Personal Views

Working in a multidisciplinary team: need it be so difficult?

BMJ 1994; 309 doi: http://dx.doi.org/10.1136/bmj.309.6967.1520 (Published 03 December 1994) Cite this as: BMJ 1994;309:1520
  1. Gill Salmon

    The tensions that can exist between members of a multidisciplinary team have recently become apparent to me. As part of a rotational training scheme in psychiatry I am working with people with learning disabilities. As in many branches of psychiatry a multidisciplinary team exists to serve the needs of the patients in the hospital setting as well as in the community. The difficulties are, however, different in these two settings.

    In the community team, assessments and follow up tend to be provided by the professional whose special skills are most likely to be needed. When I took up the post I was advised that the initial assessment of a new patient was ideally made by two professionals visiting jointly. In this way a more accurate assessment of needs could be made and an appropriate care package drawn up. This does not seem to happen in practice. I have never been asked to accompany anyone, nor have I been successful in arranging joint visits to patients that I have been allocated. An attempt to suggest the joint assessment of a new patient with another team member brought a written reply that “it would not be suitable.” I do not know whether this referred to the patient, the other professional, me, the time, or something else.

    “I think that I have more to offer than the ability to rewrite a drug chart.”

    One of the causes of tension seems to be the overlap in the potential roles of the various team members. When is an assessment best made by a social worker and when by a community nurse? What is it that a clinical psychologist does that a psychiatrist cannot do? I tried to clarify this by asking a clinical psychologist on the team how he saw our respective roles as regards one particular patient with aggressive behaviour and a possible mood disorder. His reply, “You dole out the dope, don't you?” seemed to make his position on the subject quite clear. Psychiatrists write the prescriptions, psychologists do the rest, I presume.

    After months of wondering exactly what my role was in the hospital setting, I became aware that I did not attend the regular multidisciplinary meetings held to discuss the resettlement of patients into the community. Inquiries revealed that I “was not interested enough.” Unfortunately, no one had told me about these meetings. Presumably, in the spirit of normalisation staff involved in the direct care of patients discourage visits from doctors unless in response to a specific invitation. Such ideals are, however, conveniently forgotten about when a drug chart needs “rewriting neatly” in order that a student can do a drug assessment or when “emergencies” occur and paracetamol is required.

    I am disappointed. I do not believe that it has to be like this. Having qualified six years ago and having spent three of those years in psychiatry, I think that I have more to offer than the ability to rewrite a drug chart. While all professionals have skills specific to their own training there is bound to be some overlap, particularly in the area of psychological treatments and counselling. It is the personality of the professionals rather than their job title that determines their suitability for this type of work. Most professionals working in mental health and learning disability will have had experience and quite possibly training in different forms of psychotherapy and will be keen to practise their skills.

    The best results are not obtained by professionals working in isolation. Joint working can be mutually beneficial, as well as being in the patient's interests. My conviction stems from a training experience in an earlier post on the rotation. As a registrar in child and adolescent psychiatry I accompanied a consultant clinical psychologist on home visits to the families of children with autism or challenging behaviours. The cases were discussed before and after each visit. Although I initially took a back seat during the actual interviews, I was later encouraged to take on several cases under supervision. A full behavioural assessment was undertaken in order to define the problem objectively with reference to the antecedents, the behaviour itself, and the consequences. With emphasis on the current behaviour an individual behavioural programme was then devised. The parents were actively involved by being encouraged to suggest interventions appropriate for their child and by keeping behaviour diaries. Return visits to assess progress were fairly frequent in the initial stages so that modifications could be made to the treatment programme where necessary.

    The aim of the attachment was to learn about behavioural techniques, particularly in relation to children with autistic spectrum disorders or developmental delay. Any new skills learnt would then be transferable to other therapeutic situations. In addition to learning from another professional I also learnt a lot from the patients and their families, and I hope that I gained greater understanding of the difficulties they faced.

    The benefits of attachments such as this are not all one way. Trainee psychiatrists can fulfil a service commitment by assessing and treating patients on their own and may have time to study a case of particular interest in depth. They can also be a useful source of knowledge about medical conditions, drugs, and adult psychopathology in the family that might be complicating the picture. For the psychologist the teaching of other professionals acts as a stimulus to keep up to date, prevents complacency, and may help to improve multidisciplinary working relationships.

    “For the psychologist the teaching of other professionals acts as a stimulus.”

    Trainees in other disciplines could also benefit from a period of attachment to another professional. While working in general adult psychiatry I have heard trainee clinical psychologists complain about their lack of exposure to acute psychiatric illness. What better way to rectify this than to spend some time with a psychiatrist as he or she makes emergency assessments while on call.

    The time has come for professionals working with people with mental health problems and learning disabilities to accept that it is difficult to draw absolute boundaries around the skills that can be offered as a result of their training. Some overlap is inevitable. If this occurs perhaps it will no longer be necessary to fight to defend what is misguidedly seen as the territory of one and not another. We could then begin to pool and expand our skills more effectively. In the long run this will benefit patients as well as trainees.