Medicine Is a Collaborative Profession
Know your resources.
Most of medical practice is straightforward, enabling a former Gloucester associate to observe years ago: “Ninety percent of what one needs to know in medicine is within the ken of 90 percent of the doctors.” For that which is not, we turn to others. Medicine is a collaborative profession. We cannot do it alone.
Only after a few years in practice did I begin to recognize the true mean-ing of “collaboration” and “the clinical professions.” Until then, I thought that doctors consulted only with doctors, nurses with nurses, etc. Now I know better. “The clinical professions” include everyone who is profession- ally trained to care for people: physicians, nurses, social workers, clergy, and therapists of all kinds. What is especially fascinating is how our professional paradigms and needs overlap and how much we can teach each other about the care of our patients.1 Much of that overlap lies in the human side of medicine.
The collaboration between nurse and physician has been around a long time; each is an extension of the other. Especially in recent years in the hos- pital, home, and nursing home, nurses and doctors have become partners, extending each others’ insights and observations. Wise nurses and doctors ask of each other, “What do you need to know from me that will help in the care of our patient?” Physicians have long underutilized the collaboration with social workers, who have skills in exploring and coordinating commu- nity resources and special talents in dealing with complex family relation- ships. Collaboration with hospital chaplains and other clergy provides additional views into the spiritual life and resources of the patient and fam- ily. Information from mental health professionals, physical and occupa- tional therapists, and others in health care settings often holds the key to better care. The clinical professions have much to learn from each other.
Collaboration is “the ability to engage diverse groups in shared acts of discovery and evaluation.”2 No physician should be reluctant to ask for consultation if it will benefit the patient. Deciding which consultant to ask requires these sorts of considerations: How will the new information affect the decisions? Who is the best consultant for this problem and the patient? “When I chose you as a doctor, I also chose those doctors who are your con- sultants” was one patient’s way of telling me that he approved of the urolo- gist I had chosen to do his cancer surgery. He appreciated the urologist’s technical skill, compassion, and understanding. He trusted the consultant because he trusted me. Through the years I discarded from my list of consul- tants those who were technically competent but incapable of developing an effective relationship with my patients.
Physicians consult with other physicians for various reasons.
• The consultant may have certain specific skills. The skills may be with proce- dures—gastroscopy or heart surgery, for example. They may be intellectual skills—expertise in diagnosing complex infections, for instance, or talent in di- agnosing relatively rare illnesses with which few physicians have experience. A physician may ask for consultation because the consultant has therapeutic skills beyond his own—skill in using a drug or doing psychotherapy.
• It may be unclear what is going on. Consultation affords another way of looking at things.
• The physician may initiate consultation in order to validate her own views. She reflects, “I think I’ve got this right, but I’d like to bounce my ideas off a colleague whose opinion I trust.” Like the patient noted before, even the physician “must visit a wise man from time to time to discover what one already knows.”3 Con- sultation provides an opportunity for self-critique.
• The physician may initiate consultation in order to reinforce for the patient and the family the physician’s own approach, to validate for them the diagnosis, treatment, or prognosis. Sometimes the reputation of the consultant or the in- stitution may be the reason. Even though the primary physician knows that the diagnosis is correct and that he has considered all the therapeutic options and chosen the best one, he recognizes that the patient may need the endorsement of the medical center or physician regarded as the best.
• The patient or the family may ask for consultation. Especially when things are not going well, consultation may reassure the family that “everything is being done.” No physician should feel defensive when asked. A savvy cardiologist put the parents of a newborn son with a birth defect at ease when they requested an- other opinion: “We get others’ opinions all the time. If you’re wrong, you learn something; if you’re right, you’re a hero.”
• Sometimes it is the personality. There may be conflicts between the patient and the physician that are unrelated to the medical issues at hand. Inserting another person into the transaction may resolve the conflict.
The level of consultation varies. There is the “formal consultation” and the “curbstone consultation.” There is the focused consultation and a broader one. There is the single-visit consultation and an ongoing one, a series of meetings with the patient. And there is another kind, what I like to call the “self-consultation.”
A formal consultation often takes this pattern.
• Surgeon to internist: “My patient is running a fever several days after his gall- bladder surgery, and I can’t find the cause. I’d like you to see him.”
• Internist to another internist: “My patient has been tired now for several months, I’ve struggled to come up with an answer, and I’ve done a number of tests that haven’t helped. I think she needs another point of view, and I’d like you to see her.”
In the curbstone consultation, one physician asks another to help answer a question without seeing the patient.
