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The Clinical Team

Each person must stay personal, and all persons must communicate personally.
(Formulated or conventional protocols of behavior [fulfilling the minimal requirements of the job description] cannot substitute for dynamic understanding of the patient’s unique problems, responsible sharing of information among the team and responsive communication with the patient by the team as a whole.)

Clinical phenomena occur only among and within persons, do not include institutions, agencies or corporations but are affected by them.  The intrapersonal and the interpersonal are where it’s at for the patient, therefore for the clinician and for the team of clinicians.  The patient experiences disease not only within his or her body but within her or his life and human context.

Any abstraction into terms of pathology, biochemistry, pharmacology and so forth is perhaps deep and intricate, brilliant and admirable, but nonetheless it is an distancing away from the personal; it may be a useful tool only when brought back to the patient and delivered effectively.

To deliver the goods to the patient is not accomplished by oration of medical lectures in incomprehensible polysyllables, nor mumbled incantations of diagnostic labels while grasping the door-handle of the consulting room on the way out.  To deliver the goods to the patient is not to flash a computer printout of laboratory data, nor even to scrawl a prescription, authoritatively tear it from the pad and hand it across the void.

I cannot get an image of clinical activity and interaction from any technical textbook, for in textbooks we attend to abstractions rather than to realities.  I cannot get an image of clinical reality from any accounting records, insurance code catalogues of diagnoses or procedures, nor from research articles; only, perhaps from case discussions.  I cannot get an image of what happens to persons in clinical settings from intricate protocols or decision trees.  “Don’t confuse me with the facts; I care only for the truth.” 

In previous chapters I have tried to conceive of the clinical relationship as if it were between two parties only, the patient and the clinician; but my oversimplified conception on the flat blackboard seems not very closely to resemble what I see in real life--in the clinic, the emergency department, the intensive care unit.  Why are those appearances discrepant?  I should be able to bring them into focus all together.  If you bear with me I shall here try.

It has not been easy for me to communicate effectively with patients over the past four decades.  Oh, I have tried often, and as you see I have thought hard about the obstacles and how to overcome them.  My open communication with patients has helped me never yet to have been sued by anyone (though some must have been sorely tempted).  I usually have been able to make contact with the person as patient by attending to the predicament by which she or he seems confronted; zooming out a bit I see that person’s life-history and current human context, and zooming back in again I look to practical alternatives at the present moment.

My batting average or yours with such simple methods may be good, but what happens when others get involved, even other good and seasoned professionals?  How can there be harmony when there are several clinicians?  (By “clinician” I mean all the persons who attend a patient as if at the bedside, or upon whom that patient depends as a “client,” even if that relationship is from a clerical cubicle at great distance, processing the medical bill.)

I write today taking time off from the largest corporation in the universe in health care which no longer will buy back at a discount my “paid time off”.  Otherwise I fear I would always be a workaholic1 at the clinic.  Instead the corporation makes me “use it or lose it” during this contract year, the end of which is upon me.  So I am in my sister’s guest room, a mere visiting workaholic (she herself the resident one).  Ironically, at this very hour an orthopedist is “scrubbing in” to re-operate on the left knee of a nice man who fell on a construction job just more than three years ago injuring his right shoulder and left knee especially severely, but also his neck and back.  His right shoulder surgery was over two years ago, went well enough although post-surgical physical therapy rehabilitation was rather lengthy and painful.  The left knee surgery which required a prosthetic joint replacement was delayed by more than a year by insurance company arguments that since there was evidence of previous left knee surgery they should not pay for the artificial joint.  The patient’s symptoms of depression intensified, driven by the frustration of the delay of surgery and years not only of pain but of unemployment and inactivity, desperate fear of loss of resources for home and food.  Psychologic therapy and antidepressant medication had to be added.  Concerted consistent reiteration by the neutral physicians and the partisan attorney for the plaintiff resulted in the eventual authorization of the placement of the knee prosthesis.  Knee pain and swelling have persisted several more months despite extended post-surgical physical therapy (a total of ninety-nine sessions for both knee and shoulder now; I have been reluctant to extend it to a hundred, especially as I am not sure further therapy produces progress for the patient).  His attorney, through the nurse case manager representing the insurer, arranged a consultation with a second knee specialist orthopedist without consulting me (the primary physician for the injury) or the orthopedist who had done the knee prosthesis originally.  Radiographic images and laboratory tests were not convincing (“pathognomonic”) for infection (which would have necessitated urgent surgery), yet suspicion remained that the prosthesis was unstable, the metal shaft not solidly anchored into the bone.  I stalled a scheduled second surgery on the knee when notified by fax to send the data of the pre-operative examination for the already-scheduled second surgery to the office of the second surgeon who had failed to communicate with me or with the first surgeon.  I had assumed erroneously that the referral had been made by the first knee orthopedist rather than through the attorney (who thought he was doing a favor for the patient and for the second surgeon by initiating the referral).  By the time I was calling him to clarify the communications he was out of the country, and his office staff couldn’t or wouldn’t get him on the phone to me.  The first surgeon was also out of the country (perhaps at the same conference, but they did not know to talk with each other for the patient’s sake), so repairing communications had to wait for their return.  Meanwhile the patient was in doubt and fear about the scheduled surgery which I spent much time and energy assuring him I myself had delayed hoping resolution of these multiple layers of confusion would help rather than harm him.  Subsequently he saw the first surgeon again who denied the prosthesis could be loose and accused the patient of trying to delay recovery for the sake of disability payments (“secondary gain”), which plummeted the patient into further depression and fear for the ultimate integrity of his body or future functioning.  With some effort the psychologist and I propped up the fragile ego enough to have us all (including the patient) looking forward to some benefit from today’s procedure.  My arbitrary limit of one hundred physical therapy sessions will have disappeared like mist in morning sunlight, for further rehabilitation will be necessary.

