Transcript TBI and Other Healthcare Professionals

TBI and Other Healthcare
Professionals
R. Jeffrey Goldsmith MD
Cincinnati VA PTSD & Anxiety Disorders
Program
Professor of Clinical Psychiatry, UCCOM
TBI Epidemiology
• Hoge et al. 2008, NEJM, military N=2525
– 4.9% loss of consciousness
• 44% PTSD, significant major dep
– 10% altered mental status
• 27% PTSD
– 17% other injuries
• 16% PTSD
– mTBI associated with more physical c/o
Chronic Pain
• Nampiaparampil, 2008, 23 studies
– Civilians: chronic pain mTBI 75% v. 32%
– Headaches common, variable initiation
– mTBI 89% headaches, 18% severe TBI
Collaboration Multidisciplinary
Definition 1978
•
•
•
•
Sharing responsibility for care
Each role must be defined
Each professional has standards of care
Patient must know of each role
Definitions
•
•
•
•
Collaboration
Consultation
Supervision
Team work
Guidelines for Collaboration
• Talk to each collaborator
– Ahead of time?
– How many can you handle?
• Define roles
• Define communication technology
– HIPPA issues?
• Cross-coverage issues
• Billing issues
• Forensic issues
Models of Collaboration
by Lorenz et al 1999
• Collaboration is an attitude and an interpersonal process that embodies
cooperation and a spirit of working together. Professionals with divergent
training work within a convergent framework. Competition and turf
battles are left behind as professionals rise above power struggles and
petty status competition.
• Collaboration is a way for professionals to provide quality, comprehensive,
and efficient care. Collaboration recognizes each party’s presence,
expertise, and special talents. It is not leaderless, amorphous, inefficient
group process. The team leader varies depending on the situation. …
• This spirit of collaboration applies equally well to patients, families, and
communities. If professionals can work together, the next logical step is to
include the patients and those who care about them.
Key Ingredients for Effective
Collaboration by Lorenz et al
• Good working relationships: take time,
mutual respect and shared responsibility
• Common purpose: general patient welfare
• Paradigms: shared or blended
• Communication: clear, no jargon, continual,
HIPPA issues
• Location: co-location can simplify some issues
• Business management and payment methods
VA Integrated Care
• One goal of the VA’s Mental Health Strategic Plan is
to “develop a collaborative care model for mental
health disorders that elevates mental health care to
the same level of urgency/intervention as medical
health care.” Program funding commenced during
fiscal year 2007 after a request for proposals for new
programs to promote the effective treatment of
common mental health and substance use disorders
in the primary care environment.
• It recognizes under-diagnosis in PC, patient comfort
in PC, and ease of referral on site.
British PCMH Collaboration, 2007
by Nolan et al, 2008
• Assumptions of “better working together”
without defining process of success
• Clarity of goals is important
• Differing opinions and paradigms are barriers
• Local v. national models of quality
• Little consumer involvement in policy
decision-making
British Collaboration, 2007 part II
• Do we develop new professionals or more of
the traditional ones with their departments?
• Drive towards information technology ignores
richness of face-to-face communication
• Equality of information access
• Co-creating a peer community of inquiry,
developmental learning process for all
Collaboration Research
• Inconsistent definitions of collaboration
• Discreptant attitudes between Dr’s and Nurses
• Comparable with aviation findings
– Elimination of measurable deficits in safety
• Medicine is more interrupted
• Some unexpected critical events
– ICU must respond ASAP
• Some redundancy in roles capture mistakes
Other Healthcare Professionals
• Neuropsychologist
• Speech Therapist
• Physical Therapist
• Occupational Therapist
• Pain Specialist
• PTSD Therapist
• Physiatrist/PM&R
Speech Therapist
• Unawareness: intellectual awareness,
emergent awareness and anticipatory
awareness, not psychological denial
• Working with mTBI: early phases and later
phases, might work on environment changes
and family assistance
– Attention, time pressure management, specific
memory interventions, self-management and selfefficacy, CBT
My Results
• Not always match the Neuropsychology
testing
• Not many CT scans abnormal
– many not done if far from injury
• PTSD anxiety interferes with concentration
and attention
Pitfalls for Many Collaborators
• Overvaluation of pharmacotherapy and/or
psychiatrists
• Overvaluation of psychotherapy or physicians
• Each professional works independently
• Only the doctor knows about pharmacology
• Ignore the psychology of medications
Pitfalls part II
• The doctor will try to take over
• The patient is too sick for psychotherapy
• My collaborator always agrees and is
comfortable discussing things with me
• The psychiatrist takes over if the patient
worsens
• The psychiatrist covers when the therapist
leaves town/vacations
• Physicians are only interested in medication
Pitfalls part III
• The patient worries the doctor will force
hospitalization
• The patient worries the doctor will stop meds
• All uncomfortable feelings are side effects
• Keeping secrets damages collaboration
• Splitting (projective identification) means
good guys and bad guys on a teetertotter
Final Thought
– Let us live by their example. We can acknowledge
that oppression will always be with us, and still
strive for justice. We can admit the intractability
of depravation, and still strive for dignity. We can
understand that there will be war, and still strive
for peace. We can do that--for that is the story of
human progress; that is the hope of all the world;
and at this moment of challenge, that must be our
work here on Earth.
• Barack Obama, Nobel Peace Prize, 2009