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Collaborative Triumph Part 1

Posted By Julie Kaprelian, Linda Rio, Friday, December 5, 2014


This is the first of a three part series on real stories from real people who have experienced collaborative triumph. Check back for more next week


Approximately 2 ½ years ago, leaders in our field wrote brief anecdotes of their own collaborative care ‘follies’ in the main CFHA blog. These ‘aha’, ‘uh, oh’, ‘doh!’ or ‘SMH’ moments covered good learning points and insight. They normalized the experience of an accidental misstep or foot in the mouth in their efforts to provide solid collaborative healthcare. Veteran and novice collaborators alike took comfort (and perhaps a little chuckle) in knowing they weren’t alone, and took note of possible minefields to avoid!

In this series, we complement the problem based narrative with a strength based one and offer similar learning opportunities through collaborative triumphs! We focus on stories that emphasize ways to address family concerns in a collaborative setting and the importance of including family on the care team. Patient concerns do not occur in a vacuum; we are inherently social and relational creatures. Regardless of how well patients’ families are connected, involved, and aware of patient concerns, they impact patient well-being and vice versa. So, sit back, relax, and enjoy (and learn) as new and established professionals take you through stories of collaborative success. 

For a refresher on the Collaborative Follies blogs, click here, here, here, and here.


What else can I do for them?” is a common question that I hear again and again from pediatric residents in their weekly pediatric continuity (primary care) clinic.  It is inherent that they want to practice best medicine while meeting all of their patients’ need.  I have been providing integrated primary care services to the pediatric residents’ continuity clinic for several months and while implementing the service has been challenging, there have been important triumphs along the way – both for patient care and the department’s providers.

A week into summer vacation, 10 year-old Sara presented with her mom to see her pediatrician, a third year pediatric resident.  Mom had called the department for an appointment a few days earlier stating that there had been concerns raised by teachers about Sara’s back and the way she walked; Mom wondered if she injured it while playing softball but had not noticed anything unusual herself.  The resident obtained an account of the presenting complaint and completed a review of systems and physical exam – everything was within normal limits.  The resident thought it was peculiar that Mom reported that Sara ran around and played typically at home but that teachers went as far as asking Mom, “Does she have scoliosis?”  When the resident asked Sara about her “crouched walking” at school, Sara stated that she didn’t know why and immediately became tearful.

The resident briefed me on the situation and asked, “What else can I do for them?”  She knew a referral to Orthopedics was not indicated based on physical exam but also did not want to simply say, “Come back if the problem continues.” Integrated primary care allowed us the opportunity to discuss the patient’s presentation, consider additional relevant questions, complete a successful warm hand-off, and speak to the family together about the likelihood of anxiety playing a role as there was no organic cause.

The last time I saw Sara it was a shared visit with her pediatrician 

Sara came to see me in pediatric primary care for four brief visits over a period of 3 months.  She identified that her first trigger was presenting a project to her class; from there her anxiety escalated at school.  I encouraged her to practice getting into that stance in the privacy of her own bedroom and then practice regaining a straight posture.  She practiced this regularly and at her next visit was able to show me this in the exam room; she established mastery and control.  She then was able to identify a few other academic stressors that triggered her anxiety; psychoeducation and establishing coping strategies helped to decrease these.  Parents remained closely involved and encouraged her to practice her new skills at home; this was critical as parents helped her maintain an awareness of any physical responses.  The last time I saw Sara it was a shared visit with her pediatrician. She excitedly shared that she had gone to 5th grade orientation the day before; she met her new teachers, saw her classroom, and talked with peers.  She approached the next school year with enthusiasm and the knowledge that she had the resources to manage her anxiety effectively.  Parents were grateful and pleased that they were able to return to Pediatrics for any additional questions or concerns. 


In the pediatric residents’ continuity clinic we reviewed this case and continue to regularly review the patient cases that warranted an integrated care visit to understand how this model and family involvement provides better patient care and provider satisfaction.  We use this time to ensure that residents and attendings recognize that the reasons to complete a warm hand-off to the behavioral health provider are endless.  There is no neat, comprehensive list titled “Patient presentations that warrant bringing a behavioral health provider into the exam room” – rather it becomes educating the pediatric residents early on in their training that it is alright when they do not have all of the answers and how to then effectively use the available resources in an integrated model.  The opportunity, as a team, to collaboratively work with the family on answering the question, “What else can WE do for them?” improves the outcomes for all involved.


