From ‘quarterback’ to ‘coach’: the policy implications of family physicians’ evolving role in team-based care

TL;DR

This paper explores how family physicians are shifting from direct patient care to coaching roles in team-based care and the policy changes needed to support this shift.

Contribution

The paper introduces policy implications for supporting family physicians' transition to coaching roles in team-based care models.

Findings

The shift from quarterback to coach requires payment reform, cultural change, and training for physicians and team members.

Training should focus on human resource skills like hiring, team dynamics, and change management.

Policy makers should address interprofessional hierarchies, communication, and scope-of-practice renegotiation to scale such care models.

Abstract

Project Colourful, an innovative model for delivering team-based care and improving access to family physicians at a specific Canadian clinic, provided a window on how physician-led primary care teams are evolving. Colourful allowed an action research team to draw out broadly applicable policy lessons as family physicians moved from exclusively ‘quarterbacking’ direct patient care to also taking on a more off-field role as ‘coaches’ of registered nurses.

Participant observations (n = 12) of Colourful’s design and implementation were supplemented with semi-structed interviews (n = 11) that focused on the project’s origins; plans for scaling; and interprofessional teamwork issues. Transcribed interviews were analysed using an interpretive descriptive approach.

The shift from quarterback to coach requires not only payment reform, but cultural change and training for physicians and other team members. Specific training here focuses on developing human resource skills and capacities that span: hiring, scope-of practice education, team dynamics, team member retention, and change management.

Key support, resource, and governance considerations for policy makers looking to scale care models like Colourful include education to: flatten traditional interprofessional hierarchies; enable the communication required for successful teamwork; as well as, bolster the HR skills of physician coaches; ensure an optimized interprofessional mix; and empower team members to renegotiate scopes of practice at clinical and provincial levels.

Full text

Background

Canadians’ access to family physicians (FPs) has become an acute policy challenge [1–3]. This long simmering crisis in access [4–7] has evolved alongside decades of policy innovation focused on creating and supporting FP-led teams of primary health care (PHC) providers [5, 8–10]. With concerns expressed about the health system’s capacity to recruit, educate, and retain FPs [11–13], questions about the viability of FP-led teams and the role physicians play on them come to the fore. In a funding, clinical, and North American political/cultural environment where FPs have been ‘quarterbacking’ [14–17] what does a shift towards ‘coaching’ involve? If there is indeed a move from on-the-field leadership towards from-the-sidelines oversight happening, what does it look like practically and are present policy supports well adapted to ensuring the success of these new teams?

To answer these research questions, this paper draws on qualitative observation and interview data collected as a team of PHC providers in Alberta, Canada embraced a new ‘coaching’ role for FPs. On the one hand it is an account of the specifics of the Alberta providers’ experiences as they designed and executed “Project Colourful” (Colourful)1 to respond to their local iteration of Canada’s access-to-PHC crisis. On the other, the paper highlights broadly applicable policy considerations as the nature of team-based care and the activities and competencies of FPs are changing. In this sense we have sought answers to the broad research questions stated above by studying the specifics of Colourful as it was conceived of and initially implemented to meet the challenge of an outsized waiting list (See Appendix 1 for more details).

Since the introduction of Canadian Medicare in the 1960 s [14], and across models like the now widely-adopted Patient’s Medical Home (PMH), FPs have been described as ‘quarterbacks’ of primary care teams [15–18] This is to say they have been seen as acting on-the-field to deliver PHC; leading teams of in-clinic providers such as registered nurses (RNs) or medical office assistants; and managing referrals out to specialist care as a steward of the broader system’s resources [17, 18]. However, with the advent of expanded scopes for other health care professionals [19–21]; the increasing complexity of patient needs [2]; and a dearth of FPs [11] these teams led by clinic-owning doctors paid on a Fee for Service (FFS) basis, have come to be regarded as unsustainable and inadequate [1, 12, 22]. In response, polices changing FP funding [23, 24] and pursuing more robust team-based care [25, 26] have emerged, introducing the possibility that FPs may be moving to coaching from quarterbacking.

