Читать книгу Concussion - Kester J Nedd DO - Страница 19
ОглавлениеConformational Intelligence – Another Point of View
DR. OMALU SPEAKS about “conformational intelligence” in many of his talks that I can relate to. There is a kind of status quo that exists in the realm of success and privilege, which unless you have a chance to deal with, is hard to understand. The people who demonstrate this kind of behavioral characteristic are all around us. It is about not breaking with established traditions and having everyone around you follow that path no matter what. As the saying goes, “if it isn’t broke, don’t fix it.” But it is broken, and traditions and fear have led to the chaos that we now see in this field. The real discoveries of the past and modern times have come from people who “think out of the box” and are willing to leave the draw of conformational intelligence behind. Following an established script may be attractive now and offers some level of security, but you can sacrifice your future and the future of others trying to hold on to traditional ways of doing things at times.
My story as a physician in a well-known academic center and spearheading the development of a large brain injury program illustrates what conformational intelligence is all about. I spent 25 years creating this program and subsequently saw the program go up in smoke when a new management team took over the hospital. Without their clear understanding of the program’s value, impact on the flow of patients through the system, the positive image of the hospital and community, positive financial impact on the system, and service to the community, the entire program was shut down without notice and without significant thought of how to continue the program or find a replacement. Yes, maybe I was too much of an entrepreneur. Maybe I did not fit all the traditional stereotypes of one carrying the message of brain injury at a major medical Institution. Maybe just having trained at the same institution and going on to develop your own way of thinking was not seen as prestigious. Yes, maybe there was someone else out there who could do a better job. And maybe the ego of one or more of the leadership team was just a little bit bruised. Thus, shutting down an economically viable and sustainable program without notice or explanation was the thing to do. Starting in 1988, when TBI and concussion were like a foreign language to neurologists, few training programs in neuroscience incorporated training for students and residents to include the evaluation and treatment of TBI/concussion. Around that time, I was part of a growing movement of neurologists who took an interest in developing the field of neurological rehabilitation and brain injury. I must give credit to the protection and support provided by many of the old forerunners in the field of neurology, some of whom are not alive today. They gave me a chance to develop a program with my own creativity. I am forever grateful and thankful to my many professors and the visionary leaders at the University of Miami, Miller School of Medicine, and the Jackson Health System who overlooked my many limitations and gave me a chance. Visionary doctors such as Peritz Scheinberg, Noble David, Barth Green, Walter Bradley, and many others not mentioned here took a risk but gave me an opportunity to develop this program. With little administrative skills and financial support, I was able, with the help of others and my team, to build a strong program. There was a time when we had 60–80 patients admitted to the different hospital departments, being treated for some form of TBI or concussion. The centers included the inpatient and outpatient neurological rehabilitation unit and an acute early intervention neurological rehabilitation program, known as the Intermediate Head Injury (IHI) unit. In the IHI unit, patients were transitioned from the ICU. Our version of the IHI unit was one of only a few that existed around the country at the time. I recalled going through the trauma accreditation site a few years ago when one of the reviewers said to me that this concept of the intermediate brain injury unit was transformative, beyond its time, and he wished that others would adopt such a program. He further indicated that in his entire career as a neuro-trauma doctor, he had never seen this kind of transitional program in the acute care settings, where early neurological rehabilitation intervention was introduced to manage physical, cognitive, and emotional disabilities while in the acute care. The success of this program lay in aiding discharge planning, identifying challenging neurobehavioral, cognitive, and physical impairment early, and providing early treatment interventions to avoid longer-term challenges. This is where we learned the value of early intervention instead of the wait-and-see approach that many programs have adopted and continue to practice even today. On the IHI unit, we were able to take patients at a time following their injuries where most physicians and nurses felt uncomfortable with providing care. This is when I believe TBI/concussion patients are the most neglected, and the consequences of such neglect have major long-term implications for the patients, their families, and society. This stage of care was in the intermediate phase between the ICU and going to the rehabilitation center, prior to going home from the acute care, or before going to a long-term care facility from acute care. This was the stage where patients are treated for some of the most difficult signs and symptoms associated with TBI and concussion, such as agitation and aggression, pain, medical complications, and some of the worse physical, cognitive, and neurobehavioral impairment. It is during this period that the brain starts to develop compensatory behavior that can have long-term effects on recovery. Be that as it may, in hindsight, given the value of such a program, I wish I had done a little more in my time to promote this concept nationally. The impact of this kind of system on patient care, physicians, families, and the outcomes of the patient were impressive. This together with an integrated neurological rehabilitation program operated by neurologists for many years