Intentionally Interprofessional Care: DorAnne Donesky, Michelle Milic, Naomi Saks, & Cara Wallace

Eric 00:25

Welcome to the GeriPal podcast. This is Eric Widera.

Alex 00:52

This is Alex Smith.

Eric 00:53

And, Alex, who do we have with us today?

Alex 00:56

We have a tremendous interprofessional team here with us today. We’re welcoming back to GeriPal, Naomi Saks, who’s a palliative care chapter, an assistant professor in the Division of Palliative medicine at UCSF. Naomi, welcome back to GeriPal.

Naomi 01:09

Thank you. Good to be here.

Alex 01:11

We’re delighted to welcome Michelle Milic, who is a pulmonary in critical care and palliative care doc and associate professor of clinical medicine at Georgetown. Michelle, welcome to GeriPal.

Michelle 01:22

Thanks for having us today.

Alex 01:23

And we’re delighted to welcome DorAnne Donesky, who is a palliative care nurse practitioner at Queen of the Valley Medical center in Napa and professor emeritus at the UCSF School of Nursing. DorAnne, welcome to GeriPal.

DorAnne 01:36

Good to see you. Thanks.

Alex 01:39

And Cara Wallace, who is a hospice social worker and endowed chair and professor in the St. Louis University School of Nursing. Cara.

Cara 01:47

Hi, everybody. Glad to be here.

Eric 01:50

So I’m gonna correct you, Alex. This is not an interprofessional team that we’re talking about. This is an intentionally interprofessional team. Cause that’s our topic for today, and we’re going to describe what that is. But before we do, Cara, do you have the song request for Alex?

Cara 02:08

I do. Our song request is nothing’s gonna stop us now by starship. And this song really feels like an invitation to me, which is something that we’re trying to do with this conversation with this textbook and this project that we’ve done together. We’ve built a lot of momentum around intentionally interprofessional, palliative care and talking with authors and talking about people interested in the textbook and in those conversations. It’s starting to feel like nothing’s gonna stop us now.

Alex 02:38

Love it. This song brings me back to my youth all right, here’s a little bit.

Alex 02:45

(singing) Looking in your eyes I see a paradise this world that I found is too good to be true standing here beside you want so much to give you this love in my heart that I’m feeling for you let them say we’re crazy I don’t care about that. Put your hand in my hand, baby don’t ever look back let the world around us just fall apart maybe we can make it if we’re hard, too hard and we can build this dream together standing strong forever nothing’s gonna stop us now and if this world runs out of lovers we’ll still have each other nothing’s gonna stop us nothing’s gonna stop us us now.

Eric 03:47

Man flashbacks to 8th grade dances. [laughing]

Alex 03:52

Move your hands up, please. [laughing]

Eric 03:59

Don’t you need a duet for that, Alex?

Alex 04:01

Yeah, I do. That’s true.

Eric 04:04

We’ll see.

Alex 04:05

Maybe I’ll overdub something on the audio version. We’ll see.

Eric 04:09

Yeah, maybe a little interprofessional. Intentionally interprofessional duet going on there. Okay.

DorAnne 04:20

With that song, as you were singing it, I was thinking about another really important person who isn’t here today, which is Barbara head, who was our senior editorial advisor for this book and unfortunately passed away on hospice right before the book was published, but not before she had written the introduction. And as you were singing that, it just brought her to my heart and I wanted to acknowledge her, so I got it.

Eric 04:47

Because most of our listeners may have not seen this book, may have just figured out that we’re going to be talking about a book. So you published this book intentionally. Interprofessional palliative care has a ton of great authors, an inter professional list of amazing authors. Does somebody want to just give me, like, a couple liner? Like, what is this book? I’m going to call on you, DorAnne, since you’re the first to speak.

DorAnne 05:15

Okay. Yeah. This was a complete epiphany moment at annual assembly one year when I happened to be talking to an Oxford editor, and she said, what do you want to write about? And I said, interprofessional practice. And she said, okay, great, write the book. And I said, but how can I do that without an inter professional team? That seems really silly, like trying to tickle yourself and then wonder why you’re not laughing. It’s like, we need to be together. And so all of our listeners are.

Eric 05:47

By the way, they’re trying to tickle themselves right now, and it’s not very good.

