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.
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
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.
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.
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.
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.
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
- 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.
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:
- American Academy of Pediatrics, www.aap.org/parents.html
- Pediatric Development and Behavior, www.dbpeds.org
- National Association of School Psychologists, www.nasponline.org
- Society for Developmental and Behavioral Pediatrics, www.sdbp.org
- Candlelighters Childhood Cancer Foundation, www.candlelighters.org