What follows illustrates an emerging conceptualization of ‘team’ and identifies key areas for policy development in cultural competency, communication, human resources (HR), and professional governance that are likely required for FP ‘coaches’ to become a broadly successful solution to the access crisis. Specifically, we follow the thinking of, and issues encountered by, the Working Group members of the PHC Clinic (hereafter ‘the Clinic’) who were responsible for designing and implementing Colourful (see Appendix 1 for more details).

Methods

An embedded action researcher from the University of Calgary (AM) was a participant observer at Colourful’s planning and rollout meetings (N = 12), supplementing these observations with review of the project’s documents, and interviews with Working Group members. The Working Group verbally consented to the researcher’s presence at the meetings, and was aware that she was taking field notes as well as actively participating in and contributing to the design of Colourful. The field notes from the meetings were used as sensitizing elements for the interviews and analysis that would follow.

Ten Working Group members, from a pool of 16 people, were approached for interviews and 9 agreed to participate, completing a written consent form prior to doing so. Table 1 shows how 11 interviews (9 initial and 2 follow up) were conducted with a range of internal (to the Clinic) and external participants between February 2024 and August 2024. Interviews were conducted online and in person during work hours at participants’ place of work, based on their availability. To protect anonymity, we only ascribe a high-level descriptive title and number to these participants. Their comments have been anonymized and edited to balance privacy and brevity with the provision of important context and detail. Key quotes from the interviews illustrating our analysis are summarized in the Results section of this paper, and can be found in full in Appendix 2.

Table 1. Interview recruitment & participationWork TitleInterview Request AcceptedInterviewCompleted (O = Online; IP = In Person)Follow-Up Interview RequestedFollow-Up Interview CompletedParticipant Codes Used in Appendix 2Internal - NurseYesYes IPADMIN1Internal - AdministrationYesYes OYesYes OADMIN2Internal - NurseYesYes OADMIN3Internal – Physician(Late Career)YesYes OPHYS1Internal – Physician(Mid-Career)YesYes IPPHYS2Internal – Physician(Mid-Career)YesYes OPHYS3Internal – Physician (Early Career)YesYes OPHYS4Internal – Physician (Early Career)Non/aExternal participantYesYes OYesYes OEXT1External participantYesYes OEXT2

Concentrating interviews on a smaller number of content specialists has been shown to be sufficient for attaining data saturation and adequate information power [27]. In the case of the present study, we were able to obtain data saturation with a relatively small sample size because the Working Group was composed of engaged key informants who were amenable to sufficiently lengthy interviews [28]. As embedded action researchers we were able to conduct near real-time checks with our participants, gaining their insights and feedback through an initial report for Clinic consumption, and drafts of the present manuscript. We developed an interview guide based on the broad research questions described above, and our ongoing observations of the Working Group as it accepted its mandate, identified a root cause problem, and designed Colourful as a ‘coaching’ solution to that root cause. The interview guide was used to structure the conversations with participants and can be found in Appendix 3 Table 2.

Table 2. Interview statisticsTotal Number of Interviews Completed11 interviewsLongest Length74 min 53 sShortest Length25 min 06 sAverage45 min 17 sStandard Deviation15 min 10 s

Digital interview recordings were transcribed by a professional service, and then quality checked by the researchers, before being analysed using an interpretive description approach [29] with the support of MaxQDA™ software [30]. Like other commercially available qualitative analysis software packages, MaxQDA facilitates the storage and manual coding of manuscripts and so the identification of themes and a broader interpretation of the various participants’ viewpoints. Coding categories were developed, expanded, collapsed, and checked by the researchers iteratively, with instances of disagreement discussed until a consensus interpretation could be reached. Interpretive description focuses on identifying applied knowledge and allows for specific attention to participants’ institutional commitments and perspectives [31–33]. It provides insights not just into areas of commonality but also areas of disagreement among participants, with an eye on unearthing pragmatic suggestions to improve policies and outcomes [29, 34]. As noted, we continued to engage as action researchers with our participants, providing them with initial reports, and then drafts of the present manuscript to check and reflect on. In this way our emerging interpretive description of Colourful’s design was merged back into its rollout, informing how the Clinic implemented on the ground and approached advocacy with policy makers.

