Team-based care in specialist practice: a path to improved physician experience in British Columbia | BMC Health Services Research

The STC initiative met its stated objective of improving physician experience, increasing efficiency, and improving patient experience. Specialists reported increased job satisfaction, work-life integration, and efficiency, specifically in terms of having more time for documentation and spending less time on their EMR at home. The majority of patients also reported high satisfaction and positive experiences receiving care within a TBC model. While specialists’ team members showed improvement in their overall experience, the increased administrative burden on MOAs and office managers, coupled with team member attrition at 70% of practices is worth noting. This particular finding, which was an unintended consequence of the STC initiative, is aligned with findings in the primary care setting where changes that reduced clinician burnout did not decrease, and in some cases, worsened, burnout among staff [28]. Sheridan et al. reported that medical assistants (akin to MOAs in Canada), had a greater workload (73%) and greater job satisfaction (86%) when working in team-based primary care models [29]. This highlights the need for sustainable workloads for all team members in future iterations of STC.

At the start of the STC initiative, 50% of participating specialists reported burnout, similar to that reported by physician peers across Canada (53%) and BC (52%), as measured by the Canadian Medical Association’s (CMA) 2021 National Physician Health Survey [3,4,5,6]. This survey used the Maslach Burnout Inventory two-item scale [30, 31] in addition to the Mini Z questions. This similarity in results indicates the specialists are highly likely to have poor mental health and to reduce or modify their clinical hours. Notable differences were observed between the STC and CMA data. At baseline, STC specialists scored worse than average BC physicians in terms of sufficient time for documentation, time spent on EMR at home, and work-life integration, but responded better on stress [4]. The CMA survey revealed that BC physicians spend an average of 9.7 h on administrative tasks per week [1, 4]. These comparisons suggest that while participating specialists face similar administrative burdens, they may have experienced a greater workload—whether perceived or actual—stemming from documentation and EMR use.

Interestingly, the Mini Z indicated that stress worsened for some specialists over the course of the initiative, but the interview data indicated that some specialists experienced decreased stress or that their stress was related to other parts of their physician role. It is also possible that the stress question in the Mini Z may have been misinterpreted because of the reverse agreement scale, which produced a false signal. Nonetheless, by the end of the STC initiative, improvements in workload and documentation time were noted, both of which are predictors (recognized as part of organizational factors) of burnout [6, 32]. We anticipate that these changes directly related to administrative burden will continue to provide protective effects for specialists under the TBC model. Benefits related to burnout, job satisfaction, and professional fulfillment will accrue over time, especially as physicians and their teams continue to work more optimally together, manage workloads, cultivate positive team culture, and achieve professional fulfillment [33, 34].

Physicians often lack formal training in leadership and team-building; this is not a core part of their medical education, despite the necessity of these skills in their professional practice where they must frequently work within teams. Essentially, physicians are expected to acquire these abilities on the job [35]. The STC initiative was designed to support action learning by implementing a TBC model and encouraging specialists to develop these skills through practice. According to the literature, teams progress through distinct phases, and inadequate support during these transitions can lead to unmotivated employees and higher attrition rates [36, 37]. This issue was evident in the program, with many teams experiencing the loss of at least one member. This underscores a significant opportunity to better support specialists adopting TBC and enhancing the sustainability of these models. However, simply working in a TBC model is not enough, as teams must also develop and nurture structures (processes) and culture to become effective. Working in tight-knit teams is associated with less clinician exhaustion [34]. Therefore, establishing a formalized education pathway to equip specialists with the necessary skills for managing transitions and developing sustainable teams would improve overall team effectiveness and the quality of care delivery [38, 39].

Early results on improved patient outcomes and reduced health care utilization are promising, demonstrating how TBC can address all aspects of the IHI Quadruple Aim. Participating specialist teams enhanced various aspects of care delivery, including patient education and self-management. These care practices are known to lead to better outcomes, such as improved quality of life, decreased anxiety, fewer complications, adherence to care plans, and patient empowerment [40,41,42,43,44]. TBC also facilitated multidisciplinary care in outpatient specialist practices, which may yield benefits similar to those observed in other care settings, such as cancer clinics, orthopedic rehabilitation centres, and in-hospital units [45,46,47]. The participating sites demonstrated positive patient experiences, and a systematic review by Doyle et al. indicated that such experiences are associated with clinical effectiveness, patient safety, better health outcomes (objective and self-rated), health-promoting behaviours, and reduced resource use [48]. High levels of positive patient experience, self-reported decreases in care visits (to the ED, family doctor, and walk-in clinic), and provider perceptions of preventative care all support the notion that TBC provides patients with the care they need and potentially reduces costs to the health system.

Limitations

This study has both strengths and limitations. A strength of the study is that multiple sources of data were collected across the 15-month program, and the data were obtained from specialists, team members, and patients. A weakness is that this first iteration of STC has a relatively small sample size. We used a validated tool, the Mini Z, for measuring the constructs of burnout, stress, and control over workload; however, our sample size was small. While the results showed a positive trend, it typically takes more time than the length of the STC for these results to decrease significantly [49,50,51]. Finally, it is worth acknowledging that this cohort of specialists are early adopters of TBC. It is possible that there are unique pressures on this cohort due to the provincial visibility of this work and additional characteristics in this cohort related to their willingness to innovate that we have not explored. Specialty-specific factors are an area for future study, as specialists are a heterogeneous group in terms of work setting and practice conditions [52]; thus, there are likely relevant specialty-specific differences that we did not examine in this first iteration of STC. Long-term impacts to patient outcomes, costs to the health care system, and sustainability of specialist TBC will continue to be studied in more direct ways as part of ongoing and future work.