Collaborative health care teams in Canada and the USA: confronting the structural embeddedness of medical dominance.

ABSTRACT

There has been a renewed interest in collaborative models of health care delivered by 'interdisciplinary teams' of providers across several health care systems. This growing phenomenon raises a host of issues related to the management of professional boundaries and the contemporary state of medical dominance. In this paper, we undertake a critical analysis of the factors both promoting and impeding collaborative care models of primary and mental health care in Canada and the USA. The data our arguments are based upon include a combination of documentary and interview data from key stakeholders influential in various collaborative care initiatives. Based on these data, we develop a conceptual model of the various levels of influence, focusing in particular on the macro (regulatory/funding) and meso (institutional) factors. Our comparative policy and institutional analysis reveals the similarities and differences in the influences of the broader contexts in Canada and the USA, and by extension the different ways that the structural embeddedness of medical dominance impinges upon and reacts to recent policy changes regarding collaborative health care teams.

KEY WORDS

Sociology, collaborative health care teams, medical dominance, structural embeddedness, primary care, mental health care, Canada, United States of America

Introduction

There has been a renewed interest in collaborative models of health care delivered by 'interdisciplinary teams' of providers in many health care systems. The impetus is in part a response to real, perceived or projected shortages of physician human resources and in turn access to health care services (Goodwin et al. 2005: 856; Patel et al. 2000:117). Many policy documents echo Besrour (2002:4) who states that 'effective solutions to problems of access and continuity can only result from close working relationships between the different actors involved.' Such collaborative models implicitly draw upon health care providers that are considered to be at least partly substitutable where physicians are in short supply. The move towards team-based care can also be seen as an attempt to curb rising health care costs; that is a move towards the lowest cost or 'most appropriate provider' (cf. Health Canada 2004). For example, Canadian health service researchers, Pitblado and Pong (1999:4), have argued that:

'it is well known that some of what physicians do can be done, and can be done quite effectively and possibly at lower cost, by other providers such as.... nurse practitioners ... psychologists, etc. in appropriate settings and in collaboration with physicians.'