DorAnne 05:52

Nobody’s laughing. So the first thing that the editor and I did was put together the team, because even if I had started down the direction, it would have been a nursing book with other people’s input. I wanted it to be fully, intentionally interprofessional. So before the first word was written on even the proposal to Oxford that they had invited, we had our team together.

Eric 06:17

And why was that so important?

DorAnne 06:20

It just seems obvious to me. So maybe one of my colleagues can say why it just doesn’t make sense to be doing inter professional with, without an interprofessional team.

Naomi 06:30

I can chime in a little bit. So everyone in our whole field, plus the World Health Organization, the national Consensus Project, everyone says that interprofessional collaboration is what we’re supposed to be doing. It’s all what we signed up for when we signed up on the dotted line to be in healthcare and palliative care. We’re supposed to be the leaders and what we found and from our own experience. And then by doing this book in such a collaborative way, that across the country, the idea of what interprofessional is multidisciplinary, transdisciplinary.

We’re all talking about different things, and we really, as we came together with this book, with the editors and the authors, we all came together on a vision, a revolutionary vision, that actually, we have to be as intentional about learning collaboration as we are about pain and symptom management as we are about facilitating complex family meetings. The collaboration is actually the center. It’s like the jewel of what we do. And it not only leads to better outcomes for patients, it leads to our better sustainability. We can do this work longer. We also know that people get their whole, their whole selves assessed when we have a full team. And so we really wanted to put this book out as a love letter to this idea of. No, actually, we love collaboration, but we really have to be intentional about it.

Eric 07:54

That’s really interesting, because what I think back to a lot of palliative care teams. Sorry, I just cursed. But if you think back to, like, even studies in palliative care, we just did a podcast on this, is that when we think about interprofessional teams, as far as evidence base, a lot of our evidence base of interprofessional teams is a doctor and a nurse, or a doctor and a social worker. And I guess that was intentional. But is that interdisciplinary, or is that intentionally interdisciplinary?

Alex 08:30

Interprofessional.

Eric 08:31

Interprofessional.

Alex 08:32

We heard a lot of terms, dang it. We do need to learn what these terms might mean and how they’re different. Multidisciplinary, interprofessional.

Eric 08:38

Back to your question. Yeah, let’s get to both of those. Let’s ask the first question. Is your thoughts of, like, we talk a big game in palliative care? Are we walking the walk?

Cara 08:48

I’ll take this one. I’m thinking about, you know, I come from the hospice world where we had our, you know, idts. We sat around as our interprofessional team, and I thought, this is what I do, right? So I got invited to write this textbook or an edit this textbooks with Dorian, and I was like, oh, yeah, I got this. This is what I’ve always done. I’m a researcher now. I build interprofessional teams. Like, I’ve got this. I’ve got this in the bag. This is what I do. And I think you mentioned when we talk about collaboration, and it sometimes just pockets and two people or three people. What I really learned in doing this textbook was there are ways to do it better. There are ways to be more intentional.

I am shocked at how much growth there was for me personally on the subject area. And not only that, but how much more we have to learn as a field in this topic and how little there is out there, actually, in terms of how to do this well. So that was really a big eye opener for me, and I think that’s one of my, I think, biggest takeaways. But I think, really, response to that question is, are we doing this? Yeah, we’re doing it. Okay. We don’t want the message to be that we’re not doing this well, but there’s so much room to do it better. And I learned that at every turn in this textbook, I would come to a conversation with my ideas and have great ideas, and the product was always better. When Michelle had given her perspective and Naomi had given her perspective and Dorian had given her perspective, and we always landed somewhere different. And that’s why it was so important that every chapter had to be touched by multiple professions at every step in the process of this textbook.

Alex 10:27

And just to put some numbers to the response, though palliative care is assumed to be interprofessional. This is from the last chapter of your book or near the end. The National Palliative Care Registry. In 2018, survey data revealed that only 41% of survey adult practices had the full complement of funded core team members, which is up from 25% of 2016. So moving in the right direction, but still less than half have the full complement of core team members.

Michelle 10:56

And I’d like to add something to that as well, too. I think we’ve all been in a situation where things just connected and there was a vibe and a sense of this collaboration that felt like it’s the secret sauce of palliative care. What is it? What is that that allows us to work well together and to really understand and be additive and be invitational to each other? I think one of the big things that I picked up from doing this work is that there is more of a formula to that. There is intentionality to it. There’s curiosity, there’s humility, there’s invitations in every direction that really allows for each person that is at the table to bring their area of expertise, their perspective, their impressions, and that all of that is additive. If nothing, if not, leads to something greater, like the alchemy that we always talked about, that we developed while doing this work.