The clinical team is the interacting human matrix which relates to the afflicted patient personally.  The individuals in the team must be related to each other personally (though not always directly) for the sake of that real patient.  When there is failure of relation or communication among the clinical team there will be failure of relation and communication with the patient.

We need not concern ourselves for long with the hierarchical structure of the clinical team.  This is not a question of the sociologic phenomena of cooperation among various individual professionals.  No order can come merely from following orders.  There is no longer any overarching authority anyhow, like the attending physician used to be.  Ours today is rather a task of considering how each clinician can relate to each real patient as worthy and unique, then to transcend mere individual coherence or ethics to allow authentic aggregate action in relation to that real patient.

At one time there seemed a pyramid of authority whose pinnacle was the Doctor whose orders dictated all diagnostic and therapeutic maneuvers, all expenditures of attention and resources.  That was a picture in which the understanding of the natural history of the disease related to the unique life-history and physiology of this patient.  Comprehension of the techniques of diagnosis and treatment was expressed in the physician’s formulation of the case and orderly recommendations for action (in other words, the true problem and the true solution had their reality between the ears of the physician). 

The laws of the various States still reflect that set of assumptions, although that authority of the physician has long since been upended.  The laws still hold the licensed professional responsible for the methods and outcomes of diagnosis and treatment, yet the physician today has no such control (nor probably ever did, for the ‘tin-god” picture of the physician was always a false mirage).

Since the unannounced “pivotal moment” or “sea change” around and after 1965 the history of American medicine has shifted from the professional authority of the physician to the regulatory authority of the new powers:  government bureaucracy and insurance management.  Laws holding the physician responsible for what he or she cannot control have not been changed because we have not yet developed concepts of responsibility for politicians, regulators and managers in relation to methods and outcomes in individual cases of diagnosis and treatment (nor, despite the patent equity of such a change, will it ever come to be, for it is they who have power, and the emperor will always be held blameless even when buck naked).  The real enterprise of medicine shifted from out of the control of white male doctors who needed to make their Mercedes payments to the powers of big business and government executives who simply must make their Lexus payments.

We don’t have to be concerned about these seemingly important historic changes, for as clinicians we have outgrown such change and are back to caring for real patients.  Health care was never truly done by the bare-fisted individual clinician, nor will it ever be done by the complex “health care system.”  The clinical team can function in the context of a system if it can depend on the professional skills and ethics of each of its real individual members.  But the clinical team and system we need to understand in our studies today is made real only in relation to each real patient.  The patient is the catalyst by which these endeavors can become crystallized, the clinical “touchstone of reality.”

There is nothing new here:  Hippocrates’ First Aphorism shows his comprehension of this basic truth (see “The Clinical Relationship in Occupational Medicine”):  Life is short, the art intricate, experiment slippery, decision hard to come by.  The physician must be ready not only herself (or himself) to do what must be done, but also to engage the patient or any outsider--even third parties (translation and emphasis mine).  The physician must indeed be ready to do what must be done, but in our current context little can be done by any clinician alone.  Certainly the physician must engage the patient, and anybody else who belongs to the project.  That is what I mean by “the clinical team,” the interacting human matrix which relates to the afflicted patient personally.

I’m afraid the alternative orientations don’t stand up well or long.  If it were for the sake of the physician that the team of persons be motivated, the Mercedes payment might be met but little else.  If it were for the sake of any individual other than the patient, similar frustration of purpose will prevail.  If it were for the sake of the team itself, or the corporation that owns that team, moral and practical failure eventually ensue (earlier rather than later).  As discussed in “Third Parties in the Clinical Relationship,” the interests of all parties (other than attorneys) are promoted only by the health of the patient.  And notice, it is not the patient’s demands but the patient’s real healthy needs which are to be served, for the patient cannot reliably judge or act alone.

So, let us look for the real clinical team, trees hidden in the forest.  Whom does the patient’s health depend on to understand and to act in harmony with a complex aggregate of others?  Who are members of this symphony orchestra, who the supporters whose cooperation is essential to the success of the performance even though we do not identify them as musicians per se?  Who is the conductor (perhaps no longer the physician simply)?  Who is the composer?  Are you willing to be the audience should we ever get into and out of rehearsal?

