He Said, She Said: “Do Your Job”

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He Said

The main reason I enjoy following sports is not entertainment, but rather because I am fascinated by how athletics reflect life’s themes with such clarity that the lessons are blatantly apparent. Earlier this month, the New England Patriots won the Super Bowl behind Bill Belichick’s “Do Your Job” command. In other words, perform your role as you are taught, trust that your teammates will do the same, and as a result, the team as a whole will experience success.

This same lesson applies to health care. In fact, practitioners actually use the word “team” when describing the collection of providers who collaborate to help a given patient. This treatment team consists of a primary care physician and any number of specialists, including psychotherapists, dietitians, physical therapists, and others who are all essential to the patient’s care.

Equally essential is understanding the importance of each practitioner doing his or her own job, no more, no less. Nobody is an expert in every single facet of health care; consequently, all providers have limits to their scopes of practice. One of the traits that separates the best practitioners from their peers is recognizing where their boundaries lie and taking care not to step over them.

Unfortunately, some practitioners, who no doubt have their hearts in the right places, exceed these boundaries. Quite often, Joanne and I encounter situations where other members of a treatment team have provided the patient with nutritional advice. The result is almost always confusion and a step backward in the patient’s care.

For example, one of my patients recently told me about different pieces of nutritional advice that his primary care physician and his personal trainer had given him. In both cases, the guidance he received was off base. My poor patient, he was so confused that the result was a temporary undoing of progress he and I had achieved together.

The doctor no doubt meant well. Doctors are absolutely critical in health care. Primary care physicians are trained to be first-line responders for conditions ranging from splinters to cancer. Specialists dedicate their lives to their individual disciplines, and their unique expertise oftentimes quite literally makes the difference between life and death. Personally, I owe an unpayable debt of gratitude to my neurosurgeons, Dr. Griffith Harsh and Dr. Jean-Valery Coumans, for giving me the quality of life that I have now.

However, doctors receive a scarce amount of nutrition education in medical school. According to one study, students received only 23.9 hours on average of nutrition instruction in medical school, which amounts to basically a long weekend workshop. That is almost 24 hours more of formal nutrition education than most people, but still nowhere near what dietitians receive.

During a Google search, I came upon a blog entry a doctor wrote in which he attempted to dispel the “myth” that doctors do not receive adequate nutrition training. He cited the mountains of organic chemistry, biochemistry, and physiology that medical students take in addition to learning about the roles that various nutrients play in the body. However, his argument only serves to prove my point. The hard science is of course important, but so is having a solid understanding and appreciation for how food is complexly intertwined with other facets of life, such as social, cultural, and financial factors. Dietitians, not doctors, receive this comprehensive training, which perhaps explains why so many patients come in here having been given rigid, unsustainable, and plainly unrealistic “doctor’s orders” regarding how to eat.

As a former personal trainer who still maintains my certifications even though I no longer practice as one, I can attest to the important functions that trainers serve. Great trainers can put together workout programs that increase safety, effectiveness, and enjoyment while simultaneously reducing the intimidation, confusion, and boredom that sometimes accompany exercise.

Having been through the personal training certification process and having worked in the field though, I can tell you that most trainers have no nutrition knowledge beyond what most laymen hold. Looking through the manual that I studied for one of my certifications, I see that the nutrition chapter is 15 pages long. As I have argued before, sometimes a little bit of nutritional knowledge is worse than none at all. Registered Dietitians hold degrees in the field, complete rigorous internships that include everything from chopping squash in a cafeteria kitchen to ordering intravenous feedings for intensive care unit patients, pass credentialing boards, and hold state licenses to practice dietetics. Fifteen pages versus all of that. From whom would you rather receive your nutritional guidance?

Similarly, we dietitians have limits to our expertise as well, and we must respect them. Because emotions can be so intertwined with food, strong feelings and deep-rooted issues sometimes arise during our sessions. Acknowledging these emotions and taking them into account are important parts of our work, but we cannot address them as effectively as trained therapists can. For that reason, providing the quality of care that our patients deserve sometimes means suggesting that they consider adding a therapist to the team.

Practitioners of all disciplines fill important roles in patient care, but if we want to achieve victory, which in this case means helping our patients to the best of our collective ability, then we need to follow Coach Belichick’s guidance by staying within our scopes of practice and trusting that everybody else on the team will do the same.

From the patient’s perspective, keep in mind that well-meaning practitioners sometimes reach beyond the bounds of their expertise in an effort to help, but the further he or she stretches, the less accurate the guidance is likely to be. If you want reliable expertise regarding a particular issue, then seek it from a practitioner who has dedicated his or her professional life to that specialty and let him or her do his or her job.

 

She Said

What an exciting Super Bowl that was! Jonah and I were on the edge of our seats for the entire game, and the finale was just amazing! It got us thinking about the Patriots’ motto this season: Do Your Job. It was clear that every Pats player had such an important role in that game and that each player did his job extremely well. In order to work together as a team, they needed each person to execute his job as he had been trained. And it really paid off!

The Pats slogan got me thinking about how eating disorder (ED) patients need a strong treatment team in place in order to recover. Each member of the treatment team needs to do his or her job to support the patient, and there needs to be a clear line of communication among all team members. In addition, each member needs to try to practice within his or her scope of expertise without taking on the others’ roles.

In ED treatment, the team can consist of a number of different players. If the patient is in an inpatient or residential program, the treatment team will likely include a doctor and/or psychiatrist, a nursing staff, a therapist, a case manager, residence counselors, and a dietitian. In an outpatient setting, the team ideally includes a physician, therapist and/or psychiatrist, and a dietitian who specializes in EDs. It could also include teachers, advisors, deans, coaches, and in some cases, the patient’s family as well. You know the saying that it takes a village to raise a child? Well, it takes a village to help a patient recover from an ED.

As much as we try not to do so, sometimes treatment team members will fumble the ball by giving advice that is outside of our scope of practice. I remember one of my patients had a therapist who was actually making changes to the meal plan I had developed for the patient without talking with me first. Although I am sure the therapist only meant to help, it gave the patient mixed messages about what roles the therapist and I would play. Similarly, there are times when my nutrition counseling sessions seem to take on a more therapeutic nature. Most people have a lot of feelings around food, eating, and weight, and sometimes it is difficult to know where the boundary lies between nutrition therapy and therapy! But I always strive to bring the conversation back to the food and then suggest the patient discuss his or her feelings more in depth with his or her therapist.

Another important aspect of treatment team work is that the team usually functions best when there is one quarterback running the show. In most cases, this individual is usually the ED physician or therapist, although sometimes it can be a case manager or even the dietitian. In reality, the patient is really the quarterback, but when he or she is really struggling with ED, a trained professional is the safest bet to step in and manage treatment.

Above all else, communication is the cornerstone of a successful treatment team. Clear communication, whether by phone, in person, or via email, can really make such a difference in a patient’s quality of care. If we are all on the same page, the patient will get a consistent message and hopefully feel more confident and secure that his or her treatment team is a cohesive unit that will help him or her eventually beat ED.

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