The Clinic Team In Orthotics And Prosthetics
The following article originally appeared in Facility Facts (Vol. I, No. 2) of the American Board for Certification in Orthotics and Prosthetics, Inc., in the summer of 1962. The opinions expressed by the ABC staff in the article are not necessarily shared by this publication. Nevertheless, periodic re-examinations of our own prejudices are doubtless in order. To this end, "The Clinic Team in Orthotics and Prosthetics" provides food for thought.
"Are you in favor of clinic teams?"
In 1961, during the Survey of Prosthetic Services, four classes of answers were obtained from this question:
Yes, they mean more business.
Yes, they provide more information about the patient and result in better service.
Yes, but only for difficult cases.
No, they are too time-consuming.
Your answer will depend not only on your personal experience with clinics, but also on your understanding of what "clinic team" means.
It is important to recognize, first, that the clinic team is not something new, even though it was popularized by the Veterans Administration in the latter part of the 1940's, and second, that the ortho-tist as well as the prosthetist operates within the clinic team framework, even though the latter is much more aware of this than the former.
For the purposes of this presentation we would identify three types of clinic teams: (1) formal clinic teams, (2) serial clinic teams, and (3) informal clinic teams. Before we define these types, however, let us examine the word "clinic" to see if it will shed some light on our problem.
The word "clinic" in its original Greek form meant "pertaining to the bed." Later it came into use as a term describing instruction by the bedside, through lecture or demonstration, in which patients were examined before a class of students. Today we hear this practice referred to in some hospitals as "grand rounds" or "clinic rounds."
More recently the term "clinic" has been used to describe a place where patients are seen for special study and treatment by a group of physicians, often representing different specialities but practicing medicine together. Clinic team as we refer to it is an expanded clinic which includes a variety of personnel representing disciplines in addition to medicine.
Using this simple definition it follows that a prosthetic clinic team would include a medical specialist (the physician), a prosthetic specialist (the prosthetist), a training specialist (the therapist), and other personnel where special types of problems warranted. Likewise the orthotic clinic team would include the physician and the orthotist with a nurse and/or therapist and other specialists as required.
One important aspect of the clinic team is that the physician has the medicolegal responsibility for his patient. Therefore he is the head of the team in fact if not in function. There can be no clinic team without the involvement of a physician or, as a matter of fact, a patient.
Let us now look more closely at the three types of clinic teams:
Formal Clinic Teams
At an appointed place and an appointed time members representing the disciplines required to treat a given class of patients assemble. Likewise, the class of patients is assembled, and one by one they are brought before the team. This is a formal clinic team.
The formal clinic team may be patient-centered, but all too often it is physician-centered, therapist-centered, or appliance-centered. This depends to a great extent upon the personalities of the team members and the role they see themselves playing in relation to the patient and other members of the team.
This type of clinic team is used by many institutions as a teaching medium. Medical residents are asked to present cases, and the other specialists are consulted as to the management of the patient. Therapists and other specialists are brought in to observe and glean facts from the proceedings, which will help them to serve their patients more expertly.
Prosthetists are more often involved in this type of clinic team operation than are orthotists. This may change, as the orthotist fitting "functional" upper-extremity appliances is discovering. The reason for this is that the schools, beginning with the suction socket program of the late 1940's on through the present programs carried on at the University of California at Los Angeles, New York University, and Northwestern University, have catered to and taught this concept of the formal clinic team.
The original rationale for the formal clinic team was sound. It was to create a medium for the communication of ideas between specialists involved in patient management-especially communication between medical and paramedical personnel.
In practice, however, we see few of these formal clinic teams operating in the best interest of each discipline represented and the patient. Why? Let us enumerate some of the problems.
The physician does not allow for the exchange of ideas.
The patient is bewildered by the number of specialists examining him. He finds that an impersonal atmosphere prevails and many times becomes confused about his course of treatment and prognosis.
While one physician and one therapist are in attendance, usually more than one prosthetist or orthotist is present. This creates a situation wherein the prosthetist or orthotist is forced to sit, like a "dog waiting for a bone to be thrown in his direction."
The practice of most formal clinic teams is to rotate work among "approved" companies. This leads to a factor of competition which is not based on professional competence, and prevents many prosthetists and orthotists from contributing to the work of the team, and thus the service of the patient.
Many "approved" companies send representatives who are little more than order-takers to the formal clinic teams.
We must, then, recognize that the formal clinic team, while excellent in theory, does not generally work in a way that will develop our profession of prosthetics and orthotics.
We must further recognize that the reason behind the teaching of the formal clinic team operation was the establishment of a line of communication between disciplines and thus a mutual respect for the capabilities which each discipline offers in serving the patient. To "fixate" at this "teaching" level indicates a lack of willingness to utilize the maximum competencies of each discipline.
The formal clinic team must, therefore, be looked upon as a transitional stage in the development of an efficient patient-management system.
Serial Clinic Teams
These may be formal or informal. Their advantage is that they are definitely patient-oriented and patient-centered.
In operation, the members of the serial clinic team examine the patient independently and, from the point of view of their specialty, draw their own conclusions and prepare a recommended course of action.
If the serial clinic team operates in a formal context, the members meet together, discuss each patient, compare conclusions, and decide on a joint-complementary course of action. This formal meeting is usually made up of a single representative of each discipline and affords the maximum service to the patient.
If the serial clinic team operates in an informal context, the members exchange their conclusions and recommendations directly with the physician-in-charge who, upon weighing the cumulative body of knowledge, prescribes the course of treatment.
The disadvantage of the serial clinic team operation lies in the fact that a dominant personality might well prevail in determining the course of treatment for the patient. This, however, is less likely to occur in the serial clinic team than in the formal clinic team process.
A second disadvantage would be expressed by the prosthetic or orthotic facility which was not called upon to participate in the serial clinic team operation. But here we must face up to the question of whether we are a business or a profession. The question is not of the "either-or" type, but rather is answered by the relative emphasis placed on each.
Facilities emphasizing the business of prosthetics and orthotics prefer the formal clinic team, where they are assured of at least a certain number of prescriptions to fill in a given period of time. Facilities emphasizing the profession of prosthetics and orthotics prefer the serial or informal clinic team, where they are recognized for their competency and service rendered to patients in their care. The interesting point is that this latter group finds that by emphasizing their profession, the business aspect of their practice takes care of itself. The professional medical practitioner found this to be true many years ago.
Informal Clinic Teams
Here the communication process between disciplines, when operating, has probably reached its highest form. There is both mutual understanding and respect between disciplines. This is on a one-to-one basis.
The informal clinic team usually operates in the field of orthotics, where, historically, the relations between physician and orthotist have been closer. This has occurred to a large extent because the orthotic device is often but one part of an ongoing treatment program for which the physician is responsible.
Much of the work of the informal clinic team is carried on by telephone. The examination by the various disciplines is serial, but seldom do all of the disciplines meet together or channel conclusions and/or recommendations to a single source.
The major problem with the informal clinic team is that it may become too informal, or assumed understandings may not have foundations in fact.
The two poles of clinic team practice extend from the regimented formal clinic team to the laissez-faire informal clinic team. While committed to the clinic team concept, we would recommend neither. In fact, we would encourage abolishing both in favor of the middle approach-the serial clinic team. Our reasons may be simply stated. We desire the best possible service for the disabled; we desire the recognition of our specialities as professions; we desire an adequate compensation for the services we render. It is our considered opinion that only the serial clinic team offers the opportunity for these desires to become realities.
Our thanks to Bertram D. Litt, Associate Project Director of HEW/OVR/RD-430 for research on this subject for the ABC staff.