The Primary Care Team

Health professionals are finding that working in teams enables them to provide better health care to a greater number of people. In particular, the primary care team is proving to be beneficial in many ways. It utilizes the combined skills and expertise of many health professionals, reduces medical costs for patients, and helps bring quality health care into underserved areas of the country. Yet, while this team approach is being used more often, medical students still receive little information about other members of the team and rarely interact with them. As the benefits of teamwork become clear and the team approach becomes a more common mode of practice, it is important to give medical students the opportunity to learn about, and to work with, the other members of the team.

• How can we, as physicians-in-training, ensure that our training includes exposure to the team method of health care?
• How is an interdisciplinary health-care team suited for primary care?
• What are the advantages of the team approach to health care?
• Are there any disadvantages to the team approach?

Medical students often ask questions about other health professionals and their roles in local hospitals, clinics and offices. This Project-In-A-Box module suggests several activities intended to promote informed discussions about the health care team and introduce medical students to some of the many kinds of health professionals they may be working with during their careers.

Although this Project-In-A-Box focuses specifically on the roles of nurse practitioners (NPs), certified nurse-midwives (CNMs), and physician assistants (PAs) in the interdisciplinary primary care team, keep in mind that there are many possible types of health care teams with a variety of members, some of whom are in subspecialty and allied health fields. The interdisciplinary team approach is used most extensively in primary care, where, other than physicians, nurse practitioners, certified nurse-midwives and physician assistants are the most visible members of the team. Through the discussion your activity generates, students can examine the nature of each profession's patient-care expertise and debate the direction of their changing roles.

STUDENT ORGANIZERS GUIDE
Along with information on the members of the primary care team, this Project-In-A-Box provides suggestions for activities designed to teach medical students about the roles of various team members. It also gives tips on how to find speakers for your activities, key questions to ask them and where to find more information on the topic. Use your own ideas and the suggestions below to create a fun and informative primary care team activity.

Activity Suggestions

• Organize a "brown bag" lunch series to discuss the roles of the various members of the health care team. This could also be done after class or over dinner. Invite a different member of the primary care team to speak each time and distribute information to all participants. Encourage everyone to keep an open mind.
• Create a panel discussion. Invite physicians, advanced practice nurses, PAs and other members of the team to discuss their roles. Allot time for each practitioner to speak and answer questions to ensure that students get exposure to each position. Try to invite practitioners who have worked with physicians for several years so they can provide the most relevant perspective for medical students.
• Plan a potluck dinner where medical students intermingle with other members of the health-care team. Invite physicians, NPs, PAs, CNMs, occupational and physical therapists, social workers, nutritionists, and pharmacists, as well as students from those various professions. Ask one of them to be your featured speaker. And if no one likes to cook, order out for pizza.
• Observe their work first-hand. Many health care team members teach courses or hold meetings on primary care issues like nutrition, breastfeeding, diabetes and so forth. These may take place after hours in medical offices or local clinics. Invite the health professional to your planned activity and arrange to visit a class or meeting to observe their work first-hand.
• Review and react to case studies. There are three team-based patient case studies included with this Project-In-A-Box. Use them to generate discussion in your group during one of the activities mentioned above or design an activity around them to encourage thinking about patient care from a team perspective. Ask the health professionals to work with the students on these cases.

Who can you call to find speakers?

• Local birthing centers can suggest nurse-midwives.
• Community-based clinics and nursing homes have a strong tradition of utilizing the health care team. They may also provide you with leads on other sources.
• Local chapters of the Visiting Nurses Association of America may have suggestions.
• Local chapters of La Leche League support natural childbirth and breastfeeding through meetings and classes. They might be able to suggest speakers and may allow students to attend a meeting.
• Local schools of nursing, pharmacy, social work, public health and so forth may be able to provide speakers and/or students to participate in your event.
• Ask your dean or another physician for contact names at local institutions.
• Ask community physicians for suggestions of other professionals to call.
• Ask local health professional groups for speakers.

