Journal of Interprofessional Education & Practice 9 (2017) 115e120 Contents lists available at ScienceDirect Journal of Interprofessional Education & Practice journal homepage: http://www.jieponline.com The aristotelian ethics of collaborative care a b s t r a c t Keywords: Interdisciplinary care Collaborative care Health care ethics Collaborative care is common among health care practitioners, serving multiple benefits for the patients. Clinical procedures are in place to serve as a checklist, ensuring that the proper means of treatment is provided. This essay details an Aristotelian ethics that defines teleology, that which achieves the final good. In the sense of the patient's telos, the rehabilitation clinician should be viewed as a co-laborer in working towards this end, rather than a means showing that a process was followed. This distinction is important when determining the optimal care for the patient. The works of Aristotelian ethicists Edmund Pellegrino and Alysdair MacIntyre are introduced in describing teleology, science, art, virtue, and practice. Two cases are presented that show how, in current practice, collaborative care is used differently in achieving the final good as defined by the patient. Finally, the model of International Classification of Functioning, Disease, and Disability (ICF) distinguishes how the viewpoint of physicians can differ from that of rehabilitation clinicians. © 2017 Elsevier Inc. All rights reserved. 1. Introduction Health care practitioners are taught, as part of their school training, the concept of interprofessional practice. This training includes values and ethics, roles and responsibilities of all providers, interprofessional communication, and the composition of health care teams.1 The preparation is designed to improve the quality of the delivery of health care to the patient when implemented in both inpatient and outpatient settings. The thought process behind such a delivery of health care is to introduce various experts and points of view in treatment of patients. While introducing other disciplines to collaborate on the plan of care for a patient seems intuitive, it is not practiced in all clinical settings as students in health care would expect it to be based on the stress it is given in academia. With the intention of treating the impairment, the practitioner (whether it is the physician, pharmacist, or physical therapist) has the patient's overall health and function in mind. However, the mode of treatment in the United States generally aims towards following the proper means in treatment. This rationalist approach to treatment emphasizes what should be done with a population of patients with a particular diagnosis or clinical presentation. This is similar to the scientific process the physician reads in medical journals. What is a reasonable treatment for a patient with a specific diagnosis? This methodology is evident in the way many physicians manage, for instance, the care of a patient with mechanical pain. The approach typically follows a methodical pattern where the treatment options begin with the least invasive option (e.g., oral medication or a referral to physical therapy). Gradually, the patient will receive more aggressive treatments (injections or surgery) if the previous ones are unsuccessful. Conversely, an empirical approach focuses on the patient as an https://doi.org/10.1016/j.xjep.2017.09.005 2405-4526/© 2017 Elsevier Inc. All rights reserved. individual with a particular set of values and characteristics that influence decision-making. It is the goal of this paper to argue for the inclusion of rehabilitation clinicians in treatment of patients not simply as a means, but rather as a collaborator in attaining the good of the patient. In doing so, I will be referring to Aristotle's teleology with the patient as the one to define the good life, drawing on Edmund Pellegrino's explanation of medicine and Alysdair MacIntyre's definition of practice. This will help the reader understand how the patient's understanding of the good life should enter the conversation in treating a patient, and how a clinician whose specialty is rehabilitation of the body can be used efficiently in restoring the patient to that good life. In addition, I will be referring to several cases throughout the paper to introduce scenarios of where collaborative care currently works well and seems to address this telos, as well as instances where opportunities exist. This change in the mindset of how rehabilitation professionals should be consulted will assist the physician, and the patient, in moving closer to the patient's telos. 