Abstract
Background:
Nonspecific chronic low back pain (CLBP) is a highly prevalent and costly public health problem with few treatment options that provide consistent and greater than modest benefits. Treatment of CLBP is shifting from unimodal to multimodal and multidisciplinary approaches, including biopsychoso-cially-based complementary and integrative care. Multidisciplinary approaches require unique levels of communication and coordination amongst clinicians; however, to date few studies have evaluated patterns of communication and decision making amongst clinicians collaborating in the care of challenging patients with CLBP.
Methods:
As part of an observational study evaluating the effectiveness and cost-effectiveness of an integrative, team-based care model for the treatment of CLBP, we used multiple qualitative research methods to characterize within-team cross-referral and communication amongst jointly-trained practitioners representing diverse biomedical and complementary disciplines. Patterns of communication and coordinated care are summarized for 3 cases of CLBP treated by multiple members (≥3) of an integrative medical team embedded within an academic hospital.
Results:
Patients were aged from 36 to 88 years with varied comorbidities. Qualitative content analysis revealed 5 emergent themes regarding integrative patient care and treatment decision in this clinic: (1) the fundamental importance of the clinic's formal teamwork training; (2) the critical communicative and collaborative function of regular team meetings; (3) the importance to patient care goals of having the varied disciplines practicing “under one roof”; (4) a universal commitment to understanding and treating patients as whole persons; and (5) a shared philosophy of helping patients to help themselves. These key themes are all interconnected and form the foundation of the clinic's culture.
Conclusions:
Our qualitative findings provide context for current trends in enhancing patient-centered, coordinated, and team-based care; efforts towards better understanding interprofessional communication; overcoming barriers to successful collaboration; and identifying best practices for fostering clinical teamwork and a strong team identity. Our findings also support the need for further qualitative research, in combination with quantitative research, for evaluating the effectiveness and cost-effectiveness of resource-intensive integrative models for the treatment of chronic conditions.
Keywords: Clinician communication, collaborative care, coordinated care, back pain, qualitative research
Abstract
Antecedentes:
el dolor lumbar crónico (chronic low back pain, CLBP) no específico es un problema de salud de gran prevalencia y coste público con pocas opciones terapéuticas que proporcionen beneficios consistentes y evidentes. El tratamiento del dolor lumbar crónico está cambiando desde enfoques unimodales a enfoques multimodales y multidisci-plinarios, incluida la atención de tipo biopsicosocial complementaria e integral. Los enfoques multidisciplinarios requieren niveles únicos de comunicación y coordinación entre médicos; sin embargo, hasta la fecha pocos estudios han evaluado los patrones de comunicación y toma de decisiones entre los clínicos que colaboran en la atención de pacientes con dolor lumbar crónico difíciles.
Métodos:
como parte de un estudio observacional que evalúa la efectividad y rentabilidad de un modelo integral de atención para el tratamiento del dolor lumbar crónico realizado en equipo, utilizamos múltiples métodos de investigación cualitativos para caracterizar las referencias cruzadas y la comunicación intragru-pales entre médicos que representan diversas disciplinas biomédicas y complementarias que habían recibi-do formación conjuntamente. Los patrones de comunicación y aten-ción coordinada se resumen para tres casos de dolor lumbar crónico trata-do por varios (13) miembros de un equipo médico integral que formaba parte de un hospital docente.
Resultados:
los pacientes tenían edades comprendidas entre los 36 y los 88 años, y diversas comorbilidades. El análisis cualitativo del con-tenido reveló cinco temas emergentes respecto a la atención integral del paciente y la decisión acerca del tratamiento en esta práctica clínica: 1) la importancia fundamental del adiestramiento formal del equipo de trabajo; 2) la función de comuni-cación y colaboración crucial que representan las reuniones regulares del equipo; 3) la importancia para los objetivos de atención del pacien-te de tener las diversas disciplinas ejerciendo “bajo el mismo techo”; 4) un compromiso universal para com-prender y tratar a los pacientes como personas completas; y 5) una filosofía compartida de ayudar a los pacientes a ayudarse a sí mismos. Todos estos temas clave están inter-conectados y constituyen la base de la cultura de la práctica clínica.
