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The Lone Ranger Rides No More

Posted By Brian Bonnyman, Thursday, September 15, 2011
I finished my residency in family medicine in 1993, and returned to my hometown to start work in private practice. My office was located in an affluent suburb, and my patient population reflected that affluence. The patients were generally well-educated, insured, and motivated, and I thoroughly enjoyed caring for them. I had several excellent colleagues in my practice, but we generally worked as solo practitioners under the same roof, only consulting each other on occasional cases. I call this the Lone Ranger model of providing primary care, which is typical for most private practices, and represents the traditional and time-honored way of doing things.

After 15 years of work in this setting, I left that practice and started working across town, at a large urban community medicine clinic. The zip code of my office location changed by one digit, from 37922 to 37921, but those sites are worlds apart. Now my practice includes many homeless people, refugees, recent immigrants, and ex-convicts. The psychosocial disease burden in this population is astonishing, especially compared to my prior practice. As one person put it, the main problem for patients at our clinic is not medical in nature, but that their lives are broken. I have had to dramatically adjust my expectations for patient compliance and outcomes, and change the way I practice medicine. Among the many adaptations I have made in this transition, one of the most pleasant is working as a member of a team (rather than as a Lone Ranger), side-by-side with psychologists. In my old practice, if I thought a patient would benefit from therapy, I would have to give the patient a phone number of a good therapist. I call this referral method sending a message in a bottle, given the low likelihood that the patient would follow through on the recommendation.

If I successfully convince the patient of the benefit of seeing a mental health specialist (which is part of the art of medicine), I can now have a therapist see the patient in the very same exam room after me. I can get immediate feedback and additional history from the therapist. For mental health diagnoses, we collaborate on reaching an assessment, with appropriate treatment and follow-up plans. With this arrangement, we estimate that 80% of behavioral cases can be managed without further consultation. This is not too different than the 90% figure that I always heard represents the percentage of cases seen in primary care that can be managed without further consultation.

I see a significant improvement in the quality of care that I now provide, thanks to working in a team environment with behavioral health specialists. Now, if I have a patient that is non-compliant with diabetes, for example, I can enlist the help of the behavioralist to help treat a medical condition. Patients that are ready to address their substance abuse problems can enroll in a treatment program run by the psychologists. Likewise, I can get patients easy access to treatments that I have read for years are beneficial for a variety of difficult-to-treat conditions, but I could never offer my affluent, insured patients at my prior practice. Motivational interviewing for substance abuse and cognitive behavioral therapy for fibromyalgia are two examples.

Just having another person get additional historical information from the patient can improve quality of care, with little additional cost. Since about 80% of the data I need to arrive at a diagnosis comes from the patient’s history, every bit of information helps. For example, a psychosocial condition unrecognized by me, but detected by the psychologist, can be the key to getting the correct diagnosis of a challenging case. The patient with hypertensive crisis who admitted his cocaine use to the behavioralist (but not to me) comes to mind. Rather than work him up for some obscure cause of malignant hypertension, we could concentrate on his substance abuse. To paraphrase the old medical saw, I have learned that when I hear hoofbeats in the hall, it is more likely to be a horse with a behavioral problem, rather than a zebra!

As a clinician experienced in the ways of the Lone Ranger model, working in a team setting can be difficult in some ways. In a conservative field like medicine that has a history of less-than-nurturing educational methods, teaching an old dog (like me) new tricks can be hard. At times, the learning process can be a challenge to one’s ego, as when I find that my assessment of a psychiatric condition is off base. Recognizing that the correct diagnosis is in everyone’s best interest (especially the patient’s!), and seeing these moments as opportunities for learning help minimize potential embarrassment. Having supportive mental health colleagues is a big plus since their communication and collaboration skills are miles ahead of many of my MD friends, who aren’t used to working in teams. I now realize how much of my medical education revolved around intellectual one-upmanship, and appreciate the importance of creating a mutually supportive collegial environment in the office.

Overall, though, giving up the Lone Ranger role to work as part of a team makes sense, both for providers and for patients. Heck, even the Lone Ranger had a Tonto!


Brian Bonnyman works as a family physician with Cherokee Health Systems in Knoxville, Tennessee. He enjoys treating patients of different cultures, who cannot easily obtain care elsewhere. Habla un poquito de español, tambien.

Tags:  Cherokee Health  family medicine  Integrated Health  primary care 

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Comments on this post...

Jennifer Hodgson says...
Posted Thursday, September 15, 2011
Appreciated your post....your journey will benefit a large number of providers.
Permalink to this Comment }

Peter Y. Fifield says...
Posted Thursday, September 22, 2011
A true medical champion for the integration of behavioral health and medical health services. Thanks for your insights.
Permalink to this Comment }

Lisa Zak-Hunter says...
Posted Thursday, September 29, 2011
Your experiences working with two vastly different populations and the associated 're-learning' parallels mine as I simultaneously held two vastly different family therapy internships. Thanks for sharing!
Permalink to this Comment }

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