2. Background Collaborative care, also termed interprofessional or interdisciplinary practice, is not new to the medical community. It involves health care providers working collectively as a team to provide care to the patient. Benefits are believed to include, among others, increased efficiency, improved patient satisfaction, and better outcomes.2 In discussing a case regarding a medical student placed with a midwife as part of his educational training, Burcher points to the issue raised by the student that he was trained to be a physician and not a midwife. Burcher argues that it is an obligation of the medical educators to incorporate interdisciplinary training into the educational setting.3 In doing so, each clinician learns what 116 M.D. Markee / Journal of Interprofessional Education & Practice 9 (2017) 115e120 foundational knowledge other practitioners can bring to the table. Health care organizations (e.g., hospitals and clinics) implement policies and procedures that incorporate the use of collaborative care in treatment for patients. Clinical pathways are sometimes implemented as guidelines to standardize care with the hope of improving overall outcomes for an organization. Such protocols, when implemented from the outset, involve other disciplines as a sort of checklist to ensure a thorough approach. For example, when a patient is admitted to a hospital with generalized weakness, the protocol for the admitting physician may entail a referral to physical therapy to address this weakness. In doing so, the therapist and physician will exchange clinical opinions regarding the patient. This process of referring according to previously set clinical guidelines lends itself to a procedure where the rehabilitation clinician is seen as a means rather than an end. To use the generalized weakness example, the referral to physical therapy is similar to that of a referral for imaging studies or for oral medication, where the physician follows a rational approach by following a set of rules for what is typically done with a particular presentation. I will now present Aristotle's version of the good and its relation not only to the patient, but to the health care provider and to the relationships that result. 3. Telos In describing his ethics, Aristotle details what leads to a good and virtuous life by man. The final end, he says, is a state of perfect happiness and this happiness is part of the intellect. This happiness and intellect not only separate us from animals, but it is also what we share with the divine. Achieving this telos of happiness involves intrinsic virtues that Aristotle lists extensively, emphasizing the mean between excess and deficiency.4 Applied to health care, the telos of the patient is something that is intrinsic and unique to each patient. The health of the patient contributes to this final end. The patient recognizes this telos in everyday function. When a patient seeks medical care, it is frequently because hea notices a decline in function, or a loss in his health status. Upon seeking medical care, the physician will evaluate the patient in order to determine a diagnosis. This evaluation partly includes a subjective examination where the physician gathers relevant information to determine symptoms that relate to the person's problem. However, in this conversation, the physician must also determine what is good for the patient. The remainder of the evaluation involves a more objective assessment, where data is collected then correlated to the patient's subjective report. This correlation results in a plan for the patient that involves restoring the patient's health, at least to some degree. Since the patient is the instigator of this conversation, and the primary focus, the patient must be the one involved not just in consenting to treat, but also in the conversation of how his function should be restored. It is with the purpose of achieving the aforementioned telos through the intellect that the patient and physician must be focused. The expertise of the physician can help the patient in ascertaining whether or not function can be fully restored and to what extent. Understanding a patient's view of the good is arguably challenging for a practitioner to achieve in the course of one office visit. Emanuel and Emanuel detail four models in the physician-patient a For consistency to the paper, the patient will be referred to as male, and the health care practitioner as female. relationship: paternalistic, informative, interpretive, and deliberative. While allowing for certain scenarios where each model may be appropriate (e.g., a patient unable to give consent would enter into a paternalistic relationship with the physician), the authors explain that the deliberative model is the optimal relationship insofar as it allows the physician to help the patient choose the appropriate treatment based on his health-related values. In this model, the “physician must delineate information on the patient's clinical situation and then help elucidate the types of values embodied in the available options”.5 The relevance of the relationship is important to mention at this point since the physician's understanding of the patient's values will allow the physician to recommend the treatment most aligned with the patient's original goal for seeking treatment. This article has two shortcomings that should be mentioned here. Emanuel and Emanuel note that specialization is a threat to the deliberative model. They see that some physicians, only seeing a patient once, may choose an informative relationship with the patient. In this model, the physician gives facts pertaining to the patient's medical condition. He, in