How Interdisciplinary Teams Elicit Collaborative Communication

Recent science policy encourages the installation of Responsible Research & Innovation (RRI) practices, which should help solve grand societal challenges and be more readily adopted by society. RRI may be implemented by setting up interdisciplinary innovation development teams, bringing together technical and non-technical experts from various disciplines and backgrounds, enabling engineers to let their work become inspired by – or even partly co-shaped by – societal insights and viewpoints, while societal actors get acquainted with techno-scientific context. We developed a Decision Support Tool to support interdisciplinary innovation teams, that visualizes innovation project performance and success chances. It supports communication and collaboration in interdisciplinary teams by proposing practical improvement areas, based on shared expertise, including socio-ethical, societal, economic and management related aspects. Still, further investigation is needed to learn how such a tool can be used to systematically integrate RRI in practice, to harness its full innovative potential.

How decisions are made and communication is handled are essential to ensuring a good outcome.In the case of Scardoni v Hawryluck,1 Mrs H was an 81-year-old woman with advanced Alzheimer disease, cardiovascular illness, and septic shock whose family and physician could not agree on goals for care, requiring that a legal decision be made regarding the level of care to be provided. Over time and after much discussion, the multidisciplinary team on the intensive care unit (ICU) reached a consensus that intensive care for Mrs H would not improve her condition. So it was decided that after Mrs H was stepped down to a general medical unit, should an infection or respiratory distress develop, she would not be returned to the ICU. The attending ICU physician informed the family that instead of ICU care, “the hospital would offer her palliative care: painkillers and sedatives to keep her comfortable while her afflictions took their course.”2 In this particular case, the patient’s family challenged the health care team’s recommendations and insisted that their mother be readmitted to the ICU so that aggressive life-sustaining treatment would continue.This case, although Canadian, is relevant to ICU settings throughout North America. The purpose of this discussion is not to provide an in-depth ethical analysis, but rather to use the case of Mrs H to characterize one type of health care situation that clinical ethicists could help facilitate. Medical recommendations such as those involved in the care of Mrs H are made to prevent the “revolving door” patient, who according to ICU teams will receive no medical benefit if returned to the ICU. Decisions not to readmit are euphemistically referred to by some ICU staff as the “one-way ticket out of ICU” or “celestial transfer.” Such language shared between colleagues reflects a coping strategy, a “gallows humor,” intended to manage difficult feelings like sadness, anger, grief, sympathy, or moral distress. Cases like that of Mrs H are of particular concern to critical care nursing. Research has indicated that moral distress, a significant contributing factor to burnout, is encountered by ICU nurses when the care they are providing to a patient is regarded as futile.3It is not uncommon for hospital-based clinical ethicists to receive a request for consultation when disputes regarding similar recommendations for care arise between substitute decision makers and the ICU treatment team. These cases can lead to moral distress because of commonly held opinions among team members that futile treatment is being provided. Although staff can provide many life-sustaining treatments to such a patient, ethical questions often arise during the patient’s stay in the ICU. What ought to happen when an ICU team decides that a patient should be transferred to a general medical unit to receive comfort measures only, with no readmission to the ICU? Although teams discuss the practical questions about what can be done, the ethical questions about what ought to be done are sometimes not as clear. The following discussion explores how clinical ethicists can provide valuable assistance with the kinds of ethical challenges these situations customarily present. Particular emphasis will be placed on working within a process-driven, interdisciplinary framework that maintains a communication-oriented approach to ethical decision making.Clinical ethics is a relatively new field, and the role and purpose of clinical ethicists can vary somewhat according to the particular health care setting. For the purpose of this discussion, the authors describe the knowledge, skills, and activities of clinical ethicists through their review of relevant literature as well as their own training and experiences as staff clinical ethicists at 2 acute care settings in Ontario, Canada.Greater legal clarity or legislative measures to specifically address conflicts that arise over withdrawal or withholding of treatment for terminally ill patients are required, according to at least one legal expert. Current Canadian law, according to this same scholar, leaves doctors, patients and their families in a “grey zone” as to who should have ultimate authority on such decisions.4 The daily reality in most North American ICUs is that this gray zone persists—for better or worse. Although hospitals attempt to provide guidelines for addressing conflicts such as the one involving Mrs H, it is the quality of communication and relationship within the interdisciplinary team and between the treating team and the patient’s family that has a marked influence on decision making.5–7 In most cases similar to this one, consensus about level of care is first achieved by the interdisciplinary team, and a subsequent agreement is reached between the treatment team and the patient’s substitute decision maker and family. However, when agreement cannot be reached because of irreconcilable notions pertaining to what constitutes benefit to the patient and what constitutes harm, the results can be uncertain, stressful, and most unsatisfactory for both the health professionals involved and the patient’s family. This combination of an unfortunate turn of events for the patient, sharing of bad news with family members, and the recommendation for care outside of the ICU is a juncture of decision making at which conflict can occur and ethical challenges are most apparent to members of the interdisciplinary team.8,9Much has been written about the difficulties in communication within the ICU and how this affects patient care. Considerable evidence indicates that communication between the ICU team, patients, and patients’ families can be inadequate, leading to conflict and a possible long-term effect on the patient’s family.6,8,10,11 In one study,8 46% of families who had a loved one die in the ICU reported conflict over decisions to withdraw or withhold life-support measures. These family members also reported conflict over the manner in which staff communicated with or behaved toward them. The authors of that study8 cited family members who felt pressured by staff to “hasten their loved one’s death because they placed a burden on valued resources.” The importance of communication between treatment teams and patients and patients’ families cannot be overstated. In addressing the difficulties and deficiencies that have been identified, 2 experts concluded, “communication with caregivers is consistently identified as the most important and least achieved factor in patient/family satisfaction surveys.”12Intensive care is primarily intended to provide maximum benefit to those patients who are likely to recover from their infirmity or trauma.13 When the interdisciplinary team is not clearly communicating ethical considerations as well as the criteria they are using to determine the effectiveness or success of the treatment plan, patients’ families may develop erroneous expectations that life-sustaining interventions will continue to be offered.6 At the same time as a loved