurse manager model to a self-managed model. In contrast, Hyrkas & Appelqvist-Schidlechner found that some health professionals perceived an improvement of joint decision making following the introduction of team supervision. There is no guarantee that an egalitarian approach to teamwork will result in shared leadership and decision making; it could result in chaos, ineffectual decision making and disorder as people jockey for power or sit back and provide no leadership input. Improving collaboration in multidisciplinary CDM may require a review of team management in relation to the model of team management used, the context of the team and the power relationship between team members.
Some healthcare teams rely on clinical practice guidelines to standardize decision-making points and thus decrease the need for collaborative decision making. Grumbach & Bodenheimer (2004) claimed that a single specialty primary care practice with clear role delineation and clear divisions of labour can minimize the collaborative component of multidisciplinary CDM by ensuring that team members have defined tasks, task training, systems to support practice tasks, effective communication, on-the-job team training and time for team training. They reported that in this context, cohesive primary care teams could be formed where ‘team members do not attend endless team meetings’ (p. 1248). However, for many healthcare teams the diversity of clinical situations and patient needs precludes such a task-oriented structure, and regular team meetings provide a welcome and positive avenue for the dialogue required for collaborative multidisciplinary CDM.