turn, must choose the best treatment option according to his value system, regardless of the physician's set of values. Where the authors fall short is in the inclusion of other professions in the patient's care at this point that can better understand the patient's values and move him closer to his telos. It must be noted, though, that the nature of health care, specifically the rehabilitation sciences, is vastly different in the current system than it was at the time of publication. Diversity of professions and specialization has changed the context in which these relationships occur. Second, Emanuel and Emanuel do not mention whether the patient and physician agree on the relationship. Without consent as to which relationship is optimal given a particular situation, the two parties may understand differing models of the relationship. For instance, an older patient who sees a physician as the sage may take the relationship as a paternalistic one; whereas, the physician who is more of a learned bioethicist may choose to enter a conversation with the patient regarding his health related values. This conflict will likely hinder the construal of the health care provider as she moves closer to understanding the patient's version of the good. Similarly, the patient may have a perspective of a virtue that is unlike the perspective of that same virtue by the physician. The authors do mention that patients frequently select physicians based on virtues that are similar. Yet, those virtues, as they shape the telos of the patient, may change based on the patient's condition (e.g., a patient who suffers a serious injury and has unrealistic expectations of his outcome). The deliberative model mitigates this in a provider who “integrates the information and relevant values to make a recommendation and, through discussion, attempts to persuade the patient to accept this recommendation as the intervention that best promotes his or her overall well-being”.5 Taken out of context, this citation seems like coercion; however, it includes an understanding of the patient's values and allows the provider to incorporate not only the scientific knowledge, but the skill of diagnosing and establishing a prognosis. This “art” of medicine will now be discussed. In defining the form of medicine, Pellegrino focuses on the end when it comes to the physician-patient relationship. An interruption in function of the patient results in “a deviation of one's concept of well-being, a value-laden concept including social function, identity, and interpersonal relationship”.6 The goal of treatment is to move towards the end as defined by the patient and understood by the physician. This treatment not only involves treatment of the biological problem with a physical remedy, but also includes the personal restoration of the patient to an M.D. Markee / Journal of Interprofessional Education & Practice 9 (2017) 115e120 acceptable good. This will be discussed later with his description of medicine as a science, art, and virtue. For this purpose, the inclusion of physical rehabilitation professionsb seems appropriate in helping the patient's restoration of the telos. To define these licensed health care professions: physical therapists are defined as “health care professionals who can help patients reduce pain and improve or restore mobility”;7 speech-language pathologists “assess, diagnose, and treat speech, language, social communication, cognitivecommunication, and swallowing disorders”;8 and occupational therapy is a profession “concerned with promoting health and well-being through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life”.9 From the definitions of these professions that includes terms such as “mobility”, “cognitive-communication”, and “occupation”, it is reasonable to say that these professions should frequently be involved in addressing the telos of the patient. The patient understands his decline in health as a change in function. Through an extensive evaluation, these professionals, similar to a physician, include a thorough review of the patient's history. However, the difference would lie in the emphasis on the function of the patient. The subjective report informs what objective tests and measures to assess. The nature of the patient's symptoms, for example, in a 24-hour period is reviewed by physical therapists. This will determine what movements and postures to assess. The limitations of a patient at work will allow an occupational therapist to adapt his work environment to suit his posture. In a process similar to that employed by the physician, the clinician will explain how relevant findings correlate with the subjective presentation. Finally, it is with interaction between the clinician and the patient that goals are set with timelines. A valuable difference between the physician and these professions is the frequency of interaction. Whether in an inpatient or outpatient setting, a patient may be seen weekly, sometimes daily. While Emanuel and Emanuel did not mention the length of their four relationships, it can be reasonably assumed that one meeting between two people for less than an hour would not