Eitan Aziza is a second-year Internal Medicine resident at the University of Alberta.

 

Medicine has become increasingly cognizant of the role of comprehensive and integrated  care in keeping patients well. While medical therapies are essential and prerequisite to care, they are not comprehensive in their reach. Pills are necessary but not sufficient to restore health. Our medical training rightly emphasizes diagnosis and proper prescriptions; it does not provide us a broad view of all the elements needed to deliver comprehensive care. Over the course of our residency, we are given the opportunity to pair with allied health specialities in a 2 week block titled “Multidisciplinary Care Team”. In an environment where residents are steeped in a seemingly all-encompassing training regimen focused on medical therapies, this course represents a difficult shift in focus for many. Suddenly, displaying our own abilities takes a back seat to the skills of others as the emphasis of teaching is adjusted from medical leadership to medical observership. It is a humbling experience that puts our role in the healthcare team in its true context within the multidisciplinary tapestry.

My experiences with Allied Health specialties in the Intensive Care Unit showcased the role of aggressive dietary intervention in patient recovery, with daily planning down to the calorie. The oxygen needs of these critically ill patients were titrated by respiratory therapists in real-time with an emphasis on safely weaning oxygen requirements in the interest of getting them home quickly and safely. While on a ride-along, I witnessed patients being triaged in their homes by EMS in order to rapidly and accurately assess the acuity of their illness, hours before any hospital intervention. This allowed me to understand the patient journey before they reach us in the hospitals and instilled a better appreciation of the extensive network of teams involved in care. At my outpatient rehabilitation placement, clients with neurodegenerative disease participated in complex rehabilitation by experts who understood that every medical insult that befalls these patients is accompanied by a blow to their functional independence. From these experiences, I had the opportunity to reflect on health systems a whole: on how medicine represents a small part of healthcare delivery. Internists spill much ink debating the minutiae of medicine, such as selecting an ideal antibiotic that lends patients the most appropriate coverage of the infectious agent. We are arguably positioned in this way to miss the forest for the trees, often ignoring other equally important factors that will help our patients recover more quickly or allow them to live more independently. The paradigm shift away from disease toward a trajectory of wellness, however, necessitates a self-aware, synergistic approach that incorporates all individual clinical vectors.

Over the course of our residency, we are paired for an intensive two-week period with allied health specialities in a block titled “Multidisciplinary Care Team”. In an environment where residents are steeped in a seemingly all-encompassing training regimen, this course represents a difficult shift in focus for many. Suddenly, showcasing our own skills takes a back seat to others as the emphasis of teaching is adjusted from medical leadership to medical observership. It is a humbling experience that puts our role in the healthcare team in its true context within the multidisciplinary tapestry.

There is a well-described financial model that depicts the concentric levels of global healthcare. The widest circle that encompasses the rest is labeled “policy-wide resolutions”, while the innermost circle is titled “specialized services”. This concept emphasizes that broader initiatives such as sweeping policies are widely accessible by the public and are therefore ideal for investment, while specialized services are often more difficult to expand, as they represent complex needs by fewer members of the population (Figure 1). Over these formative years of my own healthcare training, I have come to realize that patients are often happier, more connected to their loved ones, and in their own natural environments when care is relegated to the most external spheres. Inasmuch as illness pulls them towards the centre of this model, the job of a competent clinician is to safely balance these needs with available resources to keep patients as close to home as possible.  Traditionally, this has not been a part of the medical education curriculum. From my recent experiences, I would advocate for a stronger emphasis on multidisciplinary care as an essential clinical exposure. When one has the opportunity to see physician care in context of the entire healthcare team, one can ultimately learn that wellness extends far beyond curative medicine.

Stenberg, Karin, et al. “Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries.” The Lancet Global Health 5.9 (2017): e875-e887.

As internists who train primarily in hospital, it is frighteningly easy to underappreciate the role of Allied Health professionals and community health outreach in cultivating wellness.  Patient mobility, functionality, dietary requirements and capacity are treated as “dispositional issues” or “barriers to discharge”, obstructions to the completeness of care. . Through MCT, we were provided the time, space, and opportunity to truly reflect on and refine our practice patterns, and, through subsequent facilitated discussions with peers and staff, develop ways to implement these new insights. Having the opportunity to be a part of Allied Health services on their own terms, to understand their own values and complexities, has highlighted to me that, although our decisions in hospital are important to making our patients well, multidisciplinary care is essential in keeping them well. We often look at time between admissions as a marker of disease severity, as though it is a static variable that cannot be controlled. It is perhaps fitting for us, in the interest of developing as well-rounded physicians, to interact with the wider web of healthcare through observation, referral, and joint participation, and thereby ultimately re-orient the trajectory of healthcare for the individual, the hospital, and the community as a whole.