Conclusiones:
nuestros hallazgos cualitativos proporcionan contexto para las tendencias actuales de poten-ciar la atención centrada en el paciente, coordinada y realizada en equi-po; los esfuerzos hacia una mejor comprensión de la comunicación interprofesional; la superación de las barreras para conseguir una colabo-ración que tenga éxito; y la identificación de las mejores prácticas para fomentar el trabajo en equipo clínico y una fuerte identidad grupal. Nuestros hallazgos también res-paldan la necesidad de una mayor investigación cualitativa, junto con la cuantitativa, para evaluar la efectividad y rentabilidad de los modelos integrales que consumen grandes cantidades de recursos para el tratamiento de las afecciones crónicas.
References
- 1.Morlion B. Chronic low back pain: pharmacological, interventional and surgical strategies. Nat Rev Neurol. 2013; 9(8): 462–73. [DOI] [PubMed] [Google Scholar]
- 2.Waddell G. Biopsychosocial analysis of low back pain. Baillieres Clin Rheumatol. 1992; 6(3): 523–57. [DOI] [PubMed] [Google Scholar]
- 3.Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000; 85(3): 317–32. [DOI] [PubMed] [Google Scholar]
- 4.Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007; 133(4): 581–624. [DOI] [PubMed] [Google Scholar]
- 5.Gaboury I, Lapierre LM, Boon H, Moher D. Interprofessional collaboration within integrative healthcare clinics through the lens of the relationship-centered care model. J Interprof Care. 2011; 25(2): 124–30. [DOI] [PubMed] [Google Scholar]
- 6.Mulkins AL, Eng J, Verhoef MJ. Working towards a model of integrativehealth care: critical elements for an effective team. Complement Ther Med. 2005; 13(2): 115–22. [DOI] [PubMed] [Google Scholar]
- 7.Keshet Y, Ben-Arye E, Schiff E. The use of boundary objects to enhance interprofessional collaboration: integrating complementary medicine in a hospital setting. Sociol Health Illn. 2013; 35(5): 666–81. [DOI] [PubMed] [Google Scholar]
- 8.O'Connor BB, Levy DB, Eisenberg DM. Case study: Osher Clinical Center for Complementary and Integrative Medical Therapies. In: Beyond the checklist: what else healthcare can learn from aviation safety and teamwork. Ithaca, NY: Cornell University Press; 2013; 102–16. [Google Scholar]
- 9.Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005; 15(9): 1277–88. [DOI] [PubMed] [Google Scholar]
- 10.Pope C, Mays N. Analysing qualitative data. In: Pope C, Mays N, editors. Qualitative research in health care. 3rd ed. London: BMJ Books; 2006: 63–81. [Google Scholar]
- 11.Beaton DE, Clark JP. Qualitative research: a review of methods with use of examples from the total knee replacement literature. J Bone Joint Surg Am. 2009;91 Suppl 3:107–12. [DOI] [PubMed] [Google Scholar]
- 12.Gordon S, Mendenhall P, O'Connor BB. Beyond the checklist: what else healthcare can learn from aviation safety and teamwork. Ithaca, NY: Cornell University Press; 2013. [Google Scholar]
- 13.Hutchins E. Cognition in the wild. Cambridge: The MIT Press; 1995. [Google Scholar]
- 14.Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf. 2006; 32(11): 646–55. [DOI] [PubMed] [Google Scholar]
- 15.Philibert I. Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications. Qual Saf Health Care. 2009; 18(4): 261–6. [DOI] [PubMed] [Google Scholar]
- 16.Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013; 310(21): 2262–70. [DOI] [PubMed] [Google Scholar]
- 17.Bell IR, Caspi O, Schwartz GE, et al. Integrative medicine and systemic out-comes research: issues in the emergence of a new model for primary health care. Arch Intern Med. 2002; 162(2): 133–40. [DOI] [PubMed] [Google Scholar]
- 18.Boon H, Verhoef M, O'Hara D, Findlay B, Majid N. Integrative healthcare: arriving at a working definition. Altern Ther Health Med. 2004; 10(5): 48–56. [PubMed] [Google Scholar]
