Clinician toolkit: Compiling a multi-disciplinary team

Enlisting other specialists to address specific symptoms can be a way for patients to get the evidence-based care they need. However, the primary care physician remains the team leader, gathering recommendations and communicating to other specialists and to the patient. 

• Set expectations and utilize frequent visits to look at small parts of the care plan rather than trying to manage every symptom every time
• Make referrals as appropriate to subspecialty physicians (e.g., infectious diseases, neurology, rheumatology, cardiology, psychiatry, integrative medicine)
• Patients with fatigue can benefit from physical medicine and rehabilitation consultation, rather than exercise guides
• Consider integrating behavioral health treatment in the clinic
• Discuss alternative medicine options that are typically low-risk and cost-effective by patient standards, depending on patient interest
• Recognize that insurance may not cover some therapists, mental health professionals or alternative medicine therapies
• Communicate expectations (download DOCX) and goals clearly to other health care professionals
• Collect and assemble recommendations from care partners, acting as the main point of contact for the patient

A multi-disciplinary team can help patients with prolonged symptoms by using evidence-based medicine for specific symptoms, validating a patient’s concern in the setting of a specialist’s office and providing the primary care physician with guidance on further management.  It is important to temper patients’ expectations that the specialist will “find the answer,” as many patients will continue to need ongoing management of prolonged symptoms.

When referring to specialists (download DOCX), being clear about the purpose of the consultation and asking them to focus on one particular symptom, such as joint pain or fatigue, might help the patient and specialist concentrate their efforts. Once again, be sure to set expectations with the patient prior to subspecialty referral.

Similarly, non-physician professionals, such as physical or occupational therapists, can provide useful insight and support. Referrals to alternative medicine providers, such as massage therapists or acupuncturists, may be helpful for some patients (Chen A, Felt-Lisk S. Unpublished data. August 11, 2022). Psychiatrists can evaluate patients to individualize pharmacologic treatments to restore optimal mental health. Referrals to mental health professionals can also provide patients with ways to discuss past traumas and alternate methods of coping.

Transportation and inability to get to appointments because of fatigue and pain can be an issue. Adding more clinicians to the patient’s list may be overwhelming.  Many insurance carriers are reimbursing telehealth video visits, which can keep fatigued patients connected to their clinicians. In these cases, the primary care physician may be the only clinician that the patient has the energy to visit–even virtually.

Multiple medical societies and the United States Preventive Services Task Force recommend routine screening for depression and anxiety disorders.  Primary care clinicians can use a standardized mental health screening tool such as PHQ-9 and GAD-7 for patients with prolonged symptoms. There are resources for patients to assess and work through complex emotions that relate to prolonged symptoms.  Similarly, there are resources for clinicians to learn how to manage post-infection fatigue, when PM&R referrals are not available.  Some symptoms can overlap with ME/CFS, so resources on managing that condition might be helpful for other IACI patients.

Welcoming patients

Evaluating diagnoses

Compiling a team

Developing a Care Plan

This effort is supported through a cooperative agreement (grant number NU50CK000597). The U.S. Centers for Disease Control and Prevention is an agency within the Department of Health and Human Services (HHS). The contents of this course do not necessarily represent the policy of CDC or HHS and should not be considered an endorsement by the Federal Government.

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