- Email: [email protected]
Interdisciplinary and intersectoral approach: a challenge for integrated care
psTiEIvr EdKATiCN ANd COUNSE[iNCi ELSEVIER
Patient Education and Counseling 26 (1995) 267-272
Interdisciplinary
and intersectoral approach: a challenge for integrated care Frank Vinicor’
Division
of Diabetes
Translation.
Centers for
Disease
Control
and Prevention,
Atlanta,
GA 30333,
USA
Abstract Integrated care for health disorders, particularly chronic diseases, is a long-term and complex challenge, particularly because of the involvement of many individuals with different beliefs, attitudes, assumptions and reward structures. Two basic conceptual models of disease - the biomedical and psychosocial - underlie many of these differences. The biomedical model views humans as the sum of multiple individual ‘subsystems,’ and disease represents dysfunction of one or more of these subsystems. This model is ‘reductionist’ and ‘individualistic’ in nature in that if ‘THE’ defective subsystem can be identified, studied and improved, it is assumed that health would return. The biomedical model focuses primarily on the individual with ill-health and has added greatly to our basic understanding of disease processes. The psychosocial model is ‘interactive’ and dynamic, and sees the ‘whole’ as more than the sum of its parts. This model values elements outside of the individual, e.g. work and home environment, as important in maintaining or establishing health. Because of fundamental differences between these 2 models of health and disease, conflicts, e.g. efficacy vs. exposure; role of individual vs. environment; etc., may exist among varying professionals regarding the nature, purpose, targets, structure, and consequences of integrated care programs. These fundamental conflicts, if unrecognized and ignored, can significantly attenuate the benefits of well-intentioned prevention and treatment integrated care programs. Keywords:
Integrated care; Models of health/disease
1. Introduction
control disease, is unlikely to be sufficient to either maintain health, or minimize disability for
Over the last several years, it has become apparent that a ‘one on one’ relationship, e.g. between physician and patient, while essential to
individuals or groups of people, alike [l-4]. Thus, throughout the world, ‘systems’ of care now involve a variety of non-physician health professionals; non-health professionals, e.g. lawyers, etc. and non-professionals, e.g. patients and their families. Thus, nurses, dietitians, social workers, etc. have become an important part of the ‘health
’ Tel.: + 404 4885ooO;Fax: + 404 4885966.
0738-3991/95/$09.500 1995 Elsevier ScienceIreland Ltd. All rights reserved SSDI 0738-3991(94)00744-K
268
F. Vinicor
1 Patient
Educ.
team.’ Non-health professionals, traditionally not part of ‘medical teams’ - economists, sociologists, anthropologists, city planners, political scientists, administrators, etc. - have now become integral participants involved in the development, implementation and evaluation of large integrated care programs. Most recently, community leaders, e.g. church elders, leaders of lay community organizations, etc. have been integrated into decisions about health matters. Finally, throughout this transition, patients themselves, as well as their families, have been increasingly viewed as essential partners in efforts to prevent morbidity and reduce disease burden [5]. 2. Why are there problems? The effort to establish comprehensive ‘integrated care systems’ is based on the assumption that there are many persons who can and should influence these ‘health care systems,’ and that a broad view and perspective of health should result in demonstrable improvements in the lives of persons threatened by potential or actual disease. While these perspectives and assumptions are laudable, the momentum towards integrated care has not occurred without difficulty and dissension (2 characteristics that will likely continue during the evolution of integrated care movements). These problems reflect in part different assumptions and beliefs inherent in 2 models of health and disease - the biomedical and psychosocial [6,7]. The biomedical model is consistent with a natural science vision, and has been the dominant perspective accounting for many advances in medical care during the 20th century. It identifies disease as a disruption in one or more of many physiologic subsystems. The isolation, study and repair of these subsystems - a ‘reductionist’ view - are steps that are necessary to understand basic disease processes, and to ultimately develop preventative and treatment strategies. ‘Causal mechanisms’ are integral to the biomedical model, and many health professions, including basic, molecular and clinical investigators, as well as most of the western medical care system, and traditional epidemiology and patient education programs, reflect the constructs of the biomedical
Couns.
