• Fresh Perspectives

    Don’t Return to Your Silo

    I remember when I was asked to lead the family medicine night COVID-19 team at Boston Medical Center in mid-March. I had been reading everything I could get my hands on, and I jumped in.

    group of three silos

    The first few nights were full of rapid responses and codes, and within days we developed a new structure for COVID-19 teams. For the day shift, at 1 p.m. twice weekly, the infectious disease assigned lead met with the attendings of the inpatient teams. For the night teams, at 9 p.m. nightly, the inpatient team leads met with the ICU, anesthesia, infectious disease and resource nurse teams to discuss the highest-risk patients. Conversations with these team members is how we managed the sheer amount of work to be done and survived the emotional toll.

    In the midst of pandemic surges, silos were broken. We all leaned on one another. We all worked together to build on what we knew, use our collective knowledge, take care of our patients and communicate with their families. In terms of patient management, we learned that not only weren’t our silos useful, they were barriers to flexibility and to mobilizing new types of care during a pandemic.

    Indeed, collaborative care models have been shown to improve patient care across the board, specifically patient safety, outcomes and duration of hospitalization. These care models also improve clinician satisfaction. Now COVID-19 has shown us how efficiently and effectively different specialties can work together to innovate and improve patient care while simultaneously improving the clinician experience.

    I’ll acknowledge that the first of these meetings was a bit uncomfortable – a mix of imposter syndrome and just getting to know other teammates. Surely someone would know something I didn’t.

    The meetings quickly revealed that we all knew something that someone else didn’t. Many of us had never met, or only knew each other in passing. Those meetings became our organizing moment, our learning, our planning and building, our community.

    In the months between the surges in Boston, our meetings decreased in frequency. During one two-month period, they essentially paused. Leadership kept meeting across disciplines, but there were fewer meetings on the floors. Individual specialties automatically shifted back into our silos. We stayed in our team rooms; we consulted one another when we had specific needs. However, the impact of the team meetings we had was lasting. I would still run rapid responses with the same resource nurses – and the benefits of having worked together so much previously carried into our regular shifts. If I consulted the ICU, chances are I knew the team better, and they knew me. These cross-sectional meetings had lasting impacts on regular patient care outside of COVID work.

    On the obstetrics side, during the first surge, we had meetings about how to get care to all of our patients: those with COVID-19 and those who were no longer coming for frequent in-person care after switching some visits to telehealth. We built new systems – an ambulance to get care to the most vulnerable women in the community staffed by our incredible midwives, telehealth protocols, take-home blood pressure cuffs, psychosocial support systems, food-and-supply delivery for pregnant patients or recently delivered patients who had COVID-19. Midwives, nurses, lactation consultants, family medicine, obstetrics, maternal fetal medicine and neonatology built new ways to deliver care together. We leaned on each other to review evidence from our own specialties, and to build new protocols and systems.

    Boston Medical Center works with 12 community health centers. Our clinics have restructured their building use, their urgent cares and their outreach teams to meet the needs of our patients during the pandemic. My health center, Manet Community Health Centers, redeployed our outreach teams to COVID-19 community testing sites. We opened our new urgent care ahead of schedule, and it has served as a testing site for the South Shore community of Massachusetts. We mobilized telehealth resources. Our outreach teams, medical assistants, community health workers, behavioral health teams, nurses, advanced practice clinicians and doctors have all worked together in different teams in this restructuring. Our community health workers have worked to get families experiencing COVID-19 the food and supplies they need.

    Now in the midst of another surge in Boston, the frequency of meetings is back up. These are meetings of people who are on the floors and in the communities, people doing the work. Although we need administration and leaders to continue to meet to spearhead policy and organizational changes, it is the meetings on the floor – with those of us doing the work – that makes the work fulfilling rather than draining. It fosters a culture of compassion and learning with each other, all for the patient.

    What I want to resist is that draw to shrink back into our silos when this pandemic ends (and I hope it ends soon). We know that our traditional structures have a history and culture behind them and a comfort to them; restructuring requires effort – leaving our comfort zones and trying something new. The pandemic has pulled us out of those comfort zones and shown us how much these collaborative models can help us innovate toward better patient care and better work satisfaction. Moreover, it has shown us that it is actually possible to switch to collaborative care quickly and efficiently. How do we avoid reverting to the status quo?

    The AAFP has updated its position paper regarding collaborative models for public health in our communities and team-based care to improve patient-oriented outcomes. We need the support of our administration in hospitals and clinics to continue collaborative learning and collaborative care.

    Whether in the hospital or the primary care center, collaborative care models show us that we are much more than the sum of our parts. Under the enormous and timely pressures of the pandemic, we have seen that when we come together to create an interdisciplinary culture of learning and respect, we can quickly innovate efficient and effective strategies to improve patient care, care delivery and longevity, as well as well-being in our teammates.

    MaryAnn Dakkak, M.D., M.S.P.H., practices full-scope family medicine and is a clinical assistant professor at Boston University Medical Center. She is women’s health director at Manet Community Health Centers. Her views do not represent those of the organizations with which she is affiliated.


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