The Physician-Educator Team Let’s Make It Work

G. Robin Beck, MD Eugene Edgar, PhD Leonard Kenowitz, EdD Steven Sulzbacher, PhD Thomas C. Lovitt, EdD Susan Zweibel, MS

THE PHYSICIAN/TEACHER TEAM DOES IT WORK?

Teachers and physicians are often expected to co- operate in the treatment of specific school-related problems of children. There have been numerous articles written on the nature and functioning of inter- disciplinary teams in special education. Likewise the role of the physician in regular education has been thoroughly discussed. 47 These statements stress the positive results of close cooperation between teachers and physicians. There certainly can be no argument as to the need for medical and educational professionals to share in the solution of many school-related problems. Connors * and Jones, Loney, Weissenburger and Fleischmann have pointed out that closer cooperation in the early grades may prevent the need for medical treatment later on. However, in our contacts with physicians and teachers, we have continually noted an undercurrent of dissatisfaction with their interactions. We decided to survey a group of primary care physicians and teachers in order to determine specific areas of agreement and concern.

PURPOSE There were two major purposes of the survey; 1. What types of school-related problems are viewed

by teachers and physicians as areas of mutual con- cern?

2. What are the major problems in establishing a mutually-satisfying relationship between physi- cians and teachers?

METHOD/PROCEDURES Two questionnaires were developed to gather

information relative to the issues under investigation.

The teacher questionnaire was distributed to 120 regular and special education teachers representing primary and secondary education. The physician survey was mailed to 250 pediatricians and general practitioners in the Washington State. Respondents were requested to return the questionnaires to the investigators at their earliest convenience (the questions to physicians are appended; the teachers received essentially the same questions, with slight wording changes addressed to them).

RESULTS AND DISCUSSION Backgmand

Of the 120 teacher questionnaires distributed, 68 were returned - a 57% return rate. Of the 250 physician questionnaires distributed, 69 were returned - a return rate of 27%. The demographics indicated that for the teachers, 19% lived in rural, 53% in urban and 28% in suburban settings. Of the physicians, 18% lived in rural areas, 41% in urban and 41% in suburban settings. As for the teachers who responded, 82% referred children to physicians and 52Vo of them worked directly with physicians during the school year. On the other hand, 83% of the physicians saw patients referred from public schools. Two major issues of concern were noted in the responses.

ISSUE 1 - TYPES OF REFERRALS There was remarkable agreement between teachers

and physicians as to the problems that were referred from the school to the physician. Table 1 lists the types of referrals by teachers to physicians and also referrals seen by physicians.

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TABLE 1

Percentage of Referrals by teachers to Physicians Referrals

Percentage of school-based referrals seen by Physicians

5 W o 3 2% 61% 30% 41% 23% 25%

Hyperactivity Behavior Problems Hearing & Vision Problems Acute Medical Problems Emotional Disturbance Musculo-skeletal Problems Seizures or Epilepsy

DISCUSSION These data indicate that there was great consistency

between teachers and physicians in the type of child referred. What is remarkable is the high percentage of hyperactivity and behavioral problems referred. Hear- ing and vision problems also account for a high percent- age of referrals. Clearly, educators are seeking advice from physicians on many school-based problems that interfere with the learning of children, especially behavioral problems.

When asked if they would attempt to intervene in cases of behavioral problems, 82% of the physicians indicated they would. Additionally, 97% of the physicians indicated that “primary care physicians must have competencies in dealing with behavioral prob- lems”, but 24% of the physicians felt they were lacking these skills. Over 60% felt additional resources (training, materials) were needed to improve their skills; and 92% indicated that interventions, other than drugs, should be explored in cases of behavioral problems.

Thus the data indicates that teachers turn to physicians for help in solving many school-related problems, and the physicians tend to accept these referrals as appropriate for them. In addition, physicians, while accepting behavioral problem-based referrals, felt that further training was required for their successful intervention.

ISSUE 2 - SATISFACTION WITH CONTACTS In response to whether or not the teachers were

pleased with their interactions with physicians, 53% said they were pleased, 40% were not satisfied, and 7% had mixed feelings. When the physicians were asked about their interactions with teachers, 73% indicated dissatisfaction, 16% were pleased and 6% had mixed

80 THE JOURNAL OF SCHOOL HEALTH

54% 50% 50% 45 Yo 41 070

37% 34%

feelings. The reasons noted by the teachers and physicians regarding their unpleasant interactions are included in Table 2.

When the data on the reasons for unpleasant interactions between physicians and teachers is ex- amined, the complaints from both groups are about the same. For example, each group is displeased with the communication systems; and each accuses the other of arrogance and the lack of follow-up or long-term interactions. Other areas of dissatisfaction include lack of knowledge concerning the job functions, the ethos of the working environments of both teachers and physicians and the relative non-existence of data sharing. It is obvious that much attention should be placed on knowing the characteristics of each other’s job functions and the development of a simple communications system between physicians and teachers. If communications were improved, complaints such as arrogance could be immediately terminated; and long-term teamwork on behalf of children could be easily initiated.