26 (1995)
267-272
model. The individual patient and/or subsystem is the focus of an intervention, with the expectation that the ‘environment’ will improve if the individual does first. The psychosocial model tends to be more ‘holistic,’ i.e. views health as more than the sum of individual subsystems. It is dynamic, i.e. sees the whole as reflective of on-going interactions of many elements and activities. The social system or environment in which a person lives/works/plays is viewed as very influential in health or disease [8]. Many aspects of the community outside the usual purview of the medical care system - e.g. housing, employment, education, political systems, etc., are considered important within the psychosocial model, and essential to the health of individuals [9]. Social anthropologists, economists, political scientists, urban developers, community leaders, etc. are examples of important persons within integrated care systems who reflect these perspectives of the psychosocial model. 3. Examples of problems Depending on the degree to which persons involved in interdisciplinary and intersectoral approaches to integrated care reflect the assumptions and constructs of these 2 models, conflicts may emerge regarding the nature and direction of health interventions. Several examples may serve to illustrate the range of difficulties which may be encountered in the creation and management of integrated care systems (Table 1). Reflecting basic philosophical constructs of the 2 models, whether efforts are to be focused on the ‘individual’ or the ‘group,’ i.e. populations, may be problematic [lO,l 11. For example, traditional medical ethics and training would encourage the individual practitioner to apply all resources necessary to the individual patient, regardless of how these decisions would affect other or future patients [l]. The person influenced by the psychosocial model of health e.g. anthropologists, behavioral psychologists, etc., might consider factors outside the individual, e.g. housing, social support units - the environment - as being critical to health [12]. The economist, in contrast,
F. Vinicor
/ Patient
Educ.
applying a utilitarian view of health, might be motivated by the ‘greatest good for the greatest number’ and want the decision to spend health dollars to be more ‘rational,’ with decisions made on behalf of society, efficiency, and ‘opportunity costs’ - not the individual patient [13,14]. This latter viewpoint might encourage making choices more explicit regarding interventions, and base these choices on the good to populations, rather than individual needs. Concepts of rationing may emanate out of this view [15,16]. The issue of efficacy vs. exposure is a second example of potential conflict emerging from different assumptions inherent in the 2 models of health and disease. For many persons trained in the biomedical model, and within most traditional patient education programs, the ultimate criterion for program impact is ‘efficacy,’ i.e. how many people who receive the program will actually improve behavior. Thus, many proposed interventional programs are multi-faceted, long-lasting, repetitive, expensive and ‘intense,’ reflecting the complex challenges of changing human behavior [17]. It is difficult to alter behaviors, and no ‘expense’ will be spared to maximize efficacy the likelihood that the individual will benefit from the intervention. Members of integrated care systems who have a ‘population’ perspective as part of a psychosocial model suggest that the expense, complexity and intensity of a program to improve efficacy may, in fact, limit ‘societal impact’ if as a consequence, only a few persons are exposed to the program (10,l 1,18). The philosophical basis of this perspective indicates that an education program which, while less efficacious at the individual level, may still have great impact from a societal perspective if many more people could be exposed to the admittedly less efficacious program. Thus, from a population perspective, ‘little by little soon means a lot,’ i.e. many people making small changes, i.e. 100% exposure, may in the aggregate be more powerful than a few persons achieving a complete transformation, i.e. 100% efficacy. A final example of basic difference in beliefs emanating from these 2 health models which may result in conflicts in integrated care programs are the targets of care. For those trained in the
Couns.