Eric 11:54

I also wonder, as you’re thinking about writing this book and creating this book, a lot of the things you talk about apply not just in palliative care, but to other specialties, too. I think geriatrics very proud of interprofessional care. If you have on dialysis, there’s an interprofessional team caring for you. How did you decide to focus just on palliative care? And is there a bigger, can more disciplines learn about working with teams? Working in teams? When reading this book, absolutely.

Naomi 12:34

We all happen to be in hospice or palliative medicine, and we know that we all think about this as a thing. We actually all don’t just think about being next to amazing colleagues. We think about how. How do we actually collaborate with them, how do we move through differences? How do we synergize our expertise in a way that we co create a care plan. So this is applicable to anybody in healthcare and actually any kind of team. The ideas that we’re talking about here can really apply palliative care, again, especially for me, for others in my field as a chaplain and other.

And I know social workers and others have told me that we can work at the height of our practice in palliative care in a way that we are not always invited to in general healthcare or being a staff chaplain or being not part of a team. And so I think it’s really important to think about the ways that we’re thinking about operationalizing this, which we have a model, a generalist specialist model, and this idea of transdisciplinary care, where we flatten the hierarchy and we all work together at the height of our practice communication. Is constant, and we co create a plan together. And so we do that with a number of different methods that we talk about in the book that are really applicable to lots of different settings in healthcare and in teams.

Cara 14:01

You mentioned, too, earlier about how we’re not taught how to do this. Right. And I think if we think about our educational systems, we’re still really siloed. And I think that that’s just a really important thing to think about, is how do we better teach interprofessional and groups before we get to the place where we’re having to practice it with no idea about how to actually do that. Right?

Eric 14:25

Yeah. I guess the question is, when you’re teaching this stuff, like, there are important, like, there’s, I guess, Venn diagrams, right? Like, it’s really important for a particular discipline to learn the core skills for that discipline. And you can’t just put everybody in the same room together for four years and assume that, like, they’re gonna a work as a team, but they’re also gonna develop those skills that they need for their each discipline when they also have to, like, learn how to work together. How should one do that?

DorAnne 14:59

You know, you mentioned something that I think is extremely important, which is making sure that each clinician is grounded in their own profession first. And we made some errors early on with our. It was published under the paper teen talk from UCSF, where we didn’t make sure that all the learners were grounded in their own profession, and chaos resulted. So we really see people as having two co equal professional identities. One is as a palliative care specialist, and one is as their own profession that they’re trained in. Both are really important, and that palliative care specialty is shared similar skills among all of us. And so, once people are grounded in their own profession, then they can be much more confident and comfortable in working with each other.

Eric 15:54

And can I ask you that paper on team talk? Like, what was. What was the issue?

DorAnne 16:00

Oh, we had this bright idea that we just wanted everyone to come together and strip them of their professional identities, and we’re just all going to be good communications learners together. And it was actually kind of interesting to see how each of the professional learning groups had very different responses. One group was very angry because they had never been at the table as an equal learner, and it became really obvious that they had some anger they needed to work out. Others were very disrespectful of the other learners, not realizing who was in the room, and they were just talking smack about each other. And then others just simply bowed out and just said, forget, and I’m gonna.

I’m gonna get on my phone here and do something else. So we now do the opposite and are very careful to make sure people are grounded in their own profession. And even among the four of us, I don’t want anyone to think that this was not a time of sometimes discomfort and pretty serious disagreement. But then we would go back to being grounded ourselves in what was important to us, both personally as well as professionally. And then we would seek for alignment. We aren’t always agreed. We don’t all agree on every single word that was written in the book, but we got to the place of alignment where we could support each other and move forward with the book, because.

Eric 17:28

You have a whole chapter on tension in professional teams. And I think if anybody has worked in a professional team, you know, it’s all not like, you know, puppies and kitties and roses. Like, there is tension. And in some ways, if I remember your chapter, it’s like tension is part of working in a team. Is that right?

DorAnne 17:52

I’m curious what Michelle has to think about.

