Introduction
In the report,Health
Professions Education: A Bridge to Quality1,
‘cooperation’, ‘communication’, and ‘coordination’ are identified as
essential competencies that all healthcare professionals need to have.
It implies the importance of collaborative teamwork in providing
comprehensive care. Accordingly, Western countries have implemented this
collaborative approach through multidisciplinary teams (MDTs) at all
levels of healthcare delivery, drawing membership from professionals
across different disciplines and specialties. Besides, physicians, it
MDTs also include nurses and other non-clinical healthcare professionals
like occupational therapists, spiritual healers, psychosocial
counsellors and so on to provide comprehensive and holistic care to
patients. There are multiple evidences to support importance of MDT in
hospitals. Most promisingly, it decreases length of stay, improves
health outcome, enhances inter-personal communication, yields patient
satisfaction2,3, and reduces workplace
burnout of the caregiving staff4. A number of
palliative care literature also unanimously support multidisciplinary
collaboration as a key to holistic care by addressing physical,
emotional and spiritual distress of patients at the end-of-life; it also
helps formulating comprehensive, person-centric care
goals5.6. However, few literature also point out
drawbacks of multidisciplinary teamwork like physicians’ difficulty in
fostering long-term relationships with professionals from other
disciplines, uneven distribution of work load, unequal recognitions,
heterogeneity in orientation of the caregivers and so
on7. Moreover, in the present time, when
disease-specific treatment has emerged as a dominant model of caregiving
in biomedicine, maintaining a multidisciplinary approach is difficult.
Professional boundaries have crept into MDTs, leading to “Invisible
boundaries”, as Libertii and Gorli8 describes the
situation where physicians compartmentalize themselves into watertight
specialized disciplines leaving no scope for collaboration. Specialist
physicians in the capacity of being appointed as the ‘primary
consultant’ usually follow a paternalistic model in planning care goals
for the patients, deciding treatment modalities, and unilaterally
conveying decisions to other members in the team. To utter dismay, they
pay least attention to opinions of other physicians, and also to the
preferences of the patients under their supervision. It is as if they
own patients9. Such an approach adversely affects
patient care10-13, and is particularly inimical to
end-of-life care. Professional boundaries seem to increase the unmet
need for palliation, as most specialist physicians feel palliative care
not to be their prerogative14. Similar
results emerge from works of Gardiner et al.15 and
Powell and Davies16.
In India, implementing inter-professional collaboration in caring for
dying patients is all the more difficult. Firstly, most hospitals follow
a consultative model of palliative care. It means the care is available
to terminally ill patients only on referral from the concerned primary;
palliative care is not an integral part of treatment protocol. Second,
specialist physicians-led MDT have very little representation of
non-clinical caregivers like spiritual carers, occupational therapists,
community nurses and so on. And finally, unlike West, where MDTs are
available at different levels of healthcare delivery
system17, in India MDT formation is limited
to hospital staff, making it highly disadvantageous for the physicians
to network with stakeholders beyond institutional
boundary18. Apart from these few insights, there is
lack of information as how ‘eolc’ is managed in MDTs; what are the
challenges and drawbacks. This study presents a number of observations
from a multispecialty hospital to address to the information lacunae. It
lays special focus on intra/inter-professional boundaries that are
potentially disadvantageous to MDTs.