Medical silos,social identity,and duty of care: A call for health leaders to improve transitions of care

Abstract

This article explores the concept of medical silos, particularly within hospital systems, and examines their deeper roots in social identity and the fiduciary duty of care of healthcare providers. While traditional perspectives focus on informational and communication barriers, this analysis highlights how professional identity and moral obligations contribute to the persistence of silos. Social identity theory reveals that strong in-group affiliations, formed during medical training and specialization, fosters collaboration within groups but also create divisions between them. Similarly, the fiduciary duty of care, central to ethical medical practice, may inadvertently reinforce silo boundaries in resource-limited environments. By emphasizing the role of centralized leadership, the article proposes that health system managers and leaders, with the broadest possible duty of care, must take action to dismantle these barriers. Recommendations include re-evaluating policies for patient transitions and fostering integrated care pathways to improve overall system flow, rather than simply balancing the agendas of stakeholders within their silos.

Medical silos: More than a structural barrier

The concept of silos in healthcare typically refers to the division of a system into areas or groups separated by both physical and behavioural barriers, which ultimately impair cooperation and collaboration across the entire system. Popular discussions often focus on informational or data silos, attributing the breakdown in collaboration to poor communication, fragmented information technology systems, and an episodic approach to care. ¹ This view of silos as unfortunate accidents arising from the otherwise unplanned and organic development of health systems limits our analysis and leads to oversimplified solutions urging providers to just collaborate more and communicate better. While dismantling informational barriers is undoubtedly essential, it fails to address the other root causes of silos.

Recently, social identity theory has been used to understand the development of silos as an outcome of medical enculturation and in-group formation, reflecting the inevitable divisions through which members of a larger group derive meaning, self-esteem, and standards of practice. ² In healthcare, this process starts early in training and becomes fixed as providers become progressively specialized. ³ This complicates our thinking about silos. Professional identity certainly yields obvious benefits—family physicians who see themselves as lifelong caregivers may adopt a holistic approach to patient care, while internists who identify as diagnosticians ensure thorough evaluations, even in routine cases. However, differences in attitudes, routines, and speciality norms can equally foster suspicion, misunderstandings, and an unwillingness—or inability—to coordinate care with those who don’t share your identity, and therefore can’t share your values. ⁴ It has been proposed that the same conditions that enhance productivity within a speciality may constrain collaboration with those from different specialities. ⁵

While more complicated than a structural definition of silos as mere accidental features of a piecemeal healthcare system, an analysis that reveals how a naturally positive phenomenon—namely, the development of a strong sense of identity—can lead to barriers between individuals and teams serves two purposes: it explains the persistence of silos (and perhaps why they are ultimately ineradicable), while also prompting consideration of more intricate workarounds that leverage the underlying causes.

The fiduciary duty of care: Another double-edged sword

Despite the myriad differences in identity between members of various silos, medical ethics generally provides a shared framework and language for moral questions in clinical care. While the substantive nature of ethical dilemmas may differ across silos (for instance, the ethics of withdrawing life-sustaining treatments in the intensive care unit vs maintaining confidentiality while treating multiple family members in a family medicine clinic), the overarching principles remain consistent. Among these principles is the duty of care, which, like social identity, serves as both a fundamental source of good in healthcare and a significant factor in the development of silos.

The fiduciary duty of care is central to the patient-provider relationship. As per Beauchamp and Childress, “The patient-physician relationship is a fiduciary relationship—that is, founded on trust or confidence; and the physician is therefore necessarily a trustee for the patient’s medical welfare.” ⁶ While originally a medico-legal concept (the importance of which has been confirmed by the Supreme Court of Canada), ⁷ its foundation as a concept within medical ethics has been increasingly explored and described. Beyond the broad and content-thin principles of doing good for your patients where possible (beneficence) and avoiding harm (non-maleficence), the fiduciary duty of care creates richer specification: the fiduciary is entrusted by a vulnerable beneficiary (the patient) with the power to apply their knowledge and skill to render service, and thus owes the beneficiary a duty of care, loyalty, and good faith. ⁸