Eric 17:53

Yeah, Michelle.

Michelle 17:56

I think it is a part of working in a team, and just from the physician’s perspective, you know, in traditional training, we’re taught to take the lead in a lot of conversations and a lot of actions and a lot of actionable activities at bedside. Just very recently, I was on call in the ICU just about a week ago, and I was the doctor in charge, and there were, you know, 15 people in the room, but I had the one that was signing the supervision orders of what happened during this, you know, Perry code situation. And it was so interesting to see how, you know, I’m evaluating the room. I’m looking around, I’m running through my checklist in my head, and one of the nurses said, would you like to have, or can we. I was almost like, can we offer you this next suggestion? And I just. It kind of caught me where I was at that moment that this had this sense of awareness of this was. It was an invitation. It wasn’t a, you need to start this new medicine.

It wasn’t. It was an invitation. It was an ask. It was almost a permission and this sense of deferential communication. And I just looked at her and I said, you are five steps ahead of me. Thank you. This is exactly what we need. And it’s being self aware in those moments and realizing that everyone on that team is bringing something important and valuable and showing respect in that moment, whether it’s a crisis, an emergency situation or something that you really have time to plan and to prepare for. For instance, a family meeting or an update or communication with families.

DorAnne 19:37

I just want to jump in there. But that story reminds me of my own training, which was several decades ago as a nurse. We had a whole class session on how to frame our suggestions to physicians in question so that we wouldn’t offend them. So this is a systemic issue, I think, that Michelle is talking about. I just want to mention that this is more than just interpersonal personalities. We kind of buck in the system here, but I’m so grateful that Michelle notices that and calls it out.

Naomi 20:11

I think also, I was going to say, and to add to what Doran and Michelle were saying in that chapter specifically, they talk about power differentials and hierarchies and how that’s such a constant thing that we have to work on. A lot of it we don’t even have control over. It’s also our training is quite different. What we’re doing in the name of geriatrics or palliative care or even care is different depending on our training and our approaches, like Chaplin’s very self reflective other people, it’s quite, you know, measuring and assessing. So really, a lot of it is that we’re speaking different languages.

And just an example of, like, the power differential and hierarchy. There’s a lot of times just because I’m called the chaplain, and people project all different things, whether I’m not clinical, whether I’m not skilled, whether I’m a nice church lady that came over from across the block to visit and hold people’s hands, whatever they think I am, that’s as much power as I have in that moment. So often I have attending a physician, attending colleagues who know me really well. I’ve worked in palliative care for years, and there’s some times where I’m in the family meeting, I’m facilitating the family meeting, and then I’m reporting out to the referring doctors, and I say, what happened? And they look at me, and they just look next to me at the doctor.

And I have a number of doctors that are identified as male and white. And I just turned to them and I said, can you just please tell them what I just said? Because they can’t hear me. And so that kind of thing happens all the time. And so this whole idea that. That we are all doing our best, but Doran is the person that let me know about this theory, contact theory in the 1950s. We knew this long time ago, you can’t just put a lot of compassionate, smart people together in a room and think they’ll collaborate. There’s so many other forces that are influencing it.

Alex 22:05

Yeah. And just to name a few of the more of those from the book, this is on the clinical education and training chapter. In many settings, physicians have the ultimate legal and professional responsibility for overseeing patient care, which shapes physicians physician vision and expectations for collaboration, or lack thereof, of the core palliative care professions. Physicians are typically granted the most power and authority by the systems and then goes on to talk about billing and who can and who cannot bill, and talking about physicians can write orders that members of other professions are expected to carry out.

This language grounds the hierarchical paradigm in interprofessional relationships because of the scope of practice alone, and then also talking about how this is sort of ingrained in our trainees, as you’ve mentioned. And it’s very difficult to unlearn what you have learned in order to learn a new way, which is why we need an entire book about it.

DorAnne 23:02

I want to just make a little shout out in defense of physicians, because I do get a little worried that sometimes interprofessional conversations end up being complaints about power and hierarchy that we then project onto doctors. So, as a non physician, I want to shout out that I see you, I hear you. And I just want to mention that I was practicing full time as an RN with nursing wages for 16 years of my life before Michelle got her first job. So, you know, we talk about the financial and this and that, but physicians have put a whole lot of their early life and dollars into training. And when you talk about licensure, physicians are paying thousands of dollars for licensure to maintain their certifications, and licensure is where we pay hundreds of dollars.