Julie Kaprelian, PsyD is a licensed psychologist and currently completing a two year post-doctoral fellowship in Pediatric Psychology at Marshfield Clinic in Marshfield, Wisconsin. She provides consultative-liaison services and brief therapies to children, adolescents and families within the inpatient services at St. Joseph’s Children’s Hospital in the pediatric, pediatric intensive care, and neonatal intensive care units.  She has especially focused on program development while at Marshfield Clinic, specifically designing, implementing and assessing integrative pediatric primary care services within Marshfield Clinic Pediatric Residents’ Continuity Clinic and Department of Pediatrics.  She has presented preliminary findings of patient experience and satisfaction data at the Rural Behavioral Health Practice: Integrated Care in Rural Practice conference this past October, with plans to present final program data to Marshfield Clinic and involved organizations later this spring.  Her clinical and research interests include pediatric psychology, integrated primary care in rural settings, coping with chronic medical conditions, and program development. 



In my fourth private practice psychotherapy session with a 25 year old woman I knew that serious collaboration would not only be desirable but required. As this very thin, frail and ‘anorexic-appearing’ woman began to sob violently, she then became enraged as she talked about an altercation with a fellow-employee. Then she suddenly lost consciousness and collapsed into my arms as I caught her to prevent her from falling onto the floor of my office. I had many prior personal experiences with fainting/syncope episodes so I noticed the subtle signs just seconds before. I did not panic and assessed her basic vitals. I considered a 911 call but she regained consciousness and begged that sirens not be called. A friend was called and took her to urgent care, with a follow-up the following day with her PCP.

Over the course of her 24 month treatment I consulted (gaining appropriate consents) with her primary physician and due to my odd speciality with the hormonal-mental health connection I recommended an endocrine consult which he  agreed after her initial blood work showed my suspicions might be correct. Her endo and I spoke several times, especially since several trials were necessary to find the correct hormonal intervention. No signs of pituitary or adrenal disorders were found. This woman had severe menstrual irregularities and reported virtually no libido which was affecting her relationship with her long-term boyfriend. A host of additional issues were reported in her medical history. An eating disorder was ruled-out but only after I referred her to a nutritionist who specialized in working with eating disorders.

I met several times conjointly with this young woman and her boyfriend to assist in helping him understand that her lack of libido was medically/physiologically-based and not due to any deficit on his behalf. This was a difficult and sensitive issue for him to understand as well as for her to try to communicate to him. Other members of her family were also intermittently involved in family therapy sessions to help all better communicate and deal with the host of her perplexing behaviors that included depression, anxiety, low-energy, anger, and this woman’s general frustrations about her ill health. She was also sent home from work due to anger outbursts as well as tearful episodes that left her unable to function in spite of being well-educated and previously very competent. Her employer’s EAP case manager and I also spoke on several occasions due to fears about potential workplace violence (there was none).

I knew that serious collaboration would not only be desirable but required 


After 18 months of endocrine treatment menstrual balance was achieved and eventually also a return of sexual interest. Other health concerns were also finally resolved. She and her boyfriend got married. She maintained her job and eventually received a promotion. I don’t see her anymore but look forward to her occasional email updates.                                    

Mental and/or physical health issues do not just affect an individual. This young woman’s overall health concerns were intimately connected to her intimate/sexual relationship and her erratic and fluctuating moods certainly were a concern to her boyfriend as well as work relationships. Collaborating with all her physicians was essential to getting to core issues and helping promote an overall improved quality of life. 


Linda M. Rio, MA, MFT, is a Marriage and Family Therapist (MFT) in private practice in Southern California for over twenty-five years.  Her recent book, The Hormone Factor in Mental Health: Bridging the Mind-body Gap (2014) brings together contributors from around the world in the fields of endocrinology, medical research, psychiatry, nutrition, medical family therapy, and patient advocacy in addition to case studies and actual accounts from patients themselves. She has been an invited speaker at national, state, and local conferences, graduate and post-graduate educational institutions and others including: The American Association for Marriage and Family Therapy (AAMFT), The Collaborative Family Healthcare Association (CFHA), and The California Association of Marriage and Family Therapists (CAMFT). Linda is also one of the editors for, Pituitary Disorders: Diagnosis and Management ,(2013), which focuses on education for primary care physicians, nurses and others.

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