NASP Home > NASP Resources > NASP for Principals > NASP Principals Articles 2004-2005 > Collaborating With Physicians
Principal Leadership Magazine, Vol. 5, Number 1, September 2004
Counseling 101 Column
Collaborating With Physicians: A Guide
for School Leaders
Collaboration between educators and physicians can make
it more likely that students with medical conditions will be successful in
school.
By Steven R. Shaw, Mark C. Clayton, Jodi L. Dodd, and Ben T. Rigby
Sooner or later, most educators will work with students who have significant
medical or mental health problems. Developing a collaborative relationship
with physicians or other health-care providers can be important to supporting
these students’ unique needs and can make a tremendous difference in their
academic performance and overall school experience.
However, a number of barriers can make this collaborative relationship difficult:
Schools and health-care providers may have different definitions of disability,
there may be misunderstandings about the roles of educators and the roles
of parents and their health-care providers, and there may be differing approaches
to supporting children with acute and chronic health conditions.
Often, these barriers prevent communication between the school and the health-care
providers, which leaves the student and his or her family to navigate the
confusing, often stressful process of aligning medical and school supports.
Further, educators may find themselves in an adversarial relationship with
health-care providers. For example, a physician might demand that a school
provide special education or therapeutic services. In such a situation, educators
may view the physician as arrogant, disrespectful of school policies, or
ignorant of the school’s laws and regulations. Conversely, physicians may
receive notes from teachers or principals suggesting that they prescribe
medication for a student with behavior problems or they may receive a copy
of an IEP filled with educational and legal jargon. In these situations,
physicians might view educators as practicing medicine without a license,
providing information that is irrelevant to a student’s medical issues, or
misinforming parents.
Although these charges may contain a grain of truth, such perceptions often
interfere with the relationship between educators and physicians (Shaw & Páez,
2002). Even with the best intentions, a physician probably has limited resources
to proactively reach out to a school unless the lines of communication are
obvious and effective. Usually it is up to the school—and particularly the
principal—to take the lead in establishing constructive working relationships
with community health professionals. Principals can work with their staff
members to put the necessary systems in place at the outset of the school
year and can set the tone for the resulting collaborative relationships with
physicians or health-care providers.
When Is Collaboration Needed?
Issues of collaboration between schools and health-care providers are not
a concern for most students because the majority of students experience few,
if any, serious health or mental health concerns during their school years.
When health and mental health concerns do arise, however, they can require
significant amounts of staff time, increased home-school communication, and
conferences with health-care providers. These concerns may be as serious
as addressing a terminal illness or as transient as addressing homebound
services while a student recovers from surgery or injuries. For some students,
a chronic health condition such as asthma or diabetes—or a disability such
as attention deficit hyperactivity disorder (ADHD)— will require long-term,
ongoing collaboration among educators, families, and health-care providers
to ensure consistent and effective support.
Understanding the nature of the health problem and the different perspectives
and responsibilities of health-care providers and educators are the first
steps in creating the plan that best meets a student’s needs.
Systemic Barriers
When addressing medical conditions and disabilities, physicians and educators
use different but parallel systems of diagnosis, service delivery, and treatment.
Physicians use the International Classification of Diseases (ICD-9) and the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR) criteria
for making diagnoses. Educators use the guidelines set forth in the Individuals With Disabilities
Education Act (IDEA), which are refined by regulations in each state and
implemented by local educational agencies.
Although there are many differences between these two systems, there are
also enough similarities to create confusion. For example, a physician may
diagnose a learning disability in a student but educators find that the same
student is not eligible for the learning disabilities classification within
the special education system. Or a physician requests educational assistance
for a student with ADHD, but educators do not believe
special education services are appropriate because there is limited evidence
that the student’s school performance is impaired by ADHD.
Who is right in these scenarios? Actually, the physicians and the educators
are both right. Physicians are making correct diagnoses and recommendations
based on ICD-9 or DSM-IV TR and a medical model approach to treatment. Educators
are correctly using state education department criteria for disability classification,
complying with local procedures to implement IDEA, following legally and
educationally appropriate safeguards, and developing an effective educational
treatment plan.
Moreover, physicians make individual diagnoses while educators determine
special education eligibility and other service needs using a team approach.
Physicians do not use prereferral interventions or resistance to intervention
models, nor do they often consider students’ functioning in the context of
the classroom. Educators rarely consider family history, neurological findings,
or lab results when making eligibility or program placement decisions.