CONCLUSION Physicians and teachers must work together if the

child is to receive the best services possible. Both teachers and physicians accept this and basically agree on the types of mutual problems and also demand co- operation to solve these problems. Many teachers and physicians are still not satisfied with the results of their joint efforts. Both tend to place the blame for lack of cooperation on the other.

In our experience, the major cause of these problems is the lack of direct contact between teachers and physicians. Teachers tend to be intimidatd by physicians and yet have unreasonable expectations. Physicians often do not thoroughly understand the wide range of

FEBRUARY 1978

Teacher Complaints

1. Arrogant attitude of physicians

2. Ignorance of physicians about learning environments and inter- actions with health problems

3. Physicians have no idea about what goes on in schools

4. Physicians do not take teacher inputs

1. Not getting information quickly enough from physicians

2. Physicians do not answer or return telephone calls

3. Physicians are non-supportive and do not follow through on long-term problems

4. High cost of physician time, a phone call costs my School District

TABLE 2

Role Expectancy Problems

Communication Problems

demands that are made on teachers and expect teachers to understand more completely the capabilities of physicians. We believe there are viable solutions to the problems that many teachers and physicians have expressed. The following recommendations should provide some guidelines for improving their relation- ships.

RECOMMENDATIONS In order to facilitate a more productive communica-

tion system between teachers and physicians, the following recommendations are offered:

1. Information on roles and procedures 2. Ongoing communications 3. Local Education Agency (LEA) Organization

FEBRUARY 1 978

Physician Complaints

1. Defensive reactions and arrogance by teachers

2. Teachers demand immediate correction

3. Teachers overact to minor problems

4. Most teachers want drug interventions

5. School bureaucracy is immutable

1. Lack of teacher time and communication

2. Teachers never return phone calls

3. Teachers never send data back to physicians

4. Teachers don’t initiate communications

5. Conferences are convened at inappropriate times

6. Lack of diagnostic and assessment information

Information on roles and procedures It is apparent that information must be exchanged

between teachers and physicians in two major areas: A. The organizational and role parameters that

influence the behavior of teachers and physicians on the job, and

B. Information or data on the interrelationships between health or medical concerns in regard to learning expectancies.

Organizational and Personal Roles Teachers must be exposed to physicians and vice versa

early in their training career. Presentations by physicians with regard to their roles in school-based problems, their accessibility, their orientation with

THE JOURNAL OF SCHOOL HEALTH 81

regard to such topics as drugs and learning, data needed from schools, their job performance and medical terminologies should be presented to teachers early in their teacher education programs. Colleges of Educa- tion should adopt curriculum components in related medical areas as part of the teacher education program. At the same time, medical students should hear from teachers regarding the kinds of problems likely to be referred, information on school diagnostic procedures, school curriculums and what teachers expect of physicians. Medical students should be encouraged to intern with schools or with physicians and clinics that commonly work with school-related problems.

The need is more immediate, and the development of jointly-sponsored in-service training workshops should be commonplace in all states. Mutual problems should be explored. The team approach to specific children with medicaVeducational problems might also be em- ployed. Referral to community-based programs might be another option.

It is essential, early in the education of both teachers and physicians, that each group have the opportunity to interact and solve problems together to avoid many of the problems and concerns enumerated by both groups in the results of this survey.

Ongoing Communication Problems Even when physicians and teachers agree on the need

to work together, there is a major problem associated with maintaining effective communication systems between the school and the physician. These problems - while taken in isolation appear to be minor and easy to solve - are the major source of dissatisfaction in both teachers and uhysicians. A.

B.

C.

D.

82

The physician- a d teacher should provide each other with appropriate times when phone calls can be initiated and returned. Unfortunately, both teachers and physicians have demanding schedules that make it difficult to contact one another at random times throughout the day. However, there are times that both parties could agree to return phone calls, provided they take the time to make such an agreement. Written communications between teacher and physician would be enhanced if the type of data to be shared is mutually agreed upon. This problem has been discussed elsewhere, but it basically de- pends upon prior arrangement between the teacher and the physician. Teachers should always contact the student’s pri- mary care physician before recommending referral to another physician. Physicians should attempt to attend any school conference that deals directly with potential medi- cal concerns of one of their patients - for ex-

ample, if medication is being prescribed for class- room hyperactivity or if there is a question about seizures or side effects of seizure medication in class. Sometimes, there may even be serious class- room implications to fairly routine medicines taken for non-school related problems, such as hyperactivity as a side effect of medication given for asthma.

