Whose Choosing the Team?

There is no doubt in my mind that our childhood experiences determine to a significant degree, life-long attitudes. Take my lack of faith in the much toted “team approach” to medicine. When I was a child and grew up on a mixed farm in Saskatchewan, I and my older brother by three years had a long list of chores. Some of these chores were specific to each of us individually and some were things that simply needed to be done by us jointly. My brother learned early on that if he procrastinated or simply abdicated his responsibilities, I would eventually make sure everything was done by the time our parents returned. It was not lost on me, even at a young age; if everything was done there was joint approval, if things were not done, my parents expected me to have looked after it. This did not raise warm fuzzy feelings in me towards my brother or my parents.
The bottom line is that responsibility will usually end up with those people that “feel” responsible, not necessarily with those that “are: responsible. The corollary to this is the people who assign the tasks and expect the results are always more concerned as to whether the results are achieved, than they are as to how that came about.
Some fifteen to twenty years ago Calgary was already experiencing a shortage of Psychiatrists (this may have something to do with the fact that psychiatrists have traditionally been the lowest paid of all specialists in our health care system). As a response to this, the psychiatric department at the Holy Cross hospital decided they would take a “team” approach” on the inpatient psychiatric unit. There would be an “intake worker”, psychiatric nurses would counsel the patients, the admitting family doctor would write the orders, and the “psychiatrist on call” would be the team and patient consultant. In this scenario, as can be seen, the admitting physician had no say in the personnel on the team that was to attend the patient.
About this time I had a patient who had many anger issues, was somewhat paranoid, and I thought posed a threat to herself and possibly society as a whole. After considerable discussion she agreed to be admitted. Within two days of her admission the “team” felt she should be discharged but I would not comply. Complaints went to the department head and administration and when I demanded reasons for the discharge, I was told “she is disrupting our program”. I told them I would not comply unless the psychiatrist involved agreed to take a more active role in the “out patient” setting. When this agreement was reached and set up the patient was discharged. I was certainly left with the impression the “program” was more important than my patient.
Several days later, at approximately 3:00A.M., her room mate phoned me and said my patient had left the apartment with a gun, and her parting words were:“ I’m going to go out and kill myself some people”. I phoned the psychiatrist involved and was told there was nothing to do unless the patient actually did something. I phoned the police department and got the same answer to my concern. Naïve me, I thought taking a gun and threatening the good citizens with death was “doing something”. I guess you have to name the person you intend to kill and fire off at least one warning shot to reach the “doing something” yardstick.
Anyway, over the next few days my sleepless nights were rewarded with no drastic headlines in the newspapers, and I was able to get my patient to return to my office. With considerable time and effort I convinced her of the wisdom of a voluntary admission to the Ponoka Mental hospital. She finally agreed and spent one month under their care and was discharged. Since the active treatment wards of acute care, and their team concept was to coordinate the institutional care with the patient’s introduction back to the community, an attempt was made to have her discharged from Ponoka to the Holy Cross psychiatry unit, and then facilitate her integration into the community and set up a follow up community program. I was told once again that the unit would not oblige in this plan since their last experience with this patient caused a disruption in their program. The patient subsequently was discharged directly to the community, and was lost to follow up.
I never did see her again. She probably rightly felt that I and the system (team?) had failed her, and rightly so. Patients will lay failure at the feet of those from whom they expected help. In our “new team concept of primary health care” who will the patient expect results from? I think the answer is “whoever shows and feels the most responsibility”. Will there be someone on the “team”?
As I practiced medicine in Calgary I developed over the years a team of “like minded” specialists and care givers to assist me in patient care. This included office staff, specialists and many other health care providers. I did this through choice, observing and working with various people so that as the years went by I can say that my “team” was as thoughtfully and thoroughly chosen as any professional sports team. I was reminded of this by my patients when I retired. Many of them not only thanked me for my years of care, but also thanked me for the wonderful people that I had referred them to in the past.
Do I have confidence in the modern day concept of the team approach? Keep in mind you will see the person in the team that a triage person feels appropriate. Keep in mind you will see the specialist that has the shortest waiting list. I suppose I have as much confidence in this approach as I would of choosing a hockey team to win the Stanley cup comprised of players who weren’t anybodies draft pick.