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Creating collaborative learning environments for transforming primary care practices now.

The renewal of primary care waits just ahead. The patient-centered medical home (PCMH) movement and a refreshing breeze of collaboration signal its arrival with demonstration projects and pilots appearing across the country. An early message from this work suggests that the development of collaborative, cross-disciplinary teams may be essential for the success of the PCMH. Our focus in this article is on training existing health care professionals toward being thriving members of this transformed clinical care team in a relationship-centered PCMH. Our description of the optimal conditions for collaborative training begins with delineating three types of teams and how they relate to levels of collaboration. We then describe how to create a supportive, safe learning environment for this type of training, using a different model of professional socialization, and tools for building culture. Critical skills related to practice development and the cross-disciplinary collaborative processes are also included. Despite significant obstacles in readying current clinicians to be members of thriving collaborative teams, a few next steps toward implementing collaborative training programs for existing professionals are possible using competency-based and adult learning approaches. Grasping the long awaited arrival of collaborative primary health care will also require delivery system and payment reform. Until that happens, there is an abundance of work to be done envisioning new collaborative training programs and initiating a nation-wide effort to motivate and reeducate our colleagues.

Keywords: collaboration, patient-centered medical home, primary care teams

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A cold and bitter winter for primary care and the patients it serves nears its end. We still shiver amid the blustery, cool, battering of March rains, but signs of spring and renewal are appearing. An old woman clutches her tattered umbrella. Chilled and wet, a heavy handbag tugging on her arm, she leans into a driving rain, her flapping umbrella offering no protection as she shufties across the parking lot searching for the doctor's office. Four months of wintry weather, loss, illness, and pain took their toll on her worn body. What solace lies ahead if she reaches the door? Who waits for her and are they prepared? How many more doors will she need to visit? Or will a team go out and assure her comfort and care? The old woman represents too many existing primary care practices and their patients. This paper explores how to create learning environments in these practices that can help them transform into collaborative team-based patient centered medical homes.

The primary care physician and his or her office practice stare at menacing forces. The increasing complexity of health care systems and the rise in prevalence of complex illness accompanied by greater fragmentation and subspecialization keeps accelerating and undermines the generalist, holistic capacity of primary care (Stange, 2009). Fortunately, there is also evidence of hopeful change. These emerging signs include the patient-centered medical home (PCMH) movement, a rise in both talk and enactment of collaborative care, and fresh insights about health. We propose that now is a critical moment for primary care to activate the magic of symbiogenesis, the formation and emergence of new organisms through symbiotic mergers, through once-individual life-forms teaming up to become larger wholes (Margnlis, 1998; McCallum, 2008). When the old physician-led primary care practice merges with collaborative care models and understandings of health as process and relationship, a new and larger whole emerges, a relationship-centered PCMH.

Health conventionally refers to the absence of disease and/or the well-being of an individual body. By itself, this conceptualization ignores the inherent dependency of each person on others. An expanded understanding conceives health as the ability to function in relationships appropriate to one's culture and place in the life cycle (Fine & Peters, 2007), the ability to develop meaningful relationships and pursue a transcendent purpose in a finite life (Stange, 2010). Wendell Berry concisely summarizes these ideas with the expression, health as membership (Berry, 2002). This expansive understanding of health helps move the focus from individual and autonomy toward one that embraces physical capabilities, interdependency, and relationship, and offers new energetic possibilities for the biopsychosocial vision of primary care. Similarly, new collaborative care models represent different responses to complexity, ones that seek connection and integration rather than fragmentation. Collaborative care, a combination of the biopsychosocial model and family systems theory (Blount, 1998), has demonstrated effectiveness in complex chronic illness care within community health centers and in mental health care (Kessler & Stafford, 2008a).

