When James A. Garrity, MD, had trouble explaining a patient’s postoperative vision loss, he enlisted the help of his colleagues. “I just picked up the phone and said, ‘Can you come over and take a look?’” Dr. Garrity, a neuro-ophthalmologist at Mayo Clinic, was confident that his call would be answered because at Mayo, an organization of salaried physicians, collaboration is part of the culture. “We interact and depend on the assistance of other specialties,” he said.

“There are a lot of interdependencies in health care,” said Michael F. Chiang, MD, who is assistant professor of ophthalmology and biomedical informatics, Columbia University. “What one doctor does affects another physician’s domain. The challenge is that doctors have to be able to share information about these patients.”

Though there are few incentives in more traditional practice settings to stop everything and make a phone call, let alone return one, collaboration has never been more important. Today’s patients are mobile, and they are frequently cared for by multiple specialists. Gone are the days when one family doctor provided medical care from cradle to grave. For eye medicine alone, it’s not unusual for one patient to have three or four ophthalmologists over the course of many years. Today, a cataract surgeon may need preoperative information from a refractive surgeon. Or a retina specialist may need to exchange information with a patient’s internist or nephrologist. Neuro-ophthalmologists work closely with neurologists, and they may collaborate with endocrinologists for patients with thyroid and pituitary disease. A rheumatologist may administer uveitis medications. In this age of increasing specialization and patient mobility, nobody can afford to go it alone. At stake is nothing less than patient safety, not to mention the doctor’s peace of mind.

Good Decisions Need Whole Histories

Before Paul J. Lama, MD, decides whether to operate on an eye, he wants to know the patient’s total health picture. “A lot of patients have multiple medical problems and their lifelong prognosis is not so good. This affects how aggressive your treatment will be,” said Dr. Lama, who is both a glaucoma specialist and an internist. “That’s where communication is important. How sick is the patient?” said Dr. Lama, who is an assistant professor of ophthalmology and associate director of glaucoma at the University of Medicine & Dentistry of New Jersey. The best way to get that information is to call the other doctor. “Like any other appointments you set up during the day, with the biller or office manager, you’re going to set up the five minutes to make the call,” Dr. Lama said.

“We’re all pressed for time,” acknowledged retina specialist Abdhish R. Bhavsar, MD. Nevertheless, he makes the effort to work with other doctors, especially when a patient has advancing retinopathy. “I pick up the phone for those circumstances where I think the patient doesn’t really know what’s going on with their own care,” said Dr. Bhavsar, who is director of clinical research at the Retina Center in Minnesota, and chairman of the state’s Diabetes Eye Exam Initiative

Real-world examples. Failure to communicate can have unintended consequences. One of Dr. Lama’s pa-tients had a stroke during a glaucoma procedure, probably because the in-ternist had stopped the patient’s warfarin (Coumadin). Dr. Lama said internists often discontinue antico- agulants prior to any kind of eye sur-gery, though in this case there was no reason to do so. “It’s important for the ophthalmologist to convey to the in-ternist the relative gravity of the situation,” he said.

On the other hand, communication led to a more favorable outcome for a patient who told Dr. Lama she got fatigued after taking oral beta-blockers for her coronary disease. After observing that the patient’s IOP had remained elevated on every other medication, Dr. Lama called the patient’s cardiologist and said he’d like to try the beta-blocker before advancing to glaucoma surgery. The cardiologist gave him the go-ahead, explaining that the patient had received stents, which should have alleviated the fatigue.

Dr. Bhavsar is especially mindful of the need for collaborating on patients with diabetic retinopathy, where the underlying diabetes may affect multiple organs. “I am very meticulous about sending correspondence to other eye care providers, and, even more important, to the internist, family doctor or endocrinologist who is helping to care for the diabetes,” he said, explaining that the eye is the only end organ that other doctors can’t measure effectively. In return, he needs to know the patient’s Hb_A1C, renal and fluid status, as well as blood pressure. Dr. Bhavsar checks blood pressures, but wants to know from other providers how they’re trending.

Collaboration as a Performance Measure

On a more practice-based level, a doctor’s performance may actually be assessed by the quality of his or her communication with other physicians. Dr. Bhavsar cited a situation involving an insurance company audit of an internist’s records. The company, which was looking for evidence that the primary care physician was sending his patients for eye exams, as well as receiving information back on those exams, wasn’t satisfied with the follow-through from a particular Eye M.D. While there were concerns regarding the manner in which the audit was conducted, the intent was appropriate, Dr. Bhavsar said. “They’re asking for people to communicate more effectively. Without communication between physicians, appropriate care for patients cannot be performed.”

Poor communication also has risk management implications. OMIC risk manager Anne M. Menke, RN, PhD, said, “From a risk management perspective, the biggest problems are the lack of a hand off when physicians are going on and off call and the failure to document physician-to-physician communication.” She said that lack of collaboration is such a huge problem that the American Society for Health Risk Management is devoting an entire conference to the subject. “Teamwork, which has patient safety implications, is getting a lot of attention,” she said.

Everybody wins. But fear shouldn’t be the only driving force behind collaboration. “I learn a lot from my colleagues,” Dr. Garrity said. “And professionally, it’s quite stimulating.”

Collaboration may also be an antidote to loneliness. “Given the great flux in retinal treatments today, and all those complex decisions we’re trying to make in terms of treating the patient in front of us, we can feel like we’re in a vacuum sometimes,” Dr. Bhavsar said. “But we’re not alone. There are other physicians who can help us greatly in managing the patient. We’re managing the local problem that we’re identifying in the retina, but they can help us globally with management of the rest of the patient.”