A Model for Effective Collaboration
Team Up
How can professionals using different approaches to diagnosis and service
delivery work collaboratively? First, both professions must understand that
there are already two equally legitimate and valid systems in place. Second,
they need to appreciate that in many cases neither health-care providers
nor educators alone can provide effective services to children. Teamwork
is a requirement, not simply a refinement, and is particularly important
when dealing with conditions that do not have an obvious, clear-cut effect
on a student’s school performance (see figure 1).
Respect Professional Boundaries
The first stage of collaboration is to respect the formal boundaries of
the medical and educational professions that are established by state certification
and licensure laws (Drotar, 1995). Physicians should refrain from dictating
school educational placement decisions or educational techniques. Schools
should refrain from suggesting medication decisions or making medical diagnoses.
Information, however, can easily go across formal boundaries. For example,
a teacher may report, “Since she started taking her medication, Jane has
been falling asleep in class.” Or a physician may note, “Since she started
in the gifted class, Jane has had severe abdominal pain with no known medical
origin.” Although information sharing is important and needs to be encouraged,
professional judgment and decisions about how to apply this information should
be left solely in the hands of the appropriate professional.
Invite Participation
Although it is important to respect formal boundaries, there also must be
an informal process that reaches across barriers; there are few activities
that develop interdisciplinary relationships as much as a physical presence
(Talley & Short, 1995). When educators take time out of their busy schedules
to attend a student’s hospital discharge conference, they demonstrate a significant
commitment to working as a collaborative team. When a physician takes the
time to attend a patient’s IEP team meeting, the commitment to the collaboration
is equally clear. However, tight schedules and pressures to earn clinical
revenue and comply with third-party reimbursement rules make personal appearances
difficult for many health-care providers. It is helpful to identify other
means of participation, and inviting other professionals to review reports
or provide written input regarding a student’s progress is one of the best
ways to collaborate across barriers without the time or financial demands
of a personal appearance. For example, teachers can be encouraged to be involved
in the evaluation of efficacy and unintended effects of medical management
of behavior. Or school team members can be encouraged to invite a pediatrician
or neurologist to review the IEP for any activities that may be medically
contraindicated. Taking the initiative to invite the participation of others
is important to developing a cross-disciplinary relationship.
Communicate Effectively
The basics are also important. Return phone calls in a timely manner. Make
yourself and your staff members available by phone, fax, and e-mail. Remind
teachers and staff members to communicate in a jargon-free manner. It can
also be helpful to have a brief fact sheet that outlines your school’s general
approach to collaborating with health-care providers and includes contact
information for appropriate staff members. This fact sheet can be given to
parents or sent directly to the provider’s office.
Use Liaisons
Because medical and educational systems have very different vocabularies,
using a medical-education liaison as a translator of information is often
a helpful way to ensure that both professions understand each other (Stuart & Goodslit,
1996). The liaison is usually a person with experience in both medical and
educational environments. Examples of professionals who are well prepared
to act as liaisons include hospital-based teachers, school nurses, school
social workers, and school psychologists.
Establish a Medical Transition Team
A medical transition team can take the lead in addressing the educational
needs of students with medical problems. This team will typically include
the medical liaison, the school nurse (if the nurse is not the liaison),
a school administrator, and other relevant staff members. Someone on this
team should also serve as the point of contact for the physician. The configuration
of the team might change slightly depending on the nature of the health problem.
For instance, the school psychologist and special education teacher typically
would be part of the team assisting a student with a traumatic brain injury,
but might not be involved with a student diagnosed with cancer.
Present the Facts
There will also be times when your staff members will be expected to present
their findings through a telephone or face-to-face conversation. In these
situations, it may be helpful for school personnel to adopt a medical model
of case presentation to help organize large quantities of information into
the pertinent positives and negatives. In other words, leave out all judgments
and information that are not essential. Adopting the following tips for case
presentations may be helpful:
- Include
the patient’s name, age, ethnic origin, sex, and reason for referral in the
opening statement.
- Address
all relevant historical findings (e.g., birth trauma, history of brain injury,
developmental delays, academic progress over time, or placement in a special
education curriculum).
- List
relative strengths and weaknesses of the student through observational comparisons
to other children in the class.
- Determine
the behavior, cognitive, social, and academic requirements of the classroom.
- Given
the evaluation results, list the top three or four recommendations that will
help the student. There will likely be more than three or four, but remember
that your main goal is to communicate interventions that need to be addressed
by the physician. A quick statement regarding the other areas addressed in
your recommendations might be helpful. (For example, “Several suggestions
were made regarding IEP goals that might help this student improve her handwriting.”)
