Several years ago, Atul Gawande spoke to the graduates of Harvard Medical School. His address was published in the New Yorker under the title of “Cowboys and Pit Crews”.  In his articulate way, Dr. Gawande described the necessary cultural transition in the way health care teams operate and cooperate. His article came to mind as I was preparing to speak at the World AIDS Day Service of Remembrance this past December 1st. I was tasked with giving statistics on the current situation of HIV in Atlantic County, but I began with a poem. I wrote this back when AIDS was much different than it is today.

copyright: michaeljung/123rf stock photo

I’m Still Your Doctor

I happen to be there when you’re admitted.
My job is to keep you alive at any cost.
Lucky for you that I have experience
and I’m really good at diagnosing

the opportunistic diseases of AIDS.
So when you have the bad luck
to have a rare pneumonia
and a virus attacking your eyes,

I load you up with several toxins.
to save your vision, to save your life.
You’re ambivalent about being treated.
I’m sure you won’t be when you feel better.

In time I get to see you in the office.
You’ve gained weight and look healthy.
You wear a beaded and embroidered
white sherwani and matching kufi

over your neat and corn-rowed hair.
You look resplendent. You’ve come to say
that after long thought and deliberation,
you’ve decided to stop taking meds

that I prescribed so you can pursue
q’uranic healing under the guidance
of the mullah at your mosque.
My job as your doctor is to let

you make your own decision,
even if I know it means
you’ll die. I tell you I disagree
with your choice. I tell you

I support you and that I’m still
your doctor. That was the last
time I saw you, except in the picture
over your obituary in the Press.

It was my choice as a poet to tell this story from the first person point of view, yet the speaker is “I” not “We.” I hope that, were I to write a similar poem today, that it would include the team I depend on every day to take care of my patients.

As I reported on the current state of HIV in Atlantic County, I listed all the services provided by health care teams under the Ryan White services grant. As I read it aloud, it was a litany, a prayer of gratitude.

• health insurance premium continuation
• home health services
• ambulatory medical care for the uninsured
• dental care
• treatment adherence counseling
• mental health services
• nutritional counseling
• medical case management
• emergency housing assistance
• medical transportation services
• care outreach (for those who are newly diagnosed or who drift away from care)

As of June 30, 2015, we have over 38,000 people living with HIV or AIDS in NJ. Most (78%) are minorities. Injecting drug use and sexual contact are the major modes of exposure. The number of cases attributed to injecting drug use is decreasing, but the number attributed to sexual contact, both in NJ and globally, is rising. Of the 38,000 cases in the state, 1500 of them are in Atlantic County; 500 of them live in Atlantic City, and 373 are under our care at the Infectious Disease Clinic where I practice.

Now I can say they’re under our care rather than under my care, because of these team members that help me effectively treat an inner city population, many of whom have unstable and chaotic lives.

• I count on the front desk staff not only to remind patients of their appointments, but also to remain smiling and unflappable in the face of needy and anxious clients.
• I call on my nurses for triage of walk-ins and to be the first line of information about our services and our procedures, all while they are churning out prior authorizations by the dozen. The clinic has had to use some dexterity to switch from largely grant-funded care to dealing with the complexities of managed Medicaid.
• I’d like to say that our other support staff are there to reinforce the counseling and education I give my patients, but actually it’s the other way around. In a short office visit, I’m reinforcing the counseling and education they have already gotten from
  • the MSW who does our mental health counseling
  • the Linkage to Care Coordinator
  • the Medical Case Managers
  • and our dedicated PrEP Counselor*

*for those who are unfamiliar with pre-exposure prophylaxis of HIV or PrEP, a number of resources can be found at this website.

If my patients are doing well, and most of them are, with undetectable viral loads and high CD4 counts, it’s because they are surrounded by a caring team of pit crew members, not because they’re being corralled by a single cowboy.

What’s been your experience of working on a team to produce better outcomes? Please share a comment below.