a typically non-typical day at the family medicine primary care clinic.
ALL my morning patients show up. That must be a record! More often than
not, my patients no-show. That’s just one of the changes I’m getting
used to working here. As I’m working to fulfill my university’s
graduation requirements for clinical hours, I sometimes feel stressed
when patients do not show. Other times, I am quite relieved to have some
time to write case notes, consult with other providers, process, and
maybe catch a bite to eat. It feels like a roller coaster.
this morning, my head is as full as my caseload. At maximum, I have
about 5 minutes between sessions to digest what just occurred with one
patient and prepare for the next. This particular day, I’ve switched
therapy rooms twice- conducting therapy in two of the faculty
physicians’ offices. The clinic serves a very high needs population- low
income, immigrant, severe psychosocial stressors, complex health
concerns (diabetes, chronic pain, GI problems, renal failure, obesity
etc), non-English speaking, severe mental health issues (PTSD, severe
depression, severe anxiety problems) etc. So, I sometimes pray for the
days in grad school where a couple’s ‘only’ problem was infidelity.
the past four hours, I have worked with someone who has severe
depression, anxiety, and alcoholism. The depression is so severe that we
mostly sit in silence. The patient struggles to make eye contact and
stutters out a few short sentences while staring out the window. The
safest topics to discuss include children, the weather, sports, and
plans for the weekend. I feel like it’s a combination of an interview
and an awkward conversation with a stranger. I wonder how this has been
helpful for the past 5 weeks. My head tells me this must be or the
patient would probably not keep coming. Regardless, I feel uneasy. Even
with all my knowledge of projection, transference, and counter
transference, I can’t help but feel depressed and anxious as we leave
patient is struggling with chronic pain from an old injury. She retells
the same story about medical mismanagement of her pain. I can almost
recite the ten year history with her. Most of session is spent
validating feelings of mistrust, deceit, hurt, and skepticism. I think
back to Arthur Kleinman’s book Illness Narratives.
Conceptualizing her story from this perspective helps guide our
sessions, my suggestions to her physician, and my sense of competence.
The anxiety and depression from session one has waned. Instead, I want
to feel comfortable with the repetition and make sense of it. I come
back to the same question. Am I helping? How? It certainly doesn’t feel
like I’m pulling much from the different models of family therapy I
learned that are supposed to guide my interventions. No time to process
that- the next patient is here.
spend the next two hours in another crash course on Hmong culture. One
patient’s depression and suicidality have decreased, but perhaps only me
and her primary physician notice. The depression remains severe. I go
with my gut on this one. Teach me about your culture, I ask. If I don’t
understand what guides your interpretation of past and present
experiences, therapy won’t be the most effective. The patient’s normally
flat affect disappears a little and I see a small amount of brightness.
Even though we’re working through an interpreter, (which normally seems
to slow down the process) the session flies by. I’m soaking up
everything I’m learning, and the patient is very interactive. I’ve gone
from feeling uncertain and somewhat uncomfortable about the first two
sessions to feeling like I’m on track.
next patient is new and not really sure what I do and how I can help.
It ironically parallels my own general feelings this fall. We talk
(again through an interpreter) about what the primary physician
recommended for treatment and how she’s described my role. The patient
is not very clear, and my explanation does not seem to clarify anything.
However, since the physician has said I can help, she is more than
willing to keep returning for future sessions. Right now, I’m not sure
where to head with her case either.
rest of the day flies by. I try to make sense of what happened during
the morning. Over lunch I balance supervision, food, case notes, and
more spontaneous consultations with other clinic staff. During the
afternoon, I switch gears. I’ve gone from provider to teacher. I walk
into the precepting room to see which resident I have not shadowed and
evaluated. I ask one if I can tag along for the afternoon to help him
get his patient-centered evaluations out of the way. We don’t know each
other well since our time at the clinic hasn’t overlapped much. I don’t
know what to expect or how he might view a mental health intern serving
as a mental health preceptor for the afternoon. I’m acutely aware of the
power dynamics- I am younger, female, an intern, and a mental health
professional. I’m also still learning what I can offer in the world of
medicine and how to do it. Everything I’ve learned in theory is being
tested. In all, we see about ten patients ranging from well-child checks
to chronic pain, tension headaches, and diabetes management. By the end
of the day I am exhausted. I’ve gone up and down, riding a roller
coaster of stress, emotions, and feelings of incompetence versus
This blog feels long, overwhelming, pressured, and too detailed.
Perhaps it’s the perfect way to communicate my experience. I can’t edit
these days. They occur in full force- fast, detailed, and sometimes
overwhelming. I’ve learned how to ride the roller coaster a bit better.
I’m far from being comfortable, but I know how to hold on and not get
sick. And every now and again when it takes an unexpected turn, I get
excited. I don’t panic. I hold on tighter, lean into the curve, and look
around. Just as the roller coaster drops, I relax a little. Through
this, I see how I can help and am reminded of why I enjoy this work.
|Lisa Zak-Hunter, MS is a doctoral candidate specializing in family
therapy at the University of Georgia. She is currently completing a
behavioral medicine internship with the Department of Family Medicine
and Community Health at the University of Minnesota.
Her main clinical, teaching, and research interests lie in the realms
of collaborative health care and increasing biopsychosocial
understanding of mental and medical health conditions. She has a
particular interest in adult eating disorders.