3: “T-E-A-M, YAY, TEAM!”
“T-E-A-M, YAY, TEAM!” The Team Approach to Professional
Wills, Wonts and Won’ts.
A. Steven Frankel, Ph.D., J.D.i
Welcome to the Third article on ways to address the problem of preparing for unanticipated disruptions or terminations of practice due to death or disability. In this article, I address a more efficient way of approaching the problem, which has developed to help manage the overwhelming set of tasks to be done when a colleague dies or becomes disabled than having one partner at work – the team approach.
Where to start:
The team approach requires that a group of colleagues make an agreement to work together on development and implementation of a management plan in the event of a disruption in one of their practices.ii The modal strategy is to form relationship with colleagues who practice in your geographic area, with the specific agenda of assisting each other with a practice transition in the event of
an “event.” The typical approach is to work with fellow senior colleagues, as practice seniority is associated with a good working knowledge of how practices work, the ways in which records are kept and managed, a familiarity with other psychiatrists who practice in the community, their specialties and other indicia of relevance to being good choices for referrals of one’s patients, etc.
The Team Leader:
The selection of the team leader is a critical part of the creation of the team, as the leader’s function is to decide on the assignments of team members to the list of tasks that must be managed for the team’s work to be successful. This means that the team leader must have a sense of how each member’s
personal style and particular skill set fits with the tasks to be done, to manage the team members’ functioning, and to be sensitive to problem issues that may arise over the course of time. Such problem issues may include life problems or distractions that strike a member of the team from time to time, friction or conflict between one or more members of a team, failures of one or more team members
to abide by commitments to do the work of the team, etc. Team leaders will focus on how the team members are in place in order to manage the crises that develop when any team member has an “event,” such that all members focus on performing their assigned tasks for all of each others’ practices. Team leaders arrange for meetings of team members on a regular basis, to ensure cooperation, readiness and preparation for “events.” Team leaders are more effective when they consider the variations in the
practices of other team members. Thus, while some proportion of the team may engage in a general psychiatry practice, with medication management and psychotherapy, other practices may focus on psychoanalytic treatment, while still others may be primarily medication management in nature. Each style of practice will require team leaders to work with members such that adequate referrals are provided when needed as well as for the differences in referral needs for patients. For example, when a colleague whose practice is primarily devoted to medication management, the team will need to find referral psychiatrists who have medication management openings in their practices and may need to prescribe medications for patients who are low or out of medications when their psychiatrist has an event. Ensuring that such prescription activities are proper within the jurisdiction of the practice falls to the team leader, who should contact the Medical Board in his/her jurisdiction to ensure that such
conduct is proper. Beyond the distribution of practice transition tasks that make a team approach more efficient than a single partnership approach, is the fact that a team that meets and works together is more likely to provide occasions for colleagues to be sensitive to symptoms of possible degenerative neuro-cognitive disorders among team members. Research suggests that at least 10% of colleagues over the age of 65 are likely to develop such disorders, and, as the number of colleagues in that age range increases over the next decade or two, we will be facing significant risk among our colleagues. Thus, the eyes, ears and training of a team of colleagues may be very helpful as regards sensitivity to the development of symptoms among team members.
The size of teams:
The number of colleagues in geographic proximity to each others’ practices will be determinative of team size, as colleagues who practice in small or rural communities will have fewer colleagues close-by than will those who practice in more highly populated areas. Team size will thus, to a great degree, be determined by geography. When possible, teams of 4-5 colleagues appear to be most helpful in making the work efficient and the team effective.
Division of tasks:
The tasks faced by the team are identical to those described in the second article in this series, dealing with the partnership model.
When a team of colleagues is created, the informed consent discussion and documentation should include an identification of who the team members are, that the team members have agreed to manage the transition of the practice, and that, by signing the informed consent document, patients authorize the team members to view charts and make direct contact with the patients for the purpose of practice transition. One foreseeable problem with this part of the plan is that, especially in “small” communities, there may be patients who, at one time, have received services from one or more of the team members, and refuse to sign a release for that reason. For such patients, an alternative means of providing a
referral and transmitting records must be found.