one is receiving ICU care with a grim prognosis, families are struggling to come to terms with impending loss. Family functioning or experience in coping with loss,14 unrealistic expectations regarding health outcome, within a societal context of diverse religious or cultural beliefs, can markedly influence families’ decision making about end-of-life care. Such formidable contributing factors further emphasize that effective communication strategies, as well as an appropriate level of sensitivity, ought to be used in ICUs when dealing with patients’ families.11Team communication, in particular communication between disciplines, also has proven problematic in decisions about end-of-life care in the ICU. Critical care nurses have cited difficulties in communication and decision making within interdisciplinary ICU teams. Ferrand et al15 reported that 75% of the nursing staff who participated believed that “collaboration was inadequate during decision making” despite general agreement that such team collaboration is necessary and desired. In another study,16 about one-third of the ICU nurses who participated felt “excluded by physicians from patient care decisions and felt their exclusion to be a detriment to patient care.”In terms of the burdens carried in making decisions about end-of-life care, some evidence suggests that physicians and nurses experience equal burdens. Physicians experience the burdens associated with having to make these decisions, and nurses feel the burden of having to carry out care decisions made by someone else.17 Given the shared burdens that members of the interdisciplinary team face, as well as the reported difficulties in end-of-life care decision making in the ICU, ensuring effective communication is a key feature of high-quality patient care.7 The following discussion is intended to demonstrate how clinical ethicists can be supportive of such strategies for effective communication and decision making.Medical recommendations like those pertaining to the care of patients such as Mrs H are based on best-practice standards of care and are informed by ethical principles like beneficence, nonmaleficence, and autonomy. Continued life-sustaining support in situations where benefit is in question can be regarded as futile, a concept with inherent ethical challenges. As Weijer et al18 point out, the values inherent in medical futility arguments often confuse treatment considered ineffective and treatment that will be effective but will ultimately result in a controversial outcome such as permanent unconsciousness. A team’s decision to not readmit a patient for ICU care can be an attempt to address futility based on controversial outcomes that the team may perceive as causing more harm for the patient than good. Poignantly stated, “if the welfare of the patient is the whole purpose of providing treatment and if that treatment brings needless suffering, then the whole purpose of medicine is defeated.”19 Although the concept of futility in ICU care is a subject worthy of ethical debate, it will not be the focus of this discussion. Rather, the subject of this discussion is the role of clinical ethicists in helping decision makers address ethical considerations such as futility.The results of inadequate communication, misunderstandings, or disagreements arising from divergent views about what is beneficent and the institutional realities surrounding resource allocation can be seen in the moral distress and subsequent moral residue experienced by both the patient’s family members and the health care staff involved. Moral distress occurs when a person can identify the ethically appropriate course of action, but does not feel able to carry this action forward because of barriers that may include lack of resources, legal limits, institutional obstacles, or imbalances in power, for example. Effects of moral distress on an individual can include feelings of anger, frustration, anxiety, or depression.20 Moral residue can be encountered when “deeply held beliefs, values and principles” are set aside at the expense of one’s personal sense of integrity.21 For families of patients, moral residue can manifest in lifelong memories about difficult health care experiences.The experience of moral distress and moral residue are of particular importance to critical care nursing. Some evidence indicates a relationship between an ICU care nurse’s perception of providing futile care, inadequate communication about the care plan within the interdisciplinary team, and the incidence of moral distress, emotional exhaustion, and burnout.3,16,22 Cases like that of Mrs H can present these kinds of challenges to nurses providing care at the bedside. The discussion also highlights how clinical ethicists can assist interdisciplinary teams in addressing ethical challenges that can lead to moral distress.Finally, the ethical climate within our health care settings is shaped by the organizational values inherent in hospital policies, approaches to handling conflict, allocation of human and material resources, the daily-lived experience of staff providing care, and those to whom care is provided.23,24 Economic constraints, resource allocation difficulties, and staffing shortages contribute to the moral climate of health settings, the moral distress of staff, and burnout among health care providers.25,26In cases such as that of Mrs H, the ethical challenges are not just about treatment requests considered inadvisable but also about scarce resources like ventilator-equipped beds in ICU settings. In the minds of some families, the need for an ICU bed is the primary reason that palliative measures are now being recommended. When conflict surrounds decisions about level of care, it is the bedside ICU nurse who fields the questions, concerns, and emotions expressed by patients’ families.It is through such challenging decision making, in which no agreement is reached, that the moral climate is regrettably defined for all persons with a stake in the decision. However oppressive these disagreements feel to both health care professionals and patients’ family members, most often the disagreements, ironically, do not result from a lack of good intentions on either side of the debate. Rather, these circumstances reflect the complex ethical challenges that are inherent in contemporary health care settings. Clinical ethicists can be an important resource to health care teams, patients, and patients’ families in addressing these difficult challenges.Clinical ethicists who provide consultative services may be requested by the ICU team when conflicts such as the one surrounding the planning of Mrs H’s level of care arise. What are the characteristics, skills, and knowledge that make clinical ethicists a useful resource in helping to address conflict over decisions about level of care for stable but critically ill ICU patients?Clinical ethicists come from a diverse background of training: clinical and academic experiences that include but are not limited to medicine, nursing, social work, theology, philosophy, and anthropology. Most clinical ethicists have advanced academic degrees and/or training in clinical ethics. Despite this diversity in background, clinical ethicists engage in common functions: consultative services, research, education and the development of policies pertaining to patient care and organizational ethics.27–29Clinical ethicists are trained to view ethical problems within an interdisciplinary health care environment whose primary commitment should always be to provide the best patient care possible. Patient care and goals for care are best understood through the wishes, beliefs, and values of the patient and the patient’s family. The approach taken by clinical ethicists in providing consultation is to model interdisciplinary collaboration and effective communication with patients and their families, with the objective of enhancing ethical decision making.28–30In effect, clinical ethicists in cases such as the one involving Mrs H act as facilitators of communication and decision making about goals for care, while directing attention to the ethical considerations