The PCMH is, in part, a political construct addressing many disparate, but related special interests and issues including the information technology industry, the chronic care model (Wagner, Austin, & Von Korff, 1996) and the insurance company focus on disease management, consumerism, and the core principles of primary care (i.e., first contact/access, comprehensive, coordinated, personal care; Starfield, Shi, & Macinko, 2005). Multiple state pilots and demonstration projects are active across the United States with more to come since passage of national health care legislation (Patient-Centered Primary Care Collaborative, 2009). Current definitions of PCMH emphasize physician leadership (American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association, 2007), practice improvement instrumentalities (National Committee for Quality Assurance [NCQA], 2008), and serving patients' perceived needs (Davis, Schoenbaum, & Audet, 2005). Although valuable, these definitions and the pilot projects underway seek to modernize existing primary care practices while preserving the social relationship status quo. This will not be enough to get us out of winter; this is not the transformed PCMH that must emerge. This is not symbiogenesis. The inadequacy of this change or remodeling is one of the lessons from the American Academy of Family Physicians' National Demonstration Project (NDP). A truly successful primary care requires transformation in how care is organized and in everyone's roles and mental models, not simply renovation. In addition to the internal motivation of all the collaborative team players, external support from other stakeholders in the form of delivery and payment system changes (e.g., bundled payments) are critical for enabling true transformation (Nutting et al., 2009; Crabtree et al., 2010).

A new symbiogenic PCMH is not about primary care practice as a place but as a collaborative team, a new set of relationships within a particular ecology. This relationship-centered PCMH is a collaborative team of people embedded in a community seeking to improve health and healing within that community through enacting the fundamental tenets of primary care, including developing new ways of organizing practice responsive to the community, continually improving internal capabilities, and being supported by appropriate health care delivery system and payment changes (Stange et al., 2010). Fortunately, two recently completed PCMH pilots show us the beauty and power of this new redesign, this new species of PCMH, and this transformed advanced primary care. Both Group Health in Seattle and the Indian Health Service in south-central Alaska transformed their care teams, point-of-care services, outreach into the community, and management processes. They achieved dramatic improvements in patient and employee experience, quality of care, and cost reductions (Reid et al., 2009; Eby, 2010). Both also have active involvement of the community in their governance. These cases represent a hopeful future.

Exploring how we prepare and train our existing colleagues from multiple disciplines for creating and thriving in the collaborative, relationship-centered PCMH is the intent for the remainder of this paper. It represents a personal synthesis of 45 years combined experience creating, lead ing and teaching in three different collaborative family medicine residency training programs (WLM at University of Connecticut and Lehigh Valley Health Network & JCK at University of Massachusetts and Lehigh Valley Health Network), 20 years of research on primary care practice development that included serving as one of the evaluators of the AAFP National Demonstration Project or NDP (WLM). Some of the topics we will visit on this journey include: different kinds of teams and how they relate to levels of collaboration; creating a collaborative educational culture and environment; special practice-building and team skills and tactics, and some challenges in collaboration across disciplines. The adventure concludes with a few suggestions about format and resources. We are emphasizing existing professionals because their large numbers and more entrenched traditions require the greatest amount of immediate effort and resources. Nonetheless, nearly all that we say, and a few examples, imply changes in graduate level training as well.

CREATING COLLABORATIVE LEARNING ENVIRONMENTS

Teams and Stages of Collaboration

Collaboration means "working together" or "colaboring" on a common process. This contrasts with coordination, which refers to "coconnecting" or "weaving together" some series of things or activities, and with cooperation, which means to "cosupport" or "assist each other" in a common course of action. Coordination and cooperation protect personal autonomy and can occur among people involved in different locations. Collaboration, on the other hand, requires presence in a common physical space with some modification and reduction of autonomy in service to a larger purpose shared with others. Collaboration nearly always involves coordination and cooperation but the latter two can happen without collaboration.

It is also important to distinguish between autonomy and agency. Agency, the capacity for exerting power and influence, is not diminished in collaboration. Autonomy refers to self-governance and the absence of external controls. Collaboration involves the deliberate choice (i.e., agency) to share power and potentially submit to the external control and influence (i.e., loss of some autonomy) of others with whom you colabor. Participating in a team always implies some degree of collaboration. Being explicit about these distinctions can be useful in assisting clinicians in letting go of autonomy.

