Many trainees tell me they’re attracted to rheumatology because it demands becoming a complete physician. We need knowledge of the brain, eye, lung, kidney, liver, skin, bones and vascular system to be effective rheumatologists. And because our diseases are frequently multisystem diseases, rheumatologists must be the quintessential collaborators.
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For more than 30 years, I’ve directed a clinic for patients with ocular inflammation. Although I’m trained as a rheumatologist and have no formal training in ophthalmology, I’ve relied heavily on ophthalmologic colleagues to forge a collaboration that seems to work for patient care.
We live in an era of dysfunctional compromise. Look at Congress, which struggles to pass a budget and in which members of one party rarely side with their peers from the opposite party.
Unfortunately, sometimes it seems we as physicians don’t do much better than our politicians. Some of us feel powerless in a system that obstructs achieving our ideals. The electronic health record, prior authorization and the challenge to provide biologics to those who lack insurance remain among the obstacles that vie for our time and make it nearly impossible to find a window within the day to discuss patient welfare with another provider. Finding common ground with a doctor from another specialty isn’t always easy. Barriers include defining whose advice is the ultimate guide for patient choice; how we are compensated for the additional time involved; and the difficulty in avoiding making the patient feel like a ping-pong ball batted between two personalities strong enough to survive medical school and postdoctoral training.
I have three suggestions that may improve the way we communicate, compromise, complement and collaborate with doctors from other specialties. I hope they are practical. I should probably try to avoid giving advice about practice because I’ve never been in private practice. But you’re now reading the words of someone who has not let the lack of ophthalmology training deter him from offering advice about the eye.
First, be a good listener. Allow your colleagues to state their perspectives. Then reinforce that you’ve listened by paraphrasing what you heard. After those first two steps, you’re entitled to state your own opinion. And then you work to find a mutually satisfactory course.
I’ve formulated this approach by modifying advice I read in a paper called, “Addressing Physicians’ Impaired Communication Skills” by Barry Egener.1 I’m not aware of any medical school that teaches a class in collaboration, but my assumption is every business school offers some lectures on how to negotiate and compromise.
Second, find a colleague with whom to start an interdisciplinary clinic. Maybe spend a half-day each month in the office of a nephrologist, a dermatologist, a pulmonologist or a neurologist. In our academic division, we established an interdisciplinary clinic with dermatology. Patients benefit from better care, better coordination and assurance their specialists have conferred with one another. Doctors benefit from instant consults and improved teaching and learning. And if your goal is research, you have the perfect population.
I know of an interdisciplinary pediatric rheumatology-ophthalmology clinic in England that’s changed how uveitis associated with juvenile idiopathic arthritis is managed. I know of many successful ophthalmology-rheumatology clinics in Spain. Orthopedists and rheumatologists often practice effectively together in a shared space. Most patients do not object to two bills from an interdisciplinary clinic. If the patient attended two offices, they’d receive two bills anyway, and a great deal of additional time would be spent.
Caution: I’m also aware of attempts at forming an interdisciplinary clinic that have failed. The reasons for failure may be complex, but I suspect one contributor is that both parties ignored advice number one.
Third, encourage your nearest medical school to teach a class, a course or just a grand rounds on communication and collaboration with our professional peers. Several medical schools have started to offer classes on how to communicate with patients; I’m unaware of similar classes about communicating with peers.
We practice shared decision making with our patients, but we often fail to achieve shared decision making with our peers from other specialties.
We make compromises for the sake of our families, our careers, our patients and our colleagues. There are professionals who understand and specialize in compromise. Imagine if, for every patient with lupus nephritis, a couple’s therapist could help formulate the therapeutic plan, which often differs between the nephrologist and rheumatologist. We practice shared decision making with our patients, but we often fail to achieve shared decision making with our peers from other specialties.
When couples exchange wedding vows, they frequently assert, “You complete me.” A bride and groom seek to complement each other’s personality and skills. Wouldn’t it be wonderful to fulfill your role as a rheumatologist by hearing from an ophthalmologist, nephrologist or dermatologist, “You complete me?”
On their album, Abbey Road, the Beatles released a song called, “Come Together.” I’ve never understood some of the words (e.g., “ju ju eyeballs”), but the title has stuck with me. As rheumatologists, if we come together with our peers, our patients will benefit, and consequently, we will benefit as well.
James T. Rosenbaum, MD, is the Edward E Rosenbaum Professor of Inflammation Research at Oregon Health & Science University and the Richard Chenoweth Chair of Ophthalmology at Legacy Devers Eye Institute, both in Portland, Ore. He receives support from the William and Mary Bauman Foundation, the Stan and Madelle Rosenfeld Family Trust, the Spondylitis Association of America and Research to Prevent Blindness.
Acknowledgment: I’m indebted to Jennifer Barton, MD, and Lisa Rosenbaum, MD, for their critical reading and constructive suggestions for this manuscript.
- Egener B. Addressing physicians’ impaired communication skills. J Gen Intern Med. 2008 Nov;23(11):1890–1895.