Local Education Agency [LEA] Organization We would also like to recommend an ongoing organi-

zation at the LEA level that would provide avenues for continuous interaction and problem solving between school personnel and primary care physicians. This might be a formal committee, composed of physicians in the community and teachers, that would be responsi- ble for dealing with many of the issues raised in this article. In this way, realistic, accurate and permanent solutions to problems such as communication and inter- displinary appreciation could be recommended. The committee could also conduct larger training awareness sessions in the community and perhaps recommend district policy to the school board. This ongoing com- mittee system could do much to improve communica- tion and ultimately improve educational/medical services to children.

BIBLIOGRAPHY

Kinsbourne M: School problems. Pediatrics 6:697-710, 1973. Safer DJ: Drugs for problem schqol children. J Sch Health 41:491-

Silver LB: Acceptable and controversial approaches to treating the 494, 1971.

child with learning disabilities. Pediatrics 55:406-412, 1975.

REFERENCES

1. Starfield B, Sharp E: Medical problems, medical care and

2. Haverkamp LJ: Brain-injured children and the school nurse. J

3. Wallace: Interdisciplinary efforts in learning disabilities. J

4. Lampe JM: Preparing school health personnel. J Sch Health

5 . Randall HB: School health in the seventies - a decade against

6. McGrady HJ: Learning disabilities: implications for medicine

7. Bourne IB: A pilot project for improvement of school health

8. Connors CK: J Learn Disabil6349-351, 1973. 9. Jones N, Loney J, Weissenburger F, Fleischmann D: The

hyperkinetic child: what do teachers know? Psychologv in the Schools

10. Sulzbacher SI: Chemotherapy with learning disabled children. The Learning Disabled Child, Bellevue, Washington, Edmark Corporation, 1975, pp 44-60.

school performance. J Sch Health 41:184-187, 1971.

Sch Health 40:228-235, 1970.

Learn Disabil9:520-526, 1976.

41 : 109-1 11, 1971.

disease. J Sch Health 41:125-130, 1971.

and education. J Sch Health 41:227-234, 1971.

services. J Sch Health 4128-292, 1971.

12:388-392, 1975.

THE JOURNAL OF SCHOOL HEALTH FEBRUARY 1978

APPENDIX Thank you for your time in completing the question- naire. Please check one: My practice is located in a

rural setting urban setting surburban setting

1. Do you see referrals from public schools? Yes No If yes, please check the appropriate categories:

Learning Disabilities (please specify), ie, Reading Spelling Comprehension Mathematics Others (please specify)

Hyperactivity Behavior Problems Emotional Disturbance (exhibits bizarre behavior) Hearing and Vision Problems Speech Problems Acute Medical Problems Musculo-Skeletal Problems Neurological Problems Seizures of Epilepsy Others (please specify)

Please place an asterisk * beside the most common or frequent category of referral you see. 2.

3.

If you see behavior problems, do you intervene dir- ectly or refer the child and/or family (check one)

Intervene directly Comments - Refer child and/or family Comments Primary care physicians must have competencies in dealing with behavior problems. Please rate the ac- curacy of this statement by circling the appropriate number:

1 2 3 4 5 not accurate very accurate Please record your confidence in your competence as an intervention specialist for behavior problems:

very competent no competence 1 2 3 4 5

4.

5 .

6.

7.

8.

If you do see school-based referrals, what major pro- blems have you experienced in your interactions with school personnel? Comments If you diagnose significant developmental delay or severe mental retardation, what resources - either in your community or regionally - do you use in the management of this child and hisher family? Resources:

Do you believe that significant attention should be placed on training physicians in the use of interven- tion other than drugs for behavior problems? Yes No Comments Do you feel a need for additional resources (other health professionals, workshops, materials to help your work with schools) to improve your effective- ness in helping children with school problems? Yes No In dealing with school referrals, who is your pri- mary contact?

Nurse Teacher Principal Other (please specify)

G. Robin Beck, MD, is Assistant Professor of Pediatrics, University of Washington, 1959 Pacific Street, Seattle, WA 98195. Eugene Edgar, PhD, is Associate Professor of Education, University of Washington, 103 Miller Hall, DQ-12, Seattle, WA 98195. Leonard Kenowitz, EdD, is Project Director of WESTAR, University District Building, I107 NE 45th - Suite 215, Seattle, WA 98105. Steve Sulzbacher, PhD, is Assistant Professor of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195. Susan Zweibel, MS, is head teacher in the Lake Washington School District, Kirkland, WA . Thomas C. Lovitt, EdD, is Professor of Education, Experimental Education Unit, WJ-I 0, University of Washington, Seattle, WA 98195.

FEBRUARY 1978 THE JOURNAL OF SCHOOL HEALTH 83