underlying such decisions. Generally, clinical ethicists can help clarify differences in the way ethical considerations such as sanctity or quality of life are valued on the basis of religious, personal, or cultural values. Some evidence suggests that ethics consultation generally has been useful in preventing or resolving conflicts, and in reducing the incidence of prolonged controversial treatment.31,32 Current trends in the training and education of clinical ethicists have emphasized skills, knowledge, and expertise better suited to provide ethics support in real time as dilemmas and conflict around decisions related to patient care unfold.28What is particularly important about the approach used by most clinical ethicists is the emphasis placed on fair and just processes for decisions of such importance and consequence in an ICU environment.In cases such as the one involving Mrs H, it is not just what decision ought to be made that is of interest to clinical ethicists, but if and why a particular decision is ethically defensible. If so, to whom is it ethically defensible? How ought discussions and conflicts be managed? These questions raise ethical concerns about justice, fairness, and a reasoned approach to decisions of such consequence. Ethical consideration must also be given to the moral climate, how people feel treated, and the concerns and opinions of key persons with a stake in the decision making, with overarching consideration given to trust in the process used to make such important decisions. Therefore clinical ethicists are as concerned with procedural fairness as they are with outcome when assisting with ethically challenging situations in health care settings.Principal aspects of procedural fairness are as follows: that the process for decision making be as transparent as possible to all involved; that concerns of key persons with a stake in the decision making be considered; that the reasons or rationale behind decisions can be understood and defended; that people responsible for decisions be held accountable; and that in the event disagreement occurs, decisions can be reviewed, taking into account the concerns of those who disagree.33 Process-driven approaches to decision making or to resolving conflict used by clinical ethicists are dependent on using frameworks to guide communication. Such frameworks for communication are not just ethically defensible; they have been shown empirically to be part of good practice standards in ICU settings.6,11,34 Lilly et al35(pS398) found that using a standardized framework for communication resulted in health care providers seeing decision making as a “process rather than as an event”—an attribute consistent with principles for ethical decision making.An example of such a framework to guide communication is described by Lautrette et al,34 who identify such attributes as timeliness, opportunities for the patient’s family to speak, use of appropriate and sensitive language, and ensuring that the setting is private and comfortable. In addition to these attributes, clinical ethicists would include discussion of the values in conflict and ethical obligations that underscore decision making.Frameworks for communication appear well supported in the literature anyway, so what makes the involvement of clinical ethicists of added benefit?Despite advances in implementing communication strategies in many settings, improvement in general is needed in managing communication, enhancing understanding, and meeting needs of ICU patients and their families.6,8,10,11 Furthermore, Sherwin36 believes that communication frameworks and hospital policies can be used coercively, to enforce a particular outcome, if those who lead these discussions or who adhere to policies are not reflecting on personal biases, institutional pressures, and ethical considerations.Clinical ethicists act as facilitators, helping to raise important ethical questions, model effective communication, and model ethical decision making by using teachable moments to heighten the awareness and understanding of the ethical considerations in each case. Within most health care settings, necessary and unavoidable imbalances in power are present between various persons who have a stake in the decision making. Clinical ethicists assist in discussing the values that underlie decisions of such importance, making these transparent to and understood by key involved parties. They model the principles of procedural fairness. Inherently challenging decisions about level of care, as in the case of Mrs H, are often met with challenging feelings and opinions, making fairness and ethical reflection more important than less to involved parties.Clinical ethicists advocate for policies and practices that reduce coercive consequences that can arise when members of the ICU treatment team, patients, or patients’ family members feel overruled or dismissed. In conducting an ethics consultation, the clinical ethicist leads discussions with the interdisciplinary team members about ethical considerations that contribute to moral distress, for example, the conflict in the way benefit and harm associated with a particular therapy or level of care are understood. In most instances, the clinical ethicist must ensure that concerns raised by members of the interdisciplinary team and concerns expressed by patients’ family members are shared and considered. This process is handled in an open and transparent manner. In creating an opportunity through the consultative process for the interdisciplinary team to address concerns, related to both areas of conflict and moral distress, clinical ethicists are also capitalizing on valuable teachable moments in which knowledge about ethics and decision making can be enhanced. As Kälvemark Sporrong et al37(p835) concluded, “Ethical competence is a key factor in preventing or reducing moral distress.”We have found that consultation on an individual case often helps treatment teams identify preventative strategies to reduce or avoid conflict and to engage in more timely discussion about ethics the next time a complex care situation arises. Such measures are necessary in creating a moral climate in which discussion about ethics in daily practice can be supported and thus reducing the effects or incidence of moral distress. The potential exists for all members of the interdisciplinary ICU team, including the most responsible physician, to be so engaged in ethical reflection and decision making on challenging cases. Clinical ethicists model skills of effective communication, ethical reflection, and decision making as well as principles of procedural fairness within the consultative process that they facilitate.We are not suggesting that effective communication, procedural fairness, ethical reflection, and decision making are deficient whenever clinical ethicists are not involved in such cases. In reality, complex and ethically challenging cases occur routinely in ICU settings, most often without the involvement of clinical ethicists. What is being proposed is that clinical ethicists should be seen as a valuable resource for addressing challenging cases in the ICU. Better understanding is needed about the role of clinical ethicists and the kinds of assistance they can provide.In most cases, the ICU team and patient’s family agree on recommendations that comfort measures be provided on a medical intermediate care unit or a palliative care unit for a stable but critically ill patient. However, as in the case of Mrs H, these decisions may be met with considerable emotion from the patient’s family and with differences of opinion about benefit and the appropriate level of care. We think that clinical ethicists can be a valuable resource when challenging cases arise. By providing consultation, clinical ethicists can model effective communication, ethical reflection, and decision making, while following principles of procedural fairness, all of which are key elements to upholding ethics in daily practice and are of particular importance when conflict occurs about level of care in the ICU.The following are practical considerations for critical care nurses:

The pace of scientific advancements in medicine, driven by artificial intelligence as much as by novel biotechnologies, demands an ever-faster update of professional knowledge from physicians and collaboration in interdisciplinary teams. At the same time, the increased heterogeneity of patients' lifeworlds in socially and culturally diverse societies requires healthcare professionals to consider diverging personal and cultural perspectives in their treatment recommendations. Both developments require conveying to students a professional virtue that can be summarised as epistemic humility-a teaching process which, we argue, can and should be supported by novel technologies. By embedding students in realistic scenarios, virtual reality can play a crucial role in teaching medical students a stance of epistemic humility. Such stance implies acknowledging the limitations of one's knowledge as well as taking individual patients' perspectives and experiences seriously. In this sense, epistemic humility can also provide a crucial step towards tackling epistemic injustice and biases in medicine. We discuss how teaching epistemic humility with virtual reality tools can succeed and suggest the development of novel teaching tools that make use of this technology to immersively enable moral growth. Our paper thereby contributes to the emerging field of digital bioethics, calls for more work in the area of experimental bioethics and informs ongoing debates on how medical ethics teaching can prepare future physicians for the challenges of tomorrow's practice of medicine.

Introduction/Background A massive haemorrhage can be a rare but serious complication of paediatric trauma and obstetrical cases. In order to optimize the management of massive haemorrhages, a protocol was implemented at our centre. However, recent audits showed that necessary improvements were to be made to many aspects of its application. Our objective was to evaluate the application of a massive hemorrhage protocol and the ability to work in interdisciplinary teams using simulation and targeted training. We also aimed to evaluate confidence levels of different team members to apply the protocol and to hold their role in an interdisciplinary team during a crisis situation. Methods Prospective observational study held at the simulation lab and at the blood bank of a tertiary mother-child health care facility in 2012. Participants were nurses, respiratory therapists, orderlies, anesthetists, obstetricians, pediatric emergency physicians, intensivists and hematologists, as well as blood bank technologists. Pediatric emergency/intensive care and obstetrical/anesthesia teams were submitted to high-fidelity (HF) simulated pediatric trauma and post-partum massive hemorrhage scenarios respectively (SimbabyTM (Laerdal) and NoelleTM (Gaumard)). Blood bank technologists were videotaped and telephone conversations between them and participants at the simulation lab were recorded for review. If hematologists were consulted, they were called back by the blood bank chief technologist and asked to answer questions relevant to the application of the massive hemorrhage protocol (MHP). Each participant was asked to hold their usual role in an interdisciplinary team. Scenarios were developed, programmed and run by experts in each field. Targeted training consisted of a debriefing session and a presentation reviewing the MHP and teamwork skills. Documents on MHP, as well as a key article on crisis resource management were distributed during the first session in order to prepare for the post session two weeks later. Confidence questionnaires were filled out during both sessions. All sessions were videotaped and four blinded independent trained raters assessed the performances. Raters were blinded to the pre/post phase and were not involved in the study. For the application of the massive hemorrhage protocol performances, raters used a checklist derived from the original protocol by experts in the field. For the ability to work in teams, raters used the Mayo High Performance Teamwork Scale. Blood bank technologists were evaluated using a checklist derived by transfusion experts rating necessary steps for preparing and delivering blood products in cases of massive haemorrhages. Scores on performances of the application of the protocol, as well as teamwork performances were recorded. Means and standard deviations of scores for performances were calculated for each scenario. Pre and post training scores were compared using an ANOVA test to assess differences in means. Descriptive statistics of items on the confidence questionnaire were calculated prior to and following training. To assess differences in confidence levels, a Mann Whitney test was used. An alpha of 0.05 was set for all statistics. Results A total of 62 healthcare professionals involved in 8 interdisciplinary teams (4 obstetrics/anaesthesia and 4 paediatric emergency/intensive care) as well as 8 blood bank technologists and 8 haematologists participated in the study. Following training, scores for the application of the protocol improved by 24% (95% CI 10-39). Scores for the ability to work in teams improved by 17% (95% CI 6-28). Confidence levels in the ability to apply the protocol and work in teams improved by 13% (95% CI 11-16). Notable were confidence improvements in leadership and communication skills as well as role and task assignment. Conclusion Targeted training involving HF simulated scenarios and protocol review improved participant ability to apply the massive haemorrhage protocol and to work in interdisciplinary teams. Confidence levels improved among participants from all disciplines. Disclosures None.