Key questions to ask your speakers

• What are the benefits and drawbacks of the team process? How have you seen it work?
• How can medical education be changed to give physicians-in-training experience working with health care teams? What will be the result if they continue to receive little exposure to teams?
• What differentiates a nurse-midwife from an obstetrician, and what are the strengths of each?
• How do PAs differ from NPs, and how can the primary care team best utilize the skills of each?
• Should NPs or PAs be able to prescribe medications?
• How can physicians best work with nutritionists, pharmacists and other health professionals?
• How can the team approach be used to solve or alleviate some of the major problems of our health care system, such as high costs and uneven physician distribution?
• What is the future of the primary care team and the health care team in general?

The Primary Care Team
As our nation faces the critical challenge of providing all Americans with access to quality, cost-effective medical care, health professionals are focusing on the team model of primary care delivery and its possible benefits. Although specific team members have changed over the years, the core of the primary care team today includes primary care physicians (osteopathic or allopathic), PAs, NPs, CNMs, and often mental-health and dental-health professionals, working together to provide integrated, comprehensive care to patients.

The health care team often utilizes the expertise of numerous health professionals, including psychologists, nutritionists, pharmacists, social workers, physical therapists, health educators, dentists and dental hygienists, occupational and speech therapists, audiologists, and more. Each health care team -- whether it is primary care, subspecialty care, hospital-based or a rural network connected by computers -- determines for itself what types of practitioners will be most beneficial based on the specific needs of the team's patient population.

Regardless of the specific type of team, all members must work together to make the team effective. To promote effective collaboration, the team often must address issues of group process, including role clarification, team unity, communication, and patterns of decision-making and leadership. It is important to recognize the difference between a multidisciplinary health care team, in which different types of health professionals work with the same patient but make independent recommendations, and the interdisciplinary team, in which the various team members collaborate to develop an integrated plan of treatment. The interdisciplinary nature of the primary care team represents a move away from the traditional, top-down, physician-dominated model of care and toward a more "horizontal," collaborative approach.1 It is important to recognize the difference between a multidisciplinary health care team and the interdisciplinary team.

Other Types of Health Care Teams
Health care teams are as varied as the populations they serve. A community-based, health care team may include physicians, advanced practice nurses, PAs, dentists, health educators and mental-health professionals (such as psychologists). In a geriatrics ward, nutritionists and physical therapists may join the team. For hospice care, nursing assistants who assist with daily life activities, such as moving and bathing, and social workers are integral team members. In rehabilitation, occupational therapists, physical therapists and speech therapists make important additions to the team. Subspecialty teams include: surgical and trauma teams made up of surgeons, anesthesiologists or nurse anesthetists, and PAs; cardiovascular teams composed of cardiologists, nutritionists, exercise therapists, and case managers; and HIV/infectious disease teams made up of infectious disease specialists, pharmacologists, social workers/case managers, and so forth.

A hospital-based team will go on rounds together or hold conferences to facilitate communication about patients and their care. An outpatient-based team, centered in offices or clinics, will meet frequently to keep team members up-to-date on patient care.

Health professionals no longer need to be physically close to each other to work as a team. With computers and teleconferencing, they can easily confer and interact over long distances. Therefore, a health care team is not restricted to one office or even to one city.

Regardless of its specific makeup, the interdisciplinary health care team collaborates to provide the most comprehensive, integrated care for its patients. The physician may diagnose and prescribe medications, the NP may educate the patient about the illness and the treatment, and the social worker may counsel the patient on community resources available to him/her.

Who are advanced practice nurses?
Advanced practice nurses consist of NPs, CNMs, and clinical nurse specialists (CNSs). They are registered nurses (RNs) who have received additional graduate level training in a specialty area. RNs can be trained through four-year university programs offering a baccalaureate degree in nursing (BSN), two-year college programs offering an associate degree in nursing (ADN), or diploma programs offered in hospitals.

Nurse Practitioners (NPs)
An NP provides nursing and medical services to individuals, families and various patient groups (student health centers, occupational clinics, community clinics, etc.), emphasizing health promotion and disease prevention. NPs can also diagnose and manage typical acute and chronic diseases. NPs have specialized training in health assessment and often work in collaboration with primary care physicians. As noted above, NPs are RNs who have received extra clinical training in an accredited NP program and have passed a certification exam. NP specialties include adult, family, pediatric, women's and geriatric health.