When combined with a strong sense of professional identity, this duty of care fosters a profound sense of responsibility among providers for the well-being of their patients—something that only they and their colleagues can deliver. The combination of professional identity and obligation concentrates rather than diffuses responsibility. In a resource-rich system, this might even lead to a healthy competition, with providers seeking out opportunities to use their skills and serve patients, rather than having requests for care thrust upon them (akin to a pull rather than push model of care as described in the Lean Thinking model of system flow). ⁹

However, in a resource-limited environment, this combination of professional identity and duty of care can create more rigid and divided silos. The obligation to apply specific knowledge and skill for a vulnerable patient becomes stronger for the patients already under care, and weaker for those who are not yet a provider’s responsibility. Care becomes rationed, with time and resources fiercely protected for established patients, while those awaiting care transitions are sidelined.

Examples of these barriers are familiar to anyone working in a Canadian hospital system. While emergency departments cannot limit the patients who present themselves to their doors, they may attempt to divert or deflect referrals from community providers or smaller centres, even when the need for a more complex level of care is clear. Admitting services, overwhelmed by inpatient demands, may delay or refuse consults from emergency departments, leading to conflicts and ambiguity over primary responsibility for patient care, ultimately resulting in clogged and overcrowded waiting rooms. Once admitted, services face pushback in transferring or escalating care to other busy services, even when a patient’s primary issue or acuity clearly changes. After discharge, patients often face uncertainty about whether to follow up with their primary care provider or a specialist, creating a confusion of responsibility that can lead to lapses in care and a return to emergency departments.

While these obstacles to care transitions stem from resource limitations, they cultivate patterns and habits that persist even when resources become more readily available. For example, an Intensive Care Unit (ICU) might attempt to defer admission of a deteriorating patient on a ward, even when a bed becomes available, as a reflexive action to fulfil their duty of care; even with available resources, the threat of overcapacity always lurks just over the horizon, and the fiduciary duty of care for their unit must be met and protected against future demands. The suspicion and misunderstanding that arise between silos with strong in-group identities can lead to an assumption in these cases that the out-group is resisting care transitions simply due to laziness, or sheer hostility. This is a form of fundamental attribution error that fails to recognize the true root cause (a desire to protect resources and honour pre-existing fiduciary duties without creating new ones) and only leads to further conflict.

Emphasizing the total duty of care of strong, centralized leadership

Just as social identity theory helps explain silos as a negative but likely inevitable outcome of an otherwise positive social force, analyzing barriers to transitions of care via the fiduciary duty of care can clarify their emergence as an inevitable consequence of a positive moral force in a resource-limited context. Ultimately, the key to dismantling these barriers may lie in harnessing the very social and moral forces that foster them in the first place.

Proposed solutions to the problem of overly narrow social and professional identities often call for broadening identity and expanding the in-group—essentially encouraging a shift from speciality identification to a broader organizational or professional identity.^4,5,10,11 Suggested mechanisms generally involve increasing communication and collaboration between different groups of providers, with the hope that this will foster a broader identity. However, this approach is unlikely to effectively dismantle silos for two reasons. First, it essentially amounts to advocating that members of an in-group simply choose to join a bigger group, with no clear way to counteract the strong unconscious and largely positive social force that leads to the smaller in-groups in the first place. Second, it addresses only the social aspect of silos without tackling the moral force of the duty of care. Even with a broader identity as “healthcare provider,” a member of a speciality in-group may not feel a duty of care for patients they do not perceive as their responsibility. Thus, silos are unlikely to be dismantled voluntarily from within.

There is, however, a group whose professional identity and duty of care are already broad enough to encompass the entire patient population served by a given health system: health leaders and system managers. Leveraging this identity and duty of care can aid in the breakdown of barriers to transitions of care.