C. J. Peek, building on the work of others (Doherty, McDaniel, & Baird, 1996; Seaburn, Lorenz, Gunn, Gawinksi, & Mauksch, 1996), proposed the following five stages of collaboration: minimal, basic collaboration from a distance, basic collaboration on-site, close collaboration in a partly integrated system, and close collaboration in a fully integrated system (Kessler & Stafford, 2008b). We consider the first two stages as degrees of cooperation only. The third stage emphasizes autonomy while promoting greater cooperation and coordination. The fourth stage is transitional. The fifth stage, on the other hand, emphasizes shared and sustained common action with significant reduction in autonomy, which can be either intensely hierarchical and tightly controlled or locally empowered and more improvisational.

Basic on-site collaboration is similar to a baseball team where the required teamwork is situational and focuses on role performance (Keidel, 1988). The key to success is having superstar performers in each role. The most common fourth and fifth stages of close collaboration tend to emphasize hierarchical control and mimic a football team with scripted plays and tightly controlled teamwork. This approach, we suggest, is inappropriate for the highly variable, broad, and unpredictable environment of primary care. Improvisational jazz ensemble is a better metaphor for close collaboration. Here the required teamwork is spontaneous and emphasizes mutual adjustment and innovation with triumph being dependent on excellence at communication and rapidly interpreting feedback. The improvisational team skills of the jazz ensemble are helpful for collaborative primary care teams (Miller, McDaniel, Jr., Crabtree, & Stange, 2001). One of these is turn-taking, alternating between soloing and supporting and knowing when to do each. Each member of a team practices how to solo and how to support and provide background and space for the soloist to develop the melodic idea. They also learn how to pass-off and recognize the cues, the changes in rhythm, speed, pitch, volume, silence, hesitation, turbulence, and gesture. These are similar cues to the high yield moments in clinical encounters, the moment when a patient is ripe for change. A second essential skill is learning how to build on what others are doing and requires empathetic listening, listening for what others are trying to do while also monitoring yourself and what you want to play. Empathic listening enables continual negotiation and the skills of decision-making, sense-making, and knowing how to ask helpful questions. All of this, in order to mesh, needs facilitative leadership that fosters participatory democratic experiences. Excellent practice teams hang out together where they create folklore and stories, exchange observations, and build memory.

In such a collaborative, relationship-centered PCMH, the team players could include physicians, advanced practice clinicians, psychologists, marriage and family therapists, social workers, clinical pharmacists, complementary healers, medical assistants, multiple levels of nurses, and business personnel--a rich and diverse ecology for collaboration. Include patients and community groups in this mix and the opportunities for spectacular improvisational jazz and healing amaze. Unfortunately, one of the more salient findings of a recently published qualitative research synthesis on cross-disciplinary primary care teams was that many of the people currently performing these different roles are not ready or prepared enough, because of past professional socialization, to leave the comfort of their discipline and enter this transformational collaborative life (Belanger & Rodriguez, 2008). The work to help them get ready starts with creating the appropriate educational environment.

Creating an Educational Environment for Collaboration

Collaboration is difficult (Zwarenstein & Reeves, 2000; Edmondson, Roberto, & Watkins, 2003). Working closely with others with different skills, perspectives, and social status around insistent, emotionally charged problems in often demanding, pressured situations can generate tensions, conflicts, bruised egos, misunderstandings, and unresolved messiness. We should not be surprised when many of us view subsequent opportunities for collaboration with a sigh of"dread" (Brown, Brewster, Karides, & Lukas, 2011). Yet I have witnessed collaborative moments of wonder, exhilaration, and care. Two of the critical factors that differentiate distress from excitement are the perceived psychological safety of the collaborative environment and the expectations of the participants; these factors require intentionality.