Common services provided by NPs include:

• Taking medical histories
• Performing physical exams
• Diagnosing and treating acute and chronic conditions
• Providing treatment programs
• Prescribing and/or dispensing medications
• Educating patients, emphasizing preventive care

NP Facts
In a review of 15 studies, NPs were shown to be able to perform between 75% and 80% of adult primary care services, and up to 90% of pediatric primary care services.3

In a review of 26 studies comparing NPs and physicians, NPs received higher scores than physicians in several areas: amount and depth of discussion regarding child health care, preventive health and wellness; amount of advice, therapeutic listening and support offered to patients; completeness of history and follow-up on history findings; completeness of physical examination and interviewing skills; and patient understanding of the management plan given to them by the provider.4

Studies show that if a solo physician's practice utilizes an NP effectively, total productivity could increase by approximately 70%.5

NPs are able to prescribe medications in 47 states and the District of Columbia. In eight of these states, they can do so without any physician supervision (AANP, 1996).

A 1988 survey of NPs found that 88% practiced primary care. About 20% of NPs practice in rural areas and 50% practice in inner cities. They are accessible to almost all population groups because they practice in a wide variety of settings, including health departments, hospital-based outpatient departments, community-based clinics, prepaid group practices and schools.6

A large number of NPs, in addition to other advanced practice nurses, continue to choose primary care practices in rural or underserved areas.7,8 For this reason, NPs are considered by some a possible solution for uneven physician distribution in our country.

Certified Nurse-Midwives (CNMs)
A CNM is trained to manage the health of women and newborns. As with all advanced practice nurses, CNMs are RNs who have received additional clinical training. Post-graduate training leads to eligibility for the American College of Nurse-Midwives' national examination, which must be passed in order to practice. CNMs practice in a variety of settings including hospitals, birthing centers and clinics, regardless of practice location. Each CNM is typically affiliated with a physician who is available for consultation or referral if necessary.

Common services performed by CNMs include:

• Providing gynecological services (eg, pelvic exams, breast exams and pap smears)
• Delivering babies and examining newborns
• Evaluating and providing care for newborns
• Assisting mothers with breast and bottle feeding
• Advising women on reproductive health and contraception
• Providing care and emotional support for pregnant women
• Consulting and referring to a physician when necessary

CNM Facts
CNMs manage approximately five percent of births in the United States and provide primary care as well as family planning services.9

According to a 1986 report by the Office of Technology Assessment, the quality of CNM care is equivalent to physician's care within their area of competence. Further, they tend to be more effective than physicians in providing preventive care and in counseling patients on health care services.8

Surveyed patients strongly prefer an obstetrician-CNM team over either practitioner alone for both prenatal and delivery care.6

CNMs have Caesarean section rates of 12% for both high- and low-risk patients.10 Physicians have an average 25% Caesarean section rate.6

The average cost of a normal pregnancy is three times higher when managed by an obstetrician as compared with a nurse-midwife.6

Significant cost-savings for deliveries are achieved with a primary care team composed of obstetricians and CNMs.6

Although 71% of ob/gyns had been named in lawsuits as of 1987, only 10% of CNMs had been sued.11

Physician Assistants (PAs)
PAs are health care professionals licensed to practice with physician supervision. PAs are trained in education programs accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP), and offered through medical schools, universities, teaching hospitals or the armed forces. The typical PA student has a bachelor's degree and four and one-half years of health care experience prior to admission to a PA program. Graduates of accredited PA programs take a national certification examination developed in conjunction with the National Board of Medical Examiners. To maintain their certification, PAs must log 100 hours of continuing medical education every two years and sit for a recertification exam every six years.

Because PAs work closely with physicians, they are educated in a medical model designed to complement physician training. The relationship between physician and PA is one of mutual trust and reliance. A PA's duties depend on the type of practice, level of experience, and his or her working relationship with the supervising physician(s) and other health care providers. In general, a PA practices within the scope of the supervising physician.