provided us a unique opportunity to marry physical rehabilitation, neuropharmacology, neurophysiology, neuro-cognition, and neuro-behavior with function based on the limitations noted in brain organization. It was in these programs that I truly learned the concept of brain hierarchical organization and got to understand what recovery and outcomes meant. We saw a large number of patients with varying degrees of severity of injuries and worked with neurologists, trauma surgeons, neuropsychologists, orthopedic surgeon, oral-facial maxillary surgeons, neuro-radiologists, rehabilitation specialists of all kinds. We had the best laboratory to not only evaluate and treat brain injury but also to understand the natural history of how a brain recovers. I can confidently say that there are very few programs today that allow for such comprehensive and inter-disciplinary evaluation and treatment of TBI/concussion. I was fortunate to be at the helm of this program. It gave us a chance to develop certain principles to treat brain injury that has restored many lives and allowed others to achieve a level of functional independence that they would not otherwise be able to. I chose to write this book for generations beyond because of the unique opportunity I had and hope that it will stimulate others to develop similar programs.
At that time, we were the only level 1 trauma center in all of Miami-Dade County for almost all the years I practiced, and all trauma patients came to our center. This is no longer the case. I can confidently say that Jackson Memorial Hospital had the best laboratory over the years for us to truly understand the natural history of TBI and concussion. While we were able to conduct some studies, we did not have clear leadership in place to do what was required to provide the kind of research needed, and that I regret.
Other than the fact that certain decisions often made by administrators may have come from a place of fear, anger, hatred, self-centeredness, traditions, and biases, shutting down a brain injury program with over 25 years of history that was clinically relevant, financially sound, independently self-supporting, and with an excellent reputation was a travesty. This left a huge gap in trauma care at our institution, starting from acute care to neurological rehabilitation and into the outpatient system. The motivation for the move remains a mystery to the doctors in the system, nurses, therapists, and the community. I truly believe that unless someone else could provide a better explanation, this situation best fits the term conformational intelligence gone loco. I have seen this type of situation with many of my colleagues around the country, and in one national meeting, this was forwarded as an issue. At the time, I did not think our program would come to the same fate and freely gave advice to others that I could not take myself. Putting myself out there would give administrators, board of directors, medical professional organizations, legislators, physicians, nurses, and patients a voice to say no to zealous leaders who do not understand the facts about how their decisions can impact not just a delivery system but also the lives of people needing care. I can speculate what was on their minds, but to date, no explanations were provided for the move.
I am telling you this story because I see this as a trend in the field of brain injury and just about all of medicine in the country. The boards of hospital systems and the senior leadership of programs should be transparent and accountable when making such decisions, as these concerns need to be thoroughly evaluated. Too many of my colleagues are now reporting this sort of irrational approach to administration, which has created great insecurity for professionals who want to maintain programs at major healthcare institutions, because of radical and frequent changes in the leadership and, hence, the direction of health institutions. There was no due process and no forum to openly debrief our feelings about the sudden end of the program, neither for me nor all the people working for and with me. Such examples discourage young professionals who would otherwise choose a career in academic medicine. This is where the checks and balances need to be put in place. Administrators must present clear reasons and explanations for such decisions. I see a brain-drain move and a level of instability created in many strong programs because of those kinds of decisions and rogue administrators. While many decisions may prove to be financially sensible or logical at a time for programs that are seen as a financial drain on the system (this was not our case), not all care can be profitable in medicine. There are “economically lost leaders”, and that is particularly true for medical specialties. Tendering the issues of finance and care takes special administrators and physician leaders. Unlike what we see in the banking and financial industry, medicine and health care must be looked at through a different lens. I had a conversation with a parent whose son had made multiple suicide attempts, and when discharged from a psychiatric hospital in Miami after his last Baker Act, he reported feeling less than a human. He had been stripped of all his clothes and placed in a locked-downward with highly psychotic patients who had no sense of reality. By the time his mother discovered our clinic, Design Neuroscience Center in Doral/Miami, Florida, she had exhausted all the resources she could access, but it had made her son worse. His mother made a profound statement that made me sit up and take note: “I cannot imagine how many people leave the emergency room, doctor’s office, or trauma center and never get a follow-up after a concussion or TBI.” We have no idea how many of the patients who leave acute-care settings after a TBI/concussion go home and become depressed, anxious, and suicidal, lose their jobs, have challenges in their marriages, perform poorly in school, and just literally experience some extreme breakdown in their lives. Very few studies have been performed on this subject. If you are a medical professional, think for a moment about all those patients whom you discharged and never saw again. What happened to them?