Developmental dyslexia is the common term for the neurobiological disorder known as “Specific Learning Disorder in Reading” in the Diagnostic and Statistical Manual 5. It is believed that 14% of students in the United States of America have this diagnosis (Dyslexia Basics - International Dyslexia Association, n.d.). Dyslexia can significantly impact the academic, vocational, social, and emotional aspects of a person’s life, disrupting their meaningful engagement in occupations. Because dyslexia is a complex language disorder with multiple phenotypes and symptoms, no one profession can address all areas of difficulty. Occupational therapists are often brought into interdisciplinary teams in schools to support the writing of students with dyslexia. Historically occupational therapists have worked within a very limited scope, most commonly to address the individual prerequisite components of writing, such as visual motor and perceptual skills, fine motor skills, cognitive and executive function skills, and sensory processing skills (Grajo & Gutman, 2019.) Given the broad range of skills and practice scope that occupational therapists have, and in keeping with the current emphasis on top-down approaches and consideration of how literacy impacts the child's life role as a student, it is time for occupational therapists to consider best practice for occupational therapy interventions in supporting the occupation of transcription for students with dyslexia. Objective A scoping review with narrative synthesis was conducted to ascertain the strategies being used currently to improve the writing of students with dyslexia. The knowledge gained from the review was used to inform the overarching aim of this thesis: To guide occupational therapists and speech-language pathologists working under an interdisciplinary team model in supporting the occupation of transcription for students with dyslexia. Method Articles for this scoping review were identified through a computerized search of five electronic databases accessible by the Otago Polytechnic library: PubMed, ProQuest Central, Taylor and Francis, Cinahl, and ERIC. To ensure current and relevant information was considered, each article's date of publication was within ten years of the current year, 2010 - 2020. The literature search procedure was complimented by manually scanning the reference lists of retrieved articles. This identified two articles outside the inclusion dates. Because these articles were named in multiple reference lists, they were considered relevant and important to current thinking and thus included. Articles were evaluated according to predetermined criteria for inclusion at the title, abstract, and article levels. Seven articles were selected for review. Descriptive content analysis was used to map the current use of strategies and interventions. Results This scoping review identified that the strategy currently used and recommended to improve the writing of students with dyslexia is interdisciplinary team collaboration, including and prioritizing the student's family, individualizing, and providing explicit multi- component interventions. The necessity of understanding the language and interpretations of other professionals in the field in order to be an effective and respected team member was highlighted. The purpose of this review was to use the new knowledge to guide occupational therapists and speech-language pathologists working under an interdisciplinary team model in supporting the occupation of transcription for students with dyslexia. It is very clear from the findings that it is time for occupational therapists to reconsider their current roles and create the opportunity to increase their functional role in literacy. There is plenty of space in this complex field for occupational therapists to upskill and embrace literacy holistically while remaining within their scope of practice.

