Because of the increasing complexity and scope of patient problems presenting to the health care environment, patient care now routinely combines the efforts of physicians of different disciplines, skilled nursing professionals, and other health care professionals. Comprehensive patient care often involves trying to solve problems which are beyond the scope of expertise and training of any one provider. Thus, the organization of professionals involved in one patient's care has evolved from that of a hierarchy, with the physician in a "command" position, to that of a multidisciplinary team, interfacing many different kinds of health care professionals, each with separate and important knowledge, technical skills, and perspectives. In a teaching hospital, team membership becomes that much more complex with the presence of students, interns, residents, and fellows.
How do teams work together?
Working together as a team, professionals must balance responsibilities, values, knowledge, skills, and even goals about patient care, against their role as a team member in shared decision-making. Because many physicians, in particular, are accustomed to a practice environment in which decisions are "made" by the doctor, and "carried out" by other professionals, it is difficult sometimes for physicians to adjust to a team approach, in which majority opinion, deference to more expert opinion, unanimity, or consensus may be more appropriate methods of decision-making than autocratic choice. Further, physicians who maintain a hierarchical concept of medical care may face serious problems when disagreements arise with other physicians of equal "stature" on the medical team. Interdisciplinary conflicts are seen in all areas of medical practice, but the operating room environment is particularly rich in examples in which patient care involves interdisciplinary cooperation, conflict, and compromise.
Who is in charge in the operating room? Isn't the surgeon "Captain of the Ship"?
You will certainly hear at some point in your medical training that the surgeon is "captain of the ship" in the operating room. While recent legal decisions have essentially "sunk" the concept, it is important to understand the ethical and legal terrain.
The phrase "captain of the ship" was first used by the Pennsylvania Supreme Court in 1949 in McConnell vs. Williams. In that case, an intern at a charity hospital was responsible for blinding a newborn by improperly applying silver nitrate drops to her eyes. Laws in widespread application at the time provided many hospitals with "charitable immunity" from legal damages, and the parents of the newborn were unable to get money from the intern because he acted as a hospital employee. They therefore brought suit against the obstetrician. The Pennsylvania Supreme Court allowed a finding of negligence against the obstetrician, despite the fact that the obstetrician had had no direct part in the negligent act, specifically so that someone would pay money to the parents. In its decision, the court used an analogy from maritime law, in which a captain can be held liable for the action of all members of the crew of his ship.
Since 1949, several key changes have taken place. Hospitals are no longer immune from liability in most jurisdictions, in part because hospitals generally carry insurance against the negligent acts of their employees. Courts also recognize that the scope and complexity of medical practice is such that no single provider generally has complete control over a patient's medical care. The diversity of medical practice and the different forms of training and certifications required for specialty practice testify that different professionals have different expertise and therefore diverse levels of responsibility for individual acts in patient care. In this aspect the law is fair: the greater the authority and expertise asserted in a given act, the greater an individual's legal responsibility becomes.
In recent years, many state Supreme Courts have specifically thrown out the "captain of the ship" doctrine in disgust. Cases in which the captain of the ship doctrine has been specifically discarded include those in which plaintiffs have asserted that the surgeon was responsible for the acts of nurses, nurse anesthetists, anesthesiologists, radiologists, and radiology technologists, and in which plaintiffs asserted that the anesthesiologist was responsible for the acts of surgeons, nurses, and nurse anesthetists. Ironically, some recent law suits have been successfully pursued against surgeons for the actions of other operating room personnel, only because the surgeon himself asserted that he had, or should have had, complete control over everyone in the room at the time of the negligent act!
What are the ethical obligations of members of the interdisciplinary team in patient care?
Ethically, every member of the operating room team has separate obligations, or duties, toward patients, which are based on the provider's profession, scope of practice and individual skills. Team members also have ethical obligations to treat each other in a respectful and professional manner.
Relationships between professionals on the multidisciplinary team are by their nature unequal ones. Different knowledge and experience in specific issues both ethically and legally imparts unequal responsibility and authority to those care providers with the most knowledge and experience to handle them. But also because of differences in training and experience, each member of the team brings different strengths. Team members need to work together in order to best utilize the expertise and insights of each member.
Do I have to do whatever I am told by the attending physician, even if I disagree with their plans?
Professional relationships not only exist between different professions, and specialties within similar professions, but between students and teachers as well. The student-teacher relationship is also an unequal one, not merely because teachers generally have more authority than students, based on their training and years of experience, but much greater responsibility as well. An attending physician, for example, may be held both morally and legally liable for the actions of students or residents, whether or not she approved of those actions. Ethically, teachers have obligations to observe and control the actions of junior members of the medical team, both to prevent harm to patients from inexperienced care-givers, and to educate students in appropriate care. Students and residents, conversely, have obligations to their patients and to their teachers, to not act recklessly or without the knowledge and approval of supervisors. Whenever a student or resident disagrees with an attending physician's plans, he should seek input from the attending, both about the reasoning to pursue the attending's plan, and about the reasoning for rejecting her own. A respectful exchange of views may provide both parties with new information, and certainly serves to further education.
What is meant by "respectful" exchange of views?
Precisely because of the inequality of authority and responsibility in inter-professional, inter-physician, and student-teacher relationships, obligations of mutual respect are particularly important on the multidisciplinary team.
Disagreements between professionals are common and expected, because of different knowledge, experience, values, and perspectives of the various team members. While disagreements might be settled in a number of ways, mutual respectful behavior is a mandatory feature of professionalism. Thus, while it is not only possible, but expected, that members of the patient care team will disagree at times, it is never acceptable for disagreements to be verbalized in an unprofessional manner.
Respectful behavior begins with both listening to and considering the input of other professionals. Ask yourself whether your perception of whether you are respected depends more upon whether the other party agrees with you, or whether, despite disagreeing, they listened and acknowledged your point of view.
Respect is demonstrated through language, gestures, and actions. Disagreement can and should be voiced without detrimental statements about other members of the team, and without gestures or words that impart disdain. Both actions and language should impart the message: "I acknowledge and respect your perspective in this matter, but for the following reasons. I disagree with your conclusions, and believe I should do something else..."
It should go without saying that disrespectful behavior from a colleague does not justify disrespectful behavior in return.
How can disagreements on the multidisciplinary team be handled?
In the best situations, disagreement leads to a more complete interprofessional discussion of the patient's care, resulting in a new consensus about the best course of action. The new consensus may require compromises from each individual.
When members of a team cannot arrive at a consensus of what should be done, it may be helpful to consult other professionals who are not directly involved in the patient's care team for objective input. If the disagreement still cannot be resolved, another resource may be the hospital's ethics committee, which can listen to disagreements and help suggest solutions.