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Interdisciplinary Approaches Reflection Paper
Diane Morris
WASHBURN UNIVERSITY
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Interdisciplinary Approaches Reflection Paper
When reflecting on my clinical experiences thus far, it is very apparent that effective
communications and respectful interactions between health care disciplines play a crucial role in
maintaining the continuity of care for patients. This has been most evident for those patients that
I have cared for during inpatient hospital admissions, which is where I will focus the discussion
of this reflection paper.
Obviously, #3 of the Course Outcomes is most appropriate, which states: “exhibit
advanced communication skills in interdisciplinary settings”, as well as Program Outcomes #3
“collaborate with interdisciplinary groups within the role and scope of advanced practice
nursing”. While being involved in hospital rounds for inpatients, my preceptor and I have had
multiple opportunities with almost every inpatient in communicating with other healthcare
disciplines. As an internal medicine physician, Dr. Michael McGinnis (my preceptor) is often
the admitting physician for the patient and thus acts as the main orchestrator of care. However,
many of his admitted patients are very medically complex and require consultation with other
disciplines such as: cardiology, nephrology, gastroenterology, pulmonology, infectious disease,
and urology (to name a few). One such example occurred this week; a young 21 year old female
was admitted through the emergency department for what appeared at the onset to be a simple
gastroenteritis with upper abdominal discomfort and intractable vomiting. After obtaining a
thorough history and physical, we learned that the patient had just returned four days prior from
a two year missionary stay in Peru. She had traveled deep into the jungle areas approximately
one week before her return to the United States. She became ill just before traveling home with
upper abdominal “burning pain”, extreme nausea with vomiting, rigors, chilling, and intermittent
low grade fever. She also revealed that approximately two weeks before becoming ill, she had a
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pruritic rash to her legs bilaterally, for which she received two separate injections of “cortisone”.
The patient stated that access to prescription medications is much different in Peru, and a friend
who was a nurse had a dose of steroids at home and gave her the injections approximately one
week apart for persistent itching. She was unsure of the exact name of the steroid or the doses.
We also learned that Malaria prophylaxis was not given to this patient during her travels,
although she did report that insect repellants were used generously and other precautions such as
mosquito nets were used routinely during her travels. Upon admission to the hospital, a
consultation with infectious disease (ID) was immediately requested. Since her admission was
later in the afternoon, this consultation with ID did not occur until the following morning.
Fortunately, my preceptor is a very effective communicator and had already visited with the ID
physician via phone conversation upon admission, so blood work and stool cultures were ordered
upon admission. However, since collaborating disciplines do not “round” together on inpatients,
they are frequently dependent upon reading each other’s progress notes in the patient’s chart and
reviewing any additional tests/medications that may have been ordered. This mode of
communication is difficult, as some providers are very effective in communicating their plan of
care in a written note, while others are vague in their documentation. In my opinion this
approach is often ineffective, as certain disciplines may not round until late in the day, delaying
testing and treatment. Utilizing phone and paging systems can assist with more timely
communication but it does not replace face to face collaboration.
In addition to the medical disciplines, we are frequently involved in collaboration with
physical therapy, occupational therapy, social work, and diabetic educators. These
communications are also very important in ensuring that patients are capable to independently
perform their activities of daily living and remain safe, as we prepare for their discharge from the
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hospital. One example of this was a 64 year old patient admitted for a syncopal fall with loss of
consciousness. Her medical history included type II diabetes and chronic renal insufficiency.
Her fall was related to overuse of narcotics after recent foot surgery. Unfortunately, her renal
function had diminished and we had to discontinue her Metformin therapy. It was obvious her
diabetes was not well controlled with this agent, as her Hgb A1C was 10.1. Due to her sulfa
allergy, switching to a sulfonyrea was not an option and her financial status prevented the use of
other, more expensive oral agents. My preceptor decided that insulin therapy was her best
option, but she did not have any education or experience with this therapy. We requested
collaboration with the diabetic nurse educator to do patient teaching and provide a new blood
sugar monitor, as the patient’s was broken. We also involved physical therapy and occupational
therapy to ensure the patient was prepared to safely be sent home, given her issues with altered
mobility due to her recent foot surgery for Charcot foot. While the patient was ready for
discharge from a medical perspective, this was delayed one additional day, as the “order” for
diabetic education was missed and that education did not take place until the following morning.
Unfortunately, this was not in our control but the miscommunication cost the patient an
additional overnight stay. This patient’s situation offers another perspective on interdisciplinary
approaches that are very critical to safe patient care, yet somewhat outside the arena of
“medicine”. Another perfect example of involving other disciplines relates to discharge
planning. The social workers that I have been involved with recently in the inpatient setting are
invaluable in the preparation for discharge, especially of the elderly patients. Due to Medicare
constraints and other insurance requirements, utilizing the expertise of the social work
department is very helpful in making sure patients are placed in appropriate care facilities, based
on their medical needs and projected length of stays. One patient I treated this week was an
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elderly 83 year old lady who sustained a non-syncopal fall with chest contusions. Medically, she
did not necessarily need to stay in the hospital for pain management but with Medicare, it is
required that she be an inpatient for three “overnights”, in order to qualify for temporary
placement at a skilled nursing facility for rehabilitation. To me, this seemed overkill and a poor
use of hospital resources. The social work department was instrumental in orchestrating her
discharge to this facility.
It is very apparent that effective, timely communication with all the disciplines in
healthcare is crucial to providing safe and appropriate treatment for patients. As a nurse
practitioner, it seems at times challenging act as a care provider making recommendations with
other disciplines that typically involve physicians. Obviously a physician’s decisions seem to be
weighed more heavily (as they often should be), but maintaining a respectful approach to
questions and suggestions is sometimes awkward. Time and money seem to be the driving
forces behind healthcare but involving the appropriate disciplines for care and choreographing
these in an expeditious manner proves challenging.