be ideal for communicating one's virtues and vision of the good. As a rehabilitation clinician has more frequent meetings with a patient, the patient's version of the good is better understood and matched with clinical findings. Throughout the course of treatment, the rehabilitation clinician can collaborate with the physician not only to compare findings and scientific knowledge of the disease,c but also to become co-laborers in working towards restoring function of the patient. In describing the clinical judgment of physicians, Pellegrino refers to the diagnosis, prognosis, and therapy. While he seems to refer to “therapy” as any treatment, he says, when considering the therapeutic process, the patient should be perceived as a “lived body … that experience of our body which cannot be objectified”.6 This is contrasted with the living body, which he equates with simply being alive. For these rehabilitation professionals to focus on the patient not merely as a diagnosis, but as an individual who only experiences a disease that affects function, the therapeutic process b While the list is not exhaustive, physical rehabilitation in this paper will include the disciplines of physical therapy, occupational therapy, and speech and language pathology. These are the most commonly found specialties for rehabilitation in hospitals in the United States. c Here, “disease” can refer to any pathology or ailment that affects a patient's health. 117 bridges the biological living body with the functional lived body. This increased frequency along with the collaboration of professionals expands the opportunity of the providers' ability to discover the relationships “between the causes of health and disease and the effects of these causes on individuals”.6 4. Science, art, virtue In Pellegrino's essay entitled “Anatomy of Clinical Judgment” in the same text, he examines further the challenge confronted in medicine with choosing the appropriate action for treatment. Naturally, with the extensive training, health care practitioners have knowledge of the science of medicine regarding the structure and its function. In applying this knowledge to a particular patient, the physician knows that certain subjective and objective findings correlate to a particular diagnosis. A physical therapist knows that most patients who lack motion in a certain direction respond favorably to manual therapy of a particular kind. In this manner, medicinedand health care, in generaldcan be seen as a science. This science, while taking a rational, methodical approach in constantly seeking the right answer with a high level of certitude, must still be oriented towards the end as defined by the patient. This variability of the patients' characteristics is a distinguishing feature of health care when comparing it to a physical science. In addition to being a science, Pellegrino also claims medicine is an art in which skills are needed to make clinical decisions. Aristotle defines art in book VI of Nicomachean Ethics as “a disposition tending to produce with true reason that which may or may not be”.4 He makes a point to label art as a “production” and not an “action.” An art produces by “bringing something into existence”.4 To relate this to health care, a provider has a practical end that is specific to each patient. In applying the scientific knowledge mentioned previously, the practitioner needs a particular set of skills to make clinical decisions in order to move this patient closer to restoring his health. This is what separates, say, a physician treating someone with nausea and vomiting from a layperson who has read a textbook on the gastrointestinal system and is giving advice. A physician decides what medical tests and imaging to order. She also determines that a patient needing medication needs a pharmacist, or a patient with difficulty swallowing may need a speech-language pathologist. The speech-language pathologist, in turn, must make the decision of when to recommend the patient to begin swallowing foods of certain consistency. This distinction of art as a production and not an action is where the good in the Aristotelian sense of medicine seems to vary from the good, or beneficence, described by Beauchamp and Childress. By defining beneficence as “an action to benefit others”,10 their simple version of doing good towards the patient does not take into account the complexity of the values that the patient brings to the table. These values and habits shape the teleology of the patient, a final good towards which all action of the medical provider must aim. This distinction can be explained by a patient diagnosed with cancer being recommended different treatments from two separate oncologists. While one treatment may be seen as more aggressive than the other, both aim to do good by benefiting the patient. With the viewpoint of medicine as an action, either form of treatment is aiming to do good for the patient by either selecting a more aggressive form of treatment for eradication, or a less aggressive option to focus on patient comfort. From the standpoint of this art as a production, the physician must bring something into