Observations of teamworking in a multidisciplinary diabetic foot clinic: Bridging roles of podiatry and technology

Diabetic foot ulcer (DFU) is arguably the gravest complication of type 2 diabetes with high disease burden and mortality. Its complexity as a chronic disease with acute presentation necessitates rapid access to a multidisciplinary team (MDT), typically comprising vascular surgeons, endocrinologists and podiatrists. We conducted a focused ethnography of 55 (82.5 h) observations, 10 interviews with patients and several opportunistic in-situ conversations with patients and members of the care team at the multidisciplinary foot clinic of a tertiary public hospital in Singapore. In the clinic, the patient sat in the centre of the treatment room to be attended to by various members of the MDT who entered and exited the room singly, then collectively, to diagnose and recommend treatments. This led us to adopt a dramaturgical model as our theoretical framework to explore the movements and interactions composing what can be recognised as teamworking. The clinicians' teamworking could be organized into front-stage planned activities of history-taking and diagnosing and treating the foot wound; front-stage ad hoc activities of clinical deliberating and recommending; back-stage planned activities consisting of discussions on workups, interventions and appointments and coordinating these for performing teamwork in the front-stage; back-stage ad hoc activities such as interprofessional discussions away from the patient and outside the clinic; and off-stage activities in the patient's lifeworld pertaining to patients' everyday decisions and concerns. The protracted treatment work of the podiatrist places her in a bridging position between the patient and the medical members of the MDT that could plug knowledge gaps, and enrich clinical explanations and decision-making. Technology enabled backstage interaction and sustained teamwork outside the clinic even when decision-makers among the medical team members were not physically present. The occurrences from the patient's lifeworld pose an essential influence that can inform teamworking in the clinic. We discuss implications for practice.