We take one exam once for licensure and maybe another one or two for certification, and then we just have continuing education after that, where Michelle is taking a board certification literally every two years for the rest of her life at the cost of thousands of dollars. So I want physicians to know that we see you, we hear you, we really appreciate you, and we’re simply advocating that you see your role as a role, and you’re really, really valuable, as is everybody. When there’s a code situation and somebody needs to make a discussion, we don’t have time for a committee meeting, and the physician role is to make that decision, and our role is to back off and make it happen. And then hopefully we debrief afterwards and we make it much better.

So I’m really hoping that physicians who are listening also hear us as very invitational we see you, we love you, we need you desperately, and we also recognize the commitment, dedication, money, time you have put in to your training. And we’re all in this together ultimately. And we also need you to bring all of us along.

Cara 25:15

To me, Dorian, this brings up for me the intentionality behind understanding, right. Some of those things that aren’t apparent to us at face value and how hard it is to really make time for that. But how important it is, like how important it is to make time to say what do you see as you know, your primary role here? What is your field of practice and what you bring to this space? What are your strengths? What are your challenges? How do those overlap with my strengths and challenges? How do those overlap with my scope of practice? Where are those points where we do overlap that we could have conversations about how to coordinate those within those areas of practice? Those conversations take time and intention.

I don’t think it’s naturally baked into the way that we practice to have those conversations and understand the background and training and all of the thing that shapes how we practice and how we show up in those spaces. So that’s what that’s bringing up for me, Dorian, as you’re telling that story, is that we don’t understand all of this unless we ask and make space and time to have some conversations about it.

Michelle 26:25

And I’m going to add to that too, that that goes in every direction. Writing with and editing one of the chapters on the scope of social work practice and even seeing in the literature how little is acknowledged and recognized as a full scope of social work practice was really eye opening. I think sometimes based on our work location, our limitations in the system, we focus our work in a very small, narrow part of our actual spectrum of what we are capable of doing and what we could do at the endless boundaries of our disciplines. But I think we end up, because of the system and how we work, we sort of narrow our own minds and our vision as to what each of us can bring and can do.

Eric 27:13

I love that because we actually had a palliative care. We’ve never had a palliative care pharmacist until now, actually several years ago. And so I didn’t know what I was missing until we got a palliative care pharmacist. And it took a while to figure out, like what’s the role of a palliative care pharmacist on our team? And now I can’t imagine not having a healthcare pharmacist and as a doctor, I feel like I should know about drugs and how to prescribe them. But there’s this, again, there’s this overlap in skills and knowledge and expertise, but we have very distinct expertise. And I wonder how in practical, real life scenarios, how does one do this? And Naomi, you mentioned this concept of generalist specialist model. What is that? And is that the solution?

Naomi 28:12

It’s one idea. What we know is that collaboration hasn’t been operationalized very much. So we took this idea of, and it’s really an invitation from the national consensus project that every member of the team should be screening in all domains. So this is a practical, really basic idea that can be applied to clinical practice. It actually can be applied to research and education, too. So it’s this idea that we all are generalists in every domain. So that means that we all screen for every domain in our interactions. And a screening is one to two simple sentences to identify need in that or distress in that domain. So, for instance, I do a psychosocial screen, I do a physical screen, I do screens in all the other domains.

All my team members are taught how to do spiritual, existential, religious screens. Not because they’re going to unpack the box and they’re expected to intervene on everything, but they can recognize it, and then they are taught what to do with it. Whether they have a social worker, a nurse, a physician, an NP on the team, they know what to do with that information. If they don’t, they know how to get to community resources. So that’s one idea. And then the other part of this is that we’re all specialists in specific domains. And that’s the part where we go deep. And unfortunately, since what Alex mentioned is that across the country, most teams are not fully staffed with the core or even all the expanded, amazing team members that we would like in palliative care or geriatrics or medicine. So what happens is you don’t actually get to see the full advanced practice of these colleagues. And so, number one, you don’t know what they do. You think they’re nice, they kind of, they’re there a couple days a week. They come. They mostly go in themselves because they have a huge caseload.

