Sharing in Caring

“I’m so thankful to both of you for helping me feel like myself again.”

As an embedded psychiatrist working in a primary care clinic, hearing these words from a grateful patient thanking me and her primary care provider highlighted to me once again that collaboration is key in successful comanagement of patients.  

This patient was originally referred to me by her PCP, who had attempted over several months to treat the recurrence of her major depressive disorder with multiple well-chosen trials of medication, all cut short by intolerable side effects. He ultimately sent her to me when the patient declined any additional interventions for fear of side effects, yet remained depressed and anxious, causing significant difficulty in her job and marriage.  

I encounter this situation often and can usually work with patients to create a treatment plan they’re comfortable with, introducing a new medication slowly while monitoring for and addressing any negative side effects. However, this patient couldn’t be convinced. Over multiple visits, influenced by a combination of depressive ambivalence and her difficult past experiences with medications, she remained reluctant to try another medication, and continued to suffer despite a deep desire to get better. Her biggest concern was antidepressant-induced hyponatremia. I proposed an antidepressant less likely to cause this and attempted to reassure her with plans for monitoring sodium, but to no avail.  

The breakthrough in her treatment came when I offered to discuss options with her PCP, who she had known and trusted for years. After our discussion, the PCP was able to reassure the patient and to confirm that he would see her regularly to monitor serum sodium levels while she continued to work with me to track her depressive symptoms and titrate the medication. 

Over several months on increasing doses of medication, her mood improved, her anxiety lessened, and her sodium levels remained stable. I received the statement above in a heartfelt message from her, thanking me for sticking with her and collaborating with her PCP. 

The key to a successful outcome with this patient was effective communication between the PCP and me. In a collaborative care model, comanagement offers the opportunity to leverage collective strengths. In this case we were able to combine my knowledge of psychiatric medications with the strong rapport the patient’s PCP had built with her over time. Approaching collaborative care as a chance to work together and combine a variety of individual strengths will lead to better patient care and foster more rewarding professional relationships.  

A few tips for success when communicating with other providers about a shared patient: 

1. Connect early and often.

Soon after seeing a new patient for the first time, send a message to other providers you’ll be collaborating with, sharing your plan, any insights on the case, and areas where you can work together. It’s helpful to connect from the start to encourage communication whenever necessary so that providers can notify each other of any concerns that arise in between visits. 

2. Learn from each other.

When collaborating with another clinician, don’t be afraid to ask questions on management. Why did you choose this medication over another? Have you ever actually seen this interesting but rare side effect of a medication, and what does it look like? We often take our expertise for granted and forget that there’s so much we can teach and learn from each other.  

3. Use synchronous communication when possible. 

We can all appreciate the convenience of communicating asynchronously, sending EMR messages or emails in between patients and tasks when we have a rare spare minute. But if time and scheduling allow, speaking by phone, video chat, or even in person offers additional depth of discussion, gives the opportunity for both parties to ask questions, and further develops working relationships with colleagues. 

4. Make the patient aware of your communication.

Patients are almost always grateful and comforted to know that you’re collaborating with others. Let patients know that you work closely with others in caring for them. 

Communication in comanagement shouldn’t be viewed as an administrative burden but rather as an opportunity to collaborate to best serve patients. Reaching out to other clinicians caring for a patient with you can provide better patient care and can foster improved professional relationships.  

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.