26 (1995)
267-272
269
biomedical model, the focus of the intervention will likely be directed to the individual with the disease condition. The single individual is where the problem resides, and should be the focus of interventional strategies. Program directions more consistent with the psychosocial model would be towards the ‘environment,’ e.g. community exercise facilities, better food choices in grocery stores, improved housing, etc. We are all influenced by our environment and thus, ‘environmental impact’ is powerful [8,12,18]. It is not only conflict about the content and direction of integrated care programs which may reflect 2 different health models, but also the very structure of the integrated care program, as well as reward systems for participants. Reflecting the ‘causal relationship’ and subsystem framework of the biomedical model, it is highly likely that a hierarchical organizational model would be favored by those trained in, and supportive of, this model of health/disease (Fig. 1). ‘Linear relationships’ and authority responsibilities are important derivatives of the biomedical model. The psychosocial model would suggest an interactive, non-hierarchical, ‘co-equal’ organizational structure in which (1) the patient/client is a central and active part of decision making (5,19,20); and (2) many non-physician professionals have interactive input, i.e. ‘interdisciplinary care,’ into health decisions (Fig. 2).
rh 0
Fig. 1. Organizational structure. The figure on the left represents a hierarchical, ‘line’ organizational structure. The figure on the right represents an interactive organizational structure based on program and project needs.
270
F. Vinicor
/ Patient
Educ.
Couns.
26 (1995)
267-272
Multi- vs. Inter- Discipline
MD RN
\
RD
RD
RN
Fig. 2. Interactive care patterns. The figure on the left represents ‘multidisciplinary care, ’ in which while several different health professionals are involved in the assessment and care of the patient, this involvement is sequential and non-interactive among the health professionals. The figure on the right represents ‘interdisciplinary care,’ in which a variety of health professional are involved in patient management, but in a process that requires sharing of information, ideas, and recommendations with a single, consensus program for and with the patient emerging.
Finally, regarding rewards for participants of integrated care systems, clear and precise improvements in outcomes associated with individual (and precisely identified) patients would be viewed as essential indicators of program effectiveness, consistent with the tenets of the biomedical model. The process of care, and the improved health and sense of well-being of the population, will be viewed as very important to those whose beliefs emanate out of the psychosocial model E71. 4. Where should we go? Given the differences between the 2 models of health and disease, as the above situations exemplify, it might seem that any effort to establish an interdisciplinary and intersectoral approach to integrated care would be destined for failure. Indeed, the potential for conflict may seem
substantial, because of the depth and pervasiveness of the differences in fundamental beliefs and philosophical constructs that may exist among the leadership of integrated care programs. Yet, there is reason for optimism. Most who participate in interdisciplinary and intersectoral approaches to integrated care want to do ‘good.’ While there may be differences in the means to achieve the goal, the ‘ends’ remains improved health for people. In addition, there are practical steps that can be taken which will result in confluence among the wide array of perspectives which would be beneficial to the integrated care program [21-231. Simple, but essential, recognition of the likely differences in beliefs, attitudes, etc. among the various leader participants is an critical first step in minimizing conflict. People from the medical, social, economic, or administrative worlds will not have similar perspectives, and this fact must be recognized and accepted at the beginning.
F. Vinicor
/ Putient
Educ. Couns.
Second, it is essential to remember that being an effective and productive member of a ‘team’ is not part of one’s genetic structure, but must be learned and practiced. Program managers/ leaders must establish mechanisms to (1) teach team participation; and (2) allow discussion about differences in fundamental perspectives. Such efforts, certainly, are not always without ‘risk’ ~241.
Third, it is important that integrated care systems permit as many perspectives as possible, regardless of which health model underlies these varying beliefs, to be part of the actual program. Given the differences that are likely to emerge in the early phases of the development of integrated care programs, there must be a process which will allow disparate views to be voiced, discussed, and incorporated into program decisions. Fourth, given the differences in reward structures that reflect contrasts between the biomedical and psychosocial models, it will be important to establish mechanisms to give all members of the interdisciplinary and intersectoral committees a clear sense of accomplishment and progress. 5. Conclusion These are very exciting times in that without diminishing the notable achievements of the biomedical model, a broader view of health and disease more consistent with a psychosocial model is increasingly influencing integrated health programs. Transition is always associated with strain and difficulties, and these inevitable conflicts will be heightened by differences in fundamental beliefs and assumptions. The movement to integrate interdisciplinary and intersectoral approaches into care systems is certainly laudable, but to be maximally effective, it will be necessary to establish time and mechanisms to articulate, discuss and resolve natural conflicts. The challenge for integrated care managers is to both recognize the potential danger of these conflicts, as well as the potential gain for a program which includes the many perspectives. To maximize the benefits of an interdisciplinary and intersectoral approach, it will be clearly necessary to ‘go slowly to move fast.’