existence; in this case, restoring health of the patient and achieving the telos as the patient knows it to be. Skills are needed by the physician in order to make sound clinical judgments. These skills include, among other things, communication with the patient and collaboration with other practitioners with whom the patient has M.D. Markee / Journal of Interprofessional Education & Practice 9 (2017) 115e120 118 had interaction. Medicine also is a virtue in order to “heal a particular whose good is the true end of the whole activity”.6 This Aristotelian view of virtue blends with the purpose of medicine as acting towards the good of the patient. Using the oncology example in the last paragraph, the virtuous side of medicine is manifested in the actual interaction with other professionals and the decisionmaking that follows. Enabling the right therapy for the right patient at the right time involves not only a skill, but also a virtue to ensure that the right end is produced. 5. Practice and virtue Now that I have introduced an Aristotelian sense of virtue as Pellegrino defined medicine as a science, an art, and a virtue, I will explore this concept of virtue with another Aristotelian, that of MacIntyre. In order to unpack his interpretation of virtue, it is imperative to appreciate his definition of practice. Practice is “any coherent and complex form of socially established cooperative human activity through which goods internal to that form of activity are realized in the course of trying to achieve those standards of excellence which are appropriate to, and partially definitive of, that form of activity, with the result that human powers to achieve excellence, and human conceptions of the ends and goods involved, are systematically extended”.11 Let us examine this definition in the context of health care. This complex social activity of practice begins with a “cooperative human activity,” the interaction of the patient and the provider. Not only is this a human activity, but it also requires a certain level of cooperation where expectations by each party seem congruent, to improve the health of the patient. There are standards of excellence in the medical community, frequently seen as restoration of the patient to a healthier state. Finally, the internal goods to the practice of health care is that which cannot be monetized, but can only be “recognized by the experience of participating in the practice in question”.11 Mention of the internal goods as part of the practice adds an intrinsic quality that is greater than the sum of its parts. This is what differentiates a musician practicing his trade from a novice picking up an instrument for the first time. In medicine, this distinguishes a physician making a diagnosis, prognosis, and prescribing therapy from someone reading a textbook and determining appropriate treatment. This description of practice is similar to Aristotle's view of a production and how it differs from just an action. This practice is more than just a set of skills. It is a using these skills to achieve an end. Collaborative care can be seen as such a practice, with the name alone hinting at a human cooperation.d The aim of this interdisciplinary care is to achieve excellence, which is the human conception of the end. The patient is the source of this telos, and should be involved in this human cooperation for the practice to reach its standard of excellence. Then, the discussion must be had as to what is the internal good that is attained with collaborative care and can it be achieved by a group rather than by an individual. The first part can be answered in the power of the group. In treating a patient, each practitionerdthe physician, the physical therapist, the occupational therapist, and the speech-language pathologistdhas an understanding of what the patient's final good is. In isolation, the practitioner will work towards improving her understanding of this good and d The word “collaborate” is derived from the Latin verb collaborare, literally meaning “to labor together” (www.merriam-webster.com/dictionary/collaborate). aim treatment towards it. As a group, however, the professionals will collaborate with each other to better understand the end and good involved. Each practitioner's relationship with the patient can bring a new construal of the telos towards which they are moving. A characteristic of the achievement of this internal good is “a good for the whole community who participate in the practice”.11 MacIntyre incorporates this into his definition of virtue, which is “an acquired human quality the possession and exercise of which tends to enable us to achieve those goods which are internal to practices and the lack of which effectively prevents us from achieving any such goods”.11 Building on his description of practice, he details how technical skills are needed for a virtue, which someone can “acquire” through training. Yet, the understanding of the internal good must be present as well. This description of virtue and integration of practice is complementary to Pellegrino's description of medicine as a virtue. It is “acquired” through both formal and informal training of the provider, allowing the internal good of health care to be realized. This applies to both the practice of health care by an individual and to practice of health care by a group. 