• Internist to cardiologist: “I’m having trouble controlling my patient’s arrhyth- mia (irregular heartbeat). What are your suggestions?”
• Cardiologist’s response: “What’s the clinical context for the arrhythmia? What else is going on with your patient?” She then suggests either that the dose of the drug be increased, that the current drug be changed, or that the patient does not need treatment because the arrhythmia is not dangerous and will cause neither symptoms nor shortening of life.
The “curbstone” may turn into a “formal” consultation when the cardiolo- gist suggests that “there are enough unanswered questions and undefined issues that maybe I should see the patient.”
The focused consultation addresses a single problem.
• Family physician to urologist: “Please see my patient with a kidney stone and help in her management.”
• Internist to podiatrist: “Please see my patient who has diabetes and an ingrown toenail and do what needs to be done.”
The broad consultation addresses many problems.
• Psychiatrist to internist: “My elderly patient is depressed. I’d like to know if there are any physical causes for her depression and I’d like you to help in her overall care.”
• Surgeon to internist: “My patient is to have surgery next week for colon cancer.
He needs an overall evaluation, and I’d like you to follow him in the hospital. See him as often as you think it’s necessary, after he’s had the surgery.”
Sometimes what starts out one way changes to another. A request to fo- cus on the care of diabetes turns into broader care and defining new issues, as in Case 2, in chapter 2. A curbstone consultation turns into a formal one. What seems to require only a single transaction turns into a series of meet- ings. Sometimes the wrong question is asked. Sometimes when the need warrants, the consultant does even more than asked.
Then there is the self-consultation. When I have been stymied over a pa- tient’s diagnosis or treatment, before I ask for consultation from a col- league, I will sometimes ask myself, “How would I approach this patient (or case or problem) if I were called to see him as a consultant?” I look at the case in a fresh way, reinterview the patient, review the patient’s chart, re- construct a problem list, define the issues afresh, and, often as not, come up with the elusive answers. When I do that, I achieve one of the goals of a good medical education: I become my own teacher.
The ideal consultation is one with give-and-take between the consul- tant and the referring physician, who may recall small nuances of the pa- tient’s history of importance to clinical decisions. The conversation provides the basis for a more complete and thorough consultation as physi- cians test each other’s hypotheses and plans and raise questions the other had not thought about.
We ask for consultation when cases are complex. Certain illnesses have many issues with which to deal regarding cause, treatment, and a clinical course with many ups and downs. “Complicated cases are complicated,” an orthopedist taught me, and acknowledging this reality helps to mobilize all the available resources. Complicated cases with many consultants work best when each knows who has the responsibility for what part of the pa- tient’s care. “Each one understood his role and the other’s.”4 In addition, someone has to be in charge, a physician who acts as a “general contractor,” the overseer of the process, and the interpreter and final common pathway to the patient and family. That person integrates all of the information, judges its worth, says “yes” or “no” to tests, procedures, and treatment, and helps to resolve conflicting points of view.
When no one is in charge, many things can go wrong. Ten years after a 70-year-old woman had a cystectomy (removal of the urinary bladder) for cancer, she began having fever, presumably from a kidney infection. Her consultants included a urologist and an infectious disease specialist. Treat- ment included surgical drainage of the kidney and intravenous antibiotics. Yet the fever persisted. The infectious disease specialist said, “If I could get the tube out, the fever would be gone.” The urologist said, “She’s getting better and can go home.” Her daughter said, “She’s worse. I’d like another opinion.” Paying attention to the daughter’s view, a new consultant, now in charge of the care, reinterpreted all the information and found the an- swer, unfortunately a recurrence of cancer, sometimes the cause of unex- plained fever.
Sometimes the patient self-refers to the wrong consultant. Then it is the consultant’s task to see that the patient gets to the right one or back to the primary doctor. When a 60-year-old woman saw an allergist to get skin tests for “asthma,” he realized that her wheezing was not from asthma but rather from congestive heart failure and arranged for her internist to see her im- mediately.
For some patients, the mechanism of referral requires extra sensitivity.
Referral to a mental health professional, for instance, often carries a stigma that can be overcome by the referring physician: “Just as I would call a sur- geon if you had appendicitis because I don’t have surgical skills, now I’m suggesting that I arrange for psychiatric consultation for similar reasons. I want you to be in the best hands possible, so that you can get better as quickly as possible. And during this time, I will continue to stay involved.” A referral to an oncologist carries different burdens, for one is placing a pa- tient with a life-threatening illness in another’s hands.