PAs believe in the team approach to health care and do not seek independence from physician supervision. State laws generally define supervision in a way that promotes efficient utilization of PAs and encourages physicians and PAs to stay in close contact at all times.

Common services provided by a PA include:

• Taking medical histories and performing physical exams
• Ordering and interpreting results of diagnostic studies
• Diagnosing illnesses and diseases
• Developing and implementing patient treatment and management plans
• Performing procedures, including assisting in surgery
• Prescribing and/or dispensing medication
• Counseling patients

PA Facts
The PA profession was created 30 years ago to help extend physician services to areas without enough physicians. In 1996, one third of all PAs practice in rural communities of less than 50,000 people (AAPA, 1996).

Physicians are authorized to delegate prescriptive authority to PAs in 40 states and the District of Columbia. In 30 of these states, this authority includes prescribing controlled substances (AAPA, 1996).

Studies conducted by the RAND Corporation and other researchers have found that PAs save as much as 20% of health care costs, can perform at least 80% of common patient care services performed by physicians and are widely accepted by patients.

Studies in health maintenance organizations (HMOs) have shown PAs to be high-quality, cost-effective primary care providers.8

Most insurance programs, including Medicare and Medicaid, cover physician services provided by PAs.

A Discussion of the Team Approach: When Did It Originate?
Initially, the idea of primary care teams gained recognition in the late 1960s and 1970s. At that time, health professional students began to work together in collaborative outreach projects, and their efforts gained support from medical professionals concerned about the decreasing numbers of physicians. With fewer physicians, it seemed logical to fully utilize the resources of other health professionals to try to make health care more accessible. Educational programs for NPs and PAs were created specifically for the purpose of increasing the availability of primary care services and improving access for underserved populations. Many primary care teams were developed in the 1960s when the U.S. Office of Economic Opportunity funded several neighborhood health centers. At that time, a typical primary care team included a physician, nurse, social worker and neighborhood health worker.1

As the number of physicians increased during the 1980s, the popularity of health care teams diminished. However, the idea did remain strong in some areas of medicine. Primary care teams have demonstrated great success in community-based practices (individual or group, non-hospital-based practices) and in HMOs, as well as in the practices of geriatrics, hospice care, mental health and rehabilitative medicine.

Where are teams successful?
Hospitals are utilizing health care teams more often and for various reasons. For example, PAs often work on surgical teams in surgical suites. In HIV wards, social workers use their expertise to access community resources while pharmacists help monitor patients' numerous medications.

Most importantly, advanced practice nurses have responded to the shortage of physicians in many rural and urban areas and are providing accessible, affordable primary health care to thousands of Americans. Instead of recruiting physicians to these areas, long-distance technology can be used to link the advanced practice nurses with physicians working in other areas to create more primary care teams.

Idealogical debate on some of these critical issues lags behind actual policy because NPs, CNMs, and PAs have already established important roles and high levels of autonomy in our health care delivery system. For example, many states already allow NPs to prescribe medications and/or practice without the supervision of a physician:

• 47 states and the District of Columbia grant prescriptive authority to NPs, and eight of these states allow NPs to prescribe medications without a co-signature or approval from a physician (AANP, 1996).
• NPs have prescriptive authority in 21 states for controlled substances (ie, "class IV" drugs or narcotics) previously prescribed only by physicians (AANP, 1996).
• 45 states and the District of Columbia also grant prescriptive authority to nurse-midwives, enabling them to prescribe medications for preventive care such as prenatal vitamins and oral contraceptives, and for medical problems such as urinary tract infections and vaginitis.2

In addition to prescriptive authority, reimbursement is another important issue of independent practice. NPs were traditionally required to practice under physician supervision in order to receive reimbursement from insurance companies. Twenty-five states now authorize direct reimbursement to NPs by private and commercial insurers, taking away another barrier to independent practice.13

HMOs are taking advantage of the increasing autonomy being granted to NPs, CNMs and PAs in an attempt to decrease costs and maintain quality. For example, a total of 66 nurse-midwives practice in Kaiser Permanente's Southern California Region and manage 70% of low-risk births (Kaiser Permanente press release, March 30, 1992).

