Economists in multidisciplinary teams: Some unresolved problems in the conduct of health services research

SoC Set & Med Vol 14C, pp 217 to 221 © pergamon Press Ltd 1980 Printed m Great Brttam

0160-7995/80/0901-021750200,0

REPORT ECONOMISTS IN M U L T I D I S C I P L I N A R Y TEAMS: SOME UNRESOLVED

PROBLEMS IN THE CONDUCT SERVICES RESEARCH*

OF HEALTH

GAVIN H. MOONEY and ALAN H. WILLIAMS Health Economics Research Unit, University of Aberdeen and Institute of Social and Economic Research, University of York Abstract--In July 1979 a meeting was held at the University of Aberdeen to bring together five mulhdisciplinary research teams, each containing at least one economist, from different European countries to discuss the problems involved in integrating economics and economists into multidlsciplinary research teams in health care.

PREAMBLE

It is widely recognised in Health Services Research that much of the work calls for a multidisciplinary approach. It is also widely recognised that multidisciplinary working imposes special strains on the participants which are additional to the difficulties experienced in the kind of teamwork which unidisciplinary groups practice. But are there, in addition to all these, still more problems if one or more of the members of the multidisciplinary team happens to be an economist? And, if so, what are they, and how do they arise? Are the problems mainly ones which the economists create for their colleagues, or ones which their colleagues create for the economists? And why have they occurred in some groups and not others? How (if at all) have they been "solved"?. And if they have not been "solved", how does one learn to live with them? It was not just idle curiosity that prompted these questions, but a desire by 5 such teams (1 each from Denmark, England, the Netherlands, Norway and Scotland) to offer their collective experiences to others, in the hope that people setting up such teams, or thinking of adding an economist to an existing team, should be aware of the kind of problems that may be encountered. This was not intended to be a "frightening-off" exercise, since all the teams regarded themselves as having handled their problems fairly successfully on the whole, with the economists well integrated into the teams. It was intended rather as a way of generating more realistic expectations about what is possible, about the strengths and weaknesses, the potential and the limitations, of an economics input into a multidisciplinary team of health service researchers. What we have attempted to provide is a set of guidelines in the spirit . . . . "if you go down this road, these are the hazards you may well encounter, whereas if you go down that one, there are a different set of hazards, namely . . . . ". The reader can then * Report of a Meeting of Multidisciphnary Teams in Health Care Research, University of Aberdeen, July 1979. 217

choose which risks are preferable in his or her particular context. This digest of the material is organised into sections as follows: Origins; Problems in multidisciplinary working in general; Problems with/for economists in particular; Size and internal structure of teams; External relations and research strategy; Motivation and implementation. The note ends with some disclaimers and speculations in the Epilogue. ORIGINS The teams fell into two groups: those that were established as a specific response to a specific research problem (and therefore had limited life and restricted terms of reference) and those that were a general response to a generally felt need for a multidisciplinary team with an economist in it. One of the teams had already progressed from the first group to the second, and another was seeking to do so. No team was more than 10 years old, and the median age was 7 years. The initiating and funding bodies were rather disparate, comprising Research Councils, Universities, Ministries of Health and the Health Service itself. Some teams which were initially solely dependent on one or other of these sources felt that greater diversification in funding would be advantageous, but it was recognised that this might mean that more effort got absorbed in fund raising, more complex patterns of accountability and the "struggle for survival". The funding arrangements affected not only the formal patterns of accountability, but also the attitudes of the researchers concerning the appropriate research strategy for the team (of which more later). It also affected the terms and conditions of employment of the team members. It was common for University-based staff to be only part-timers in their research teams, whereas those financed by Research Councils and Ministries of Health were usually full-timers. The fulltime/part-time dichotomy was not mentioned as a

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significant influence affecting working relationships favourably or unfavourably, but being part-time was regarded as potentially important in providing researchers with a continuing source of contact with others of their own discipline, a point to which we shall return later. Recruitment of economists into such groups was not easy, but things seemed to be improving slowly with the growth of health economics generally, but it was still rather a severe constraint in the smaller countries. It was generally regarded as more important to get a good economist with the right attitudes than one who had already worked on health problems but had little else to commend him or her. One team even argued that if you could not get good people in a particular discipline, it was better to try to get good people in some neighbouring discipline and reshape the work accordingly. P R O B L E M S IN M U L T I D I S C I P L I N A R Y W O R K I N G IN G E N E R A L