The lessons from these examples apply to almost every consultation: the need for one physician to oversee and coordinate the care, the reassurance that the doctor will not abandon the patient, an adequate explanation for the referral, and the reassurance that the consultation will provide more, not less, than the patient is already getting. Even the expert consultant is not always right.
Patients and families are part of the collaboration process. I learned from a patient with breast cancer, “Cancer follows certain patterns, but its spe- cifics are your own adventure.” My 90-year-old friend and patient wisely declared, “I am the professor of myself.” The patient’s story provides the clues to diagnosis, and once a tentative diagnosis is made, further discus-sion with the patient helps to validate or refine the diagnosis. I will often say to a patient, “You’ve been ill for several months now. Surely you must have thought about what might be wrong with you.” That conversation of- ten flushes out more details. Patients and their families know the unique ways a disease behaves for them.
The “textbook” description of an insulin reaction is sweating, rapid heartbeat, and hunger; so when my patient with diabetes seemed especially surly after his leg surgery, I did not give it a second thought and said to his wife, “He seems to be behaving like his old self.” She disagreed: “He’s hav- ing an insulin reaction!” Her special knowledge of her husband prompted immediate treatment. Especially with diabetes, but also with other chronic illnesses, patients need to be their own consultant, because they need to make daily judgments. Part of our task as physicians is to reinforce that role as they address questions such as “If I’m going to be more active today, do I need to take less insulin? My toe looks red; do I need to see the doctor to check about infection?”
If not for dedicated family and friends, many patients would not survive. “Last summer my husband almost died [from knee surgery and a complicat- ing infection],” one of my patients told me, “and we nursed him back to health.” It is sometimes folly for a physician to tell a patient “You’ll be well in X days, weeks, or months” or “You have three months to live,” for people dif- fer and patients know their strengths and resources better than the doctor.
At the beginning of the course, I tell my students, “Though I want your papers to be your own work, I want you to get together with a class partner to talk it over before you begin to write. When you do this, you will clarify your ideas and identify gaps in your knowledge. You will recognize your prejudices and help each other to neutralize them. There is another reason to work with a partner: I want to emphasize to you that medicine is a collab- orative profession. By working with a partner, you will get handy with that process and begin to discover the qualities of a good consultant as you and your partner teach each other and hone your skills.”
In a class session on collaboration, we explore ways in which various clinical professionals work together and involve the patient and family. So- cial workers, public health nurses, and hospital chaplains help clarify and enlarge the story and the clinical history, identify the issues, and show how the relationship with the patients and their families can facilitate care. I encourage the students to review the case history before class and give some thought to the issues so that they can more fully participate in the dis-cussion. As in a real situation, planning a patient-centered conference ahead of time rather than doing it at a moment’s notice allows all of the participants the opportunity to organize their thoughts and questions and to focus more precisely.
One case we discussed was that of a 73-year-old man, whose dementia began subtly with slight memory difficulty and progressed over four years to confusion, loss of mobility, and incontinence. During that time, he had tests to check for treatable causes of his brain disorder and saw a neurolo- gist. His internist shepherded him and his wife through this illness and ulti- mate admission to a nursing home, where he died.
During the class, the physician, social worker, nurse, chaplain, and the patient’s widow had a conversation. We asked questions of each other, filled in the blanks of the history, got a further sense of the patient’s and his wife’s experience, and discovered where the care might have run amok. We defined the issues: What is the diagnosis? Is it treatable? What is the natural history of the illness? Where are the uncertainties? How are they coping with the illness? What are the implications regarding nursing home care? What are the losses? We considered the impact of his illness on the patient and his family, the need to provide care for both, the importance of address- ing the psychological and social issues in his illness, and ways in which the patient, the family, the physicians, and other professionals could collabo- rate. We explored what we could learn from this story that has application to other patients and their illnesses.
We learned that separation, relief, guilt, and financial cost are among a family’s concerns; that losses include independence, companionship, emo- tional support, and dignity; and that patients and their families fear a long illness that is “out of our control,” with invasive tubes and other uncom- fortable treatments. We learned the danger of making invalid assumptions, the need to respect the patient’s right to take some risks, the importance of providing a safe environment for people to express themselves, and the need for someone to oversee the overall care.
We discovered that complex family relationships and conflicts become more evident at such moments. In this case, a son who lived out of town and a daughter who lived nearby had different views on how to proceed. “Ethical dilemmas pit the good guys against the good guys,” an experienced hospice nurse once taught the class. When struggles surface about what to do next, how to begin to solve a seemingly unsolvable ethical dilemma, it is usually safe, until proved otherwise, to assume that everyone’s intentions are good.