26 (1995)
267-272
271
References [l] Greenlick M. Educating Physicians for Population based Clinical Practice. J Am Med Assoc 1992, 267: 1645- 1648. [2] Barondess J. The Academic Health Center and the Public Agenda: Whose Three-legged Stool? Ann Int Med 1991: I1 5: 262-212. [3] Showstack J, Fein 0, Ford D et al. Health of the Public: The Academic Response. J Am Med Assoc 1992; 267: 2497-2502. [4] White K, Connelly J. The medical school’s mission and the population’s health. Ann Int Med 1991; 115: 968-972. [5] Anderson R, Funnell M, Butler P, Arnold M, Fitzgerald J. Evaluation of a patient empowerment program. Diabetes 1994; 43(Sl): 20A. [6] Engel Cl. The need for a new medical model: a challenge for biomedicine. Science 1977; 196: 129- 136. [7] Nijhuis H, Van Der Maesen L. The philosophical foundations of public health: an invitation to debate. J Epidemiol Community Health 1994; 48: l-3. [8] Anderson R. The challenge of translating scientific knowledge into improved diabetes care in the 1990s. Diabetes Care 1991; 14: 418-421. [9] McCulloch D, Glasgow R, Hampson S, Wagner E. A systematic approach to diabetes management in the postDCCT era. Diabetes Care 1994; 17: 765-769. [IO] Rose Cl. Sick individuals and sick populations. Int J Epidemiol 1985; 14: 281-286. [II] Khaw K-T. Genetics and environment: Goeffry Rose revisited. Lancet 1994; 343: 838-839. [I21 Wallerstein N, Bernstein E. Introduction to communitv empowerment, participatory education, and health. Health Educ Q 1994; 21: 141-148. [I31 Eisenberg J. Clinical economics - a guide to the economic analysis of clinical practice. J Am Med Assoc 1989; 262: 2879-2886. P41
Laupacis A, Feeny D, Detsky A, Tugwell P. How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. Can Med Assoc J 1992; 146: 473-481.
Eddy D. Connecting value and costs: whom do we ask and what do we ask them? J Am Med Assoc 1990; 264: 1737-1739. Mechanic D. Trust and informed consent to rationing. 1161 Milbank Q 1994; 72: 217-223. P71 Ruggiero L, Prochaska J. Readiness to change: conclusions. Diabetes Spectrum 1993; 6: 58-60. WI Vinicor F. Barriers to the translation of the Diabetes Control and Complications Trial. Diabetes Rev, in press. 1191 Etzweiler D. Diabetes translation: a blueprint for the future. Diabetes Care 1994; 17(Sl): 1-l I. PO1Kassirer J. Incorporating patients’ preferences into medical decisions. N Engl J Med 1994; 1895-1896. WI Altman D, Endres J, Linzer J, Lorig K, Howard-Pitney B, Rogers T. Obstacles to and future goals of ten comprehensive community health promotion projects. J Community Health 1991; 299-314. [I51
212
F. Vi&or
/ Patient Educ. Couns. 26 (1995) 267-272
[22] Francisco V, Paine A, Fawcett S. A methodology for monitoring and evaluating community health coalitions. Health Educ Res - Theory and Pratt 1993; 8: 403-416. [23] Butterfoss F, Goodman R, Wandersman A. Community
coalitions for prevention and health promotion. Health Educ Res - Theory and Pratt 1993; 8: 315-330. [24] Bergman A. Meeting mania. N Engl J Med 1994; 330: 1622-1623.