This assures the physician that the more systemic issues are receiving attention.
Engage Parents
Before the collaboration begins, make sure that parents have completed all
appropriate release forms and understand the nature of the collaboration.
Most parents believe that such an interdisciplinary relationship can only
help their child; however, some parents choose to keep medical and educational
issues entirely separate. The parent’s right to such a separation must be
honored. In these cases, however, the school might request that the parent
provide an appropriate staff member with any important information regarding
their child’s treatment, medication, and symptoms to facilitate the school’s
ability to support the child’s needs.
The Ultimate Beneficiary
Collaboration between educators and physicians can be an exciting and rewarding
experience, and school administrators play a key role in ensuring effective
collaboration. When educators follow simple tips for collaboration and educate
themselves about the needs of various professions, they can build strong
working relationships with health-care professionals that are based in mutual
respect and clear communication. When all the players within the team work
together, the student ultimately reaps the reward. PL
References
- Drotar,
D. (1995). Consulting with pediatricians: Psychological perspectives. New
York: Plenum Press.
- Shaw,
S. R., & Páez, D. (2002). Best practices in interdisciplinary service
delivery to children with chronic medical issues. In A. Thomas & J.
Grimes (Eds.), Best practices in school psychology (pp. 1473–1483). Washington,
DC: National Association of School Psychologists.
- Shields,
J. (1995). The eco-triadic model of educational consultation for students
with cancer. Education and Treatment of Children, 18, 184–200.
- Stuart,
J. L., & Goodsilt, J. L. (1996). From hospital to school: How a
transition liaison can help. Teaching Exceptional Children, 28, 58–62.
- Talley,
R. C., & Short, R. J. (1995). School health: Psychology’s role.
A report for the nation. Washington, DC: American Psychological Association.
This article was adapted from a handout published in Helping Children at
Home and School (HCHS) II: Handouts for Families and Educators. Copyright 2004 by the National Association of School Psychologists. “Counseling
101” articles and related HCHS II handouts can be downloaded at www.naspcenter.org/principals.
Steven R. Shaw is a psychologist for
the division of departmental and behavioral pediatrics at the Children’s
Hospital in Greenville, SC, and associate professor of pediatrics at the University of South Carolina. Mark C. Clayton is a developmental pediatrician and Jodi
L. Dodd is a clinical neuropsychologist with the Children’s Hospital in
Greenville. Ben T. Rigby is a school psychologist with
the Speech, Hearing, and Learning Center in Greenville.
Case Study of a Terminally Ill Student
On Monday morning, the faculty and staff members of a large suburban high
school were informed that one of their students, a 16-year-old sophomore
named Corey, was diagnosed with cancer. Corey’s mother left a message on
the school counselor’s voicemail over the weekend. Corey was diagnosed with
a brain tumor known as an astrocytoma, specifically glioblastoma multiforme,
which is a rapidly spreading form of cancer that is difficult to treat and
has a high mortality rate. Corey is one of 8,000 children diagnosed with
cancer each year. When the staff members heard that Corey had cancer, there
was a great deal of confusion, sadness, grieving, and the vague feeling that “we
need to do something.”
The administrators at Corey’s school had already developed a medical transition
team. The primary goal of this team is to address the educational needs of
students with medical issues (Shields, 1995). This team has been used to
improve physical access for a student with a walker, help a student make
the transition back to school after time in an inpatient drug and alcohol
rehabilitation center, accommodate a student with a guide dog, and educate
teachers on emergency procedures for a student with epilepsy. The team has
even helped the kitchen staff develop safe meals for two students with severe
peanut allergies. The team is composed of the school nurse, a school counselor,
an assistant principal, and a special education teacher with an orthopedic
handicap certification. A community pediatrician is also available for consultation
on specific issues; however, any specific student information requires written
parental permission before consulting with the pediatrician.
The principal spoke with Corey’s mother to learn more about Corey’s condition
and to determine her wishes regarding Corey’s education and how students
and staff members should be informed of Corey’s condition. She communicated
her wish that Corey’s peers be informed and educated about his condition.
The principal also asked Corey’s mother if she would like to meet with the
medical transition team.
The medical transition team met with a nurse and social worker from the
Division of Pediatric Oncology—again with written parental permission. These
medical professionals explained the specific condition, the course of treatment,
and the educationally relevant limitations that could be expected. The team
then scheduled times for an oncology nurse and a social worker to discuss
Corey’s condition with his classmates and teachers. Although parent involvement
in such educational sessions is uncommon, Corey’s mother participated. The
medical transition team also set up a counseling group of two school counselors
and four school psychologists for classmates and teachers in need of grief
and bereavement counseling.
