Planned comanagement essential for treating subspecialty disorders

August 2005

To treat children with both common, uncomplicated and complex subspecialty disorders, a team of generalists and specialists is needed.

“Planned comanagement is essential, because patients are complex. We need teams that can provide timely care. This decreases headaches on the part of everyone, and it decreases the emergency consults that occur when things go really wrong,” said Christopher J. Stille, MD, at the 2005 Annual Meeting of the Pediatric Academic Societies, held in Washington.

To illustrate his point, Stille, from the division of general pediatrics at the University of Massachusetts Medical School in Worcester, Mass., discussed elements of a case from his own practice, in which his patient has an eight-member team.

Complex case

Stille described a male adolescent with spastic quadriplegia, profound mental retardation and a seizure disorder. His mother is single, and he is an only child. He has had issues with malnutrition and osteopenia, which have resulted in a nontraumatic femur fracture. Additionally, he has severe scoliosis and recently had an episode of pneumonia that placed him in the ICU for two weeks. After his recovery, he presented for a follow-up visit.

The adolescent has a primary care physician and four specialists — an orthopedist, a surgeon, a gastroenterologist and a pulmonologist. The last time he saw the orthopedist was a year ago. He sees the surgeon intermittently as needed. The gastroenterologist saw the adolescent while he was hospitalized with pneumonia – the first time in over a year. A pulmonologist recently became involved in his care because of his severe pneumonia.

His team also includes others, such as his home care nurse and his school nurse. “His mother is probably the most important person on the team. She speaks primarily Spanish, which has led to some gaps in communication from time to time. The adolescent’s current issue when he comes to see me is how to prevent future episodes of severe pneumonia, and I’m at a bit of a loss,” Stille said.

He asked the audience at his presentation to consider the following questions:

• Will medical and nonsurgical interventions be sufficient?
• Does he need a spinal fusion?
• If yes, does he need it now or later?
• He needs better nutrition, but how much better?
• How can better nutrition be achieved?

To determine the answers to these questions, Stille said, the specialists met. Then, a few of the specialists met with Stille and the adolescent’s mother on a nonurgent basis.

While the subspecialists concentrated on their areas of expertise, the generalist provided basic care and served as both a language interpreter and a medical interpreter. The generalist is the first-line contact for problems, Stille said. Additionally, a bilingual care coordinator and/or excellent interpreter services are needed, because his mother needs to be empowered to make her wishes and priorities known.

Creating a team

Communication is the key to an effective team, because poor communication can lead to fragment of care. It can result in too many or too few services being given to families, and a study in 1999 by Charles J. Homer, MD, et al. showed that poor communication between physicians and parents was the number one contributor to parent dissatisfaction.

In that survey of 4,724 parents, parents most often noted problems related to hospital discharge planning. They reported fewer problems concerning communication about surgery or transmission of information to children. In that study, Homer and colleagues noted “problems in communication between clinicians and parents correlated most strongly with overall quality ratings by parents (r = 0.59). Parents’ specific reports of problems with care accounted for 42% of the variation in their overall assessments of the inpatient care experience.”

In 2001 Stille and his colleagues conducted a survey about communication, asking physicians how frequently they receive information from other physicians. The choices were 0% to 20% of the time, 21% to 40%, 41% to 60%, 61% to 80% and 81% to 100%. Any answer over 60% was defined as frequent. They found that more primary care than specialty physicians perceived a problem with communication. Only a small number of specialists replied that they received information more than 60% of the time, while a larger number of primary care physicians reported that they received information more than 60% of the time. The biggest problem the specialists perceived was the lack of a good system. “Interestingly, on the other hand, when asked about frequent receipt of information, fewer specialists than primary care physicians reported receiving any information, even though primary care physicians reported that it was more of a problem,” he said.

It is important to note that while most physicians have access to e-mail, not all of them use it frequently. The survey found that specialists use it more than generalists. “If you are in a coordinated system, it is much easier to use e-mail. However, current logistical barriers prevent e-mail from being transmitted effectively and securely between primary care physicians and specialists,” he said.

In an ongoing study, parents reported they feel as though they should take an active role in their child’s care, but few families felt they should be the primary link between generalists and specialists. The team needs to include the family. “There needs to be a team leader,” he said. There also needs to be very clear division of responsibility between general pediatricians and subspecialists. “One of the most important functions of the generalist is to negotiate a happy medium when opinions are different between general pediatricians and the various subspecialists. The family needs to get a clear message,” he said.

In addition, specialists indicated that they want to receive explicit questions from the primary care physician. If specialists see a child without receiving specific questions, they may not answer all of the primary care physician’s questions. “A little bit of content is better than none at all, so even just a brief note can help with the sharing of information,” Stille said.

A tight web of consultants

When forming a good team, it is important for all team members to know each other well. Stille said that a tight web of consultants is important. All team members need to exchange more than just their office phone numbers. They should also exchange their backline numbers and fax numbers. Also, team members should discuss the best times and ways to make contact.

“People need to know who else is on the team, and roles need to be defined. Specialists need to not be afraid to ask generalists to assist them. As far as training goes, I think as early as selection for medical school, we need to select and train people to be collaborative. Doing well on your MCATs or in organic chemistry does not necessarily make you a collaborative person,” he said.

Team size can also be an issue. The adolescent patient has several team members, which creates several lines of communication. If the generalist is going to be the hub of the team, he needs to be available. “We need to serve the mediator function. General pediatricians have more training in patient and family issues and developmental aspects, which may be sometimes lost with some specialists. However, the care coordinator at our clinic is a specialist who has some social work training. She’s available frequently when I’m not, and she can spend more time with the patient than I can during a typical visit. She arranges meetings and phone calls,” he said.

There are many variations of successful teams, but it is clear that both generalists and specialists are needed.

For more information:

• Stille CJ. Creating a generalist-specialist team. Presented at the 2005 Annual Meeting of the Pediatric Academic Societies. May 14-17, 2005. Washington.
• Stille CJ, Primack WA, Savageau JA Generalist-subspecialist communication for children with chronic conditions: a regional physician survey. Pediatrics. 2003;112(6):1314-1320.
• Homer CJ, Marino B, Cleary PD, et al.B. Quality of care at a children’s hospital: the parent’s perspective. Arch Pediatr Adolesc Med. 1999;153(11):1123-1129.