Patient Education and Counseling 26 (1995) 267-272
Interdisciplinary
and intersectoral approach: a challenge for integrated care Frank Vinicor’
Division
of Diabetes
Translation.
Centers for
Disease
Control
and Prevention,
Atlanta,
GA 30333,
USA
Abstract Integrated care for health disorders, particularly chronic diseases, is a long-term and complex challenge, particularly because of the involvement of many individuals with different beliefs, attitudes, assumptions and reward structures. Two basic conceptual models of disease - the biomedical and psychosocial - underlie many of these differences. The biomedical model views humans as the sum of multiple individual ‘subsystems,’ and disease represents dysfunction of one or more of these subsystems. This model is ‘reductionist’ and ‘individualistic’ in nature in that if ‘THE’ defective subsystem can be identified, studied and improved, it is assumed that health would return. The biomedical model focuses primarily on the individual with ill-health and has added greatly to our basic understanding of disease processes. The psychosocial model is ‘interactive’ and dynamic, and sees the ‘whole’ as more than the sum of its parts. This model values elements outside of the individual, e.g. work and home environment, as important in maintaining or establishing health. Because of fundamental differences between these 2 models of health and disease, conflicts, e.g. efficacy vs. exposure; role of individual vs. environment; etc., may exist among varying professionals regarding the nature, purpose, targets, structure, and consequences of integrated care programs. These fundamental conflicts, if unrecognized and ignored, can significantly attenuate the benefits of well-intentioned prevention and treatment integrated care programs. Keywords:
Integrated care; Models of health/disease
1. Introduction
control disease, is unlikely to be sufficient to either maintain health, or minimize disability for
Over the last several years, it has become apparent that a ‘one on one’ relationship, e.g. between physician and patient, while essential to
individuals or groups of people, alike [l-4]. Thus, throughout the world, ‘systems’ of care now involve a variety of non-physician health professionals; non-health professionals, e.g. lawyers, etc. and non-professionals, e.g. patients and their families. Thus, nurses, dietitians, social workers, etc. have become an important part of the ‘health
’ Tel.: + 404 4885ooO;Fax: + 404 4885966.
0738-3991/95/$09.500 1995 Elsevier ScienceIreland Ltd. All rights reserved SSDI 0738-3991(94)00744-K
268
F. Vinicor
1 Patient
Educ.
team.’ Non-health professionals, traditionally not part of ‘medical teams’ - economists, sociologists, anthropologists, city planners, political scientists, administrators, etc. - have now become integral participants involved in the development, implementation and evaluation of large integrated care programs. Most recently, community leaders, e.g. church elders, leaders of lay community organizations, etc. have been integrated into decisions about health matters. Finally, throughout this transition, patients themselves, as well as their families, have been increasingly viewed as essential partners in efforts to prevent morbidity and reduce disease burden [5]. 2. Why are there problems? The effort to establish comprehensive ‘integrated care systems’ is based on the assumption that there are many persons who can and should influence these ‘health care systems,’ and that a broad view and perspective of health should result in demonstrable improvements in the lives of persons threatened by potential or actual disease. While these perspectives and assumptions are laudable, the momentum towards integrated care has not occurred without difficulty and dissension (2 characteristics that will likely continue during the evolution of integrated care movements). These problems reflect in part different assumptions and beliefs inherent in 2 models of health and disease - the biomedical and psychosocial [6,7]. The biomedical model is consistent with a natural science vision, and has been the dominant perspective accounting for many advances in medical care during the 20th century. It identifies disease as a disruption in one or more of many physiologic subsystems. The isolation, study and repair of these subsystems - a ‘reductionist’ view - are steps that are necessary to understand basic disease processes, and to ultimately develop preventative and treatment strategies. ‘Causal mechanisms’ are integral to the biomedical model, and many health professions, including basic, molecular and clinical investigators, as well as most of the western medical care system, and traditional epidemiology and patient education programs, reflect the constructs of the biomedical
Couns.