It was repeatedly emphasised that multidisciplinary work called not only for a particularly agile and flexible intellectual make-up, but also for a patient and tolerant temperament and certain social skills which can, to a certain extent, be inculcated by careful induction and training. Although no team had a formal initiation programme to help this process along, one had selected as researchers only people who had successfully been through an interdisciplinary seminar, which included two days of intensive discussion of problems generated in response to their own attempts to explain a piece of theoretical or empirical work specific to their discipline. At the other extreme, another team had simply relied on a self-denying ordinance "to allow each other to be stupid". It was also regarded as important "to take time", and to make sure that everybody reads what everybody writes, with common discussion of material and insistence on clear, non-technical, step by step exposition. Drafting sessions, painful and tedious though they sometimes seemed, brought matters to a crux, were very revealing, and were held to be "very sobering". If successful they led to a thorough exploration of the underlying assumptions and values of each participating discipline, and the emergence of a common language and shared perceptions. The relative youth of the participating groups and the nature of multidisciplinary work meant that there could be a greater degree of uncertainty involved, in terms of a future career structure, for individual members, than in unidisciplinary research. This appeared to be a partial explanation of the extent of part-time working in multidisciplinary teams. PROBLEMS WITH/FOR ECONOMISTS IN P A R T I C U L A R

The non-economists saw their economist colleagues as often naive and over enthusiastic, tending to assume that their own (technical) usage of (common) words was the only "correct" one, and believing that they had access to a more rigorous analytical apparatus than anyone else. They seemed often to operate on a rather abstract plane, were overkeen on conceptualisation and modelling, and surprisingly ignorant

and impractical about money. They also had very little urge, experience or skill in collecting primary data, which was rather surprising in view of their generally high level of numeracy (too high, in some cases, since this makes for further difficulties in communication). The economists' mirror image of these attitudes was manifested in feelings that their colleagues were often rather woolly and unsophisticated in the way they formulated questions, failing to appreciate the interdependence of economic variables, and unwilling to accept the necessity for explicit simplification if research was to proceed on an economically sound theoretical basis. The economists resented being regarded as "glorified cost accountants", and felt that it was not sufficiently appreciated that economics was a scientific discipline in its own right applicable to a wide range of behavioural problems, and not just a bag of tricks to be used selectively here and there wherever money crept into the discussions. One participating economist admitted, however, that in the interests of harmony and improved communication with his colleagues he had decided to abandon the more formal technical model-building approach which had been inculcated in him during his professional training, in favour of more informal modes of discourse, and although he did not, on balance, regret this, he was rather uneasy about it, and wondered whether he would be regarded by other economists as having sacrificed too readily his scholarly obligations to his subject! All participants agreed that it was not good if the economists were kept, or kept themselves, at arm's length from the rest of the team, or indeed if they were treated any differently from other disciplines within the group. They had an important role to play in ensuring that the right questions were asked, whether the problem under discussion was an "economic" one or not. They could often provide a distinctive disciplinary perspective on such problems. Conversely, economists must be prepared to be challenged about matters on which they might feel they had special expertise, and to let others join in the collaborative reformulation of "their" problems. SIZE AND I N T E R N A L S T R U C T U R E O F TEAMS

The way in which these tensions manifested themselves and were handled varied according to the size and internal structure of the teams. The smallest team consisted of one doctor and 2 economists, the largest of over 20 people formally organised into smaller subgroups of half-a-dozen or so. Attempts to get the participants to suggest an optimal size for such a multidisciplinary group failed to elicit a clear cut response, because it was held to depend on the nature of the task to be undertaken. The smallest group felt itself to be too small, however (it needed more noneconomists!), and the largest group admitted that it did not really work as a totality, the effectively integrated working group being 5 or 6 people. This suggests that it may be prudent for people setting up such teams not to go beyond that size for the first few years if genuine integration is to stand any chance of being achieved.