6. Cases Next, I will apply these concepts of Aristotle's teleology, Pellegrino's medicine, and MacIntyre's practice to two drastically different cases. The former will show where collaborative care is provided, whether intentionally or not, with an Aristotelian approach. The latter will present an opportunity for interprofessional care earlier in the process, with the hopes of streamlining care by incorporating rehabilitation professionals as a collaborator. 6.1. Case 1 e Mr. S Mr. S is a 72 year old R-hand dominant patient who is seen by a neurologist on an outpatient basis following discharge from a hospital for an acute ischemic cerebrovascular accident (CVA). Mr. S is married to an independent 67-year old partner, and they live in a 2 story house with the bedroom on the first level. He has a bathtub with an overhead shower. He reports difficulty bathing, feeding himself, and accommodating stairs but denies difficulty swallowing or with his memory (this is confirmed with his spouse). He also denies pain or dizziness, but mentions he does occasionally feel “light-headed.” He feels “winded” with walking around the house. His past medical history includes hypertension and tobacco use, although he claims to have quit smoking “years ago.” The patient mentions he has a goal of wanting to walk the neighborhood with his wife and to attend his grandkids' athletic events. This R-sided CVA left him with L-sided hemiparesis of the upper and lower extremities. His examination shows independent use of a R hemi-walker, and his vitals are as follows: Blood pressure: 144/88 Pulse: 86 beats per minute Respiratory rate: 15 breaths/minute O2 sats: 97% In addition to medical management of his medications for continued control of his hypertension, the physician refers Mr. S to physical therapy and occupational therapy. The physician asks the patient to return to the doctor's office in 2 months. Upon evaluation, the physical therapist reports back to the physician that she will be addressing Mr. S's dependent gait, endurance with walking, and transfers from the bed and chair. The occupational therapist intends on addressing his ability to bathe and feed himself, as well as other activities of daily living that she notices could be done more M.D. Markee / Journal of Interprofessional Education & Practice 9 (2017) 115e120 efficiently to minimize his fatigue. After every 2 weeks of treatment, the therapists collaborate in person with each other and with the physician in order to understand the patient's constantly changing goals. At the first such meeting, it is relayed that the patient has updated goals to play bocce with his friends, and to begin a regular fitness program at a local gym to reduce the risk factors associated with CVA occurrence. 6.2. Case 2 e Mr. L Mr. L is a 45 year old with reports of low back pain that has been present for three months. This pain is worse with prolonged sitting and is present with certain movements, such as bending forward to put on his shoes. His past medical history is unremarkable for prior back pain. He denies any radicular symptoms or any numbness or tingling. The patient wishes to get dressed and sit at work without pain. This is the second visit to see the physician, who initially prescribed him a non-steroidal anti-inflammatory oral medication one month ago. The patient reports no change in symptoms since the last visit. The physician refers the patient to physical therapy and explains that if therapy is not successful, she will order further imaging to be done. Following three weeks of treatment by a physical therapist, the patient returns with a mild improvement in symptoms and that he is now able to put on his shoes without pain, and his pain with sitting at work is slower in onset. The therapist has communicated electronically with the physician via a progress note to detail what treatment has been provided and the progress made towards functional goals. The physician notices an updated goal of the patient being able to play basketball again, something that was previously unknown to her. At this point, the physician must make a decision on how to judge the success of the rehabilitation of the patient thus far. She must decide whether to advise the patient to continue with therapy or to order further imaging tests to determine the source of pain. 6.3. Case analyses These cases present two distinctly different patient presentations and different approaches in decision-making. The first case considers a health care team who collaborates on a regular basis with the rehabilitation team. In order to determine the good of the patient, each provider gets input at different points in care by communicating with the patient. As the level of function for that patient changes, so too can the patient's understanding of an attainable telos. For a patient suffering a devastating CVA, the end goal for Mr. S was to casually walk the neighborhood and attend sporting events. As his condition