26 (1995)
267-272
model. The individual patient and/or subsystem is the focus of an intervention, with the expectation that the ‘environment’ will improve if the individual does first. The psychosocial model tends to be more ‘holistic,’ i.e. views health as more than the sum of individual subsystems. It is dynamic, i.e. sees the whole as reflective of on-going interactions of many elements and activities. The social system or environment in which a person lives/works/plays is viewed as very influential in health or disease [8]. Many aspects of the community outside the usual purview of the medical care system - e.g. housing, employment, education, political systems, etc., are considered important within the psychosocial model, and essential to the health of individuals [9]. Social anthropologists, economists, political scientists, urban developers, community leaders, etc. are examples of important persons within integrated care systems who reflect these perspectives of the psychosocial model. 3. Examples of problems Depending on the degree to which persons involved in interdisciplinary and intersectoral approaches to integrated care reflect the assumptions and constructs of these 2 models, conflicts may emerge regarding the nature and direction of health interventions. Several examples may serve to illustrate the range of difficulties which may be encountered in the creation and management of integrated care systems (Table 1). Reflecting basic philosophical constructs of the 2 models, whether efforts are to be focused on the ‘individual’ or the ‘group,’ i.e. populations, may be problematic [lO,l 11. For example, traditional medical ethics and training would encourage the individual practitioner to apply all resources necessary to the individual patient, regardless of how these decisions would affect other or future patients [l]. The person influenced by the psychosocial model of health e.g. anthropologists, behavioral psychologists, etc., might consider factors outside the individual, e.g. housing, social support units - the environment - as being critical to health [12]. The economist, in contrast,
F. Vinicor
/ Patient
Educ.
applying a utilitarian view of health, might be motivated by the ‘greatest good for the greatest number’ and want the decision to spend health dollars to be more ‘rational,’ with decisions made on behalf of society, efficiency, and ‘opportunity costs’ - not the individual patient [13,14]. This latter viewpoint might encourage making choices more explicit regarding interventions, and base these choices on the good to populations, rather than individual needs. Concepts of rationing may emanate out of this view [15,16]. The issue of efficacy vs. exposure is a second example of potential conflict emerging from different assumptions inherent in the 2 models of health and disease. For many persons trained in the biomedical model, and within most traditional patient education programs, the ultimate criterion for program impact is ‘efficacy,’ i.e. how many people who receive the program will actually improve behavior. Thus, many proposed interventional programs are multi-faceted, long-lasting, repetitive, expensive and ‘intense,’ reflecting the complex challenges of changing human behavior [17]. It is difficult to alter behaviors, and no ‘expense’ will be spared to maximize efficacy the likelihood that the individual will benefit from the intervention. Members of integrated care systems who have a ‘population’ perspective as part of a psychosocial model suggest that the expense, complexity and intensity of a program to improve efficacy may, in fact, limit ‘societal impact’ if as a consequence, only a few persons are exposed to the program (10,l 1,18). The philosophical basis of this perspective indicates that an education program which, while less efficacious at the individual level, may still have great impact from a societal perspective if many more people could be exposed to the admittedly less efficacious program. Thus, from a population perspective, ‘little by little soon means a lot,’ i.e. many people making small changes, i.e. 100% exposure, may in the aggregate be more powerful than a few persons achieving a complete transformation, i.e. 100% efficacy. A final example of basic difference in beliefs emanating from these 2 health models which may result in conflicts in integrated care programs are the targets of care. For those trained in the
Couns.
