Time for some patient driven change | Marc Levitt | TEDxColumbus

In medicine, complex problems are often approached without coordinated planning, analogous to building a bridge by having cement layers arrive Monday, steel workers Tuesday, architect Wednesday, and engineers Thursday.

Some children are born without an opening for stool (anorectal malformation).

A cloacal malformation is a condition where the bladder, gynecologic system, and colon all converge into one opening.

Cloacal malformation is not compatible with life without surgical intervention.

Once surgically corrected, cloacal malformation has unique implications on the child's quality of life.

In cloacal malformation, the bladder, gynecologic, and colorectal structures are anatomically adjacent to each other, and each is handled by a different type of doctor.

Effective management of cloacal malformation requires doctors from different specialties to work together.

Twenty-five years ago, the speaker's mentor attempted to provide colorectal surgery, urology, and gynecology care for these patients as a single provider.

As medicine became more complicated, a single provider became incapable of solving all problems in complex malformation cases without gathering a multidisciplinary team.

The speaker's vision was to unite GI motility specialists, colorectal surgeons, gynecologic surgeons, and urologic surgeons to work together in a unified approach for complex children.

Surgeons, particularly, like to be in charge and do not like to share patients or be told they cannot go first in an operation when another team needs to go first for the patient's benefit.

Hospitals face logistical challenges with collaborative care including billing, clinic scheduling with all doctors present on the same day, and managing surgeon productivity when a 10-hour operation requires a specialist for only 2 hours.

When a surgeon is needed for a portion of a long operation, they cannot leave to do other work because they must be available when needed while the patient is under anesthesia.

Patients with complex malformations face significant burdens when specialists are in different cities, including scheduling multiple appointments at different times and dates, travel costs, and sibling care logistics.

There are clinical circumstances where a child benefits from one operation where tissues can be shared between surgical teams.

In a case where a segment of colon was not working and the bladder was too small, a section of colon could be removed from the fecal stream and added to the bladder to augment it, performed simultaneously in one operation.

Typically, bladder augmentation would be performed first, and 6 months later someone would perform the colonic work as a separate operation.

Implementing collaborative care requires deep infrastructure including coordinators, administrative assistants, schedulers, and multiple types of specialized nurses (floor, operating room, clinic).

Nationwide Children's Hospital provided institutional support for the collaborative care model, whereas other institutions where the speaker had attempted this approach did not successfully adopt it.

The siloed approach to subspecialty care was the traditional way of practicing medicine.

In the collaborative model, 1 + 1 equals 3, meaning the sum is greater than the individual parts.

The collaborative care model could be applied to other hospital programs, such as a limb program requiring orthopedic surgery and rehabilitation medicine, where teams meet before the patient arrives and see the patient together on the same day.