Well, here is the real deal. Many of them are living productive lives in society. But there are also those who get arrested or become drug addicts, engage in antisocial behavior, and have trouble integrating with society or have chronic emotional, physical, and neuropsychological disabilities. Hospital administrators and physician leaders, think of those clinics you could have invested in but didn’t because you wanted to divert resources to more lucrative health care ventures. Think of the program you could have funded to train more doctors, therapists, and psychologists to treat this traumatic condition.
Having said this, at the time of the publication of this book, I was on the frontline in the field, serving as Medical Director of the Sports Concussion Program at the University of Miami. I am forever grateful for this opportunity to be trained and subsequently to work for this fine institution.
I am about to brag just a bit about the very positive aspects of the Concussion USports Program at the University of Miami. I feel proud to see that despite many challenges, this program has advanced beyond our wildest dreams with grants from major institutions, while also meeting the needs of injured athletes. Our fearless leader, Dr. Gillian Hotz, has done an outstanding job in moving this program forward. We now serve most of the sports injuries from the high schools (third-largest high school system in the nation) and some of the universities in Miami-Dade County. The USports Concussion Clinic by working with athletic trainers, has built a unique system of monitoring, evaluating, and following brain-injured athletes. This program has been in place for many years and the real recognition comes from the people we treat by solving complex issues associated with concussions, thereby allowing them to return to play and to the classroom, and to lead successful lives.
Since my departure from the Jackson Memorial Health System in 2014, a hospital affiliated with the University of Miami Miller School of Medicine, I have been fortunate to have created a comprehensive brain injury program (Design Neuroscience Center) in Doral/Miami Florida, where we attend brain injury patients in a multidisciplinary program with 5 neurologists, 1 PM&R, a team of neuropsychologists, physical therapists, occupational therapists, and speech and language therapists. We treat patients at all levels of injury and recovery and from the local and international communities, following many of the principles of the BHET methods. Clearly, the training, experience, and opportunity to lead at Jackson Memorial Hospital and the University of Miami prepared me for this venture.
Our community needs experts who are sincere, hardworking, and smart and can build teams providing a comprehensive program that works. Administrators who are touched by science, the patients, and their humanity. Of course, there is the need for financially savvy individuals who can think out of the box. The key to success is building the right team and doing all within our power to preserve a sustainable working system. It can take years to hone talent and gather experience, but these can be thrown away by an uncalculating political establishment in an academic setting or hospital system.
Individuals involved in the evaluation and management of TBI and concussion represent a really small community, and stakeholders must be aggressive in preserving such systems of professionals and organizations.
I want to express my opinion in the most profound way: when you look at what is going on in the field of brain injury and notice the chaos, you can understand why it is so difficult to find fundamental answers for the care and treatment of TBI/concussion patients. On the one hand, the consumers and patients are screaming for answers. On the other hand, the people who are in a position of power in the medical, administrative and political establishment are a generation behind, promoting traditional values (confrontational intelligence), egotism, elitism against a backdrop of tokenism, and limited diversity. This is not only about culture and preference but also about ideas and looking at the coin from both sides. Many in our healthcare and business systems will tell you they believe in diversity and freedom of expression. However, their actions clearly reflect that they do not give themselves a chance to think out of the box. In the spirit of protectionism, they can throw away the most important ingredient without even realizing it. Institutions are building edifices that carry great names from donors, but there is little focus on programs and people which can make a difference. It is time for our leaders to not only invest in buildings, but we must also invest in people and programs. At a time when one of the hottest issues in medicine is brain injury, I encourage hospitals around the country, which are addled about what to do and where to go, to wake up and make a difference. We can address this issue by building a continuum of care for TBI/concussion patients together with the support of the community. This system is badly needed in our community and the country. Unfortunately, very few out there have the knowledge, experience, and the desire to do so. This must change!
