Search for tag: "multidisciplinary"

Interviewer: Coming up next on The Scope, learn more about a specialized clinic that treats just diseases of the aorta. That's next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. Jason Glotzbach is a cardiothoracic surgeon, and Dr. Claire Griffin is a vascular surgeon, both at University of Utah Health, and they're both part of the Aortic Disease Program at University of Utah Health. And today I want to get a better understanding about that specialized clinic, why somebody might be referred there, and the advantage for the patient versus other options.

So, first of all, why is it necessary to have a clinic dedicated to the treatment of aortic disease?

Dr. Griffin: So the aorta is one of the major blood vessels in the body, and any pathology associated with it can be very complex, and it's often not something that regular doctors have a lot of familiarity with. So our training gives us the opportunity to understand not just focused pathology in one particular area, but the whole aorta. And working together means that patients can come to one place and have a variety of opinions that really helps get the full scope of treatment options, natural history of the diseases associated with their aorta, and the full gamut of specialists to help take care of everything in one place.

Interviewer: So what I'm getting is it's a pretty complicated part of your anatomy and you need some pretty specialized people to take care of it?

Dr. Griffin: Yes.

Interviewer: Let's go back to anatomy class, Dr. Glotzbach. Where is the aorta? I know it's somewhere near the heart and it carries blood, but beyond that I don't remember much.

Dr. Glotzbach: Absolutely. That's a good place to start. The aorta is the largest artery in the body. It starts at the heart. So the aorta is the first stop of blood. As it leaves the heart, it goes into the aorta, and then from there it goes up and around the aorta and, through all of its branches, goes to every part of the body.

So the aorta is literally the kind of main superhighway for blood as it travels through our body. And so given that, obviously diseases of the aorta are very critical to the entire body, and so we have arteries in the chest, the abdomen, the legs, all that feeds off of the aorta.

Interviewer: Dr. Griffin, you'd mentioned that it takes, you know, a specialist to kind of understand this. In your general four years of med school, how much of this part of the body is really covered?

Dr. Griffin: So the understanding of most medical students coming out of medical school is probably exactly what Dr. Glotzbach just highlighted. It's the superhighway for blood, it's what takes blood everywhere else, but the understanding of the diseases that are in the aorta and how to treat them, and the thought process behind the approach to them is all something that is specialty training.

Interviewer: And what's the advantage for the patient to come all the way to University of Utah Health, I mean, other than the experience part which, I guess, is a pretty big advantage, right?

Dr. Glotzbach: Oh, we like to think so. I think we like to look at the patient as a kind of individual and tailor the treatment to each individual patient's needs, and I think that that's one of the things that we can do well here, is that we have specialists from multiple different disciplines so that we can think about the disease process in many different angles or from many different perspectives.

Interviewer: When you say "from the patient's needs," what does that mean exactly?

Dr. Glotzbach: Because the aorta is such a complex organ and aortic diseases are very complex in that they are very unique to each person, so one person's disease may not be the same as another person's disease, which is a little bit different than other problems that we focus on. So it's really important to take each patient as an individual and look at exactly what kind of treatment they need, and then hopefully we can provide that in a very targeted, individualized way.

Dr. Griffin: We just have very different thoughts when we approach the aorta. The training that I received, I spend a lot of time thinking about complex endovascular or minimally invasive ways to treat the aorta and its branches. And the approach that Dr. Glotzbach might have from a CT surgery perspective comes more from a major open perspective, and having the two of us working together means that we really constantly open each other's eyes about different ways to approach the same problem.

Interviewer: Yeah, you might be able to do something a little less invasively, perhaps?

Dr. Griffin: Exactly.

Interviewer: Or you might be able to talk to each other and go, "Well, actually we do have to be a little bit more invasive in order for it to be successful?"

Dr. Griffin: And talking about those cases together and making sure that there's open collaboration means that there's never a time that Dr. Glotzbach doesn't weigh in on something or I don't weigh in on something, and so we really get the benefit of both training backgrounds for every patient.

Interviewer: Two heads are better than one.

Dr. Glotzbach: Absolutely.

Interviewer: And you have even more than just the two of you on the interdisciplinary team. Who are some of the other members, and how do they contribute?