Finally we asked not only, “What’s this like for the patient and the pa-tient’s family,” but also, “What’s this like for the physician, the social
worker, the nurse, the chaplain, and all others who participate in the pa- tient’s care? What can we learn from each other?” We learned that the pro- fessionals shared insights about care, validated and critiqued each others’ conclusions, experienced loss, and supported each other.
GENU INE COLLABORATION
Care often involves a complex collaboration among many professionals. When we collaborate—genuinely collaborate—we enhance our ability to serve our patients, streamline care, and generate ongoing opportunities to learn and enhance trust.5 Absence of collaboration can adversely influence outcome or delay recovery as much as incorrect diagnosis or inappropriate treatment can.
We can learn a great deal from the following two contrasting stories, chosen because they involve collaboration among various health profes- sionals rather than solely among physicians.
Case 1: A Story with No Collaboration
A 72-year-old widow had diabetes, hypertension, and a seizure disorder for sev- eral years. On a day when her blood sugar concentration was very high, she fainted. Her physician concluded that neither her previously diagnosed seizure disorder and hypertension nor the drugs she was taking caused the collapse. He increased the dose of her diabetes pills, and she had no recurrence.
Though she had had diabetes for many years, she had no obvious complications of it. Her vision, kidney function, and circulation were good. She was not de- pressed, and her memory was sound. She had moved to an apartment after her hus- band’s death several years previously, lived alone in a small apartment, spent time with friends, and occupied herself with various activities outside her home. Her children lived nearby and looked in on her frequently.
Her blood sugar concentration remained elevated, though she did not feel ill. Nevertheless, her physician decided that her diabetes was inadequately controlled on oral medicine and that she needed to take insulin injections. He felt that she had neither the dexterity nor the intellectual capacity to administer her own in- jections and recommended that she move to a nursing home. The visiting nurse endorsed that view and, when the patient declined, threatened to “report her to the county adult protection agency.” When her daughter made an initial inquiry at nursing home about fees, she was told that they “would have to pay $3,000 up front.”
Given the choice between “better control of her diabetes” in a nursing home and independent living, the patient chose to remain at home. Dissatisfied with her physician, her nurse, and “the system,” she sought an opinion from another doctor.
Her physician had identified all her medical problems and he had care- fully addressed the potential causes of her episode of collapse. The nurse had visited her periodically to assess the efficacy of her treatment. The nursing home social worker had provided information to the patient and her daughter when they inquired about the process of nursing home admis- sion. But when each of them was called upon to help the patient and her family make a complex decision about her care and living arrangements, they failed. They neither worked together nor talked it over with each other. They failed to involve the patient and her family in examining the alternatives. They provided information without context. They assessed the medical and technical issues but neglected the patient’s resources, val- ues, and preference for independent living. She dismissed them all!
Case 2: A Story with Genuine Collaboration
A 73-year-old man with long-standing diabetes was referred to the social worker by his home care nurse. He had become almost completely blind in the pre- vious eight months, had poor leg circulation, a foot ulcer, hypertension, partial pa- ralysis from a stroke, and was depressed. When the nurse became concerned about his ability to manage independently at home, she discussed his problems with the social worker and arranged a joint meeting with the patient, the nurse, the social worker, and the patient’s son and daughter-in-law, also a nurse.
During this meeting, they discussed home care options and addressed his ongo- ing needs. All agreed to avoid the patient’s moving from home for as long as possi- ble, and they explored ways to accomplish this goal: a live-in companion who would do household tasks in exchange for room and board, a homemaker to assist in daytime needs when the person sharing the home was away, and a volunteer vis- itor through the neighborhood “Block Nurse” program. They agreed on referrals to the Society for the Blind for assistance in training for use of his kitchen, to a physi- cal therapist to give home instruction on the use of a lightweight walker, to an oc- cupational therapist who arranged for bathroom safety apparatus, and to a psychologist to help him deal with his depression.
With the concurrence of this physician, all of these suggestions were imple- mented. With each referral to and conversation with another agency or resource, the social worker provided context to each new participant in the patient’s care: not only the list of his medical problems but also his story and special needs. Throughout his care, the social worker and the nurse provided emotional support to the patient and his family and coordinated all the services provided. Once, when he became weak and unsteady, the nurse questioned whether his blood pres- sure medicine was the cause and she called his physician, who decreased the dose; the patient’s symptoms improved.
