"Addiction treatment does not work." Years ago, I was angered to hear this observation. As an addiction specialist, I have had ample evidence that, in many cases, addiction treatment does work. However, the system is not even close to being perfect, and there are strategies that could be adopted that would begin to address the raft of issues associated with failed addiction treatment (dropouts, later relapses, unmanaged co-occurring illnesses, low motivation, use of "safe" prescribed medications, etc.).
Addiction is a chronic illness, and often, co-occurring problems involve many collaborating professionals. As collaborators, we share clinical responsibility for the people who experience these addictions. Remaining in a professional silo may seem safe and efficient; however, it may not be in the patient's best interest. The effectiveness of communication between professionals can make or break addiction treatment success.
The Institute of Medicine in 1999 published To Err is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 1999), pointing out the many mistakes that occur daily in the healthcare system. These mistakes involve many people and many professions. After 14 years of research and exploration, it was noted that more than 75% of medical errors and injuries were because of communication and teamwork problems (Gordon, Mendenhall, & O'Connor, 2013, p. 4).
If we compare multiple disciplines with just one discipline on the clinical team, we see some potential benefits of multidisciplinary teams: (a) We can become more comprehensive in our care when including other health disciplines; (b) we can see colleagues as vital when we value their input; (c) future care must be negotiated sometimes, and interventions must be coordinated; and (d) interactions between everyone are considered essential when this collaborative effort happens with multiple disciplines (Casto et al., 1994, p. 73).
The Commission on Interprofessional Education and Practice pointed out a nexus to change the traditional culture. They called it the "paradox of collaboration."
In essence, then, these conditions for collaboration challenge our usual individual and institutional values. It is nothing short of a paradox, that the less competitive we are (the less we follow our usual instinct to compete), the more competitive (in other words, effective) our collective efforts will become. The less power we have and the more power we give up, the more powerful our collaborative position will become. The more we give others credit for our work, the more credit our work will deserve. The more we shift our commitments from institutions and policies and toward our joint mission, the more commitment we will have to our institution through its mission. Our usual values are thus turned upside down in the process of carrying out collaborative work. The conditions for collaboration lead us to question existing models of professional interaction and to propose interprofessional collaboration in several forms (Casto et al., 1994, p. 103).
Integrating professional emotional reactions into collaboration and establishing effective communication are both promoted by the development of team intelligence. Team intelligence produces not only effective actions but also effective interactions (Gordon et al., 2013, p. 11).
* Shared team identity allows shared models, shared language, and shared assumption to realize and accomplish shared common goals.
* Team members must be willing and able to share information and solicit feedback and coaching/criticism from team members.
* Team members must understand each other's roles and work imperatives to integrate so that common goals can be accomplished.
* Team members must help and support each other.
In aviation, the Crew Resource Management research over 30 years developed some key principles to ensure good aviation safety, avoid crashes, and deliver the customers and crews safely. The internal process for team communication involves communicating, problem solving, decision making, and conflict resolution. It is based on group identity, group responsibility, mutual support, and integrity (Casto et al., 1994). Four central elements for good crew performance are as follows: be aware of what is happening at work, know what affects your thinking and how you normally think, have a shared model to process explicit communication, and know how to manage your immediate resources efficiently (Gordon et al., 2013, pp. 34-35).
The keys to effective aviation communication are as follows: be clear and persistent about critical information, listen for other crew members' concerns, review the information and be clear and assertive about your position when safety is the issue, and be direct and obvious in communication (do not hint and hope; Gordon et al., 2013, p. 57). Thistlethwaite (2012) pointed out that, with medical teams,
Often we offend or misunderstand more from what we do not say as that which we verbalise during interactions. This is not simply about body language but about acknowledgement of diversity and being in tune with our colleagues. As individuals we recognise that we are complicated people, and yet we often presume that we can read and understand our fellow professionals, who are nevertheless as complicated as we are (Thistlethwaite, 2012, p. 28).
Although this sounds easy and trivial, the aviation industry spent hours and years teaching the flight crew how to collaborate effectively. Their process is spelled out in detail in the book Beyond the Checklist: What Else Health Care Can Learn From Aviation Teamwork and Safety (Gordon et al., 2013).
As the primary medical society advocating for state-of-the-art addiction care, the American Society of Addiction Medicine (ASAM) can borrow from the aviation industry's research into effective communication. ASAM recently released its standards of care for the addiction specialist physician. ASAM reports that collaborative care is an essential process. ASAM has not had a chance to focus on the details of teamwork and the dynamics of collaborative care, but ASAM has seen collaboration as important in developing comprehensive care.
The ASAM Standards of Care: For the Addiction Specialist Physician (ASAM, 2014) gives an overview:
Addiction is a complex disease that impacts many aspects of a person's life and requires long-term, coordinated care by a team of providers who can address the myriad physical, mental, social, economic, and legal ramifications of the disease. As a leader of this care team, the addiction specialist physician is well-poised to coordinate and provide the treatment required by persons with addiction due to his or her advanced and unique understanding of the dynamics of addiction and the dynamics of recovery, and how addiction manifests in varied medical, social, economic, and legal ways.
