Table 1

Old vs New Mindsets

Old MindsetsNew Mindsets
The doctor does it all.Share the care with the team: there is too much work to be done by 1 person, and it is too important to be left to chance.
The nonclinician team members have minimal skills and make limited contributions; so few are needed.A well-trained and mentored team of at least 2 clinical assistants (MAs or nurses) per clinician is needed to fully leverage the skills of all. Care is better and more satisfying if work is strategically delegated according to ability.
Technology replaces people, therefore fewer people are needed.People provide health care; technology plays a supporting role.
Health care is a transactional endeavor, the sum of many discrete tasks: in this model anybody will do.Health care is a relational endeavor, founded on trusting and healing relationships. Continuity with the same people matters.
Regulatory over-reach: what you want to do is not allowed.If what you want to do is safe and helps patients, do it. If each team member is trained, mentored, and audited for a certain task within the bounds of governmental regulation, health systems should allow it.
Overhead cost accounting: margins are tight, so we need to trim staff. Clinicians will have to pick up the slack and do work that the support staff might have done.
If physicians leave the organization, we will hire more physicians and/or less costly clinicians.
Opportunity cost accounting: by way of a simple hypothetical example, with a staffing ratio of 1:1 (CTC: MD) the primary care team may have the capacity to see patients that generate 6 RVUs per hour. With a staffing ratio of 3:1 the team will provide more patient visits that are more comprehensive and may generate 9 RVUs per hour. The difference is the opportunity cost: the organization lost the opportunity to generate 3 more RVUs per hour.
  • CTC = care team coordinator; MA = medical assistant; MD = doctor of medicine; RVU = relative value unit.