Creating a Health Team

When one affliction strikes, others may be lurking that require the attention of a second,
or third, health practitioner. The tough part is getting your team to talk to each other.
Here’s how one patient wound her way through this healthcare maze.

By Eric Schneider

February 2009


Aliza Sherman, an Internet consultant, had to learn to navigate a different kind of daunting web—the US healthcare system—when she faced miscarriage, postpartum depression, perimenopausal symptoms and other medical issues. A patient of both conventional and holistic practitioners, Sherman had to deal with an avalanche of medical particulars and sometimes-conflicting suggestions for treatment.

Like millions of other Americans with persistent medical problems, the 44-year-old Anchorage, Alaska resident found that, despite how painstakingly her health team was assembled through referrals, communication between these practitioners was rare. “I have found it to be a struggle to coordinate my conventional doctors and holistic practitioners. For the most part, my holistic practitioners are very open to communication, but their calls are not always received well, or answered, by my conventional practitioners,” Sherman says. (To find out who’s who in the complementary healthcare world, see the chart on page 8.)

Though Sherman found her holistic specialists were more receptive to open communication lines between fields, communication between practitioners also is not common within the holistic field. Indeed, holistic practitioners often merely “tolerate each other’s approach,” observes Ashley Lewin, ND, a naturopathic physician based in Riverhead, New York.

“It’s like this within the conventional medicine circles, too,” Lewin says. “If I’m a general practitioner, and I have a woman who has five or six medical issues, what am I going to do? I’m going to refer her to an endocrinologist, a gastroenterologist, a psychologist and others, but none of those people get together and talk. There is no approach that takes the human being sitting in front of you in their entirety.”

Getting the Most from
Your Health Practitioner

Tough creating a health team?

You can still help ensure that you are making the most of your one-on-one relationship with your doctor, whether from the worlds of conventional or complementary medicine.

Aliza Sherman has a few simple criteria for staying with her healthcare practitioners.

Topping the list is trust, but she also wants to feel a sense of mutual respect. That means her healthcare practitioners need to at least seriously consider the information she brings them that is culled from her personal research.

By Sherman’s standards, those practitioners are willing to think differently and not get stuck in one pattern.

Sherman is also looking for a degree of mettle in her healthcare practitioners. “Could they take it when I was blunt and honest, and not get offended?” she says. Conversely, she also wants her doctors to be blunt.

Researchers at the University of North Carolina at Chapel Hill School of Medicine have found that patients, or their advocates, who talk to their doctors about their values, lifestyle and concerns get better results.

In their defense, doctors are not mind readers, says Michael Pignone, MD, chief of the UNC division of general internal medicine.

Simply preparing for your medical visit by writing down your symptoms, complaints or problems, then summarizing in a couple of sentences, can make a trip to the doctor
25% to 50% more effective, Pignone says.

Have an agenda for your visit; if you have back pain, for instance, you might want to know the cause and possible treatments. Also know your medical history and medications, Pignone adds, to help avoid conflicts with other treatments.

Share your lifestyle preferences so there’s no conflict in that arena, either. Finally, ask
for clarification if needed.—E.S.

Splintered System
Nancy Taylor, executive director of the Council
of Accountable Physi­cian Practices
(www.amga-capp.org) in Oakland, California, a group seeking to create a more responsible healthcare system, says the country’s extreme medical costs are rooted in the fragmented, inefficient nature of the existing approach. “Most physicians practicing in this country still provide care in solo or small and unorganized practices without information systems or protocols for care,” Taylor says.

The information systems that Taylor is referring to include electronic medical records and computerized billing, scheduling and lab results reporting. She says care is improved when a practitioner’s office can easily communicate lab results and follow-up needs with other care providers and with patients. “Care protocols” are the guidelines that practitioners use. Having protocols available at their fingertips in a health IT system means that doctors can see the latest guidelines and make sure they have reviewed all possible solutions.

Given the splintered nature of the healthcare community, it is no surprise that communication is often strained or nonexistent, particularly between alternative and traditional medical practitioners. Sherman says her conventional doctor, citing a need for scientific backing, can be “pretty dismissive” of herbal and homeopathic treatments. “I respect that opinion,” she says, “but it doesn’t always resonate with me.”

Such a dismissive attitude can lead to discomforting communication gaps. “One time, my nurse practitioner failed to call back my acupuncturist at a critical juncture of my care for postpartum depression,” Sherman recalls. “While she claimed that she ‘never got a call,’ both my acupuncturist and I had felt she was resistant to working together.”

Since communication and cooperation between practitioners can miss the target, the responsibility of keeping track of each specialist and their corresponding suggestions falls to the patient. Sherman advises diligence in taking notes and relaying information to each practitioner “to ensure there are no dangerous conflicts between treatments. One of my symptoms of perimenopause is severe memory loss, and if I fail to take good notes, I become very confused by the process.”