In many states, increased independence for advanced practice nurses is a necessity because they deliver essential primary health care services to underserved communities. Even though the number of physicians has doubled since the 1960s, the U.S. Public Health Service currently recognizes more than 2,000 Health Professional Shortage Areas, which are characterized by a low ratio of health care providers to the population, high rates of poverty and infant mortality, increased numbers of low-birthweight babies, and decreased access to primary care services.

There are strong advocates for distinct boundaries among all the health professions--these advocates support the idea that certain patients or conditions are the domain of a particular practitioner. This is the traditional, vertical health care hierarchy. In this arrangement, the physician takes the most difficult cases and has final authority on all cases. However, in the team, or horizontal, approach, every member of the team contributes unique capabilities that can be combined to maximize the effectiveness of a patient's care.

The Future of the Primary Care Team: What Can You Do?
As the health care team concept gains recognition and acceptance, it is likely that all medical students will spend at least part of their practicing careers working on a team. In fact, one of the oldest primary care residencies in the country, Montefiore, promotes team-based training as a cornerstone of its curriculum.13 In addition, the Pew Health Professions Commission recommends interdisciplinary education and practice as key elements in training health professionals for the 21st century.14

It is the responsibility of medical education to provide exposure to, and training in, the team method. However, programs that provide team training are currently the exception and it will take concerted efforts at curricular reform to bring about change. Physicians-in-training can work to get interdisciplinary education included in their curricula by joining curriculum committees and promoting general student activism on this issue. Medical students must ensure that their training prepares them for practice in the real world. Health care providers already in practice must take individual responsibility for acquiring the skills needed to work effectively as part of a team.

In the future, it is predicted that teamwork will dominate the health care landscape. It is therefore in the best interest of every health care provider to acknowledge and use the unique capabilities of all team members in order to provide the highest quality care for patients.

For More Information

American College of Nurse-Midwives

818 Connecticut Ave, NW, Suite 900, Washington, DC 20006

(202) 728-9860; fax (202) 728-9897

American Academy of Nurse Practitioners

Capitol Station, LBJ Bldg, PO Box 12846, Austin, TX 78711

(512) 442-4262; fax (512) 442-6469

American Academy of Physician Assistants

950 North Washington Street, Alexandria, VA 22314

(703) 836-2272 ; fax (703) 684-1924

For more information about the primary care team or for opportunities to work in a team setting, contact:

• Health Promotion/Disease Prevention Project (HPDP): Administered by the American Medical Student Association Foundation and the National Health Service Corps, HPDP provides interdisciplinary summer opportunities for medical and other health professional students to develop community projects in rural and underserved communities. Contact HPDP at (800) 729-6429, x216.
• Coalition of Health Professional Students (CHPS): This is a coalition of students from all health professions, including physicians (osteopathic and allopathic), NPs, PAs, pharmacists and nurses. The purpose of the group is to improve patient care through increased communication and collaboration among the various health disciplines. Contact the coalition at (703) 620-6600, ext. 479.

