Three years after we opened the Center for Youth Wellness, I began seeing a new patient who brought home the importance of routine ACE screening. Lila was two and a half years old, blond, bubbly, and precocious. One day in the fall of 2015 I sat at the conference table with my colleagues sipping tea and reviewing her chart. Once a week CYW has multidisciplinary rounds; that’s where we discuss treatment plans for patients who have been identified by the clinic as being at high risk for toxic stress. This approach to care was something that started in the Bayview clinic out of necessity.
In the early days of the Bayview clinic, I was overwhelmed not by the workload (although that was some craziness too), but by the dire situations my patients and their families were often in. I was trained to treat asthma and infections, but my patients needed so much more than prescriptions for inhalers and antibiotics. Sometimes they needed housing, protection from abusive parents, or even things as simple as basic toiletries. One day I had a patient’s dad tell me that his family had been thoroughly burglarized; the person who broke in had even taken the toilet paper off the roll. (You know you have been good and robbed when someone takes your freaking toilet paper.) That same dad proceeded to board up the windows to prevent another break-in. Soon after, all three of his children came to me on the same day with severe asthma exacerbations, and the dad asked, sincerely, “Hey, Doc, do you think it’s bad for their lungs that we’re smoking meth in the house with all the windows boarded up?”
That same week, a seven-year-old patient was brought to me with a complaint of chronic headaches. She had just been removed from her uncle’s home, a studio apartment where she had literally watched her uncle sexually abuse her fifteen-year-old cousin, his daughter.
Back then I dictated my notes into a tape recorder, and when I listen to them now, I swear my heart remembers, aching yet again with grief for my tiny patients. There were days I would walk out of the exam room, close my office door, lay my head down on my desk, and just cry. And I definitely wasn’t the only one. At lunch or after work, I would find myself talking about my patients to our therapist Dr. Clarke and our social worker Cynthia Williams, partially to blow off steam but also because talking to one another helped. We would put our heads together to find avenues of support for our patients, which was good for them and for us.
Eventually, I realized that what we were doing at the clinic was an informal version of a practice I had learned on the oncology ward at Stanford, referred to as multidisciplinary rounds. In the pediatric oncology unit, there are understandably some really high-needs patients. Every week a group would meet that included the head oncologist, the social worker, the therapist, the child-life specialist (someone who helps kids through painful procedures), and a nephrologist (kidney doctor) or whatever specialists were needed for that particular case.
It was a perfect example of divide and conquer. When you’re caring for kids with cancer, by definition you have an incredibly sensitive and complex situation — of course no one person (doctor or otherwise) can adequately address all of those needs. When I thought about our patients at the Bayview clinic, their needs didn’t seem too different in terms of complexity of care. So instead of bellyaching in the break room, Cynthia Williams, Dr. Clarke, and I began meeting every week, bringing a stack of charts to review and calling it, Stanford-style, MDR.
Straight out of the gate, we could all feel that the practice made a huge difference. It allowed me to do my job well without having to split my energy or wear multiple hats. I knew when I walked into an exam room that I would have a place to bring all of the challenging issues at home that were also affecting my patients’ health. I didn’t need to be a social worker or a therapist; I could let Williams and Dr. Clarke do their jobs in a way that coordinated with what I was doing in the exam room. As a result, my patients got a better doctor, and their additional needs were addressed by someone who was trained to take care of them.
We weren’t aware of this at the time, but our approach would later become a best practice known as team-based care. Our patients’ lives didn’t get less complicated, but we found that this new model helped patients get better faster, and it had the added bonus of improving staff morale (especially mine). It was such a success that when we opened CYW, it was an important priority to carry that practice forward. Years later, as I looked around the table at CYW, I felt a sense of pride and confidence seeing two social workers, a psychiatrist, a clinical psychologist, a nurse practitioner, and two wellness coordinators whose job was to manage the interlocking web of patient treatment plans across disciplines. I was about to give all of them the scoop on what turned out to be my most unexpected patient in months, and I knew that together we could help her.
Excerpted from THE DEEPEST WELL: Healing the Long-Term Effects of Childhood Adversity by Nadine Burke Harris. Copyright © 2018 by Nadine Burke Harris. Reprinted by permission of Houghton Mifflin Harcourt Publishing Company. All rights reserved.