26 (1995)
267-272
269
biomedical model, the focus of the intervention will likely be directed to the individual with the disease condition. The single individual is where the problem resides, and should be the focus of interventional strategies. Program directions more consistent with the psychosocial model would be towards the ‘environment,’ e.g. community exercise facilities, better food choices in grocery stores, improved housing, etc. We are all influenced by our environment and thus, ‘environmental impact’ is powerful [8,12,18]. It is not only conflict about the content and direction of integrated care programs which may reflect 2 different health models, but also the very structure of the integrated care program, as well as reward systems for participants. Reflecting the ‘causal relationship’ and subsystem framework of the biomedical model, it is highly likely that a hierarchical organizational model would be favored by those trained in, and supportive of, this model of health/disease (Fig. 1). ‘Linear relationships’ and authority responsibilities are important derivatives of the biomedical model. The psychosocial model would suggest an interactive, non-hierarchical, ‘co-equal’ organizational structure in which (1) the patient/client is a central and active part of decision making (5,19,20); and (2) many non-physician professionals have interactive input, i.e. ‘interdisciplinary care,’ into health decisions (Fig. 2).
rh 0
Fig. 1. Organizational structure. The figure on the left represents a hierarchical, ‘line’ organizational structure. The figure on the right represents an interactive organizational structure based on program and project needs.
270
F. Vinicor
/ Patient
Educ.
Couns.
26 (1995)
267-272
Multi- vs. Inter- Discipline
MD RN
\
RD
RD
RN
Fig. 2. Interactive care patterns. The figure on the left represents ‘multidisciplinary care, ’ in which while several different health professionals are involved in the assessment and care of the patient, this involvement is sequential and non-interactive among the health professionals. The figure on the right represents ‘interdisciplinary care,’ in which a variety of health professional are involved in patient management, but in a process that requires sharing of information, ideas, and recommendations with a single, consensus program for and with the patient emerging.
Finally, regarding rewards for participants of integrated care systems, clear and precise improvements in outcomes associated with individual (and precisely identified) patients would be viewed as essential indicators of program effectiveness, consistent with the tenets of the biomedical model. The process of care, and the improved health and sense of well-being of the population, will be viewed as very important to those whose beliefs emanate out of the psychosocial model E71. 4. Where should we go? Given the differences between the 2 models of health and disease, as the above situations exemplify, it might seem that any effort to establish an interdisciplinary and intersectoral approach to integrated care would be destined for failure. Indeed, the potential for conflict may seem
substantial, because of the depth and pervasiveness of the differences in fundamental beliefs and philosophical constructs that may exist among the leadership of integrated care programs. Yet, there is reason for optimism. Most who participate in interdisciplinary and intersectoral approaches to integrated care want to do ‘good.’ While there may be differences in the means to achieve the goal, the ‘ends’ remains improved health for people. In addition, there are practical steps that can be taken which will result in confluence among the wide array of perspectives which would be beneficial to the integrated care program [21-231. Simple, but essential, recognition of the likely differences in beliefs, attitudes, etc. among the various leader participants is an critical first step in minimizing conflict. People from the medical, social, economic, or administrative worlds will not have similar perspectives, and this fact must be recognized and accepted at the beginning.
F. Vinicor
/ Putient
Educ. Couns.
Second, it is essential to remember that being an effective and productive member of a ‘team’ is not part of one’s genetic structure, but must be learned and practiced. Program managers/ leaders must establish mechanisms to (1) teach team participation; and (2) allow discussion about differences in fundamental perspectives. Such efforts, certainly, are not always without ‘risk’ ~241.
Third, it is important that integrated care systems permit as many perspectives as possible, regardless of which health model underlies these varying beliefs, to be part of the actual program. Given the differences that are likely to emerge in the early phases of the development of integrated care programs, there must be a process which will allow disparate views to be voiced, discussed, and incorporated into program decisions. Fourth, given the differences in reward structures that reflect contrasts between the biomedical and psychosocial models, it will be important to establish mechanisms to give all members of the interdisciplinary and intersectoral committees a clear sense of accomplishment and progress. 5. Conclusion These are very exciting times in that without diminishing the notable achievements of the biomedical model, a broader view of health and disease more consistent with a psychosocial model is increasingly influencing integrated health programs. Transition is always associated with strain and difficulties, and these inevitable conflicts will be heightened by differences in fundamental beliefs and assumptions. The movement to integrate interdisciplinary and intersectoral approaches into care systems is certainly laudable, but to be maximally effective, it will be necessary to establish time and mechanisms to articulate, discuss and resolve natural conflicts. The challenge for integrated care managers is to both recognize the potential danger of these conflicts, as well as the potential gain for a program which includes the many perspectives. To maximize the benefits of an interdisciplinary and intersectoral approach, it will be clearly necessary to ‘go slowly to move fast.’