Background: Multisystem disorders in patients that are difficult to solve in a single-specialty approach are becoming more and more a reality to contemporary clinical medicine. A new paradigm of dealing with this complexity has been the emergence of interdisciplinary collaboration. Purpose: The paper will provide five well-chosen clinical cases analyses to investigate the impact of an organized interdisciplinary team (IDT) collaboration on diagnostic accuracy, therapeutic decision making as well as patient outcomes in various fields of diseases. Methods: The retrospective case-series approach was selected and involved the examination of inpatients treated using formal IDT consultations in three tertiary-care hospitals between January 2022 and December 2023. Cases were sampled to reflect cardio metabolic, neuro-infectious, ophthalmological, musculoskeletal-geriatric, and autoimmune cases. Findings: In all five cases, IDT was improved by delivering a structured management, which resulted in feasible clinical gains achieved, including 30-day readmission prevention, glycaemic control, neurologic, regained ambulation, and remission of an autoimmune disease. Some of the common facilitating factors were shared care plans, joint specialist ward rounds, and goal setting with patients. Some of the barriers experienced included scheduling conflicts, fragmentation of electronic health records, and role ambiguity. Inference: Multi-disciplinary teamwork with a structure is related to optimal clinical outcomes in multisystem disease. Both spread clinical translation and broad clinical translation will be fundamentally dependent on investment in communication infrastructure and formal training in IDT.

Over the last decades there is an increasing interest “in digging into” the vast amount of MRI data collected by modern scanners. In neuroradiology, the classic approach of looking at the images of different sequences, assigning qualitatively signal intensities to normal tissues or to disease processes, measuring dimensions and several other metrics, like relaxation times (T1, T2), diffusion tensor imaging scalars (FA, ADC, AD, RD), perfusion (CBV, CBF, MTT) and magnetisation transfer imaging (MTR) continues to represent the fundamentals of our everyday practice. However, the improvement of the MRI technology provides subtle information at a voxel level, undetected even by the most keen, expert neuroradiologic eye, waiting to find its way out. If we really want to take full advantage of our data, we must admit that neuroimaging has become not a “one man’s show” but rather an interdisciplinary team reminiscent of a small orchestra consisting of neuroradiologists, computer scientists, medical physicists and engineers. The first step to a successful performance of such an orchestra is to create a common language, understandable to all parties, to express clearly “what I need to know and why” and “what I can offer and which are the limitations”. This requires continuous education and learning of the basic principles, methods and ideas of the other disciplines. As a conductor, you are not required to play all the organs in the orchestra, but you should be able to coordinate them and evaluate their fine tuning and output. In the United States National Institutes of Health (NIH) Roadmap for Medical Research, it is noted that interdisciplinary team science broadens the scope of investigation into biomedical problems, yields fresh and possibly unexpected insights, and gives rise to new inter-disciplines that are more analytically sophisticated [1]. According to the NIH Roadmap, the traditional divisions within health research can impede the pace of discovery. There are numerous examples of the fruitful fusion of neuroradiology with other disciplines. Engineering for example has recently produced hybrid systems (PET/MRI, PET/CT), with potential to change medical imaging by providing combined anatomical-metabolic image information. Computer science has always been both a loyal servant and a driving force to radiology in all aspects of image reconstruction, visualisation, analysis and storage. Mathematics and informatics along with medical physics and biophysics have been able to provide detailed models of brain anatomy and function and extract information buried in noise or reveal complex relationships, hidden patterns and unexpected trends in the brain data. New fields (radiomics, connectomics) with their own bizarre creatures (textures, graphs, multivariate patterns, independent components) invade and challenge our conceptual framework. We strive to harness the power of the new tools, but we will never succeed alone. We need to reach out for help, to assemble a team that integrates information, techniques, perspectives, concepts, to advance fundamental understanding and solve problems whose solutions are beyond the scope of a single discipline or area of research practice. Working alone is based on a common misconception that math and computers are never wrong, and you only have to buy or download a program and feed it with images to get the correct results. There are many reasons why this is not true. Devil is in the details and you need help from other disciplines to discover him. Never forget that both neuroimaging data and their analysis algorithms, despite their sophistication, remain essentially crude anatomical or physiological models of the human brain, the most complicated object in the known universe. They provide approximations of reality based on various assumptions and, although they are inherently wrong, we use them as extremely useful diagnostic and research tools. Our duty as neuroradiologists is to keep in mind these approximations and assumptions during our assessments. Take for example the tractography maps every modern MRI scanner produces with a few mouse clicks. They are beautiful and impressive 3D representations of the white matter tracts but their production is based on the simplified ellipsoid model of probability for water molecule diffusion and on the streamline algorithm. Both provide a good approximation only in the case of large parallel dense fibers. Additionally, diffusion images have been acquired with specific intensity of the diffusion gradients, which restrict the detection window of the diffusion processes. Add on top of that susceptibility and eddy currents distortions, subject motion, noise effect on quantification, partial volume effects [2] and the initial enthusiasm for the colourful tractography maps will soon be tempered. Every day neuroradiologists make hundreds of decisions impacting the well-being of their patients. Their job becomes increasingly challenging as the growing amount of images increases the workload, slows the reading time and undermines the diagnostic accuracy. New imaging technologies can alleviate the pressure and bring enormous benefits to the patients. They also present new opportunities to expand neuroradiologists’ role as public health providers, but they require a remarkable transition in the working environment. A collaborative team can help them to face the new challenges, establish their pivotal role in the healthcare system, and provide faster, more efficient and more accurate interpretation services. Contrary to the speculations that Artificial Intelligence might one day replace (neuro)radiologists, we believe that the only neuroradiologists whose jobs may be threatened are the ones who refuse to become collaborative interdisciplinary team leaders and embrace the new technologies. According to a popular quote: “We cannot direct the winds, but we can adjust our sails”. It would benefit our careers but more importantly the lives of our patients