Problems in the conduct of health services research At this size it is unlikely that a team will contain more than one person from each discipline thereby creating the problem of relying on a single individual to provide a technical methodology on which others depend. Participants had mixed views about this. Economists in particular seemed keen to maintain strong links with their professional colleagues, to continue to be regarded by them as "mainstream" economists, and to have ready access to such colleagues on a day to day basis, so that there is always another economist on whom one can try out ideas and with whom one can discuss problems. A second economist in the team satisfies the latter requirement, and the former requirement would be satisfied if both economists on a team were part-time in the research team with the rest of their time being spent (say) teaching in a University department of economics. But the stronger the links the economist has with other economists (and especially with outside economists) the less time, energy and incentive he or she will have to integrate with the other disciplines inside the team. If a researcher is isolated from others in his/her discipline, he/she has to talk to his/her colleagues, however weird they may be! There is a further dilemma here which some participants had already had to face and which they were confident could be handled effectively, even though it could be a delicate and difficult matter. This is the problem of getting rid of someone who is unsuitable. Some careful distinctions need to be made here regarding the nature of this unsuitability. If this should arise by reason of temperament and/or social attitudes or because a person turns out to have the wrong intellectual skills for the role assigned (e.g. is insufficiently numerate, or too abstract, or in some other important respect too narrow intellectually) then the problems here are no different to those which might arise in any unidisciplinary setting. However, a special difficulty arises in multidisciplinary teams where it is believed by other members of the team that one individual is just plain incompetent. All participants were confident that they could make that judgement accurately, even though there might be no other member of the team in that person's discipline. To put it more starkly, you do not have to be an economist to tell a good economist from a bad one (and in that sentence you can replace "economist" by "doctor" or "epidemiologist" or "psychologist" or "sociologist", and so on). Getting rid of weak members of a team is always difficult, but getting rid of the only representative of a discipline on a small multidisciplinary team may present special hazards, though some of the participants had faced that situation and dealt with it effectively. The process of internal communication and integration was handled differently in different teams. In each case the basic elements were writing, reading and talking, in varying dosages and within different organisational contexts. Rapid communication and sharing of perspectives is crucial, and it was recognised that time spent in casual social contact, e.g. communal coffee breaks (The team that drinks together, thinks together!), in deliberately cultivating easy personal relationships, and in overcoming organisational entropy, is time well spent, and is to be seen by everybody as an important part of the job, and it is par-

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ticularly important that the more senior people demonstrate that commitment. This raised the issue of leadership: where it should lie, what its responsibilities were, and how it should be exercised. Here the different teams manifested very different styles and structures, suggesting that there is no uniquely best way. At one extreme was the team with a formal sub-group structure, under an overall Director, with Group Leaders and Project Leaders, each with defined responsibilities. Expectations were fairly explicitly codified, and the system generated proforma which acted both as guidelines as to what was expected of people in particular situations and as a checklist for their "supervisors" to ensure that nothing had been overlooked. At the other extreme were small teams in which participants simply met frequently and improvised their way through problems as they perceived and confronted them, using their professional skills as far as they could, but otherwise "learning by doing". One team had managed to achieve an unusual level of flexibility whereby (below the level of the overall director) the whole group always worked together as a team but distributed the leadership role between them according to the task in hand, so that different people were team leaders for different functions. In all teams, the general situation was that a doctor was in overall charge, though most teams asserted that there was no reason in principle why this should always be so. All participants felt that the whole team should feel responsible for generating ideas, and not feel that this was the sole responsibility of "the leader". It was, however, also acknowledged (especially by the leaders) that it was the leader's responsibility to ensure that ideas were generated, and the promising ones acted upon. If a unit ran out of steam, the leader should blame no-one but himself/ herself. Again, this could create problems in a multidisciplinary context, if the ideas that were recognised as "promising" came predominantly from (or were filtered mainly through) only one of the disciplines represented. There was also recognised to be a special problem for smaller multidisciplinary teams in accommodating changes in personnel. Not only did the injection of a new discipline disturb the existing equilibrium, but even the replacement of one economist (say) by another might do so. One of the larger teams said that as some projects ended and others started, and as people moved on in their careers, an average term of employment of 3 or 4 years for all but the most senior staff was to be expected. Most teams reported difficult transition phases as they had "dropped" one discipline and tried to integrate a new one, but there appeared to be no magic formula for dealing with this, and it was simply a matter of more writing/ reading/talking/coffee-drinking. No particular problems were ascribed to economists in this respect. EXTERNAL RELATIONSAND RESEARCH STRATEGY The nature of the research funding agency, the research strategy, and the size and internal structure of the research team are obviously closely interrelated matters, and having to separate them for expositional purposes inevitably suppresses some of the combina-