So, what else is hindering advancement in TBI/concussion?
There is another controversial subject that I believe has negatively impacted the TBI and concussion movement in the USA. While I may be castigated by my colleagues for the very mention of this subject, I cannot finish this book without it. There is a huge fight going on in the medical field among physician specialties to determine who should treat this disease. Despite the limited number of professionals treating persons with TBI/concussions, there is a kind of warfare going on behind the scenes between the physician specialists. Leadership’s role is to get people to work together and make peace so that we can preserve programs that need to be preserved, thus creating sustainability and better outcomes.
You see, for more than 20 years, there were no physical medicine and rehabilitation (PM&R) specialists in our program at Jackson Memorial, and pretty much all of neurological rehabilitation was controlled by neurologists. When the PM&R physicians were introduced to our institution, the administrative and medical leadership allowed the development of a very toxic and competitive environment to thrive instead of uniting the PM&R program with the established neurological rehabilitation program. Simply bringing in a new specialist program without consulting the folks running the program in the first place created an all-out war between the neurology and the PM&R departments. The leadership did not take the time to understand this conflict between PM&R physicians and neurologists, which in my opinion contributed to the demise of the program as we knew it. Several of you around the country may relate to this issue. Hospital administrators and university leaders fail to understand the need for a unified interdisciplinary approach to this complex critical science, whereby both specialists working side by side would have clearly improved the program, as there was enough business for all parties to share.
This issue has been a source of chaos in our business. Unfortunately, a silent divide exists between certain specialties in medicine. I can only speak about that between the PM&R and neurologists treating TBI/concussion because I have lived it and observed similar ones nationally. This kind of political divide in medicine is driven by economics and the desire for control and political power. I hear my neurology colleagues often say that we should be the ones treating brain injury. We know more about the brain than anyone else. The evolution of care for persons with brain injury treatment and rehabilitation came out of major military conflicts where orthopedics and neurosurgery initially had the responsibility of brain and spine acute care and rehabilitation. They abdicated the responsibility of rehabilitation to the emerging field of PM&R. Neurologist, while heavily involved in the science of brain injury, took a long time to get engaged in the care of patients with brain injury in an organized manner. Most neurology training programs do not offer training in TBI and concussion. PM&R, on the other hand, has reorganized the field of brain rehabilitation by introducing the interdisciplinary team approach together with the measures of outcomes, which became their claim to fame at the national level. There are ongoing formidable studies in the field, which are transforming lives, being conducted by interdisciplinary teams of specialists that include neurologists, psychiatrists, PM&R physicians, neurosurgeons, primary care physicians, orthopedic surgeons, neuropsychologists, and other specialists and therapists.
I applaud the fact that the PM&R establishment has done a much better job than our neurology colleagues in providing leadership in brain injury rehabilitation research, program development and management, evaluation scales, and tools. Moreover, it has influenced the political establishment of state and local governments in ways neurologists could not.
Passionate chairpersons in PM&R have taken on this movement with fervor, leading to their success and dominance. On the contrary, neurology leadership has not taken on this issue in a manner that would have allowed them to thrive. Neurologists often see themselves as better prepared to handle some of the issues in TBI/concussions, but in terms of providing care, most neurologists have taken the view that this kind of patient is for another specialty to handle. Irrespective of the side of this issue, we all have biases, but we also have certain strengths and weaknesses from our training and how we are cultured at the institutions where we were trained. Also, let’s not forget our own worldviews.
This single issue has stymied the development of our science and program and is like cancer in the development of programs in neurological rehabilitation and brain injury. Neurologists who study neuro-behavior, neurophysiology, and the neuroscience of recovery are more equipped in those areas through training. PM&R specialists are more equipped in their training on all aspects of physical medicine and rehabilitation. Neurologists can clearly be trained in physical medicine, and PM&R specialists can be trained in neuro-behavior and neuro-cognition. This divide is not only evident at the hospital and university levels but also in our national organizations and in how the government and other political entities treat our specialties from a funding standpoint. The most successful programs around the countries are those where the disciplines collaborate.