Lewin faults the system and years of ingrained habits. She puts less blame at the feet of doctors. “Your medical doctor is not going to tell you certain things, not because they are bad,” she says. “These are very intelligent and, most of them, very well-meaning people, but the model that they’re coming from is the thing that’s broken.”

Learning to Adapt
Within this existing structure, however damaged, there are means of coping, though they are frequently inconvenient for the patient. Sherman says she has learned to compensate for this less-than-ideal system “by making the rounds to all my practitioners and cobbling together their advice into something that makes sense to me.”

The approach takes time and effort, but yields benefits. “I find when I only deal with one kind of practitioner, I can sometimes get tunnel vision with my treatments, but when I reach out to get another perspective, it can help me balance my views about my treatments,” Sherman says.

For example, one conventional physician put Sherman on progesterone, a female sex hormone, which “began wreaking havoc on my moods,” she says. Her ND believed she was taking too much and tapered the dose, eventually suggesting that Sherman stop the progesterone entirely—an opinion shared by her own general practitioner. “If I had stayed on the treatment without getting additional input, I would have been extremely sick and could have then been treated improperly to regulate my moods,” Sherman says.

The opinions of healthcare practitioners from the different fields can align. “My acupuncturist and my naturopath worked together to help me postpartum,” says Sherman. “In this case, my more conventional doctor acknowledged the holistic approach when I told her about it, and, while she did not participate, she didn’t dismiss it either.”

Sherman visits her general practitioner once every six months or so “to see if the new perspective can bring some clarity to a situation.” At one point, her holistic practitioners treated her for perimenopausal symptoms that included hair loss and erratic periods. After several therapies, Sherman visited her conventional doctor. “He asked me, ‘Why are you trying to fight a natural process? It seems like you are just banging your head against a wall. This is the aging process,’” she recalls. “That comment snapped me out of what had become a desperate attempt to ‘change’ the things that were changing about me. I was able to realize I needed to accept the aging process instead of trying to fight it.”

Teaming Up
Within conventional medicine, doctors are increasingly more open to working with each other. In the formal steps that have been taken towards team-based healthcare in the United States, traditional physicians are actually the primary doctors involved. Taylor, the advocacy group director, explains,

“There are large groups and physician practices, like those that CAPP represents, that do strive to achieve total care coordination for their patients, which includes working with teams and sharing information between providers.”

These teams generally do not include practitioners of alternative medicine. “There are many reasons for this,” Taylor says, “but two stand out: First, traditional physician groups rely on evidence-based medicine for their practice protocols, and many alternative remedies have not had the benefit and blessing of traditional research. Second, alternative medicine services are often not reimbursed by insurance companies.”

Among the exceptions are care management teams that incorporate nutritionists who work with diabetics, Taylor adds. And some medical groups coordinate care between primary care physicians and behavioral health practitioners or chiropractors. This kind of care coordination is generally done in larger medical groups and is gaining more recognition among researchers and policy makers.

Lewin has found a few examples of team-based clinics that operate under a holistic umbrella. “With the models in the country that actually work like this, you have a naturopath or somebody else as the gatekeeper in the clinic,” she says. “The patient comes and sees that practitioner. That practitioner is the overviewer. They say, ‘Okay, here are your set of problems. Now you have to work on your diet, etc. I’m going to talk to this practitioner, and this practitioner is going to work with you, but you’re going to be checking in with me every single week, and we’re going to make sure that you’re on the right track.’ Those are the clinics that work.”

One of the most prominent examples of team-based healthcare is Canada’s ANCHOR (A Novel Approach to Cardiovascular Health by Optimizing Risk Management, www.anchorproject.ca), a research project in Nova Scotia that aims to curtail the risk of heart disease and related ills in adults. ANCHOR has a multidisciplinary healthcare team consisting of a doctor, nurse, psychologist, dietitian, pharmacist and physiotherapist. This approach points to how Canadian healthcare differs from its US counterpart, particularly in how their system is often considered more accessible and user friendly.

Persistence Pays
The complexity, disconnect and inaccessibility of the current healthcare system are ultimately at the heart of why health teams have not gained more ground in the US. “I think most people are not in control of their health care,” says Sherman. “They blindly trust their health practitioner and never get another opinion. It can be very expensive—my health insurance does not cover naturopaths, so I have to save money to afford those visits.” Without the different opinions, though, Sherman says she could have found herself on the wrong track of treatment “to possibly devastating results.”

Sherman believes that many people are daunted by tracking—and, in some cases, even challenging—their practitioners’ suggestions. “I remember being terrified of questioning my doctors for a long time,” she says. “Since I found my voice as a patient, I have alienated several practitioners and angered many others who were not used to being questioned.” But Sherman persevered until she found practitioners “who respected my questions and answered them thoughtfully.”

In an ideal world, every patient would have access to a fully integrated healthcare team with both conventional and alternative practitioners. Until then, it’s up to each patient to create such a team on their own. “People need to remember that doctors work for them,” says Sherman. “The relationship must be mutually respectful. Until patients become more educated and empowered, we cannot make a positive change.”

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