Surgery and a course of chemotherapy interrupted Corey’s education for four
months. For three additional months, Corey received homebound instruction
so that he could continue to make progress toward his diploma. Then, nearly
eight months after the diagnosis, Corey’s parents and physicians cleared
him to return to school. The medical transition team worked closely with
the oncology team to identify transition issues:
- Corey
had lost 43 pounds from his already thin frame. Addressing his appearance
was an issue.
- Corey
would start back to school, but would only attend three hours per day. The
goal was to move him back up to a full day in two months.
- Whether
the cancer was completely removed was unclear. Even so, there is a high rate
of recurrence with this type of cancer. Therefore, Corey’s long-term prognosis
was not known.
Corey returned to school. He was weak and inattentive. His motor movements
were effortful. Teachers reduced his homework load and gave him untimed tests.
Friends carried his books and took notes for him. Corey’s mother reported
that he was as happy as he had been in months while he was at school. Corey
succumbed to his illness and died that summer. The medical transition team,
with help from the hospital-based oncology team, reassembled the counseling
group for students and faculty members.
Indirect Effects of Illness
Several factors can affect the academic performance of a student with a
medical condition. Some of these factors are a direct result of the illness—such
as in cases of brain injuries, meningitis, or brain tumors. However, the
effects of a medical condition on academic performance and behavior are often
indirect, difficult to assess, and require frequent consultation with medical
professionals. Common indirect influences that medical conditions can have
on academic performance include:
Pain. Pain affects concentration
and increases fatigue. Few things are more challenging to educators than
students in pain. Very close consultation with parents and physicians is
needed to determine the typical type and severity of pain associated with
a given diagnosis. Children learn fairly quickly that complaints of pain
are sure ways to avoid work and gain attention. Malingering can be a common
factor in pain complaints. It is not cruel to consider malingering as a possible
explanation for complaints of pain. Exaggerated complains of pain can result
in overmedication and a habit of easily avoiding unwanted schoolwork.
Fatigue. Fatigue is similar to pain
in that is a common and real result of medical conditions. As with pain,
very close consultation with parents and physicians is needed to determine
how much fatigue is associated with a given diagnosis.
Motivation. Although attending school
may not seem like an important priority for students with medical issues,
school is one of the most important influences in their rehabilitation, stress
reduction, self-esteem, and social interaction. Most students with medical
issues have problems with academic motivation. Chronic and severe problems
with academic motivation may be initial symptoms of depression and require
the involvement of mental health professionals.
Stress. Having a serious illness or chronic medical
condition is one of the most stressful events in life. Children and adolescents
frequently do not have the coping skills to effectively address stress, and
short-term and chronic stress have significant effects
on students' concentration, attention, social interaction, and academic performance.
Anxiety. Anxiety is a major mental
health issue that affects sleeping, eating, and concentration. Anxiety contributes
to fears, excessive worry, and phobias that can impair normal life functioning.
Although there is frequently a genetic component to anxiety, the extreme
stress of a serious illness can create an adjustment disorder with symptoms
of anxiety or a long-term anxiety disorder.
Treatment adherence. About half of all patients do not adhere
to the medical regimen that is prescribed by their doctors. This means that
about one-half of all students who are prescribed medication for asthma,
cancer, mental health problems, and organ transplant do not take medications
and monitor important medical information (such as blood sugar for diabetics).
Schools can provide a valuable service by working with parents, students,
and physicians to improve the process of adhering to medical treatment.
Vulnerable child issues. Well-meaning parents, teachers, and
peers frequently make excessive allowances for students with medical issues.
This is frequently counterproductive because it reduces important accomplishments
and self-reliance. Although it is important to have high, but reasonable,
expectations for healthy students, it is equally or more important to have
these expectations for students with medical issues.
Depression. Sadness, helplessness, hopelessness, problems
with concentration, sleeping and eating problems, loss of enjoyment in life
activities, and even suicidal ideation are all signs of depression. Chronic
illness can lead to feelings of hopelessness, helplessness, and a lack of
control. Without hope, self-reliance, and feelings of control, children and
adolescents are at high risk of depression.
Additional Resources
The following Internet sites provide educators, health-care providers, and
parents with information and resources that can help ensure that students
with medical conditions succeed in school: