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Who’s in charge of a multidisciplinary team caring for a single patient? Ideally it shouldn’t matter if-and it’s a big if-members can communicate and work together.
While there are certainly disorders that are considered primarily an endocrinologist’s “territory,” like pituitary adenomas and Cushing disease, there are several that fall into the scope of other subspecialities. Osteoporosis, for example, while often managed by endocrinologists, is also treated by primary care physicians, geriatricians, gynecologists, and some orthopedists. And generally, there aren’t a lot of toes being stepped on in this area, probably because there are only a handful of treatment options, and the biggest question is usually whether or not to treat.
When it comes to diabetes, however, it can become difficult to figure out who is doing what for the patient. Part of it is because treating a patient who has diabetes is more complicated than lowering blood sugar. Their care is much more complex. Cholesterol, blood pressure, and weight need to be appropriately treated. They need to be monitored and treated for complications. As such, their care requires a team approach. The question is who is the team manager? Is it the primary care physician? Is it the endocrinologist? In my mind, in an ideal world, it should be the patient. That would, of course, require a patient who is educated enough about his disease and his treatment options. Unfortunately, in this rapidly changing field of medicine, it is hard for patients to know on their own what the goals should be and how best to attain them.
Which brings me back to the question-who is the team manager? In lieu of the patient, I suppose it wouldn’t matter, if, and this is a big if, the team members can communicate and work together. Here’s the next problem, I am fully and painfully aware, that most physicians do not have the time to pick up the phone and have a conversation with the other members of the patient’s care team. You’ve got the PCP, the endocrinologist, maybe a cardiologist, nephrologist, podiatrist, ophthalmologist, and (again, ideally) psychologist/psychiatrist. If only it were possible to get everybody on a conference call and set out a plan. But in reality, the patient is treated in parts, and sometimes, treating one part has an impact on the other parts. Then the patient gets conflicting advice, or duplicate therapy and, in the end, the patient suffers.
Case in point: I have been seeing a patient for his diabetes for years and he is reasonably well controlled. He also has hyperlipidemia and recently bladder cancer was diagnosed. He is seeing another health care professional, whose specialty I do not know. He is not his PCP or cardiologist; I am told he is helping him with weight loss and “general health.” Anyway, when he came for his visit this week, he brought a printed list of recommendations from this doctor, which included stopping his statin and adding Actos. The patient asked me if Dr B had called me because he had said that he would. I told the patient that Dr B had not contacted me, but I was glad he brought his list; however, I could not agree with his recommendations. Do I believe that Actos causes bladder cancer? Not really. Nonetheless, I saw no need to add it to his regimen, since his HbA1c was at goal. And why stop his statin?
Well, later that day, Dr B did call me. He cited an “article” in the NEJM that suggested that discontinuing statin therapy during BCG treatment of bladder cancer may result in better outcomes (I later found that the “article” was a letter to the editor about a retrospective study, but that is neither here nor there). I countered that the patient’s risk of a cardiovascular event outweighed the risk and that if statin therapy truly interfered with his BCG treatment that I was certain that his urologist or oncologist would have discontinued it. In the end, we agreed to disagree. This, however, leaves the patient to decide whose advice to follow.
There is very little that is black-and-white in medicine, much of what we do is based on statistics, on lowering risk. We need to work together to create plans based on available data, based on science, for our patients’ sakes.
Does any of this ring true for you? Is effective team management possbile? What is your experience? Please leave us a comment below.