Yes, the consumers and other stakeholders need to know this. There are silent wars going on in medicine for who should treat you and with what treatments. Everyone is weighing in, and if you have enough organizational support and will, you win.
Even as a very recent specialty group with a fraction of the members compared to neurologists, PM&R is well organized to address rehabilitation issues. I cannot tell you that I am not without fault in being so critical about my neurological colleagues, but this is the big picture. Allow me to generalize for a moment: I find most neurologists are traditionalists, sometimes unwilling to think out of the box at times. We as neurologists have sometimes set standards that we can’t even keep. We have forgotten the fundamentals of financial sustainability and sensible policy: the administration of our facilities holding the purse strings, our politicians, and the influence of populations of persons that we care for.
Internal politics are prevalent in various fields. I will get on the soapbox to say this, “Stroke has become synonymous with neurology.” It is sad to say that this issue is present in just about every training program. It is stroke neurology, and more stroke neurology, only to be matched by neuro-hospitalist and critical care neurology. Follow the money! Now we are complaining that over the years, psychiatrists have taken over dementia from the behavioral neurologists, and the neuro-radiologists and neurosurgeons have taken over vascular interventional procedures and reading MRIs. We also mourn that the PM&Rs are now taking over the electrical studies of muscles and nerves.
Just look at the Medicare fee schedule and see who is being paid the most. Surgeons and medical physicians who do procedures rank as the highest-paid. Surgeons perform surgical procedures in medicine that take under an hour, and I as a neurologist see a patient with complex brain injury, educate the family, and let’s not even talk about documentation, which takes a considerable amount of time compared to documentation from other specialists. For the same amount of time spent, doing a neurological consult, someone doing a procedure will be paid more than 3–4 times what I will generate in income in some cases. So, you ask the question, why have we not focused on brain injury as a business in health care? Does it not pay enough or pay well? Mental health is now classified as among the least reimbursable disorders in medicine, and that is where brain injury fits. In fact, my neurology and PM&R colleagues have relegated the treatment of neuro-behavior to psychiatrists, who like most neurologists, generally get little or no training in concussions and TBI. No wonder we use more psychotropic drugs to manage brain injury, often making the patient worse and potentially retarding recovery. And yes, these issues of conflict in our field are affecting the outcomes of our brain injury patients. The programs that work best in rehabilitation have an interdisciplinary working relationship between PM&R, psychiatry, neurosurgery, neurology, and others. The leadership in PM&R, psychiatry, and neurology are not communicating at a level that is sensible. I will tell you that this has filtered down to the residents in all of our specialties, and I hope that the next generation of leadership can tackle this issue head-on.
Still on the soapbox!
Here is another issue that we have to face from time to time. Today, the field of neuropsychology is growing, and we are encouraged by the added number of neuropsychologists in the field of brain injury. If you want to get a neuropsychological test performed on a patient, you can find many neuropsychologists ready to test but very few available to treat. A neuropsychologist can spend 4–8 hours testing and generate between $1500–$8000 in the USA. The same neuropsychologists administering treatment for an hour with a patient can barely generate $80–$100. It is no wonder the field of neurocognitive therapy treatment is not developed to match the level of demand that exists in society. In fact, the purists in our industry go further by saying that cognitive therapy does not work. While we need further studies on the subject, I know that TBI/concussion patients improved with neurocognitive therapy. Just imagine, the monthly cost of one of those psychotropic drugs we use to treat brain injury can range from hundreds to thousands of dollars. In some cases, these drugs have a profound negative effect on the outcomes, yet we use them. So, where do cognitive neuropsychological therapists fit in all of this? This is not to say that neuropsychology is good, and medications are bad; that is far from the truth because we need both.
While I will be reprimanded by many in our industry for mentioning these volatile issues, I feel upset but also encouraged and hopeful. I have taken the negative experiences and positive opportunities and put them in context. There is no time for wallowing in our past disappointments, but we must contextualize the issues of the past to learn from those experiences and forever ride over the bumps of inattention and regrets moving forward.