Transition Tasks to be assigned to specific team members:
In the event of an “event,” the following tasks must be addressed by a team member:
1. Notification of patients: The team member’s job begins with the notification of patients that an event has occurred. This process is often best done by a team member rather than an office staff member, as psychiatrists are familiar with the grieving process and are best qualified to assist patients with the transition of care during that grieving process.
2. Making referrals: The team member’s responsibilities include referring the patients to a new treater. Ideally, the issue of what will happen in case of an “event” has already been discussed with each
patient, with an eye toward who might be the best colleague for each patient to see in the future. These discussions are typically quite beneficial to patients, who appreciate being thought of in protective ways, such that they already know who they will be seeing for future care. 3. Transfer of records: The team member’s responsibilities include ensuring that patient records are forwarded to the new treater, or
provided to the patients who request them consistent with the laws of the jurisdiction of the practice.
4. Office rental: the team member’s arrangements should already have been explained to landlords of office buildings, such that provisions for payment of rent, disposal of equipment and furnishings and associated tasks can be completed smoothly.
5. Family: the families of colleagues going through life transitions will be grieving, and the team member’s responsibilities include reassuring families that preparations for transitions have been made and are being implemented properly.
6. Estate-planning attorney (wills/trusts): the team member should be aware of the identity of the estate-planning attorney, who, in turn, should have permission to discuss the estate plan and to
provide funds for handling practice transitions, as there will be expenses associated with practice transitions.
7. Accounts payable and receivable: an important part of the transition team member assignments includes information as to billing and payment processes/procedures, such that the team member is able to ensure that bills are paid and collections are received. The team member’s name should be known to the banks, such that checks may be written and deposits made.
8. Telephone: a team member should contact the relevant phone company and arrange to forward calls to the team member’s telephone number.
9. Notices: a team member will place a notice in the local newspaper for two weeks, indicating that the practice is in transition and how to contact the surviving colleague. Further, notice should be provided
to licensing boards, insurance companies and professional societies.
10. Computer access: a team member should be fully knowledgeable as to computer passwords and computer access to information.
11. Insurance: It is strongly recommended that team members take out term life insurance policies of $10k-$20k (which, at this time in history, are quite inexpensive), to support the team during the
transition period, as the amount of time that colleagues will be putting in to assist with the transition can be compensated in this way.
12. Personal “good-bye” letters: It is a matter of grace and kindness for professionals to leave letters in the charts of all patients – which can then be mailed to each patient, with a simple statement of
farewell, of appreciation for having had the opportunity to provide care, and wishes for future benefits from the care provided.
13. Access to offices: keys, pass-codes, access to files, awareness of staff and their availability – all of these must be available to the team members.
14. For colleagues who utilize EMR for record-keeping, releases need to be signed by patients to provide access by the team member
Down-sides of the “Team” approach:
If you are still reading this article and if you have ever worked with a group, you may be coming to realize that the team approach has two significant downsides. First, depending on the geographic area of one’s practice, assembling a team may be next to impossible. Second, a major downside of the Team model is that it is a group, and, as those readers who are familiar with group processes know, groups do not always function smoothly. Disruptions in the lives of group members, conflicts between group members, problematic assignment of transition tasks to group members, problematic management style of group leaders, all can lead to disruptions and ineffectiveness of group process and effectiveness. These difficulties add to the general denial and avoidance that keeps us from developing needed plans.
The next article in this series will present a newly developing model, involving a quasi-insurance approach which assigns a colleague who is trained to be a “Transition Specialist” (“TS”) to a Subscriber’s” practice. The TS visits the Subscriber’s practice annually, assisting with the planning and management of the practice so as to facilitate practice transition at the time of an “event,” and who works with office staff (or “temps,” where there are no office staff members already) to effectuate a smooth transition .i i If you are interested in a closer look at the issues and support systems, you’re welcome to contact me via www.practice-legacy.com
ii See Dr, Ann Steiner’s “The Therapist’s Professional Will” at www.sfrankelgroup.com