From the beginning, the patient and his family were involved in defin- ing the issues, exploring solutions, and making decisions. The patient’s val- ues were immediately identified and integrated into his plan of care. All of the involved professionals knew the patient’s whole story, not simply that of his illness. There was ease of communication among the professionals. By sharing information, they facilitated important technical deci- sions—the decision about his blood pressure medication, for instance.
Each of these two stories asked the questions, “What’s best for the pa-tient?” and “Where should the patient live?” But the processes differed. One worked, the other did not, and the outcomes were different also. What do we learn from these stories? What is the difference in the approaches? And what can we learn about genuine collaboration?
In genuine collaboration, all those who need to be involved are consulted.
Though the means of inquiry, data gathering, and testing may differ among the professions, each operates from the same story about the patient and has similar goals. The goals are negotiable; where conflict exists between professionals or between a professional and the patient, those conflicts are recognized and clarified, for they often represent disparate or incomplete versions of the same story.
In genuine collaboration, the patient and the family—sometimes the forgotten partners in collaboration—take part in the decisions. Ultimately, unless the pa- tient is incompetent, she has the final approval. The patient and family may have insights about the cause and unique behavior of the illness, prior treatment attempts, what helped, what did not, and what made things worse. These observations help to streamline care and prevent catastrophe.
In genuine collaboration, there are ongoing critical review and oversight. As the story evolves, the character of the illness and the needs and the re- sources may change, and so the goals may need to be altered. In any com- plex system of care, the process may falter, but each participant knows that it can be fixed by talking it over. Genuine collaboration allows everyone the opportunity to validate their information and their approach to prob- lems, and to alter the plan of care as often as necessary.
In genuine collaboration, one person is in charge. Otherwise, no one is in charge, or someone takes charge who may be the inappropriate person, or the patient and the family have to take charge by default, even though they may prefer not to. Such occurrences increase the risk for failure.
In genuine collaboration, no artificial boundaries exist between the profes-sions; each has equal worth. The physician recognizes that some problems re- quire neither tests nor physical remedies but rather attention to psychological or social issues. Others recognize the need for a physician’s expertise. The professionals involved are at ease speaking with each other,
sharing insights about the patient’s care, and drawing from each others’ ex- pertise. They are part of an alliance, with each other and with the patient and his family. It is a comfortable alliance built on mutual trust. Often enough, the medical issues are but a few of the overall issues.
Genuine collaboration is liberating. From time to time, each professional is faced with tasks that exceed her skills. Tackling them alone is inefficient and unsatisfying. Calling upon others speeds up the process and allows each to concentrate on what she does best.
Genuine collaboration takes time. Attending to the whole story of the pa- tient’s illness and the psychological and social context in which it occurs, reflecting on the meaning of the information, identifying, clarifying, and validating the issues among all the participants, evolving a strategy for care and altering it when appropriate take time. But in the end, it is far more ef- ficient than not collaborating, because all of the collaborating partners do their jobs with special skill.
Genuine collaboration allows the patient to develop trust in the system. Trust is reciprocal. When we trust and respect patients for their observations and personal values, they can trust those upon whose expertise they rely.
Genuine collaboration gives everyone an ongoing opportunity to learn. From other professionals, we learn better ways to explore the patient’s story, to identify the issues, and to enlarge our knowledge of resources. We learn what works and what does not. By sharing our observations and inferences with others, we correct each others’ misperceptions.
We also learn from our patients. This patient taught me a valuable lesson.
After her fifth hospitalization for congestive heart failure, each of which re- quired the help of a consulting cardiologist and the use of a complex combination of medicines and electrical cardioversion, an 80-year-old patient thanked me with the statement of praise: “You’ve done it again!” I protested. “But Miss Baker, it was- n’t me; it was the cardiologist.”6 With a smile she replied, “Know your resources.”
“Know your resources” is a multidimensional lesson. We must recognize that the patient, the family, and the community can be prime resources. We must know when the needs exceed our own skills and resources, when col- laboration is necessary, and where to turn. We must know not only the in- stitutional resources, but the people within them and how they work. Can we trust their perceptions and assessments? Are they thoughtful, or do they jump to conclusions? Are they consistent in their approaches? Do they ask, “What can I learn from this patient and from others with whom I work?” Do they genuinely collaborate? Such collaborative relationships are worth fostering. We must know what questions to ask and be able to formulate the questions clearly, and the person on either end of the consultation must know when to expand the inquiry.
“Know your resources” means “know your limitations”; but it also means “appreciate yourself as a resource.” Often we can do more than we realize, just by thinking it over. Then we become our own consultant.