Results

As the Working Group designed and implemented Colourful, our analysis shows its members were thinking about, and working with, three key aspects of teamwork: Becoming a Consultant; Human Resources Challenges; and Change Management Capacity.

Becoming a consultant

Participants noted that Colourful required FPs to transition into the role of a consultant (B1Q1), overseeing the work of others on the team rather than providing direct care themselves (B1Q2). This shift to consulting work was operationalized as one where Clinic nurses became first points of contact and even ‘quarterbacks’ for patient care (B1Q3). An anticipated consequence of this delegation to nurses was that FPs would be less involved in delivering direct patient care (B1Q4).

Newly empowered quarterback nurses, working at the limits of their traditional scope of practice, were seen as central to patient evaluation, treatment, navigation, and triage (B1Q5). Newly acting as consultant overseers in a collaborative team that divides up care delivery, FPs were positioned as authorities at interdisciplinary rounds convened to keep team members informed and in conversation with one another (B1Q6). Working Group members recognized that the shift was not just potentially destabilizing for FPs (B1Q7) but that most were untrained in how to oversee work that had formerly been theirs alone (B1Q8; B1Q9). As such, adjustments to continuing medical education and medical school curricula, as well as to the educational and regulatory environments of the registered nurses to whom Colourful FPs were now delegating direct patient care, were seen as critical (B1Q10). Specifically, participants identified the necessity of education support and governance reform to clarify FPs’ legal and administrative responsibility for the actions of other team members (B1Q11).

Participants noted that the new role might offer less job satisfaction for FPs (B1Q12) and that the spread of the intervention hinged on independent FP’s willingness to delegate their authority and be trained in a new approach to team-based care (B1Q13). This willingness to delegate was in turn tied by Working Group members to historical norms in the medical profession (B1Q14), a sense of physician superiority (B1Q15), and ‘grumpy’ concerns at a loss of turf and income (B1Q16).

In sum, taking on the consultancy role in Colourful’s new version of team involves FPs delegating significant authority and direct care time to nurses as they become the on-the-field quarterbacks delivering PHC. Technical and cultural training in the new methods and mindsets required to oversee work that was once the exclusive purview of FPs is seen as necessary. This training in shared decision making and responsibility is also challenging given norms and concerns amongst physicians.

Human resources (HR) challenges

When asked which health professionals should be included on the Colourful team, Working Group members agreed that team composition should be driven by a mix of patient needs and structural features. Patient demographics and health needs, local socioeconomics and clinic resources were seen as important factors in determining which professionals are hired onto the team (B2Q1; B2Q2; B2Q3).

The cost of hiring was identified as a barrier to creating the preferred PHC team (B2Q4). Even with adequate funding available, finding the necessary trained professionals to fill the roles may prove difficult, with the lack of availability of Nurse Practitioners and Physician Assistants specifically noted (B2Q5; B2Q6). Once the team was formed, awareness of scopes of practice was identified as necessary to the creation of operating procedures to govern and clarify the delegation of tasks (B2Q7; B2Q8; B2Q9; B2Q10).

