How Can Cardiologists Be Taught the ‘Team Approach’?

Henry C. Quevedo, MD Tulane University

“Part of me suspects that I’m a loser, and the other part of me thinks I’m God Almighty.” – John Lennon

During training, physicians are taught by many cardiologists who have practiced the majority of their careers in an era when the “captain of the ship” philosophy of medical hierarchy was rampant. Team-based care has now become standard throughout much of cardiology as recommended by evidence-based guidelines, appropriateness criteria, and continuous improvement of institutional quality indicators.

But how can the next generation of cardiologists best learn to foster teamwork and cooperation in a time when so many in the field are still butting heads over territory and self-righteous attitudes?

Team-based care has been praised for enabling the quality of patient care to rise and become more consistent, but it has subsequently reduced the significance of independent physician clinical judgement. However, since physicians are human and act accordingly, differences in patient management still exist. Noninvasive cardiologists, interventionalists, and cardiac surgeons have all been guilty of exhibiting “know-it-all” attitudes as each has a tried-and-true method of approaching patients and strongly thinks he or she can be the one to “fix” them. Ultimately, that’s what we’re trained to do.

For the interventional cardiologist specifically, it might be difficult to let a patient with a single severe proximal LAD lesion with an intermediate Syntax score be referred for bypass considering the long-term benefit offered by an internal mammary graft. The hybrid approach for revascularization of multivessel disease—proposed more than a decade ago as an alternative to traditional CABG— is also promising, but not surprisingly has not become a widespread therapy partially due to the fact that it requires the surgical and interventional teams to work together in the same operating room.

Another important issue in our field is promoting cooperation and constructive feedback among interventional cardiologists. In an academic setting, it is common for an experienced master interventionalist to suggest the case strategy and even be invited to participate in the procedure. This process, however, is not always applicable in the private sector where restrictive covenants for competition exist. But even in an academic setting, physician egos can clash and ultimately leave patient care to only a single perspective. Cath conferences and organized “Heart Team” meetings with multiple perspectives and feedback oriented in planning strategies might contribute to improved procedural success and, hopefully, better long-term patient outcomes. For fellows, observing encounters like this will increase their proclivity to turn to team-based decisionmaking later in their careers.

It is no longer appropriate to work as an individual believing that all your years of training alone will lead you to the best way to manage patients. Certainly, the astute resident or fellow will learn typical patterns for recognizing common diseases presentations and best practices for treatment, but it is our responsibility as a community to stress the importance of shared decision-making for both trainees and veteran operators.

Our ultimate goal is to mitigate patient symptoms and increase quality of life, and hence our perception of being the smartest, brightest, and most omnipotent should be left behind for the benefit and well-being of those we care for.

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