They can’t always collaborate. They don’t always get to do all the generalist palliative care skills that all of us, as specialists do, which is advanced care planning, lead a family meeting, give anticipatory guidance at the end of life. Those are skills that we all have, but you don’t get to do those if you’re not staffed fully and you’re not on the team all the time.

DorAnne 30:25

I also wanna make a shout out for pain and symptom management with social work and chaplains. I have found so often, I’ve been shocked because I don’t know what. I don’t know. And we’ll have a patient with very severe symptoms that are just not responding to the normal treatments. And a social worker or a chaplain will say, wait a minute, can I go in? And they have interventions that if the pain or other symptoms have social, psychological, cultural, or spiritual or existential domains, they intervene, and suddenly the medication requirements plummet and the patients are much more comfortable. So we totally forget that all of us are symptom managers as well. And we often don’t give our chaplain and social work colleagues opportunities to do that.

Alex 31:21

Eric, should we?

Eric 31:22

Yeah.

Alex 31:22

Just in terms of very practical words to say or questions to ask, could we just ask? Naomi, when you say you’re asking about the social domain, what’s your go to question?

Naomi 31:33

So my social workers that I work with are exceptional, and they’ve taught me how to look at strengths and stressors in their social environment, with their family, in this moment. What do they turn to to cope? What do they turn to for strength? And also who are their people? Who are the care partners? And then to identify acute needs, suicidal ideation, financial needs, but also psychosocial needs. So they’ve taught me how to do that within a few sentences. And all of us in the team are looking at that. Sometimes a social worker doesn’t do this psychosocial screen when they’re in the room with us. Maybe another member of the team might do it because we’re all looking with the same eyes, and it’s all this. We’re dancing together with that.

Alex 32:15

That’s great. Thank you. And somebody other than Naomi want to volunteer how they ask about the spiritual domain.

DorAnne 32:22

We are still developing these questions. Sometimes I ask about what brings a patient, meaning what brings them joy when they feel at peace. Can they describe their experience? We’re still in development. We’re all learning together.

Michelle 32:39

I’d like to add to that, too. We’re doing some research in our ALS clinic, and the screening question that we have is, do you experience non physical pain that is deep and uncontrolled? And so it’s just a sense of where is that in them? And we recognize it, we screen for it. But if we don’t have the full cadre of practitioners and support system, then we’re oftentimes we see what we’re missing and we don’t have a chaplain there. So that’s part of why we’re doing looking into some research in that area. But pain, that is deep and uncontrolled to me.

Alex 33:21

The concept that every member of the inter professional team should be generalists and able to ask questions and regularly, routinely ask questions about all domains is probably the concept that pushes the most on the field in the way that it is now. There are many concepts in this book that have pushed on the field. That is one that’s very practical. Everyday clinical encounter, changing that. I think. I’m interested to hear what our listeners think about this and whether they feel this is practical. If they feel like they’re overstepping their boundaries, how does this, you know, what questions work? What questions ought they use? Those sorts of things. So thank you for sharing those questions.

Eric 34:07

And whether or not I’m gonna. I’ll be at a listener whether or not it’s efficient. So does everybody need to screen for the same questions? I can imagine as a patient, it gets really annoying when people are asking similar questions. And this even comes down to how we structure our teams. Are we all going it at once? Are we doing it separately? How do we think about efficacy versus efficiency in how we structure these teams? Guessing you all are going to say this is what the intentionality comes from. We do our teams. Thoughts on that? I’ll ask you, Michelle, how do you think about that?

Michelle 34:46

I’m actually going to toss this one to DorAnne because this is something that we. That we talked about in the. In one of the chapters, so go ahead.

DorAnne 34:56

Well, on our team, which is a community hospital, not an academic institution, we have our morning palliative care huddle when we all review all of the patients who have been referred to our team and that we’re following. And so we often have one person go in to do the initial contact, the initial consult, and it can be anybody from any of the professions. And then the next morning is when they report out, and that’s when we can discuss about what, what the next step, what the interventions are. So everybody is not going in and asking the same questions. One person has done the initial consult, and then we discuss as a team and then decide, do we need to go in, you know, more than one of us, or who is the next, who is the right person to. To follow up from there? Naomi being at an academic institution, and she’s actually doing some research in this area, so I’m sure it looks a little different with an academic setting.