improved, the telos was redefined to a more active state. This was with the guidance of a rehabilitation team who saw him more frequently and developed a closer relationship. The deliberative model was used to interpret the patient's health related values. Also, this case shows the art of collaborative care. By working together towards the good, the practitioners come closer to bringing health into existence. In doing so, the power of the group (an intrinsic good of interdisciplinary care) is realized. The case of Mr. L shows a more rational utilization of rehabilitation by the physician. In what is sometimes typical to a patient presenting with mechanical pain, the selection of treatments will follow a methodical approach. In this case, that is seen in the order of oral medication, physical therapy, and imaging. The level of communication here is not the “complex form” of a human activity that is expected by professional collaboration. Rather, it is a oneway communication that does not involve a sharing of ideas regarding the patient's perception of the good. Alternatively, the 119 physician and therapist can communicate more directly and have a conversation where there is an exchange of thoughts and ideas of the patient as to their understanding of the end goal for the patient. While the deliberative model may be used here, collaborative care can improve everyone's understanding of the telos and what is attainable. In asserting that collaboration is more effective than not, this argument may seem insignificant compared to some of the larger debates in the medical community. However, the case of Mr. L is common in the outpatient clinical setting. Low back pain is a common ailment affecting up to 80% of the population.12 The management of and treatment selection for patients with this diagnosis still challenges many clinicians, even calling into question the relationship of imaging studies with clinical presentation.13 For something as challenging as low back pain, understanding the patient's version of the good, particularly as it relates to function, will more accurately explain how the clinical presentation of pain affects the patient's everyday life. 7. Challenges Despite what some may see as obvious benefits to collaborative care, there may be some instances where challenges exist. I will describe here two threats to this interdisciplinary practice. First, the providers' respective understanding of the patient's telos may not be in agreement, causing confusion as to which version is correct. To illustrate this point, imagine a physician specializing in orthopaedics seeing her father as a patient. The physician, being a close relative, may have a clear understanding of the patient's version of the good based on the prior relationship. If the patient is then referred to an occupational therapist, who tries to communicate her version of the patient's good to the physician, the therapist and physician could have differing views of the patient's good as it pertains to his health. In this case, the therapist does not bring a clearer understanding of the telos compared to that of the physician. Rather, she merely provides another interpretation of the disease from the standpoint of her specialty. Second, the telos of each practitioner can cause conflict. What a physical therapist values as relevant to a patient's overall good may not be seen as equivalent in the eyes of the physician. Furthermore, the goods relevant to each profession and to each individual provider may clash. What may be an internal good to a speechlanguage pathologist may not be seen as a good to a physician or to another rehabilitation clinician. This pluralism that is inherent in society can not only be present as two clinicians interact as individuals, it also can be a result of training that is unique to each profession. 8. Conclusion What has been explained here in this essay is an attempt to justify the use of collaborative care not just to be seen as a means but as an effort for all providers to have a better understanding of the patient's telos. What is proposed is not a change necessarily in practice or a specific modification to the process of health care delivery. Rather, I propose a change in the mindset of the physician in understanding how the rehabilitation staff can be seen as colaborers in understanding the patient's good. The patient's version of the telos gives the health care provider the understanding of how the patient's condition affects his daily life. I offer that working in partnership will move not only the physician closer to an understanding of the good, but also move the patient closer to that good. Using the physical therapist, occupational therapist, and speechlanguage pathologist as a means can still, at times, be successful in treating the patient's problem and moving him closer to health and 120 M.D. Markee / Journal of Interprofessional Education & Practice 9 (2017) 115e120 Fig. 1. The International Classification of Functioning, disability and health (ICF). Reprinted from Towards a Common Language for Functioning, Disability, and Health: ICF. Geneva, Switzerland: World Health Organization; 2002 