What we know about healthy, safe families applies quite well to fostering good collaboration. Rules, roles, and boundaries are defined yet flexible. Communication is open, honest, and occurs in multiple channels. Warmth and support are frequently extended. It is safe to make mistakes; in fact, learning from mistakes is promoted, and play, curiosity and experimentation are encouraged (Hepworth, Gavazzi, Adlin, & Miller, 1988). Research in primary care practice settings reinforces this metaphor and identifies the following similar relationship attributes that are critical for successful quality improvement and practice functioning, and should be modeled within educational retraining settings (Lanham et al., 2009):

* Mindfulness--presence and openness to new ideas and creation of new categories

* Respectful interaction--honest, tactful, and mutually valued interchange

* Heedful interrelating--sensitive awareness to the way one's own role and others' fit into the larger group and its goals

* Channel effectiveness--appropriate use and mix of rich (e.g., face-to-face) and lean (e.g., e-mail) communication where rich channels used when messages are ambiguous and charged and lean channels when messages are clear and simple

* Mix of social and task relatedness--appropriate mix of conversations based on work activities and friendships and family

* Diversity--appreciation for and encouragement of differences in mental models

* Trust--belief that you can depend on each other and associated willingness to be somewhat vulnerable

Managing social status and power differences within a collaborative team is another important aspect of intentionally creating a psychologically safe, productive learning environment. Where possible, one possible strategy that has worked for us at Lehigh Valley Health Network, is transparency about status differences, especially as reflected in salary differentials. This involves open and frank discussions in a facilitated group format that identify the explicit reasons for the differences (e.g., taking call, revenue generation, and liability). It also helps to use group process to expose the many other ways in which status differences appear.

In addition, all of the clinical collaborators need to recognize and understand power in social relationships. Specifically, learning to locate where power is being manifest and by whom and owning one's own power are important first steps. Then learning to successfully aim and share one's power come next. Some clues to the abusive use of power include power heaping, dishonoring, and jargon hurling (Miller, 1994). Power heaping is invoking past prestige to take over a conversation, whereas, dishonoring refers to comments that question the intentions and motives of another. Jargon hurling is the indulgent use of jargon and abbreviations to both garner power and diminish others. The use of these rhetorical stones usually indicates the thrower's need for protection. Learning to name stones and increase safety rather than retreat or return fire takes much practice and facilitation. Skill at brainstorming, using humor (which is the intent of this metaphorical jargon), storytelling, and silence are useful for taming power abuse. As we will discuss below, because of professional socialization processes and the long history of physician power within the medical culture, each member of the team will have their own particular connection to the power issue, and will require skillfulness and support at learning to share power. One, often hidden source of misunderstanding, is around the role expectations of primary care physicians. Generalist physicians, usually the high status members of the team, are sometimes surprised at how others on the team may perceive their behavior as entitled; whereas, they simply believe they are responsible for providing total care with everyone else supporting that effort (Belanger & Rodriguez, 2008).

One of the more important predictors of successfully mediating professional status differences in cross-disciplinary, collaborative teams is leader inclusiveness or facilitative leadership (Nembhard & Edmondson, 2006). Leader inclusiveness refers both to a leader's words and deeds that indicate an invitation and appreciation of others' contributions and to the actual sharing of leadership responsibilities depending on the specific task. Creating more open and shared space in the physical layout and reducing private space also helps.

Successful collaborative care requires creating transformed practices. Primary care practices are conceptualized as having a core, an adaptive reserve, and attentiveness to the local environment (Miller, Crabtree, Nutting, Stange, & Jaen, 2010). These three represent a practice's internal capability. The core refers to the resources, organizational structure, and functional processes of a practice, or what every practice needs to thrive in stable times. The three processes, clinical care, operations, and finance, closely parallel the first three worlds of C. J. Peek's three world model of collaborative practice. Since nearly every current practice needs to transform into becoming a relationship-centered PCMH, they must also serve as learning sites for their developing collaborative teams. This is Peek's fourth world of education as an additional functional process (Peek, 2008). The adaptive reserve is what a practice needs in times of great change, such as now. Components of adaptive reserve include action/reflection cycles, the seven relationship attributes mentioned earlier, a learning culture, and improvisational skills. Attentiveness to the local environment helps a practice recognize change sooner and identify potential allies and collaborative resources. Building the necessary adaptive reserve will require all of the skills described above and a safe learning environment in order to succeed.