Hospice programs rely on interdisciplinary team (IDT) collaboration in the delivery of quality care at the end of life. The hospice philosophy advocates patient autonomy in decision making, and treatment of the patient and family as a unit of care. Including patients and families in IDT meetings regarding their care is a logical corollary of this philosophy. Hospice professionals in one Midwestern US state were interviewed by phone to determine the extent of patient and family involvement in their IDT meetings. A few programs had direct experience with patients and families attending IDT meetings, but attendance was not routine. Better communication was recognized as a potential benefit. The patient's frailty and the burdens of caregiving for the family were noted challenges to participation. Video-mediated communication is offered as a potential solution.

Historically, higher education institutions have been designed with a focus on developing mastery and furthering the body of knowledge within distinct academic disciplines. Unfortunately, this intended design has resulted in a lack of collaboration between academic units and has stifled interdisciplinary research between students and faculty across domains. The Luminosity Lab, located at Arizona State University, is an archetype for a new model of collaborative interdisciplinary research teams. Exceptional students are hand-selected from all areas of the university and come together to fuse youthful spirit, academic prowess, and business acumen—the makings of a 'great group.' Students work together to produce system-level projects that are capable of having a large-scale societal impact. Building upon concepts from systems engineering, the lab employs the use of a view model to analyze current and future systems from various viewpoints (e.g., enterprise, functional, computational, engineering, technology, services, standards). By leveraging the strengths of systems thinking, strategic design, and agile methodologies, our interdisciplinary team is positioned to tackle systemic challenges in domains such as healthcare, energy, education, and global climate. This model of interdisciplinary research was tested at Arizona State University across three academic years with participation from over 100 students, who represented more than 20 academic disciplines. The results have shown successful integration of interdisciplinary expertise to identify unmet needs, design innovative concepts, and develop research-informed solutions. By adopting this approach, higher education institutions can begin to break down the walls that exist between academic units and start to use a holistic view of research and innovation for solving global issues.

Retinoblastoma is a relatively uncommon childhood tumor. If untreated, RB grows to fill the eye and destroys the ocular globe's internal architecture. Metastatic spread usually begins after the first 6 months, and death occurs within a matter of years. When treated, overall survival rounds 97%, the alkylating drug melphalan being the most extensively used chemotherapeutic agent in localized treatment. In our hospital, pediatric oncologists asked the Pharmacy Department for assessment in order to implement a new chemotherapy protocol for the treatment of advanced intraocular elegible retinoblastoma cases using melphalan administered directly through the ophthalmic artery. In this paper, we describe the protocol implementation carried out by our collaborative interdisciplinary team as well as the clinical outcomes of five cases treated with ophthalmic intra-arterial melphalan therapy. Oncology pharmacists can contribute with their knowledge to the implementation process of new collaborative practice protocols recommending doses, predicting possible adverse effects and assessing about drug stability and elaboration, packaging and administration methods.