An addiction specialist physician functions at different levels of leadership or influence and as a part of formal and informal teams. As of this writing, we recognize that addiction treatment is not well integrated into most health systems and the addiction specialist physician workforce is inadequate to address individually the number of patients with addiction. As a result, collaborative management is necessary and the addiction specialist physician has a responsibility to be the leader within health care systems and/or their communities when addiction is present as part of the patient's overall clinical situation.
Part of this responsibility is to help other providers and health care administrators understand how addiction affects the evaluation and management of other illnesses so that appropriate treatment is provided. This responsibility will also require that addiction specialist physicians be directly involved in quality assurance and evaluation, safety management, and professional development regarding treatment of patients with addiction within the relevant systems of care where they practice. Addiction specialist physician leadership will also require that s/he teach new generations of clinicians in their practice settings and/or through involvement in their professional societies.
Many of us are not trained to work together in complex, multidisciplinary networks, and our cultural ideals of individualism lead us away from this teamwork. Clinical leadership and team leadership are necessary for every day functioning. The Commission on Interprofessional Education and Practice comments about teams and team leadership:
With or without a primary care provider serving as manager or a special case manager serving as a coordinator, the need to integrate the views, prescriptions, and plans of the specialists within and across professions requires interactions among those varied providers. In other words, what is called for is a team. What is also required is a functional, multiagency system. Both these things are so inconsistent with the traditions of American culture that they will not evolve without the specific planning of services and training of providers (Casto et al., 1994, p. 9).
Often, the collaboration and expertise of interprofessional team members can be very relevant to the specific client's problems. Combining these perspectives and skills may yield a decision that is more comprehensive, creative, and tailored to the client's values and needs (Gordon et al., 2013, p. 64). Someone needs to lead the team and monitor that everyone is focused on the central goals. The aviation industry distinguished between command and leadership to emphasize that command cannot be shared and may be designated by the organization (Gordon et al., 2013, p. 87). However, leadership can be shared between crew members and involve leadership and followership skills. The issue becomes "what is right," not "who is right." This encourages proactive movement toward conjoint goals, not reactive decisions.
IMPLICATIONS AND NEXT STEPS
The ASAM Standards of Care: For the Addiction Specialist Physician remarks that
Addiction treatment is in the process of evolving from a largely nonmedical, isolated field into a more integrated part of mainstream medical care. As this occurs, new working relationships, treatment protocols, and reimbursement mechanisms will need to be negotiated, and some growing pains will be inevitable. For example, current commercial and regulatory requirements for physicians sometimes ask them to authenticate care for patients they have never seen. This threatens high quality care and can undermine physicians' decision-making. In the midst of changes and pressures both old and new, The Standards set forth here[horizontal ellipsis]what we can and should expect from addiction specialist physicians in the treatment of individuals with substance use and substance-related disorders, and they can serve as a benchmark for physicians, payers, policymakers and patients alike as they seek to provide, pay for, regulate, and receive the highest quality care.
Collaboration and team building are crucial elements in the ASAM mission. Problem solving can be facilitated by the following assumptions of interprofessional collaboration:
Most problems can be prevented, delayed, or ameliorated when detected early and managed appropriately.
Precursors of risk factors have been found to increase the probability that certain disorders will follow, providing the rationale for strategies of early intervention that will prevent or modify the disorder.
Intervention strategies should be individualized to the stage of problem development.
Changing the structure and function of interprofessional operation and individual roles is necessitated when a problem progresses to higher stages of behavior and social dysfunction.
Overcoming barriers to effective communication between interprofessional team members is central to the process of longitudinal care (Casto et al., 1994, pp. 74-91).
These are rational, logical guidelines, which apply to addiction disorders and many other chronic illnesses. They depend on the wish to communicate, the skills to communicate with other professionals, and the interactions to communicate effectively.
What needs to be done now is to find a way to work with other healthcare professionals, such as primary care clinics, emergency room staff, inpatient hospital clinicians, and so forth. Can healthcare professionals appreciate the need to contact addiction experts if they suspect addiction problems? This follows the existing directives of screening, brief intervention, and referral to treatment. A network of addiction specialists would need to be accessible if referrals were to happen easily. Financial support has to be streamlined to cope with the demand for opiate treatment, and professionals need to be shown how to be reimbursed for collaborative interventions. We have to establish a mission that has interprofessional consensus, or everyone is flying off on different paths. A conjoint mission needs to include plans to train our current and future professional members to be competent in interprofessional teamwork. Nurses and physicians are central in this teamwork. The ASAM Standards of Care: For The Addiction Specialist Physician emphasizes that
Collaborative care is a key attribute of high-quality care and it is the responsibility of the addiction specialist physician who directly provides specialty care or supervises and manages specialty care provided by other clinicians[horizontal ellipsis]to advocate for collaboration that ideally includes multiple professionals, individual patients, and family members, and to assist patients as they maneuver through often-complex multi-component systems of care.
The ASAM Standards address the responsibilities borne by physicians who manage or oversee the care of patients with addictions. It is important to expand them to create a joint mission that includes other professionals.
REFERENCES