Multidisciplinary Care in the ICU: Who’s in Charge?

Who should direct care in the ICU? And is the model of “ship’s captain” still valid in the era of multidisciplinary team-based care? “The question of who is captain of the ship is too often a distraction and, more importantly, does not contribute to good patient management", write Michael Nurok,  MBChB, PhD, medical director of the Cardiac-Surgical Intensive Care Unit in Los Angeles  in a Viewpoint article in JAMA Surgery written with Nicholas Sadovnikoff, MD, Co-Director, Surgical Intensive Care Unit at Brigham and Women’s Hospital and Bruce Gewertz,MD,  surgeon-in-chief, chair of the Department of Surgery at Cedars-Sinai.

The solution is not to neglect personal responsibility for patient care, they argue, but as “ICU environments involve a complicated dance of overlapping team-based care activities” the suggested solution is that physicians with highly specialised skills “must interact in a collegial but nonhierarchical fashion.”

See Also: Zoom On: Michael Nurok, Medical Director Cardiac-Surgical ICU, Cedars-Sinai

The “ship’s captain” model still prevails in some ICUs and becomes obvious when conflicts arise as communication breaks down. It is also pertinent to the informed consent model. The authors recommend that patients should be told that they will receive care from many professionals in the care team. Good handoff between caregivers is crucial, they argue.

Hospital leaders need to invest in skill development for physicians in communication and coordination and incentivise and reward good teamwork and communication. Teams should ideally be co-located, for example a heart institute housing surgery, cardiology, cardiac anaesthesiology and cardiac ICU.

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