Description:
While
on placement at so far three sites, I observed that patient cases were
discussed primarily in mechanistic
terms by PTs* and other clinicans. Physical pathology appears to be still the
dominant paradigm of diagnosis and treatment, though attention was paid to
patients’ psychosocial circumstances.
Furthermore, MDT meetings were almost always chaired and led by
doctors. Some degree of control was
relinquished to non-physician specialists in various fields, such as PTs,
OTs**, nurses and SALTS***. However,
control appeared to be retained in the hands of physicians for the most part
and they appeared responsible for vetting the decisions of the entire team
overall.
Feelings:
Being brought to the norm of more traditional doctor-led medical culture, I had
to consciously remind myself to observe and analyse staff interactions from the
biopsychosocial
viewpoint to spot the above-mentioned phenomena. I did
feel that the
hierarchical structure historically associated with biomedicine
and recounted by practitioners of an older generation (such as my mother) was
not as pronounced as the stories suggest, but still palpable at a more subtle
level. I did notice how doctors
naturally gravitated towards roles of overall management and generally held the
final say in most treatment decisions.
Overall, it seemed to me that change had occurred, but that the old
culture was too deeply-rooted to completely disappear.
Evaluation:
As we were taught in course modules on biopsychosocial medicine, mechanistic
healthcare is not the ideal, given the complex and multifactorial nature of
patient wellbeing. However, given what I
observed in a clinical environment, it is often the most practical modality of
treatment, given the limited effect clinicians have on factors of a patient’s
life not related to direct physical function.
The
HCPC standards of proficiency for PTs state that therapists
should work within the bounds of their professional scope and the law at all
times and recognise when it is beyond their professional and legal boundaries
to effect change in an aspect of a patient’s life. Given patient rights to autonomy and basic
dignity, not to mention constraints of time and venue, it is my view that a
therapist will very often be limited to treating a patient’s physical wellbeing.
A top-down hierarchical organisation may not
necessarily be bad for an organisation.
Having served in the military, I can vouch for the importance of clear
chains of command and accountability in ensuring the smooth running of an
organisation. This has clear
implications in the processing of heavy caseloads in the public healthcare
sector, as efficiency of time and resource use are necessary to maximise
utility and ensure fair distribution of public spending.
Analysis:
Regarding organisation hierarchy, the question is whether doctors are
necessarily qualified to lead MDTs****.
As noted by (Atwal & Jones, 2009), doctors may not be
suited to lead in every situation, as suitability depends on an individual’s
main competencies. Given the ratio
of doctors to other clinical staff in the NHS, I concur with (Atwal & Jones, 2009) that it is
impossible for individual doctors to be experts in every possible field that
might involve their department and should instead take full advantage of
non-physician specialists within their department, such as PTs in the fields of
musculoskeletal treatment and movement re-education.
Conclusion:
While
the biopsychosocial model is the ideal standard of practice, practical concerns
will often limit PTs (and other healthcare workers) to treating a patient’s
physical causes of ill health. The main compromise
I observed with regard to this less-than-ideal situation was to treat
mechanistically, but constantly bear in mind psychosocial factors and intervene
where and when possible, eg. pushing for early discharge with comprehensive
package of care to reduce stress on a patient upset at a long period of
inpatient care.
As mentioned above, I have both observed and
reasoned that a top-down hierarchical organisation facilitates efficient
teamwork within public healthcare. While
the nominal office of leadership should indeed hold final say in
decision-making with regard to patient care, the actual position may change
hands depending on situational demands, as per (Atwal & Jones, 2009) model of fluid situational leadership. Clinicians – both current and future, like
myself – would do well to relinquish their traditional prerogatives and views
of order to embrace the fact that their place on the hierarchy can and should
shift according to the needs of the situation at hand, and be able to work in
both subordinate and leadership roles.
*:
Physiotherapists
**: Occupational therapists
***: Speech and language therapists
****: Multidisciplinary teams
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