The legal fiduciary relationship of health leaders and managers is well-established. The ethical dimension of this relationship is likely even older, recognized in the first comprehensive publication on medical ethics in the English language, Thomas Percival’s Medical Ethics, which highlighted the responsibilities of hospital administrators: “But numerous are the sufferers under sickness and poverty, to whom your hospital doors may be opened […] When admitted within these walls, they form one great family, of which you are the heads, and consequently responsible for all due attention to their present behaviour, and to the means of their future improvement.” ¹²

However, a renewed focus on organizational healthcare ethics in the last few decades has shifted attention away from the clinical dyadic duty of care toward broader system responsibilities, resulting in current discussions on organizational ethics leaning heavily on stakeholder theory and the balancing of competing demands within the system, rather than prioritizing the duty of care to vulnerable beneficiaries.^13,14 Notably, while the Canadian College of Health Leaders’ Code of Ethics acknowledges a duty to the public and society, it does not explicitly list a duty of care to individual patients under their charge. ¹⁵

The resulting landscape, in which healthcare providers within silos fiercely defend their duty of care to their patients while health leaders strive to balance the demands of the heads of individual silos, cannot possibly lead to a change in the silos themselves. However, re-emphasizing the unique and ultimate fiduciary responsibility that health leaders have to all patients within a system—rather than to the system itself—can provide a basis for strong, centralized leadership and decision-making that prioritizes a duty of care to patients over the interests of non-patient stakeholders, ultimately reducing barriers to care transitions.

In practice, this could involve:

• De-emphasizing soft calls for collaboration, communication, and shared identity, which are likely to be ineffective against the entrenched social and moral forces reinforcing silo divisions.

• Developing and adopting a research agenda focused on evaluating policies and standards for the safest and most efficient transitions of care across the system, rather than deferring the study of flow to individual silos.

• Reorienting focus toward structures that promote best patient outcomes above all else, even if this requires novel approaches or significant departmental dismantling and restructuring.

• Enforcing, through incentives or disincentives, strong centralized policies and procedures to ensure safe, efficient, and patient-centred transitions of care, even if it means overriding individual departments' desires to maintain the status quo. Examples might include:

o Clear and automatic pathways for non-emergent admission of patients to hospital directly from the community.

o Enforceable targets related to time for assessment, consultation, admission, and discharge at all levels of care.

o Comprehensive guidelines for determining the most responsible physician in emergency, inpatient, and post-discharge contexts to avoid conflict, delays, and “orphaning” of patients with complex care needs.

o Processes to distribute the burdens of overcrowding across hospital and community systems to limit overall harm (e.g., standardizing boarding, eliminating census caps, and fairly distributing inpatient loads).

o Centralized referral processes to distribute new requests for care and minimize wait time disparities.

o Greater involvement in the hiring and scheduling of medical staff (rather than deferring to individual departments) to ensure adequate coverage and minimize the impact of time-of-day on care transitions.

o Universal follow-up protocols and guidelines for patients discharged from hospital.

Conclusion

Many of these proposed steps to improve care transitions reflect healthcare-specific implementations of the “silo-busting” characteristics seen in high-performing non-healthcare organizations, such as standardized goals and outcomes, process integration, and clarity of responsibility. ¹⁶ None of these suggestions are novel, and many have been implemented in various healthcare systems. However, they remain far from universal in the Canadian healthcare context, where providers continue to struggle daily with deferring and deflecting care transitions. A central reason for this is the diffusion of responsibility among silos, a consequence of the overemphasis on stakeholder theory in modern organizational ethics, as well as the negative aspects of the fiduciary duty of care and social identity. The proposed solution—a renewed focus on the total fiduciary duty of care that health leaders owe to every patient within their silos—is not a panacea. However, by leveraging the very social and moral forces that contributed to these divisions, it may provide the justification for health leaders to move beyond merely mediating conflicts between silos and to more vigorously foster connections among them.