Dr. Glotzbach: We have basically the entire division of cardiothoracic surgery and vascular surgery are both committed to making this collaborative effort work. So my division chief, Dr. Craig Selzman is very committed to this, and so he's involved in all these collaborative discussions, and all of my partners on the cardiac surgery side have weighed in on all of these cases and, you know, individual cases and also as programmatically as a whole.

Dr. Griffin: Similarly, from the vascular division we have Dr. Larry Kraiss who's our division chief, and then the remaining members of the vascular division all are involved in the collaborative discussion of patient care. And because of other collaborations between our two divisions, as well as the Cardiovascular Center as a whole with cardiology and intervention radiology, there really is a lot of expertise at the University of Utah for this kind of disease pathology.

Interviewer: That's pretty cool. How old is this clinic? It's fairly new, isn't it?

Dr. Glotzbach: You know, we've had this expertise in kind of individualized divisions and aspects of care for years, but the collective pursuit of this as a multidisciplinary thing is really within the last year, we've been trying to build this up. And we've had a lot of buy-in from the leadership of the hospital in the cardiovascular service line, and so we're starting to really get some momentum with this.

Interviewer: One call, and you don't have to look around for all the experts, you're still in one spot.

Dr. Glotzbach: That's the goal. We're really trying to streamline things for the patient and for referring physicians who want to send people here for us to help out with. I think that it can be very complex to navigate a system like University of Utah, these large academic medical centers, and so our goal is to make it kind of a one-stop shop for the patient to come in, and we bring whatever expertise we need for the individual patient. We bring that to the table.

Interviewer: How do patients generally end up in the clinic? I don't imagine that's their first stop.

Dr. Griffin: That's a great question. There are a couple of different ways to find our program, and it really has to do with the kind of problem the patient has. So some of the aortic diseases are picked up by primary care doctors with routine screening evaluations or as incidental findings on CT scans that patients have for other purposes, and those patients really come through the referral process. There's a whole other section of diseases that affect the aorta that are really emergencies or acute findings that take patients to the emergency department, and they would come to us through emergency transport.

Interviewer: Let's talk about the referrals. If there is a patient that has been diagnosed with some sort of aortic issue and the physician doesn't know about the clinic or doesn't make a referral, is there a way a patient could find their way to you in that instance?

Dr. Glotzbach: Absolutely. We have a kind of dedicated administrative pathway where we have one phone number that we can . . . you know, both patients, or physicians, or doctors' offices could call and get an appointment with us. And it doesn't matter whether they end up needing a cardiovascular or cardiac surgeon, vascular surgeon, or both of us, you know. We can streamline that process, and our goal is to have it. So as soon as we hear about a patient, we will get them into our system and get them plugged in with the appropriate providers that can help them with their specific problem.

Dr. Griffin: One of the things that is helpful about our system, and having as much expertise as we do, is that a lot of times people can have really rare disorders of the aorta or its branches, and their primary care doctor or maybe the physician taking care of them doesn't see it enough to feel comfortable managing it, and that's one of the benefits of having such a collaborative effort that it's not rare to us. We're familiar with it, we're comfortable with it, and we're happy to help take care of it.

And in addition, I think that one of the things that's unique about our effort right now is that it's very collaborative, and so we're not competing with each other to take care of these patients. We're working together, and I think that creates an environment not just for the physicians and the patients, but also for all the support staff that really can be focused on patient care and patient outcomes instead of trying to be competing with each other.

Interviewer: And make sure that the patient gets exactly what the patient needs to get back to their life, however it may have been before they ran into the problem?

Dr. Griffin: Exactly.

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Dr. Jones: So who really knows about women's health? Are the OB/GYNs just the specialists in the below-the-knees women's health? Are internists just the specialists for above-the-knees women's health? And why don't they talk to each other? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and we are doing that today on The Scope.

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: For many OBs, women's health stops when the baby is born. For many gynecologists, women's health is above the knees and below the waist. For internists, they might cover the rest, but defer what goes on down there to the other docs. Of course, family physicians would probably rightfully claim that they can cover all the domains of women's health. But what should OB/GYNs and internists know about each other's territory to really take care of women?