Old assumptions do us little good, perhaps indeed blind us.  Let’s make an approximate sketch of a patient’s experience: 

I do not meet the doctor first or even early, nor do I necessarily ever meet the licensed clinician under whose name and number my care is billed.  I talk to someone on the phone or meet someone at a counter which serves as a barrier between the publicly accessible waiting room and the inner restricted areas of the office, clinic, emergency room or institution where I seek care.  I may wait weeks or longer to be seen.  I spend an hour more or less filling in questionnaires.  I may have to go home for my glasses or for documents like birth certificates or Medicaid cards.  My eligibility is confirmed, either as an insured or as a documented pauper, or I may be turned away.  They receive my co-payment, I receive a receipt.  When I have been cleared, documented and marked paid, someone may call me back to screen me, to have me answer a few questions about what brought me here, to check my blood pressure and temperature.  Then I wait alone.  Someone comes eventually, asks something, does something, then I am rushed out with some papers (a referral, a prescription, a return appointment).  Usually I get at best partial satisfaction, for no one seems to want my whole set of questions and concerns, including me, for I have usually forgotten something I had intended as essential.  I may live.

Many professionals from clerks to technicians to nurses may see me, and very many professionals behind the scenes whom I shall never meet and who never shall meet me.  How are they to attend to what are my problems, needs and solutions if I mean nothing to them?  That is why it is essential that every one of the clinical personnel pay personal attention to the patient.

1. In a large public clinic I often was behind schedule seeing patients.  My most reliable clinical colleague was the sweet benignly smiling janitor, a sufferer of Down syndrome (he was retarded), who often pushed a broom across the waiting area, greeting patients, asking after their families, chatting sweetly.  When the administration considered letting him go to cut costs I protested that he was essential to my clinical work of diagnosis and treatment.  They were unimpressed, fired the man, and no doubt thought me worse than merely daft, for none of the other physicians seconded my protest or advice.

2. At a large intensely busy women’s prison a severely chronically afflicted woman is again at risk of dying from what is briefly summarized as chronic alcoholism and addiction, esophageal varices and stenosis, anemia from hematemesis, anorexia nervosa, with resultant cachexia and generalized debility (weight about seventy pounds).  The bureaucratic Department of Corrections is prodded to seek effective treatment by the always looming threat of negative publicity and expensive legal action should this prisoner die in their custody.  The whole clinical staff attends to her, but especially one nurse practitioner who cares for her directly in the prison clinic, the hospital and in her cell in the high-security unit.  This clinician has known her the longest through a chain of several prison sentences, refuses to allow her to self-destruct just because her condition looks hopeless (and has looked that way throughout her existence).  The nurse practitioner carefully and patiently knits together consultations and conferences to clarify that the only way to save her life is to operate on her esophagus, but the only way for her to survive the operation is to be nourished to a higher level of physiologic stability, but the only way to do that (since she cannot swallow and refuses to eat or drink) is with “total parenteral nutrition” (intravenous feedings cautiously accomplished over many weeks, which will require the patient’s full cooperation, and protection from the interference of other prisoners).  The nurse practitioner energetically engages the cooperation and participation of the fourteen professionals most closely associated with this prisoner’s care (clinical staff, social service staff, security staff, psychological service staff, administrative staff).  Most delicate is her engagement of the patient in the conference, for none of the proposed steps of treatment can proceed without her full formal consent and cooperation.  Even though it was difficult for those fourteen overworked professionals to be away from their other responsibilities for so long, each sat patiently for the two-hour conference.  Even more difficult and tenuous was this ordeal for the physically, mentally and psychologically severely limited patient.  It was so difficult for her to trust this overwhelming committee of those who kept her imprisoned that she had to insist on leaving the room or returning to her cell three separate times during the two hours, but was brave enough each time to return.  She finally agreed to the proposals for her treatment, after the most touching and prolonged show of care and patience I have ever witnessed be offered to anyone, much less a prisoner who had been deprived of any recognizable care throughout her own life, utterly unable to care for any of the several children she had born, who had spent absolutely all her energy defiantly refusing to be controlled  by men who exploited her or authorities who punished her (even though that unheroic defiance cost her health, and undoubtedly her life itself).  I am thankful to have been included there that day, a blessing for me.  I hope she had some comfort from it after all.

I cannot strongly enough emphasize how important are the smiles, the kind words and the unconditional acceptance manifest by those of us who serve in clinical settings.  (Except grumpy old doctors who are hardly to be tolerated.)

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1 A “workaholic” is one who is constantly so busy he renders others dizzy.  He must produce thick clouds of dust to hide the reality that he never finishes any task really, for like me he may redo each thing to powder (hence the cloud of dust).  Some say, “If you want to get something done give it to a busy man.”  That is bloody erroneous, for the busy man is never finished working.  If you want it done, take it to the man at leisure, the one who has accomplished all his tasks for the nonce.  Perhaps he is fly-fishing.  You may approach him quietly, but he is likely sanely to shoo you away:  “Beat it!  You’ll scare the fish.”

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