- 19.Friedson E. Profession of medicine: a study in the sociology of applied knowledge. New York: Harper & Row; 1970. [Google Scholar]
- 20.Bloom S. The medical center as a social system. In: Vincent RH, Coombs CE, editors. Psychosocial aspects of medical training. Springfield, IL: Charles C. Thomas; 1971. [Google Scholar]
- 21.McCreary JF. The health team approach to medical education. JAMA. 1968; 206(7): 1554–7. [PubMed] [Google Scholar]
- 22.Szasz G. Interprofessional education in the health sciences. A project conducted at the University of British Columbia. Milbank Mem Fund Q. 1969; 47(4): 449–75. [PubMed] [Google Scholar]
- 23.Grant RW, Finochio LJ. California Primary Care Consortium Subcommittee on Interdisciplinary Collaboration. Interdisciplinary collaborative care teams in primary care: a model curriculum and resource guide. San Francisco, CA: Pew Health Professions Commission; 1995. [Google Scholar]
- 24.Clark PG. Values in health care professional socialization: implications for geriatric education in interdisciplinary teamwork. Gerontologist. 1997; 37(4): 441–51. [DOI] [PubMed] [Google Scholar]
- 25.Arndt J, King S, Suter E, Mazonde J, Taylor E, Arthur N. Socialization in health education: encouraging an integrated interprofessional socialization process. J Allied Health. 2009; 38(1): 18–23. [PubMed] [Google Scholar]
- 26.Reeves L, Lewin S, Espin S, Zwarenstein M. Interprofessional teamwork for health and social care. Oxford: Wiley-Blackwell; 2010. [Google Scholar]
- 27.Goldner M. Integrative medicine: issues to consider in this emerging form of health care. In: Kronenfield J, ed. Health care providers, institutions, and patients: changing patterns of care provision and care delivery (research in the sociology of health care). United Kingdom: Emerald Group Publishing Ltd; 2000: 215–36. [Google Scholar]
- 28.Axelsson R, Axelsson SB. Integration and collaboration in public health—a conceptual framework. Int J Health Plann Manage. 2006; 21(1): 75–88. [DOI] [PubMed] [Google Scholar]
- 29.Bradley F, Elvey R, Ashcroft DM, et al. The challenge of integrating community pharmacists into the primary health care team: a case study of local pharmaceutical services (LPS) pilots and interprofessional collaboration. J Interprof Care. 2008; 22(4): 387–98. [DOI] [PubMed] [Google Scholar]
- 30.Gaboury I, Bujold M, Boon H, Moher D. Interprofessional collaboration within Canadian integrative healthcare clinics: key components. Soc Sci Med. 2009; 69(5): 707–15. [DOI] [PubMed] [Google Scholar]
- 31.Chung VC, Ma PH, Hong LC, Griffiths SM. Organizational determinants of interprofessional collaboration in integrative health care: systematic review of qualitative studies. PLoS One. 2012; 7(11): e50022. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Hollenberg D. How do private CAM therapies affect integrative health care settings in a publicly funded health care system? J Complement Integr Med. 2007;4(1). Doi: 10.2202/1553-3840.1056. [DOI] [Google Scholar]
- 33.McCaffrey AM, Pugh GF, O'Connor BB. Understanding patient preference for integrative medical care: results from patient focus groups. J Gen Intern Med. 2007; 22(11): 1500–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Boon H, Verhoef M, O'Hara D, Findlay B. From parallel practice to integrative health care: a conceptual framework. BMC Health Serv Res. 2004; 4(1): 15. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Hollenberg D. Uncharted ground: patterns of professional interaction among complementary/alternative and biomedical practitioners in integrative health care settings. Soc Sci Med. 2006; 62(3): 731–44. [DOI] [PubMed] [Google Scholar]