References

1. Bureau of Primary Health Care: Interdisciplinary Health Care Teams in Practice. Bethesda, MD: Bureau of Primary Health Care; 1995. US Dept of Health and Human Services.
2. George Washington University, Intergovernmental Health Policy Project. Removing Practice Barriers of Nonphysician Providers, Efforts by States to Improve Access to Primary Care. Washington, DC; February 1994.
3. Record JC, ed. Provider Requirements, Cost Savings, and the New Health Practitioner in Primary Care: National Estimates for 1990. Washington DC: Dept of Health, Education, and Welfare; 1979. publication 231-77-0077.
4. Prescott PA, Driscoll L. Evaluating nurse practitioner performance. Nurse Practitioner. 1980;5:28-32.
5. Robin D, Hadley J. National health insurance and the new health occupations: nurse practitioners and physician assistants. J Health Politics, Policy and Law. Fall 1980;5(3).
6. Aiken LH, Fagin CM. Policy Options Regarding the Health Care Workforce: Nurses. Paper prepared for President-Elect Clinton's Health Care Transition Team; January 1993.
7. Fowkes V. Meeting the needs of the underserved: the roles of physician assistants and nurse practitioners. In: Clawson DK, Osterweis M, eds. The Roles of Physician Assistants and Nurse Practitioners in Primary Care. Washington, DC: Association of Academic Health Centers; 1993.
8. Nurse Practitioners, Physician Assistants, and Certified Nurse-midwives: A Policy Analysis. Washington, DC: US Congress, Office of Technology Assessment; 1986. US Government Printing Office.
9. American College of Nurse-Midwives (ACNM). ACNM Facts. Washington, DC; 1995.
10. Gabay M, Wolfe SM. Encouraging the Use of Nurse-Midwives: A Report for Policymakers. Public Citizen's Health Research Group; 1995.
11. Blevins SA. The Medical Monopoly: Protecting Consumers or Limiting Competition? Cato Institute of Policy Analysis, No. 246; December 15, 1995.
12. Kassirer JP. What role for nurse practitioners in primary care? N Engl J Med. 1994;330:204-205.
13. Montefiore Residency Program in Social Medicine. Program application. Bronx, NY; 1995.
14. Shugars DA, O'Neil EH, Bader JD. Healthy America: Practitioners for 2005, an Agenda for Action for US Health Professional Schools. Durham, NC: Pew Health Professions Commission; 1991.

Additional Written Resources

Advanced Nursing Practices are Invading Doctors' Turf. New York Times. November 22, 1993:1.

Baldwin DC. The Role of Interdisciplinary Education and Teamwork in Primary Care and Health Care Reform. Rockville, MD: Bureau of Health Professions. Health Resources and Services Administration publication 92-1009P.

Clawson DK, Osterweis M. The Roles of Physician Assistants and Nurse Practitioners in Primary Care. Washington, D.C.: Association of Academic Health Centers; 1993. [call 202-265-9600 to order].

Ducanis AJ, Golin AK. The Interdisciplinary Health Care Team: A Handbook. Germantown, MD: Aspen Systems Corporation, 1979.

Lecca PJ, McNeil JS. Interdisciplinary Team Practice: Issues and Trends. New York: Praeger Publishers; 1985.

Moses E. The Registered Nurse Population: Findings from a National Sample Survey of Registered Nurses. Division of Nursing, US Dept of Health and Human Services; March 1992.

Mundinger MO. Advanced practice nursing - good medicine for physicians? N Engl J Med. 1994;330:211-214.

Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis (Health Technology Case 37). Washington, DC: US Congress, Office of Technology Assessment; December 1986. US Government Printing Office.

Parker AW. The Team Approach to Primary Health Care. University of California, Berkeley; 1972. [a classic monograph - gives history].

Sekscenski ES, Sansom S, Bazell C, Salmon ME, Mullan F. State practice environments and the supply of physician assistants, nurse practitioners, and certified nurse-midwives. N Engl J Med.1994;331(19):1266-1271.

Case Studies
Except where indicated otherwise, these cases are taken and adapted from the following source: Grant RW, Finocchio, LJ; Primary Care Consortium Subcommittee on Interdisciplinary Collaboration. Interdisciplinary Collaborative Teams in Primary Care: A Model Curriculum and Resource Guide. San Francisco, CA: Pew Health Professions Commission; 1995. They are intended to provide opportunities for groups of interdisciplinary students to evaluate and discuss treatment options for interdisciplinary care.

Case 1: Primary Care and the Specialist
Mrs. Elidia is a 59-year-old woman with heart disease and painful degenerative joint disease in her left hip. She had coronary bypass graft surgery three years ago and is currently taking medications for joint pain, hyperlipidemia and hypertension. Until recently, she had been managed exclusively by a board-certified cardiologist, Dr. Jacobs. Her husband, a business executive, has recently enrolled in a new health care plan that covers his entire family and emphasizes an interdisciplinary primary care approach.