with permission of the World Health Organization. his good. Protocols and clinical pathways are established to treat the majority of patients at a particular time and frequently improve the patient to the point of moving him closer to a healthier version of himself, successfully managing the condition. However, what is defined as “successful” to the provider may not be the same for the patient. An ever-changing telos from one patient to the next will ensure that. The checklist approach will only confirm that the proper process was followed, not that the goal was the good of the patient. In an effort to measure health and wellbeing of individuals and at the population level, the World Health Organization developed a model International Classification of Functioning, Disease, and Disability (ICF).14 This model (Fig. 1) attempts to define one's health condition by relating the patient's disease to constructs such as how the body functions, the activity level of the patient, and his level of participation in society. In developing the ICF model, the patient understands his good from a perspective of activity and participation in society. For instance, in the case of Mr. L, the patient seeks medical help because of his back pain with sitting and with getting dressed. However, in the course of treatment over several visits, the physical therapist is able to garner another goal from the patient, that of playing basketball. While these seem, on the ICF model, as activities, they also represent levels of his participation in society. These are his ability to work and his recreational level with others. The physician typically approaches the patient from the left side of the diagram through body structure and function and how this relates to his activity level, with consideration of the patient's participation level in society. The rehabilitation clinician, conversely, addresses the patient's disorder from the right side of the diagram by assessing the patient's functional activity level and relating this to his participation in the community, all while considering how his bodily function correlates with these. While there may be challenges as stated previously, collaboration among these professionals in working towards the good of the patient, as seen with the help of the ICF model, can best relate the patient's disease with his subjective report that pertains to the activity and participation paradigms. Addressing interdisciplinary care as a collaborative process with an aim towards the good, rather than as a means, appears more challenging. It envisions each encounter with the patient as a way of perfecting the relationship and moving closer to his virtues.5 The uniqueness of each encounter is more laborious than following pre-set clinical guidelines. However, in moving toward perfecting this understanding of the patient's telos, the clinician moves closer to the right treatment for the right patient at the right time. Rehabilitation professionals, with their scientific knowledge and art form of restoring function for the patient, have established a practice of health care that has an internal good, as well. Collaboration that includes these professionals for the right reason can result in optimal care for the patient. References 1. Panel IECE. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, D.C.: Interprofessional Education Collaborative; 2011. 2. Yeager S. Interdisciplinary collaboration: the heart and soul of health care. Crit care Nurs Clin N. Am. 2005;17(2):143e148. 3. Burcher P. Interprofessional training: not optional in good medical education. AMA J Ethics. 2016;18(9):898e902. 4. Apostle HG. Aristotle's Nicomachean Ethics. 1984. 5. Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA J Am Med Assoc. 1992;267(16):2221e2226. 6. Pellegrino EDT. D.C. A Philosophical Basis of Medical Practice: Toward a Philosophy and Ethic of the Healing Professions. New York: Oxford University Press; 1981. 7. Who Are Physical Therapists?; 2015. http://www.apta.org/AboutPTs/. Accessed 11/20/2016. 8. Speech-language Pathologists - about Speech-language Pathology; 2016. http:// www.asha.org/Students/Speech-Language-Pathologists/. Accessed 11/20/16. 9. Definition of Occupational Therapy; 2016. http://www.wfot.org/aboutus/abouto ccupationaltherapy/definitionofoccupationaltherapy.aspx. Accessed 11/20/16. 10. Beauchamp TL. The 'four principles' approach to health care ethics. In: Ashcroft RD A, Draper H, McMillan J, eds. Principles of Health Care Ethics. second ed. West Sussex, England: John Wiley & Sons; 2007:3e10. 11. MacIntyre A. After Virtue. third ed. Notre Dame, IN: University of Notre Dame Press; 2007. 12. Manchikanti L. Epidemiology of low back pain. Pain physician. 2000;3(2): 167e192. 13. O'Sullivan P, Caneiro JP, O'Keeffe M, O'Sullivan K. Unraveling the complexity of low back pain. J Orthop Sports Phys Ther. 2016;46(11):932e937. 14. Jette AM. Toward a common language for function, disability, and health. Phys Ther. 2006;86(5):726e734. Michael D. Markee Saint Louis University, 3437 Caroline St., Suite 1026, St. Louis, MO 63104, United States E-mail address: [email protected] 6 January 2017
1/--страниц