Although Clinic nurses were seen as possessing the skills to take up on-field quarterback duties with patients, participants described the need for ongoing training to ensure those nurses were practicing at their full scope and accepting the highest possible volume of delegated tasks (B2Q8; B2Q11; B2Q12). This scope-of-practice and medico-legal responsibility training was being created and implemented by the Clinic ‘in-house’ as they were unable to find premade courses to support this kind of role expansion(B2Q13). One Working Group member noted that the Clinic’s nurses came to this bespoke training from a different cultural and operational baseline than most other nurses in the province would. The effort and resources required to bring not just nurses, but all team members to that baseline were major considerations for future spread and scale (B2Q13; B2Q14). Alongside the creation of in-house training programs, the Clinic planned to develop standard operating procedures and protocols that would support non-physician team member competencies and allow FPs to off-load more tasks (B2Q15). Working Group members noted that existing legislation limited nurses’ abilities to take over certain ‘quarterback’ tasks. Specifically, they identified the inability to sign off on reports (B2Q16), write requisitions and approve labs (B2Q17) and a lack of prescribing authority (B2Q18) as legislation limitations on nurses’ capacities to ease the FP-access bottleneck.

In summary, moving FPs from quarterback to coach role requires consideration of patient and structural issues as hiring decisions are made. Once hired, the new team members require scope-of-practice training; this training, along with standard operating procedures, will need to be developed locally, and as Colourful-like programs spread they will need to accommodate a range of baseline teamwork and integration practices.

Change management capacity

Colourful’s design and implementation were sparked by an in-Clinic mandate (see Appendix 1) and seen as part of an obligation to the Clinic’s local community (B3Q1; B3Q2). Beyond achieving local access improvements, Working Group members saw Colourful as an opportunity to be innovative (B3Q3), to try something ‘outside of the box’ (B3Q4) and redefine what PHC more broadly could look like (B3Q5;B3Q6).

When envisioning project scaling beyond the Clinic, participants described how external implementation would require more than just sharing the model. Culture work (B3Q7) aimed at shifting mindsets and establishing literacy in the Clinic’s approaches to teamwork as well as the capacity to assess local readiness for change (B3Q8) were identified as necessary. Spreading Colourful would also require additional funding, a challenge that even the alternatively financed Clinic had overcome by rerouting money away from the normal operations budget to cover startup costs (B3Q9). Specifically, Working Group members felt it was necessary to secure funds to support change management and implementation (B3Q10;B3Q11) while safeguarding regular ‘day to day’ practice (B3Q12) and the financial stability of the Clinic (B3Q13).

In summary, Colourful’s creators see it as both an obligatory response to local access issues and a potentially scalable innovation in how team-based PHC is done. For this spread and scale to occur a range of cultural, change management, and financial adjustments that go beyond the mechanics of the quarterback-to-coach shift in FP status must occur.

Discussion

With early work on the composition and scope of PHC teams emerging around the world [35–40], our findings document how Clinic team members are navigating a transition from on-the-field ‘quarterback’^14^ to consultant ‘coach.’ In this way, the deployment of Colourful to solve the Clinic’s local version of a Canadian PHC access crisis, becomes an opportunity to identify broadly applicable policy considerations. At a time when the government of Alberta – also seeking to improve access – is expanding a version of the Clinic’s alternative payment model to the rest of the province [41–43], the team’s insights into the scope-of-practice training and new operating procedure development that are required to accommodate integration and teamwork are particularly timely. As the province expands the payment model beyond the Clinic, Colourful’s physician-led approach to team-based care may well be poised to scale, but our findings highlight the importance of not just finances, but also cultural and technical capacity if that spread is to occur.

Cultural capacity

The Colourful team’s recognition that FPs’ mental models need to shift for the new consultant coach role to succeed aligns with both Cronholm [44] and Glazier’s^1^ findings that historical approaches to guarding medical turf must be set aside. Participants recognized that their ‘team-culture’ baseline and openness to innovation were not only unique, but likely more advanced than other clinics, suggesting a broad need for policies supporting competency in the cultural values and norms of effective teamwork. From this baseline, and echoing recent findings on optimal PHC teamwork [45], the Colourful team emphasized the importance of creating opportunities for all team members not just to communicate about clinical topics, but to enact the new ‘coaching’ cultural values of shared decision making and responsibility. The literature suggests that shared clinical decision making [46], autonomy and shared leadership [47] and nurturing a positive team culture [48] all create better team dynamics and reduce burnout. An important consideration for those who design initial and ongoing professional education would be to create enculturation practices that can rewire team members’ thinking to reject traditional ‘doctor with helpers’ quarterbacking and embrace innovative ‘consultative’ coaching.