A collaborative team doesn't start out as one (Miller, 1994). The collaborative process begins with the hard work of building a team and acceptance and validation of each other on the team. This requires affirmative listening and explicit agreement gained about the overall purpose of the team. This motivates permission to create and share experiences of collaboration. It is vitally important that these be positive and not "dreaded." Collaboration has begun but this is still the "pseudocommunity" stage for the collaborative team using the language of community development (Peck, 1987) or the "forming" stage of group development (Tuckman, 1965). Now follows the messier work of staying together, the "chaos" or "storming" stage. The challenge here is to overcome task avoidance issues (Rioch, 1970) by acknowledging differences and agreeing to persist. Facilitation is especially helpful at this time when the group is declaring how it will communicate and make decisions. When this is successfully achieved and relationships better developed, the group can move on to more specific and assessable goals, a shared action consensus. This is the beginning of creating "true community" or of "norming." The group is now like a good baseball team. Over time, as the team has repeated success with goal achievement and learns from their mistakes, they become more like an improvisational jazz ensemble, and they often create a new and unique language and improvisational sustained common action occurs (Miller, 1994). This collaborative team is now "performing" in the language of group development (Tuckman, 1965). It has learned to perform as several types of teams and can quickly shift into the most appropriate for any given situation.

In addition to some of the strategies mentioned above (directly addressing the power issue and sharing physical space), some situations naturally enhance the development of collaboration. These include moments when the problem being addressed is greater than any one person's or discipline's expertise or "impossibly complex" such as a patient with very limited financial and educational resources and a combination of multiple severe chronic diseases and mental health problems who presents with unexplained severe pain.

Any time there are interdependent stakeholders with clearly evident mutual benefit, collaboration is also more likely to oc cur. It is important to know what stage or level of collaboration is appropriate and when only better communication, coordination, and/or cooperation is needed. The ability to shift across stages of collaboration and perform in different team frameworks is referred to as team competence (Keidel, 1988) and is best developed as a team builds its collaborative skills over time.

In our own department and residency training program, we have experimented with strategies for creating greater safety and inclusiveness; a few concrete examples from our experience may help illustrate many of the above points about creating an educational environment for collaboration. For example, our faculty meetings always include multiple disciplinary team members whom we value as teachers: physicians, nurse practitioner, nurses, pharmacist, business administrator, psychologist, researchers, medical educator, family therapist, social workers, residency coordinator, and residency secretary. In our primary care practices, we also require weekly practice meetings that include all the clinicians, practice manager, and front and back office staff. This reflects a de-facto decision on the part of the leadership to equally value all voices (leader inclusiveness), to directly challenge hierarchy, and to acknowledge that learning and patient care requires and comes from diverse sources. At times, team members with lower social status, such as the residency secretary or the medical receptionist, question why they are included and even express their ambivalence about being called "faculty" or part of the team. Nevertheless, their inclusion remains a given and has assured them a greater voice and sense of their own importance on the team.

We have also invested a significant amount of time and fiscal resources into regular department wide retreats and team building activities designed to create a relationship centered culture that values safety, learning, and collaboration. We have found that having an internal member of our department paying close attention to communication processes (i.e., a medical educator with expertise in communication) has helped us consistently practice safety-building communication processes during all of our team meetings. These processes include rituals such as structured check-ins (when the group size is less than 10) with explicit rules around listening and avoiding cross-talk, and collaborative decision making around agenda items. In addition, we identify a process observer who pays attention to issues such as how healthy is the dialogue, what voices get left out, and how much we listen versus talk over each other. Similar examples from practice settings, such as the use of reflection action process teams (RAP teams) related to our practice improvement research are available in the literature (Stroebel et al., 2005; Crabtree et al., 2008)[degrees] The work of building healthy, safe communication takes intensive investment and prioritization by the leadership of the organization.

