Time for some patient driven change | Marc Levitt | TEDxColumbus

In medicine, complex problems are often approached in a disorganized manner analogous to building a bridge by having cement layers start on Monday, steel workers arrive Tuesday without knowing what to do, architect on Wednesday, and engineers on Thursday.

Some children are born without an opening for stool (anorectal malformation), a condition most families have never heard could go wrong.

A cloacal malformation is demonstrated on fetal MRI at 20 weeks gestation, showing bladder, gynecologic system, and colon system all converging as one opening.

A cloacal malformation with all urinary, gynecologic, and colonic structures coming together as one opening is not compatible with life and once surgically solved has unique implications on the child's quality of life.

In cloacal malformations, all anatomic structures (urinary, gynecologic, colonic) are right next to each other, each handled by a different type of doctor, requiring collaborative work to manage the patient.

Twenty-five years ago, the speaker's mentor attempted to function as colorectal surgeon, urologist, and gynecologist for these patients, but as medicine became more complicated, the speaker felt incapable of solving all problems without a unified team approach.

A multidisciplinary team for complex colorectal patients should include GI motility specialists, medical colorectal specialists, colorectal surgeons, gynecologic surgeons, and urologic surgeons working together.

Surgeons, particularly, like to be in charge and do not like to share patients or be told they cannot go first in an operation when another team needs to go first for the patient's benefit.

Surgeons must park their egos at the door when sharing patients in a collaborative model.

Hospital barriers to collaborative care include questions about billing, clinic scheduling with all doctors in the same place on the same day (not efficient), and productivity concerns when a specialist is needed for only 2 hours of a 10-hour operation.

A specialist cannot leave during a long operation to do other work because when needed, they must be immediately available while the patient is under anesthesia.

From the patient perspective, gathering multiple specialists together is difficult, especially when experts are in different cities, requiring families to schedule multiple appointments at different times and dates, possibly requiring air travel and sibling care arrangements.

There are clinical circumstances where a child benefits from one operation where tissues can be shared between surgical teams.

In a patient (Rebecca) with both a non-functioning colon segment and a bladder that was too small, a section of colon can be removed from the fecal stream and added to the bladder to make it bigger, performed simultaneously in one operation.

Normally, bladder augmentation would be performed and six months later someone would do the colon work, rather than coordinating both procedures in advance in one operation.

A collaborative care model requires deep infrastructure including coordinators, administrative assistants, schedulers, and multiple types of nurses (floor, OR, clinic) with different areas of expertise.

An institution must commit significant infrastructure to make collaborative care work, with the expectation that done correctly, more patients can be helped.

Nationwide Children's Hospital successfully implemented the collaborative care model after the speaker had tried at other institutions where no one bought into the collaborative process.

The siloed approach was the traditional way of medicine, requiring convincing to change.

In the collaborative model, one plus one can equal three and the sum is greater than the individual parts.

The collaborative care model could spread to other hospital areas, such as a limb program requiring orthopedic surgery, rehabilitation medicine, and other specialties meeting together before the patient arrives and seeing the patient on the same day.

A patient (Rebecca) would have benefited much more from the collaborative process available today than when the speaker first met her 25 years ago.

An 8-year-old patient (Michael) with daily fecal soiling was being teased at school so badly his parents pulled him out of school.

The speaker promised an 8-year-old with daily soiling that in one week he would be clean and in normal underwear, and one week later the patient achieved this outcome.

Because of the collaborative process, the team is able to make promises to patients and keep them.