Naomi 35:55

Yeah. The number one question I get when I get this all excited about transdisciplinary and a flat hierarchy and we’re all dancing, is, do we all have to go in together? That’s my number one question I get. And I’m like, no, but in any revolution, you got to actually start with, all right, who are these people? What do they do? We go in together. Sometimes we all listen to the initial consult. Sometimes, till we trust each other, we build some communication, we build some vulnerability with each other. We kind of get to know it. And then absolutely, we divide and care, or sprinkle and sparkle or separate, split and sparkle.

We call it in our team, and we all go off and do what’s needed, but we’re all looking. We constantly come back to each other, communicate throughout the day, and then we work together. So there’s nothing that says about this that we all have to screen every time or that we all have to be together. These are just seeds that we’re saying, you know what? If you want to enculturate this, you actually have to think about it, to do it very intentionally. And then once it’s seated and you keep inviting every new member of the team, you teach them how to screen in all domains. Every member of the team is invited into this transdisciplinary way of working. Then you can, and you mature in it. Then you can continue to just do work the best work you can in whatever ways you can.

Cara 37:13

I think, too, about how social workers are. Often we become palliative care specialists on the job, right. There are very few palliative care fellowships for social workers, very few specialized programs who teach palliative care as a specialty area. It’s generally one class, if you get it right. And so often social workers, new social workers who land in hospice and palliative care are taught by the system, right. How to become a specialist. And if that’s not the. And this is not always true, right. I think social workers, the goal is that we want to operate at the top of our degree and bring all of our training with us.

But sometimes the job is what it is, and it makes it really difficult to change it, especially when we’re still developing as specialists. I think this model that Naomi’s talking about, where the system has a role in how we operate and how we train, especially for those of us who become specialists on the job, how can we think about this from a systemic level all the way, obviously from education and beyond? But I just think that’s an important component as well, to consider I am.

Naomi 38:27

Going to share something a little vulnerable, too, though, because we’re friends here and it’s just between us.

Eric 38:32

Yeah. Nobody else is listening.

Naomi 38:34

I have to say that for some of us who may be perceived at lower status or not, our complete role profession is not understood. It really does help to be part of a menu together initially when we see people, so that they know that it’s just part of the work that we do. And so it doesn’t mean we all have to go together. But it is great to be conscious that we all influence our status and perception to patients and care partners and the institution, the more that we can hold up each other as equal experts and skilled people in the field. And sometimes that means introducing ourselves together. That does really help. So just wanted to share that. That is part of our. Our experience.

Eric 39:18

Well, do you also think our training needs to change? Because, like, a lot of fellowship training for palliative care physician fellows is like, we’re training them how to facilitate and lead family meetings, and they’re doing that throughout the entire year. How do you do an intentionally interprofessional palliative care family meeting and should that change? Cara, what do you think? Expert on education?

Cara 39:44

No. Well, I mean, I really think. I think understanding that other people can lead family meetings is what is right.

Eric 39:51

Doesn’t need to be the fellow.

Cara 39:53

It doesn’t have to be the fellow. And how often do fellows get to observe the social worker or the chaplain lead a family meeting? Is that happening in our training spaces? I don’t know, but I think it should be.

Eric 40:05

Yeah.

Alex 40:06

Could I ask. I know we’re kind of running up against it already because there’s so much to talk about here, about what are the qualities of high functioning teams? And to read from the book, again, this is from the chapter on critical care. Several characteristics, including humility, strong communication, trust, equity, compassion, self reflection, grace, vulnerability, and openness to engage are especially important for the combined for high functioning teams, et cetera, and goes on to talk quite a bit about humility, which I completely agree is a strong component. But I want to sort of, like, buck the idea for a little bit of that and say that high functioning teams are those that can disagree.

Right. And then maybe advocate for tension not being all bad, and that those who can live in that tension and that disagreement while still feeling like this is a safe space to disagree are often some of the most high functioning teams because it welcomes those, those divergent points of view from which the best course often emerges. Any thoughts about qualities of high functioning teams.

DorAnne 41:12

I’d add curiosity to that list. I find that curiosity and humility together when there’s tension occurring, to be curious about what happened, what is that person’s experience? And recognizing that there’s more than just my experience often takes care of it. And once again, looking for alignment, recognizing we may not ever agree, but it’s okay, we can find a path forward that works for us.