26 (1995)
267-272
271
References [l] Greenlick M. Educating Physicians for Population based Clinical Practice. J Am Med Assoc 1992, 267: 1645- 1648. [2] Barondess J. The Academic Health Center and the Public Agenda: Whose Three-legged Stool? Ann Int Med 1991: I1 5: 262-212. [3] Showstack J, Fein 0, Ford D et al. Health of the Public: The Academic Response. J Am Med Assoc 1992; 267: 2497-2502. [4] White K, Connelly J. The medical school’s mission and the population’s health. Ann Int Med 1991; 115: 968-972. [5] Anderson R, Funnell M, Butler P, Arnold M, Fitzgerald J. Evaluation of a patient empowerment program. Diabetes 1994; 43(Sl): 20A. [6] Engel Cl. The need for a new medical model: a challenge for biomedicine. Science 1977; 196: 129- 136. [7] Nijhuis H, Van Der Maesen L. The philosophical foundations of public health: an invitation to debate. J Epidemiol Community Health 1994; 48: l-3. [8] Anderson R. The challenge of translating scientific knowledge into improved diabetes care in the 1990s. Diabetes Care 1991; 14: 418-421. [9] McCulloch D, Glasgow R, Hampson S, Wagner E. A systematic approach to diabetes management in the postDCCT era. Diabetes Care 1994; 17: 765-769. [IO] Rose Cl. Sick individuals and sick populations. Int J Epidemiol 1985; 14: 281-286. [II] Khaw K-T. Genetics and environment: Goeffry Rose revisited. Lancet 1994; 343: 838-839. [I21 Wallerstein N, Bernstein E. Introduction to communitv empowerment, participatory education, and health. Health Educ Q 1994; 21: 141-148. [I31 Eisenberg J. Clinical economics - a guide to the economic analysis of clinical practice. J Am Med Assoc 1989; 262: 2879-2886. P41
Laupacis A, Feeny D, Detsky A, Tugwell P. How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. Can Med Assoc J 1992; 146: 473-481.
Eddy D. Connecting value and costs: whom do we ask and what do we ask them? J Am Med Assoc 1990; 264: 1737-1739. Mechanic D. Trust and informed consent to rationing. 1161 Milbank Q 1994; 72: 217-223. P71 Ruggiero L, Prochaska J. Readiness to change: conclusions. Diabetes Spectrum 1993; 6: 58-60. WI Vinicor F. Barriers to the translation of the Diabetes Control and Complications Trial. Diabetes Rev, in press. 1191 Etzweiler D. Diabetes translation: a blueprint for the future. Diabetes Care 1994; 17(Sl): 1-l I. PO1Kassirer J. Incorporating patients’ preferences into medical decisions. N Engl J Med 1994; 1895-1896. WI Altman D, Endres J, Linzer J, Lorig K, Howard-Pitney B, Rogers T. Obstacles to and future goals of ten comprehensive community health promotion projects. J Community Health 1991; 299-314. [I51
212
F. Vi&or
/ Patient Educ. Couns. 26 (1995) 267-272
[22] Francisco V, Paine A, Fawcett S. A methodology for monitoring and evaluating community health coalitions. Health Educ Res - Theory and Pratt 1993; 8: 403-416. [23] Butterfoss F, Goodman R, Wandersman A. Community
coalitions for prevention and health promotion. Health Educ Res - Theory and Pratt 1993; 8: 315-330. [24] Bergman A. Meeting mania. N Engl J Med 1994; 330: 1622-1623.