Today in The Scope studio, we're talking to Dr. Melissa McNeil. Dr. McNeil is Professor of Medicine and chief of the section of women's health and Director of the Comprehensive Women's Health Program at the University of Pittsburgh. She's trained as an internist in medicine and in public health, and she's here to give grand rounds to the internists and to the OB/GYNs to tell them what they should know about each other's specialties. Let's start with this: What do you think women would want their internist to know about their womanly health?

Dr. McNeil: For so many physicians, they silo women. And increasingly what we . . .

Dr. Jones: Silo them by their body parts?

Dr. McNeil: Silo them by their body parts and the domain that they will take care of. So one of the things that are increasingly happening is that, for the internal medicine community, many of our patients don't see their gynecologist as regularly as they used to. As our Pap smear guidelines go to every five years, as our women move out of the childbearing age and they don't need contraception, for many women, they are not seeing the gynecologist on a regular basis. So the things that I think all physicians need to know, particularly internists, are the following.

I think the first thing is that the folks who are charged with your heart health and preventing heart disease need to understand your reproductive health history. What we know and are increasingly aware of is that women who have reproductive consequences, such as preeclampsia, such as hypertension during their pregnancy, such as small for gestational age babies, have an enhanced risk of cardio disease early in life. So, as an internist who sees, very much as my domain, the risk assessment of women for cardiac disease, I need to understand, I need to know about those birth complications, and I need to understand how it impacts cardiovascular risk.

The second thing I think that internists need to know and understand is breast health. I think the breasts . . . it's a little bit unclear who owns the breasts.

Dr. Jones: Oh, we don't. It's no man's land, sort of.

Dr. McNeil: It's no man's land, so to speak . . . no woman's land. And so one of the things that are increasingly becoming clear is that breast health is an area of precision medicine. We talk about the need to personalize the recommendations we make the patients based on their own individual risk factors, and then a one-size screening program for breast health does not fit all. So, therefore, internists need to know and understand the risk factors for breast health, family history, they need to know how to understand the reproductive parameters that change breast health, like time of first baby, time of onset of menarche, and how to understand things like breast density.

Dr. Jones: Well, you know, this is . . . it turns out that internists don't even touch us, anymore. You know, they might wave a stethoscope sort of in the direction of your heart, but in reality, the gynecologists still take the clothes off and look at us all. But that now, it's not every year. It's maybe every five years, and even now, they're not doing that. So the concept being actually touched while doing a breast exam, now true, breast exams don't really help save lives, but they are a way of talking to your patients about their breast health. So . . .

Dr. McNeil: So that's interesting that you talk about that because I do think that the benefit of the physical exam in that arena has been called into question. Having said, that the benefits of a conversation have not. And so in a busy office practice, you get to decide where you spend your time. I still actually believe in the breast exam. I still do the breast exam on my patients for their annual visit, and certainly, if there's any complaint, an exam needs to happen. So . . .

Dr. Jones: Anything that we wish our internists would know about us?

Dr. McNeil: Yeah, and this is the last thing that I'm going to emphasize. I think that our internal medicine community needs to really become much more comfortable and savvy talking to women about the things that impact the quality of life as they age. And there are three that I think, again, fall into no woman's land. It's the management of the menopause and hot flashes, it's the management of vulvovaginal atrophy and the symptoms of dyspareunia that come with the menopause, and then, finally, incontinence. For many of our women, these things fall into the "don't ask, don't tell" category. And if you don't ask, you'll never find out.

Dr. Jones: Well, not only that. Women often switch off in terms of their healthcare. So when they get to midlife, they don't see their gynecologist, anymore. But if the internist doesn't ask, they figure the internist doesn't know and so they tend to hold those personal. They're often very personally held. And I encourage all of our listeners that if you've got a problem or concern, if you're waiting for your internist to ask you, you might need to buckle up and speak up.

Dr. McNeil: And I would second that wholeheartedly. I find that, in our Comprehensive Women's Health Program, if you ask, patients have the symptoms. I think some of the advertising we see on television has empowered women to come forward for it, but at the same time, you cannot wait, internist, non-internist, for your doctor to maybe ask about everything that might be bothering you. You need to put it forward.