Transforming Models of Professional Socialization and Building Culture

The culture of many organizations and of biomedicine, as we have been alluding to, are powerful, often unconscious, shaping forces that highlight autonomy and individual accountability and hierarchy, and thereby undermine collaboration. In addition to some of the processes we have just mentioned, it is important to explicitly use culture-building tools to enhance the culture of learning and collaboration. There are three major tools of culture building: cultural artifacts, myths and stories, and rituals (Cohen-Katz, Miller, & Borkan, 2003). Artifacts are everyday objects that are intentionally converted into symbols reminding their holders of the group's core values, expectations, and practices. In our collaborative, relationship-centered residency program, trainees select "power objects" such as a ring or cell phone that are with them all day at work. They are instructed to touch the object whenever they feel excess stress or emotion and use that moment to recenter themselves and to reconnect with the program's core values. Myths and stories hold a culture's memory and provide meaning and purpose to each day and activity. They also offer warnings about what to watch out for and how to prevent unnecessary mistakes. Rituals provide the structured space for empowering artifacts and highlighting the important stories. These are intentional moments where all of the members of the collaborative group gather to honor and celebrate key developmental moments and to reinforce the group's culture. The beginning and end of training, changing of seasons, and key transitions such as implementation of a new electronic medical record are all opportunities for ritual. Rituals are also good places to address the status issues noted earlier.

All of the above, however, requires a transformed organizing framework or model of socialization. The traditional model of socialization is the hero's journey (Campbell, 1968). Each of us, whether primary care physician, nurse, or medical and family therapist, crosses a threshold, separates from the everyday world, and enters the mysteries of our discipline. There, through a difficult initiation, we encounter endurance challenges and frightening trials that often wound us, but with the help of allies and our own personal work, we gain the special gifts of our craft and return, a hero, to share this boon with our patients and clients. From shaman to Gilgamesh and Beowulf to Odysseus and today, this model has guided the preparation and training of our healers and protectors. Unfortunately, this model has focused on preparing autonomous, masters of their own fate, healers and protectors, the hero. This is problematic if the goal is training for collaboration. Are there models for heroic collaborative journeys? We propose that J. K. Rowling's series of books about Harry Potter is an example of just such a new narrative. The overall model trajectory is the same. Harry and his friends separate from home and cross the threshold into magic and the land of Hogwarts, a land filled with cultural artifacts, mythic stories, and rituals. They undergo seven years of intense initiation and then return to the everyday world with new understanding and skills. Here the similarity ends and irony begins. The books appear to be about Harry, but they are also about Hermione and Ron and the multigenerational, cross-disciplinary skills of mentors, teachers, family to whom they remain connected, and their collaborative friends in Gryffindor. There is no single hero; there is a heroic collaborative team and the series explores how they are prepared to become that team. J. K. Rowling tells us a mythic story of how to train collaborators; she knows the magic of symbiogenesis. We encourage collaborative teams to identify other examples of this new narrative. We propose that naming these two contrasting models during the training process and when forming new practice collaborative teams, helps create an understanding of the radical change that collaboration represents within the culture of biomedicine.

Challenges in Training Professionals in Collaborative Care

While we have described the ideal conditions for educating toward collaboration, we must also acknowledge the potential barriers to making these changes. One of the more difficult challenges is helping professionals recognize their own biases and "mental models" that work against collaboration such as preferring autonomy to collaboration. Let's begin with primary care physicians. Over the past 20 years, the first author and four of his colleagues have conducted descriptive and practice improvement research in over 500 primary care practices across the country. Several months ago at one of our annual retreats, we reflected on what were the more striking and surprising characteristics of physicians experiencing the stress of change and compiled a list of six that are clear barriers to collaboration. 1) Many physicians demonstrated surprising emotional reactivity and abrasiveness with their staff. Some behavioral examples included sudden verbal outbursts, throwing objects, derisive language, and inappropriate accusations. This behavior was much more widespread than any of us had imagined. 2) There is a monumental power differential between doctor and receptionist and it often prevented the receptionist from sharing problematic information about patients or the practice with the physician. 3) Too many physicians lacked adequate self-care skills. 4) There was also a dramatic lack of communication between physicians even within the same practice. Even in small two person practices, it was common for the two to rarely speak to each other and almost never about patient care. 5) Nearly all the physicians wanted to improve, but few wanted to change. In other words, they wanted their work lives to get better as long as they didn't have to change how they did things. 6) Many physicians preferred hearing about the "right thing to do" rather than learning through the messiness of group process. In the collaborative setting, all of these are aggravated by issues of money, on-call coverage, liability, and public accountability. Physicians are socialized into a powerful culture of competence and deeply fear the potential shame of being exposed as the least bit incompetent. Naming and addressing these issues in collaborative training is essential. Being explicit about a different socialization model, as well as using other tools exemplified by recent programs in mindful practice (Epstein, 1999; Krasner et al., 2009) and narrative medicine (Charon, 2001) can potentially help physicians, and other medical professionals, to improve self-care as well as increase the capacity to acknowledge and learn from their clinical experiences, including their mistakes. Again, the investment in and commitment to these types of programs must be high and requires leadership support, but the consequences of not addressing these issues could easily undermine the collaborative process.