At her first visit to the new clinic, she is seen by an internist. The new doctor performs a complete history and physical, and changes her pain medication regimen. She is also evaluated by the physical therapist and the dietitian, and she is introduced to the PA who will be seeing her on subsequent visits.

Mrs. Elidia is pleased by the team's attention to her health. Her cardiologist, she recalled, never evaluated her joint pain very extensively or gave her exercises to improve her mobility. She is concerned, however, that "an assistant" will be managing her case and wonders whether the team is as qualified as her cardiologist in taking care of her heart problems.

• How can the team address her concerns?
• Does the cardiologist need to be involved?
• What would be the most effective way of involving the cardiologist in her care?
• Her health care plan requires written justification for referral to a cardiologist. What criteria would you use for referring to a specialist?

Case 2: Team Dynamics & Collaboration
Mr. Jones, a 57-year-old executive, comes to the clinic with complaints of fatigue and weight loss. He is evaluated by JK, a nurse practitioner, who does a fairly complete assessment, except for the rectal examination. Mr. Jones relates that he has been under tremendous stress at work lately (his company is being bought out by a competitor) and he has probably not been eating well. He is also very uncomfortable with receiving a rectal exam and thus JK defers the exam (normally, he would have included the exam as part of his work-up). JK sent some blood tests and sent Mr. Jones home after counseling him regarding stress reduction and diet habits.

At case conference later that week, JK presented the case and his management plan. Dr. Q, a general internist, became very angry with JK for not doing the rectal exam. In her words, JK was "irresponsible and negligent" for omitting an important component of the GI cancer work-up, which she felt would be indicated in an older man with weight loss. JK had considered the possibility of a GI tumor but from his interaction with Mr. Jones, felt strongly that his problems were likely due to his work stress and resulting poor appetite. Furthermore, he felt that Dr. Q's anger was uncalled for and that she "didn't know" his patient well enough to make these assumptions. Both JK and Dr. Q are competent, responsible providers with the patient's best interests in mind.

• What would explain Dr. Q's reaction of anger?
• Is JK justified in not doing a rectal exam out of respect for Mr. Jones' uneasiness?
• What are the elements of this team conflict?
• What are possible strategies for resolving the difference of opinion between the two providers?

Case 3: Obstetrics and the Health Care Team (written by Paul Jung)
PJ is a healthy, 30-year-old, married woman with one son. The birth of her first son was an uncomplicated vaginal delivery. Labor took 30 hours, and at your urging, her family practitioner, she received spinal anesthesia (epidural) to relieve the pain of labor. PJ's son is a healthy two-year old with no birth-related medical problems.

PJ is now two-months pregnant without any complications and is considering having her next child delivered by a CNM. Many of her friends have had children delivered by CNMs and report great satisfaction with the birth experience. Some have even delivered their babies at a birthing center.

PJ and her husband are both attracted to the idea of a more natural birth. PJ especially likes the idea of a birth without use of anesthesia. She makes an appointment to see you to inquire about CNMs and natural childbirth.

You are PJ's family practitioner, and you've taken care of her and her family for many years. She tells you that she's thinking about a natural birth in a birthing center.

• What is your reaction?
• How would you counsel PJ?
• What issues would you bring up regarding CNMs and home births in general?
• How would you counsel PJ regarding anesthesia?
• Would PJ's socioeconomic status affect your advice?
• If PJ did ultimately choose to deliver her baby with a CNM, would you, as the family practitioner, remain involved with her care? If so, how? If no, why not?
• Would you try to establish a collaborative relationship?

Case 4: Primary Care
Dr. S is a well-known, 65-year-old physician and biomedical researcher who began to lose his vision in his early sixties. Given his background as a physician, he had no problem searching out the best ophthalmologists in the field. Nor did he have any problems communicating with them.

Dr. S was diagnosed as having macular degeneration, an irreversible and progressive cause of blindness, and was told that there was nothing that could be done for him.

• How might Dr. S's care have differed if he had been seen by an interdisciplinary primary care team that included consultation with an ophthalmologist?
• What else can be done for Dr. S? List other assessments to be made and services to be offered, and develop a care plan with specific tasks assigned to members of your health care team.

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