Background: Mycobacterium tuberculosis is the primary causative agent of tuberculous spondylitis (TB spondylitis), a chronic granulomatous inflammatory disease of the spine. Patients with TB spondylitis may have spinal lesions in up to 50% of cases, and 10-45% may also have neurological deficits. We reported a case of severe paraplegia manifesting TB spondylitis in a young adult patient. Case Presentation: A 28-year-old female Javanese Muslim was admitted to Dr. Soetomo General Academic Hospital in Surabaya, Indonesia with back pain, inability to move, and feeling stiff in both legs. During previous therapy, the patient was thought to have spondyloarthropathy. X-ray examination demonstrated T9 to T10 retrolisthesis and T10 corpus lipping. Thoracolumbosacral MRI with contrast revealed that the patient had TB spondylitis. A debridement and hemilaminectomy of T7-8 for fusion with bone segments at T7-8 were performed on the patient. The patient was treated with oral antituberculosis drugs for 10 months and could walk perfectly 8.5 months after the initial treatment. Conclusion: This case demonstrates the complexities of diagnosing TB spondylitis, which necessitates the use of multiple disciplines. Because the clinical manifestations of TB spondylitis differ, various methods, including thoracolumbosacral X-ray and MRI with contrast, are required to confirm the disease. As a result, an interdisciplinary collaborative team is required to achieve optimal patient outcomes and to prevent long-term sequalae.

Abstracts from theCenter to Advance Palliative Care National Seminar Pathways to Quality Palliative Care<i>November 13–15, 2014</i><i>Orlando, Florida</i>

Wireless sensor networks (WSN) are a nascent technology that builds upon the recent decadepsilas advances in electrical and mechanical engineering including wireless communications, low-power embedded systems, MEMS-sensor design, network architectures and instrumentation applications. These networks promise a means by which to better monitor and understand environmental monitoring, precision agriculture and public health. The nature of WSNs motivates collaboration among researchers from diverse disciplines to leverage their skills to conduct meaningful experiments. An ongoing innovative education practice has been investigating the effectiveness of WSNs for monitoring environment signals in modern agriculture. Several undergraduate students were recruited as research assistants and given the responsibility of implementing and deploying a complete WSN solution. Using wireless sensor networks as a motivating technology, this paper documents our early experiences developing and deploying a WSN in the field. The novel aspect of this innovative practice was provided with a hands-on experience in which interdisciplinary team work, technical communications and hardware design is emphasized. Future undergraduate research areas are explored with suggestions on how WSN topics can permeate into undergraduate education.

There is an increasing awareness about the paramount importance of information technology within business in the context of large businesses. However, research about the investigation of the role of information technology resources in fostering collaborative communication, network governance and relationship longevity in the small and medium enterprise sector has remained scant. The primary objective of this study was to investigate the influence of information technology on collaborative communication, network governance and relationship longevity in Zimbabwe’s SME sector. Five research hypotheses were posited and sample data from 162 small and medium enterprise suppliers were collected and used to empirically test the hypotheses. The results of this study showed that information technology resources positively influenced small and medium enterprise suppliers’ collaborative communication, network governance and consequential relationship longevity with their buyers in a significant way. Overall, the current study findings provided tentative support to the proposition that information technology resources, collaborative communication and network governance should be recognised as significant antecedents for improved relationship longevity between suppliers and their buyers in the SME setting. Therefore, managers in the small and medium enterprise sector and small and medium enterprise owners need to pay attention to both collaborative communication and network governance in order to optimise information technology resource impact on their relationship longevity with their business counterparts. Limitations and future research directions were also indicated.

A strong and cohesive interdisciplinary support team is critical to the success of children’s mental health live-in treatment program. Kinark Child and Family Services, a leading child and youth mental health organization in Ontario, Canada, assessed the degree to which its community-based live-in treatment programs align with identified best practices and used the findings to inform the implementation of an interdisciplinary team that delivers a unified clinical approach to treatment and care. This paper reviews the results of the assessment, focusing specifically on interdisciplinary teamwork and the collaboration, consultation, and training that is crucial for staff working in live-in treatment programs. The benefits of this collaboration on the therapeutic milieu for complex children and youth cannot be overstated as clients are supported by multiple professionals throughout their treatment journey, including child and youth care practitioners, clinical therapists, psychologists, case managers, and nurses. Training in dialectical behavior therapy (DBT) is provided to all staff to ensure that all members of the patient’s interdisciplinary team offer a consistent approach in the delivery and support of individualized treatment plans. We contend that our training approach for interdisciplinary staff in our live-in treatment programs, including comprehensive training in DBT, is beneficial for clients and families. Consideration for future program evaluation and interdisciplinary training initiatives are presented.