Technical capacity – communication & HR supports

Alongside these cultural changes, the Colourful team highlighted the importance of frequent intra-team communication, confirming findings [46, 47] that show such interactions are critical for successful interprofessional collaboration. They also noted that FPs may lack the skills to: hire and coach new team members; oversee those team members in systematic ways; and manage change. At a time when top-down legislative action to enforce interprofessional collaboration has proved ineffective [5] and centralized wait lists for patients wishing to attach themselves to FPs are receiving mixed reviews [49], Colourful was developed locally with attention paid to the demographics and needs of patients on the Clinic’s waiting list. While the majority of provincial policies support this grassroots approach, they also tend to lack details on how local teams can best be composed to meet the needs of target populations [10]. In this sense, further research on PHC team development [50] is likely required to support emerging ‘coach’ teams as they assemble the right mix of members. Even more pragmatically, Colourful’s experience suggests that human resources (HR) supports for those local teams to find, hire, manage, systematically debrief [50], and retain the right qualified personnel are likely requirements for them to succeed and scale.

Technical capacity – local & provincial governance

The Colourful Team’s experience similarly suggests that education on how to clarify and operationalize the legal and ethical responsibilities involved in team-based care is an important consideration. The policy implications here have internal local and external governance aspects to them, aligning our findings with those who have suggested that a mix of local and provincial-level policy supports are likely required [10, 51]. At the local level, spreading the Colourful model will require bespoke in-house policy and education work across a range of clinical settings. As before, PHC team members cannot be assumed to already have the skills to work collaboratively or that co-location itself creates teamwork [47].

In respects to external governance issues, Colourful team members highlighted how the currently legislated scope of RN practice prevents the delegation of certain ‘quarterback’ tasks from FPs to RNs, limiting the model’s capacity to improve access. In this light, professional associations and policy makers will want to consider adjusting scopes of practice to support the spread of Colourful-like models. Given recent policy moves to grant a range of non-physician providers expanded scopes of practice in PHC, there is considerable pressure for further research and consideration of how these non-physician ‘teams’ might, or might not, work alongside FP ‘coach’ models like Colourful. Specifically, nurse practitioners [52], pharmacists [20, 21]and optometrists [53] have acquired PHC provision capacities and it is unclear how these parallel but presently unconnected care streams can, or ought to be, integrated.

Limitations

As a qualitative observational study, our data are derived from a specific location at a particular moment in time. Our analysis seeks to transcend these specifics and draw out broader lessons, but that analysis has, inevitably, been shaped by our own biases as social scientists. Although we have followed best practices in studying the context of a healthcare improvement intervention [54] - refining our interpretation of the data by consulting with our participants – our findings may not generalize to other physical clinics, cultural settings, and policy or finance programs. This is particularly true given Colourful’s focus on registered nurses when a range of other allied health practitioners are also operating on, or nearby, PHC teams. As such, further localized assessments aimed at precisely calibrating policy supports are likely necessary.

Conclusion

Payment model reform is a necessary but insufficient step as health systems seek to improve PHC access by shifting FPs from quarterback to coaching roles. Other key considerations for policy makers as these new teams emerge include dedicating support and resources to build cultural competency and technical capacity. Initial and ongoing educational focus is required to flatten traditional interprofessional hierarchies and enable the communication required for successful teamwork. Similarly, resource and governance supports that bolster FP coaches’ HR skills, ensure an optimized interprofessional mix, and don’t just train team members, but empower them to renegotiate scopes of practice at clinical and provincial levels, will contribute to successful scaling of innovative models and improved access to PHC.