Dr. Jones: And if your internist is your primary care doctor now, not your gynecologist, you need to hold them to the fire, and they can . . . if they don't know, they might be able to talk to somebody. So that gets the last question: How do our doctors talk to each other? Ideally, if we're in a healthcare system and most everyone is either a little system or a big system, why, and how can our doctors talk to each other, our internist talk to our gynecologist, and vice versa?

Dr. McNeil: I think that's a great question and I think it has both become harder and easier with our current practice structure. The idea, of course, is a multidisciplinary practice where you have internists and gynecologists practicing side-by-side so that you can just go next door and say, "Hey, I have a question. Can you come look at this abnormal finding?" Or, "What's the next test you would do with the symptom?" Or, "How do I prescribe vaginal estrogens?"

That's a luxury and doesn't happen very often. I think the next strategy, of course, is just to pick up the phone and call a friend, call a colleague. And it can either be a colleague who's actually sharing care of the patient or someone you just value who will work with you in solving those patients' problems.

The third strategy, which is increasingly being utilized, is communication through the electronic medical record. One of the benefits of a shared electronic medical record is that docs can talk to each other, docs can see what they're recommending, each specialist is recommending for the patient. And so there can be a dialogue about, "Ooh, I'm a little bit uncomfortable with this," or, "Wow! That's a great idea," or, "Maybe we should actually step out and talk about this." So the electronic medical record can be very helpful. And then the last thing I would add is that the way to make docs talk to each is patient-driven.

Dr. Jones: Right, you tell them.

Dr. McNeil: You do. As a patient, you say, "Well, you know what? My gynecologist said something different. What would you think?" Or, "Could you talk to my internist and sort out . . .?"

Dr. Jones: "You just got me started me on some estrogens. Would you talk to my internist about that so that they know?" You know, or, "My internist seems to be kind of negative about it. Would you kind of talk to them and share what you know?" I think it's in the domain of patients' rights to get their personalized care by having their doctors come together around their person.

Dr. McNeil: To make their personalized care coordinated care. And it's very hard for patients when different providers that they trust make different recommendations. So coming together with a consensus is incredibly important for the peace of mind and good-quality care that our patients deserve.

Dr. Jones: So for those of you who are listening, be brave because, now that we have electronic medical records so the other care providers within your system can be contacted easily, it's not having to look up a telephone number. So be brave. You can help coordinate your care. You can ask the questions and you'll be happier at the end of the day for it.

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Dr. Jones: If women have told us that their holistic sense of health involves much more than their cholesterol level or their blood pressure, what do we want our health team to know about us? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care and this is "The Scope" of women's health.

Announcer: Covering all aspects of women's health, this is the "Seven Domains of Women's Health" with Dr. Kirtly Jones on "The Scope".

Dr. Jones: How should our medical home think about our overall health? The seven domains of women's health - physical, emotional, social, intellectual, environmental, financial and spiritual - are all important to us. Today in "The Scope" studio, we have two professionals who've thought a lot about these seven domains. Dr. Kathleen Digre is a neuro-opthalmologist who is a specialist in headache and is the director of The Center of Excellence in Women's Health. Dr. Caren Frost is the director of The Center for Research on Migration and Refugee Integration. Together, the published a book on the seven domains of women's health. Thank you for coming to "The Scope".

Kathleen, why is it important for the health professions to understand the seven domains of women's health?

Dr. Digre: So this is really not a new concept. The WHO (World Health Organization) really defined that health is more than just physical health, but it involves emotional health and other types of health. And at the Center of Excellence in Women's Health, our members have really thought about this that if we're going to be really healthy, we have to be thinking about all the various aspects that fit into health.

So I think the importance of this is that one domain is going to affect another. For example, if you have very poor social health and you have no social support, how are you going to get to a medical doctor's office in the first place?

Dr. Jones: Caren, you come at this problem from the social part, help me understand why this matters as we begin to educate health care professionals?

Dr. Frost: I think that we're moving more and more towards interdisciplinary teams, so health professionals, nursing professionals, as well as social work professionals, they need all be aware of these different seven domains so when there's a need for resources or identifying resources for people, somebody on the team can say, "Oh, I think you're having trouble with your financial health. Let's figure out someone that you can go and speak with." So I think thinking about it in a holistic way where we have different professionals working on things together is really why this is so important.