Similarly, other professionals also bring their own biases and mental models to the collaborative process. For example, mental health professionals who are trained in graduate schools, come from a very different culture, one that emphasizes different social structures and values and differing rhythms and pacing of both care and training. Graduate school emphasizes critical thinking and originality and the rhythms of classrooms, writing, l-hour visits, and independent research; whereas, medical school emphasizes pragmatism and getting it right and the rhythms of urgency, abbreviated documentation, and short visits. Collaborating in a PCMH likely to emphasize shorter visits and less time for reflection can be very challenging, albeit exhilarating, for mental health professionals. Also, within the rigid hierarchy of the "yet to be transformed" medical setting, "nonphysicians" can easily be viewed as "ancillary" and feel isolated from their peers (Hepworth et al., 1988). Furthermore, when they witness the social power differential between physicians and themselves, they may be tempted to withdraw, react with anger and resentment, or even internalize what they perceive to be demeaning messages of a predominant medical culture. Being immersed in the cross-cultural exchange within medicine, they can feel isolated from their mental health colleagues in the larger community and worry about losing skills or being left behind. Training programs for mental health professionals who did not receive collaborative training during graduate school need to account for these many challenges, supporting mental health professionals in naming and confronting abuse of power issues directly when they see them, and in resisting responses that are likely to diminish themselves and/or the collaborative team.

COLLABORATIVE MODELS FOR FUTURE TRAINING FOR THE RELATIONSHIP-CENTERED PCMH

The improvisational jazz ensemble is described above as providing a model for how teams can best collaborate; it also offers a constructive model for how to train clinicians and staff to become a collaborative team within relationship-centered PCMHs. This model embraces the tensions between pragmatism and reflection, between individual and collaborative system focus, between agency and communion. Excellent jazz ensembles learn both separately and together. Each performer spends long hours and years developing their particular expertise as drummer or saxophone player. They also spend many hours and years playing together learning the collaboration and team skills described above. Primary care physicians, nurse practitioners, clinical pharmacists, marriage and family therapists, and psychologists also need to spend appropriate time learning their particular disciplinary craft, and they need to spend significant time working and learning with each other in situations where there is clear common ground such as the high yield conditions mentioned earlier. Peek, Baird, and Coleman recently described a complexity assessment method for identifying the level of complexity involved in the care of patients (Peek, Baird, & Coleman, 2009). Their "very complex" level

of care is both an economically helpful and educationally optimal starting point for learning the skills of collaboration. These patients are usually the source of frequent hospital readmission and high costs. Better collaborative primary care for these patients is thus in the financial interest of hospital systems seeking to become accountable care organizations and better control their costs while improving their quality. The complexity of these cases is also a "high yield" situation for collaboration since members of the team must let go of their autonomy in the interests of serving the patients' needs. Over time, the collaborative team can begin moving down the scale of complexity and also discover where just better communication and coordination are all that are needed. Preferably, the individual and collaborative training tracks are in parallel both in current practice transitions and in professional training.

Traditional training models in medical education have emphasized time as a measure of competency. This will be inadequate for training future collaborators and for retraining existing clinicians and staff. Successful completion of core competencies in both clinical work and in the skills of collaboration described in this paper will be more important as will the use of adult learning models (Albanese, Mejicano, & Gruppen, 2008; Knowles, Holton III, Swanson, 2005). Since so much learning and transformation needs to occur in existing clinical settings, the apprenticeship model will also be valuable, although with a twist. The suggested twist consists of placing resident and graduate school level trainees in clinical sites where they not only practice their disciplinary and collaborative crafts but also learn and practice leading their more experienced elders in the processes of transformation. Given that young trainees do not bring the baggage of years of socialization in the old model of care, they are tremendous resources toward helping their elders make changes. All of this training will require major support and infrastructure. The model of the health care extension service is an excellent one for beginning to address this challenge (Grumbach & Mold, 2009). Linked to regional academic centers responsible for the training of the many different disciplinary clinicians and supported by the professional organizations of all of the potential collaborators, this service could provide facilitation for practice transformation, set up regional and local learning collaboratives, educational symposiums, continuing medical education conferences, and e-learning modules with local follow-up.