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tional detail. The reader will have to exercise some imagination here in order to fill the gaps left by the rather broad generalisations offered here. The first important element in which the teams varied was in the proportion of their time and effort which was devoted to general education and training work associated with the field of health services research. This tended to be higher in the Universitybased units, but all the units attached considerable importance to the "teaching" role, even where it was restricted to addressing professional groups from time to time about the research work itself. It was felt that it was misguided for research sponsors to set limits on this kind of activity, since it had very important feedback for the future of health services research generally, as well as increasing the probability of implementation of the specific research under discussion. There were particular problems "translating" research reports into the different "languages" needed by different audiences and the challenge of exposition to an audience in a different specialty from your own was considered a valuable experience. The economists complained about the difficulty of getting statistical ideas across to doctors, and felt that there should be some obligation on "the system" to improve its own receptivity to economic argument. There emerged a sharp difference of view as to whether a research team should be free to devise its own research strategy without outside interference, or whether it was better to have a clearly defined "client" for whom a piece of work was intended, and who helped initiate and shape it, so that one could be sure at the end of the day that someone would be listening to the message! Some teams wanted to get closer to the service, others valued greater detachment. But even the groups which wanted complete independence in problem formulation and in building up a research strategy, adopted a variety of devices to get external expertise and advice on projects as they progressed. One team invited leading figures in the relevant fields to become associated with particular pieces of research by joining a panel which virtually made them honorary members of the research team, and had had no difficulty whatever in recruiting such distinguished people, who clearly regarded it as something of an honour. Others had formed "steering" or "advisory" committees which met periodically to review the overall programme of work, to make suggestions, and to act as links with the relevant services or other professional groups. But it was also stressed that to be viable the research had to be of considerable intrinsic interest to the researchers, who must be left adequate room for manoeuvre to incorporate developmental elements of their own choosing. It was also important to include in the research "portfolio" some projects which widened the capabilities of the team. Some built in capacity to help other researchers was also valued, and regarded as an important function, especially since it usually operated reciprocally. MOTIVATIONAND IMPLEMENTATION All the researchers were motivated by a desire to improve their respective health services, or more accurately, to ensure that the health of the community

was improved and that the health services played an approximately efficient role in that process. This then raised in an acute form the problem of ensuring implementation of the research, and especially when research was directed at management as much as at professional groups such as clinicians, as was frequently the case with the work in which economists were involved. It was claimed that clinicians were often much more receptive to research than were administrators which meant that it was unclear who was the "client" for health services research with an economic component. One of the snags was that administrators, like politicians and journalists, wanted simple answers to complicated questions, and this made it dangerous to seek to enlist their support directly in trying to get work noticed and implemented. It was necessary to change people's thinking by careful persuasion, hence the importance of the complementary education roles. The channels of publication for multidisciplinary work were already severely limiting, and the health services management journals offered little scope for the proper reporting of serious and complex research. If researchers really want to influence health service management, they may need to be prepared to get involved in management type activities, i.e. going beyond "initiating thought" and "interpreting its meaning" in relation to the purposes of the organisation and actually showing how it might be embodied in action. Yet multidisciplinary teams should have a distinct advantage over others in these respects, since they should already be well versed in the art of expounding technical material in a non-technical way. This might help protect the economists from having their findings noted only by financiers, thereby avoiding the concomitant danger of having money stressed rather than broader notions of cost-effectiveness. Research often inevitably fell short of its original objectives. This might happen because it had to stop (for lack of time or other resources) before getting to its natural conclusion, or it might turn out to be necessary to narrow down the area of investigation more than was originally intended, sometimes even to the extent that the main outcome was simply a much clearer formulation of the problem and possible approaches to it. Some researchers felt that even though their specific research findings did not seem to have been acted upon, they did at least feel that they had changed the climate of opinion, and that the nature of the discussions- that took place in that area of policy were subsequently very different. EPILOGUE There are some key questions which the group either did not attempt to tackle or failed to resolve, and to which attention must be drawn if we are to avoid misleading the reader. First of all, we did not attempt to establish criteria by which to decide whether a problem should be tackled in a multidisciplinary manner or not. It was, however, recognised that because of the special problems with multidisciplinary work, it would not be sensible to tackle a problem in a multidisciplinary manner if a unidisciplinary approach were likely to be equally effective.

Problems in the conduct of health services research Secondly, we did not attempt to establish criteria by which to decide whether or not a problem should be tackled by a multidisciplinary team which included an economist, as opposed to one which did not. Usually an economist had been brought in because a problem concerned with budgeting, cost-effectiveness or cost-benefit analysis had been identified as ripe for study, rather than out of any more generalised and diffuse view that an economist would be a useful resource to have around. Since the economist will want something to get his/her teeth into, it may be advantageous to await a "precipitating factor" of this kind, though (as stressed above) once in the team it is important not to compartmentalise people's activities too much. Thirdly, many of the problems which have been mentioned are doubtless familiar to research teams of all kinds and the precise extent to which they are

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more (or less) important for multidlsciphnary teams (with economist members) we have not been able to establish. To do so would itself require a major research project and we sought merely to identify the problems which the people present at the meeting thought to be significant. Finally, it should be noted that (perhaps through biassed selection of respondents) the overwhelming impression was that the participants all regarded multidisciplinary work as a very rewarding experience.

Acknowledgements--We would hke to acknowledge the financial support of SSRC for the Conference and express our thanks to all those who attended the meeting and who so willingly entered into the spirit of the occasion We are also grateful to Isabel Tudhope for her help in organismg it.