Through the Patient’s Eyes
Behind the Scenes at Mischer Neuroscience Institute’s Patient-centered Clinics
The impact of patient-centered care on clinical outcomes and patient satisfaction is well documented in the medical literature. As institutions across the country struggle to improve outcomes while reducing costs, the Mischer Neuroscience Institute at the Texas Medical Center and the Institute’s arm in the community, Mischer Neuroscience Associates, are achieving both goals through clinics that revolve around the needs of patients.
Under the leadership of Dong H. Kim, M.D., director of the Mischer Neuroscience Institute and professor and chair of the Vivian L. Smith Department of Neurosurgery at UTHealth Medical School, the Institute is replacing the traditional physician-centered system with clinics in which teams of specialists see patients together. At the Brain Tumor Center, for example, patients with malignancies see both Dr. Kim and his neuro-oncologist partner in the same visit. If necessary, the radiation oncologist joins them.
“One office visit rather than two or three helps reduce the anxiety of patients at a stressful time,” says Dr. Kim, who as director of the Institute leads Memorial Hermann’s citywide neuroscience network. “We confer together on the case, which means quicker decision-making and ultimately, a better decision based on the opinions of multiple specialists. It reduces the time between diagnosis and treatment and makes better use of healthcare dollars by charging only one co-pay for the consultation.”
Frequently, genetic counselor Krista Qualmann is called upon to consult with patients during an office visit. In cases involving hereditary cancer syndromes, she is available to explain inheritance patterns, provide education on the condition and discuss the risks, benefits and limitations of available genetic testing options. She also makes recommendations for screening, treatment and management, and provides supportive counseling.
“It’s a privilege to work with patients in a new way,” Qualmann says. “They have the benefit of meeting with an entire team without leaving the exam room. The process increases communication with patients and among physicians, which leads to improved outcomes. It’s a far cry from the old paternalistic system of health care in which the doctor was the authority figure and the patient followed doctor’s orders without taking an active role in healthcare decision-making.”
Collaboration of Neuroscience Specialists
Patients with malignant brain tumors also benefit from the close collaboration of an integrated tumor board that brings together multiple specialists — two or three neurosurgeons, a neuroradiologist, neuro-oncologist, neuropathologist and radiation oncologist — weekly. “Most tumor boards meet monthly,” says neurologist Sigmund Hsu, M.D., who joined Mischer Neuroscience Institute two years after leaving the faculty of The University of Texas MD Anderson Cancer Center. Dr. Hsu leads the Cancer Neurology Clinic for the treatment of patients with neurological issues resulting from chemotherapy, and the Brain Metastases Clinic, whose staff of affiliated neuro-oncologists, neuroradiologists, neuropathologists and neurosurgeons works closely with oncologists to provide personalized and innovative care to patients with brain tumors.
“It’s extremely difficult to get that much physician firepower together in one room, and we do it weekly, which means we review almost every case,” Dr. Hsu says. “The tumor board is a real-time collaboration that replaces the traditional paper trail of communication. It’s an active examination of the facts to ensure that we’re seeing all the pieces of the puzzle. We challenge each other. Sometimes we disagree, and through discussion to reach consensus, we raise the bar. That’s what’s unique about the Mischer Neuroscience Institute from the patient perspective. Patients benefit enormously from this collective expertise without having to spend their time seeing multiple specialists.”
A Seamless Patient Experience
Patients with epilepsy and seizure disorders benefit from the same type of close collaboration at the Texas Comprehensive Epilepsy Program, the leading program in the southwestern United States for the diagnosis and treatment of epilepsy in patients of all ages. The center is also a leader in the development and implementation of innovative technologies for the diagnosis and treatment of epilepsy.
“Many of our patients come from far afield — all across Texas and from several surrounding states,” says Jeremy Slater, M.D., director of the epilepsy program and a professor in the department of Neurology at UTHealth Medical School. “Because of the distance they travel it’s important for us to facilitate a seamless patient experience to avoid multiple visits. Our epilepsy surgery nurse coordinator, Jessica Johnson, integrates office visits between neurology and neurosurgery with diagnostic testing. If, at the end of the day, the clinician team, patient and family make the decision to undergo continuous monitoring, the patient is admitted at his or her earliest convenience, often the following day.”
At a weekly two-hour adult and pediatric epilepsy conference, nine neurologists, two neurosurgeons, a neuropsychologist and a neuroradiologist review cases and make recommendations. “Epilepsy surgery is about careful integration of multiple types of data. Reviewing these together allows the team to develop a consensus about the best approach for each case,” says neurosurgeon Nitin Tandon, M.D., director of the epilepsy surgery program and an associate professor in the Vivian L. Smith Department of Neurosurgery. “We review the medical history of each patient, all imaging studies, magnetoencephalography, neuropsychology and results of Phase 1 video EEG testing to arrive at a holistic understanding of the clinical epilepsy syndrome in each individual case. We go around the table sequentially and everyone renders an opinion, with the patient’s neurologist speaking next to last. Then I weigh in as the surgeon. The ability to use the group’s gestalt in each case allows us to arrive at a plan more tailored to each individual case. That, combined with our ability to leverage our innovative MEG, SEEG and stereotactic laser ablation techniques, provides our patients with options unavailable at most other centers.”
Vigorous debates often precede a decision. “We discuss what type of procedure will produce the best outcome,” Dr. Slater says. “When a host of experts makes the decision, it provides a greater degree of confidence in the process and result. Someone may bring up an issue no one else has considered. The patient and family know how the decision was reached and have an opportunity to give their input.”
Pediatric epileptologist Gretchen Von Allmen, M.D., director of the pediatric epilepsy program and an associate professor of pediatrics at UTHealth Medical School, observes that the Texas Comprehensive Epilepsy Program is the only group in Texas in which neurologists specializing in pediatric epilepsy work closely together with those who treat adults. “We’ve always provided excellent care, but clinical integration and close collaboration have moved our program up to another level. We’ve added new faculty and advanced technology, including stereo EEG. Our patients are the real beneficiaries. When they turn 18, they transition smoothly to the adult side in one system that provides care from childhood through adulthood.”
The Mischer Neuroscience Institute Movement Disorders and Neurodegenerative Diseases Program, known as UT MOVE, operates four patient-centered specialty clinics — Spasticity Management, Deep Brain Stimulation (DBS) Selection and Programming, Botox® Injection and Intrathecal Baclofen Pump Therapy. Because rehabilitation is integral to good outcomes, movement disorders specialist Mya Schiess, M.D., and her team work closely with physical and occupational therapists and speech-language pathologists in inpatient and outpatient clinics and at TIRR Memorial Hermann to research new approaches that improve treatment. Their expertise extends to Memorial Hermann The Woodlands Hospital, where a new UT MOVE Clinic was established in 2013, and they also see patients at Memorial Hermann Northeast Hospital in Humble.
Dr. Schiess, who holds the Adriana Blood Chair in Neurology at UTHealth Medical School, works closely with neurosurgeon Albert Fenoy, M.D., in the DBS Selection and Programming Clinic. “The best teams are those that work well together while maintaining an independent thinking process,” she says. “In the end you have more confidence in the decision. That kind of teamwork doesn’t happen overnight. It’s based on long-term experience. We each bring our personal approach to the science and art of medicine to the table.”
Like physicians at each of the patient-centered clinics at Mischer Neuroscience Institute and Mischer Neuroscience Associates, Dr. Schiess and her team are very involved in the lives of their patients. “We work with sleep labs, nutritionists, neuropsychologists and rehabilitation specialists. We’re terribly comprehensive in our approach. We really are a full-service station.”