Naomi 41:39

I agree. Alex, what you’re saying, I think some of the most amazing experiences and growth experiences I’ve had on teams and with members is when we disagree, we step on each other’s toes and we talk about it afterwards, and we’re like, oh, my God, we’re bigger than we ever could have been. And we’re like, oh, yeah, you’re mine. You’re my person. You’re my ride or die after that. And so I absolutely agree. The things that, and a lot of people study, this interprofessional collaboration, the things they talk about are clear roles, that you have to understand what the goals are, that you have to be able to be real, that the vision has to be transparent, that there has to be mutual trust, there has to be a place you can say no.

Not so often are we taught that we actually can say no to a colleague. We always think we have to say yes. So. And this idea that we actually do have to prove this case, this case is not yet proved. There’s not a lot of evidence out there that this leads to better healthcare outcomes. We wish there was, but we do have to make a financial case. We’d love to have research that supports this that says, okay, actually, we are better not just as caregivers, not just for patients, but we’re better as an institution if we work this way. And so these are the things that we still need to grow that just haven’t been. I really think one argument that is really important is if we’re all working at the height of our practice, then our capacity is actually bigger. We can go off on our own, and one person on the team can lead a family meeting, the other person can introduce palliative care. The other person could be doing something else. So that also might be a future case.

Eric 43:12

Okay, I got a question. We’re running out of time. As Alex puts on his guitar, one practical recommendations for the people who are listening or part of teams that they can do today or tomorrow. I guess it’s a Saturday. If you’re not on Saturday, Monday. To improve intentional interprofessional collaboration. Cara?

Cara 43:34

Yeah, I would say who’s missing from the room when decisions are made. Thinking about not just the clinical actions, but thinking about interprofessional at every level, which includes leadership, administration, or national societies, really thinking beyond just, just the clinical moment.

Michelle 43:52

Michelle, I feel that approaching every situation and every person you’re working with and being self aware of this is treating and approaching situations with courtesy, value, and respect. So recognizing that when we have our as trainees, a scut list of things to do when we burst into the room and we need to check with one more thing with that patient, and we’re interrupting speech therapies evaluation, which is going to help add to information that will help our care plan, that we pause, we acknowledge what’s happening, we value what’s happening in that moment and find a respectful time to perhaps collaborate or come back and approach things in that.

DorAnne 44:32

Way DorAnne, I’m going to go metaphorical and trust your open hand. If you are feeling called to this type of practice, stop working so hard, stop efforting, stop stressing yourself, and trust that you will be led forward as you open yourself to this type of practice.

Eric 44:53

And Naomi, bring us home.

Naomi 44:55

All right, I’ll bring us home. I would say enjoy integrating collaboration, like any skill or competency in palliative care, and think about it as a value that you want to continue. And the second is continue to learn how to make a case of why to leadership and to institutions of why interprofessional collaboration is the best kind of care.

Eric 45:14

Because we can build this dream together. Naomi. [laughing]

Cara 45:18

Standing tall forever nothing’s gonna stop us now, you guys. [laughing]

Alex 45:27

(singing) Looking in your eyes I see a paradise this world that I found is too good to be true standing here beside you want so much to give you this love in my heart that I’m feeling for you let them say we’re crazy I don’t care about that. Put your hand in my hand, baby don’t ever look back let the world around us just fall apart maybe we can make it if we’re hard, too hard and we can build this dream together standing strong forever nothing’s gonna stop us now and if this world runs out of lovers we’ll still have each other nothing’s gonna stop us nothing’s gonna stop us us now.

Eric 46:28

Heck, yeah. Nothing’s going to stop us now thank you. Thank you, Michelle. Thank you, Naomi. Thank you, DorAnne, Thank you, Cara, for joining us on this podcast.

Naomi 46:40

Thank you for having us.

DorAnne 46:41

Thank you.

Michelle 46:45

And thank our authors all of the time on this project. We could never have gotten to this place without every single person contributing to that book.

Eric 46:56

And we will have a link to the where to buy this book on the show notes. So go to the GeriPal website and you can find out where to buy it.

Eric

And thank you to all of our listeners for your continued support.

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Disclosures:
Moderators Drs. Widera and Smith have no relationships to disclose.  Guests DorAnne Donesky, Michelle Milic, Naomi Saks, and Cara Wallace have no relationships to disclose.

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