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Building a Better Team


By Carole Bartoo
July 2009

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In his commencement address on May 8, Jeff Balser, M.D., Ph.D., vice chancellor for Health Affairs and dean of Vanderbilt University School of Medicine, told graduates he was counting on them to shape the future of medicine, and that their success will depend on their ability to be part of a team.

“Your degree does not earn it and being the most superior competitor won’t earn it. The raw horsepower of your brain matter won’t earn it. Humility will earn it,” Balser said. “Being a member of the team is something you have to earn every day.”

Never before has the concept of team building been as important in health care as it is now.

“More and more primary care doctors are having serious thoughts about leaving the profession,” said Peter Buerhaus, R.N., Ph.D., director of Vanderbilt’s Center for Interdisciplinary Health Workforce Studies. “It’s like a volcano, we’ve seen the cracks and rumblings and small earthquakes that come before the explosion.”

Peter Buerhaus, R.N., Ph.D., director of Vanderbilts Center for Interdisciplinary Health Workforce Studies, says the health care team needs each others strengths.

Peter Buerhaus, R.N., Ph.D., director of Vanderbilts Center for Interdisciplinary Health Workforce Studies, says the health care team needs each others strengths.

Buerhaus and others at Vanderbilt are saying it is time to restructure the health care team, to open up the definition of a health care provider and to create teamwork with less focus on stratified roles and levels of power.

The Institute of Medicine Committee on the Future of Primary Care defines primary care using the term “clinician” rather than “physician,” signaling a shift toward using mid-level providers, such as advanced nurse practitioners and physician assistants, to fill the gap left by primary care physicians.

Leaders at both Vanderbilt’s School of Nursing and School of Medicine are working together to establish mutual respect for broader roles. Linda Norman, D.S.N., R.N., senior associate dean of the Vanderbilt School of Nursing, says battles over turf and scope of practice have diminished already.

“We have been approached by colleagues throughout the Medical Center to see how advanced practice nurses can be part of the practice model. They know there will not be enough oncologists, nephrologists and other physicians,” Norman said. “As access decreases, costs will increase. If you build a practice model that includes advanced practice nurses, it will be more cost effective.”

It may take some getting used to, but patients are accepting the widening role of nurse practitioners.

Linda Norman, D.S.N., R.N., senior associate dean of the Vanderbilt School of Nursing, encourages the inclusion of advanced practice nurses in the practice model. Photo by Dean Dixon.

Linda Norman, D.S.N., R.N., senior associate dean of the Vanderbilt School of Nursing, encourages the inclusion of advanced practice nurses in the practice model. Photo by Dean Dixon.

“I heard two older ladies chatting. One was telling the other she needed to come to see Ken Watford at the Vanderbilt Ear, Nose and Throat (ENT) practice. She used the term ‘doctor’ by mistake, although I am sure she was aware that Ken is an advanced nurse practitioner,” Norman said. “The point is that the title was less important to this patient, in this case, than the quality of the care she received.”

“That happens all the time,” Watford said about the misuse of his title. “I fought that battle a long time ago, but I gave up. I tell people they can call me Ken.”

Watford, who was the first nurse practitioner hired into any Vanderbilt surgical sub-specialty nine years ago, sees patients at the ENT clinic in Medical Center East. He received his master’s degree in family practice nursing at Vanderbilt, and then was hired by former chair of Otolaryngology, Robert Ossoff, M.D.

“We had some debates about these emerging models,” recalls Ossoff. “I had this vision that we needed a primary care person to be our gatekeeper. We went to the residents but could not convince them to do this. They thought they might not get any of the good surgical cases, so I decided I wanted a nurse practitioner.”

The physicians in ENT developed an intense program to train Watford as a medical otolaryngologist. He performs minor procedures, makes assessments, provides diagnoses and writes prescriptions. Watford’s skills, and those of other nurse practitioners, have allowed physicians to spend more time meeting the surgical needs of their patients.

In the Department of Obstetrics and Gynecology (Ob/Gyn), midwifery and advanced practice have gone well beyond helping physicians see more patients. In 2006, the Division of Midwifery and Advanced Practice (MWAP) became the first Vanderbilt division completely comprised of non-physicians.

“I think we are in the forefront in the nation. Our nurse midwives and our nurse practitioners are faculty members in the School of Medicine. They work sideby- side with our physician faculty in providing normal obstetric care. They teach our residents and medical students,” said Howard Jones, M.D., chair of the Department of Ob/Gyn. “I will tell you honestly it hasn’t been without bumps in the road, but it is a worthwhile model.”

Despite the bumps along the way, MWAP director, Deborah Wage, M.S.N., said the Department of Ob/Gyn is paving the way for a new model of teamwork.

“We are multidisciplinary, and all of us need to start acting as such. We are learning to appreciate we cannot have silos,” Wage said.

The numbers and varieties of midlevel providers are growing rapidly and include physician assistants like Whitney Reynolds, PA-C.

Reynolds has a Master of Science degree in Physician Assistant Studies and specialty training in cardiology. Her job is to extend the reach of the physicians by performing many of the clinical tasks needed to keep the busy Electrophysiology Lab running efficiently.

“I offer continuity so patients see one person who ties all the specialists together,” Reynolds said. “The scope of what I do is determined by the physicians I work for.”

The ever changing picture of the health care team now resembles a full, branching tree so it makes sense that the place to promote change is at the root of health care training: universities and medical schools.

“One hundred years from now, we might not have schools of medicine and schools of nursing,” Wage speculated.

Bonnie Miller, M.D., senior associate dean for Health Sciences Education at the Vanderbilt School of Medicine, agrees.

“Maybe the system is antiquated, and it is time to tear the whole thing down. A new model would not look at your title; it would look at your training. I think we have to be in the business of challenging assumptions. We won’t be able to meet the needs of the population without teamwork and thinking about who is best suited for the tasks at hand.”

It may not be possible to level the educational playing field just yet, but Miller figures she can at least introduce the players to one another. One of Miller’s successes is a new chronic care course in which family nurse practitioner (F.N.P.) students are paired with medical students to care for chronically ill patients for a year or longer.

Medical student Rafal Sobota, left, and nursing student Lisa Bolton were partners in the yearlong Chronic Care course. Here they check on patient Hildra Robinson. Photo by Joe Howell.

Medical student Rafal Sobota, left, and nursing student Lisa Bolton were partners in the yearlong Chronic Care course. Here they check on patient Hildra Robinson. Photo by Joe Howell.

First-year M.D./Ph.D., student Rafal Sobota partners with F.N.P. student Lisa Bolton. When asked about being paired with a “mid-level provider” Sobota said he didn’t like the use of stratified terms.

“I don’t understand that. It isn’t one is the boss over the other; we just have different training and different roles,” Sobota said. “I plan to go into global health. Around the world most of the health care is delivered by nurses. I will be working very closely with them.”

Sobota knows that few classmates in medical school are headed for primary care. “Most of my classmates are very ambitious; they want the knowledge to become the expert, to sub specialize.”

Bolton says building a new foundation for teamwork within higher education is a good idea. “In general, college students are idealistic and very well prepared to work together. The holistic model of nursing education prepares students so well for working collaboratively.”

Buerhaus soberly reminds us that time is limited to decide where to spend the ever-shrinking resources in knitting together a health care net for 80 million baby boomers who are aging every day.

“There is no clear consensus about the physician shortage. Meanwhile, we have not done a good job of employing federal or other funds to address the shortage of R.N.s,” Buerhaus said. “We will all need each other’s strengths if we are to respond to the need.”

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