Fellowship programs are an additional source for future collaborators and transformation. These programs place behavioral health professionals and primary care physicians side by side during their fellowship years in order to help both learn how to function well in this very different setting, as well as fostering respect between the two disciplines for what they have to offer each other. The work of Blount and colleagues at the University of Massachusetts Medical Center in establishing a primary care fellowship is exemplary (Blount, DiGiralomo & Mariani, 2006). Primary care psychology fellows learn how to cotreat patients and consult physicians, exemplifying one of the points made above, that collaboration works best when professionals join together to solve complex clinical problems. The fellowship also explicitly names the differences between traditional mental health and medical culture, and provides structured practices (dual interviewing) to help physician and psychologist learn to function well together in a clinical situation. The primary care fellow is at the same level of training as the resident (second year postgraduate, with another year left to go) which minimizes power differences. The University of Rochester Medical Center has a similar program (McDaniel & leRoux, 2007) and also has an annual 5-day intensive training in integrated care and medical family therapy for health/mental health professionals, described at http://www.urmc.rochester.edu/ smd/psych/educ_train/family/MFTI.cfm.

The Director of the Medical Education Division for the American Academy of Family Physicians recently published an important call for a new family physician educational model (Pugno, 2010). Emphasizing the importance of competency-based education and better training for participation on patient-centered primary care teams in the ambulatory setting, the proposal builds on the three key propositions of a 4-year training period, a longitudinal experience in continuity of care with a defined patient population in a community practice setting, and the ability for residents to customize their training experience. The directions of these recommendations are consistent with the proposals suggested here and, in our opinion; they don't go far enough in promoting truly collaborative care. The focus remains on physician-focused care and not on collaborative team care involving advanced practice clinicians, clinical pharmacists, psychologists, social workers, complementary healers, and others. The move to a 4-year training length may provide adequate time for the combined parallel tracks of training to be both family physicians and collaborative care clinicians. Within psychology, there has been a trend toward more postdoctoral education; the primary care fellowship program is one avenue that extends training, allowing for the psychologist to train within their own discipline and then to function within a primary care setting as part of the collaborative team. While we have emphasized physician training and psychology training, it is no less true in other disciplines that the skills of collaborative care will need to find their home in professional training programs and are likely to extend the length of training to allow for training within one's discipline and within a cross disciplinary team.

CONCLUSION

An old woman clutches her tattered umbrella. Seconds later, her grip relaxes as another hand takes hold and eases her burden. Together they walk toward the office, a relationship-centered PCMH where a collaborative team is prepared and waiting to support her and facilitate her transition toward better health. The transformative work that made this possible wasn't easy. The team spent several years building an intentional collaborative learning environment using the tools of culture formation and nurturing healthy relationships modeled on a heroic collaborative journey.

The long awaited arrival of collaborative primary health care is within our reach. Grasping it certainly requires delivery system and payment reform, but in the meantime, there is an abundance of work to be done envisioning new collaborative training programs and initiating a nationwide effort to motivate and reeducate our colleagues and start the walk from autonomy to mature interdependency. Expect troubles and get to work anyway. Magic and new life still emerges!

DOI: 10.1037/a0022001

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WILLIAM L. MILLER, MD, MA

JOANNE COHEN-KATz, PHD

William L. Miller, MD, MA, and Joanne Cohen-Katz, PhD, Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA.

Correspondence concerning this article should be addressed to William L. Miller, Department of Family Medicine, Lehigh Valley Health Network, P.O. Box 7017, Allentown, PA 18105-7017. E-maih william.miller@lvhn.org
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Date:Dec 1, 2010
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