Dr. Jones: That's why the university has been so insistent that we think about our healthcare as a medical home with many professionals on the team. Kathleen?

Dr. Digre: I would like to just add that physicians are guilty in many ways of not thinking about health in these factors. Nursing has been way ahead of physicians in team care and I really feel that this is a sea change. This is a change in our new direction in medical home thinking and also in medical care thinking.

Dr. Jones: We've been trying actually to integrate this concept of multi-disciplinary teaming into our first and second year and third year curriculums now at the School of Medicine. So we're trying but also, folks, we need some help. We need a book. So what about this book, why this book, and why now? We talked a little bit about it but tell us about the book.

Dr. Digre: The idea for this book came many years ago. When we started the Center of Excellence over 10 years ago, we started having a problem talking about what is health and what involves health. So we tasked our librarian who is part of our team to actually research what are domains of health? And they came back to us with seven domains of health. And then all the members of the team really picked up on this as really vitally important especially for women's health because we are juggling so many things in our families and in our lives.

And then Caren, because she's so cool and has a social work background, she was able to work with students and start getting some literature together in each of these domains and then the idea came, actually, we should write a book. We should have a test. We should put this out to the public so that we can make this more freely available to everybody.

Dr. Jones: Caren, who are your collaborators? You two are the editors but I see you've got collaborators all over the university.

Dr. Frost: We do. We have collaborators from what we call main campus as well as the health sciences campus. What we tried to do with every chapter was to make sure that we had a medical health sciences professional as well as a professional from another field so we got an interdisciplinary kind of discussion going on with each of the chapters. So we have people from nursing and from the OB/Gyn as well as neuro-opthalmology. And we have people from public health, people from social work, people from the College of Health, communications, and we have people from all over campus who agreed to write pieces and parts of chapters so that we could pull that altogether and show a real interdisciplinary way of looking at these seven domains.

Dr. Jones: And who's your intended audience?

Dr. Digre: Of course, the medical students. We'll have to get that as part of the curriculum but who else?

Dr. Frost: I think we saw anybody involved in patient care. So medical students, nursing students, also the College of Health students, pharmacy students. It should be permeating everything that we do. So I would say anybody, any provider that provides care to patients.

Dr. Jones: Caren, I would say it's for anybody who cares for persons because sometimes people out in the community, maybe someone who's doing resources within the social domains for communities of refugees, those patients aren't patients. Those persons aren't patients. They're persons. So maybe as we think about those who care about persons should take that. What do you think about that?

Dr. Frost: I think that is an excellent suggestion. One of the things that the Center of Excellence group had been talking about is how do we make sure that this information becomes tangible to everybody out in the community as well so we've been talking about and using what we call our circle of health in different settings so for example when I do workshops with refugee women, we have translated what we call our circle of health into two or three different languages and when we present it to refugee women in that language who say that that's exactly it. That is health. All of those domains, they're all connected. And they're always so glad that we see it the same way they do so we've used that model.

Dr. Digre: I would like to add that I think that when we have presented this in public, it really resonates with people. They say yes, of course, all of this is related. We can't just separate one piece from another. It's all integrated into one piece.

Dr. Jones: So this book is unique because they're not just words, there are some added attractions. Tell us about that.

Dr. Digre: I think that one thing that's cool about this book are all the discussion questions. If we're in a classroom and we want to discuss a certain domain of health, we've got actual questions that help people guide discussions in a group setting and help you to explore the seven domains.

Dr. Jones: Caren?

Dr. Frost: We also have case studies at the back of the book and we were lucky enough to get a number of different professionals on campus to come in and one person was a simulated patient. Dr. Jones was one of our simulated patients.

Dr. Jones: I get to be an old, slightly demented person. It was fantastic. Thank you.

Dr. Frost: And then we had a number of professionals come in from health sciences, the medical field, as well as the social work field and talk about a variety of different kinds of needs that somebody would need to have addressed during that discussion with an interdisciplinary team. We have that in there as well and the link to those case studies is available for people to use.

Dr. Jones: We hope that our healthcare team and the professionals who teach them can realize that we as women take our healthcare holistically is this circle of health in our circle of life and thank you for joining us on "The Scope".

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