Narrative Means to Disastrous Ends
Randall Reitz, PhD, Family Therapist
St Mary's Family Medicine Residency
As a relative neophyte in family medicine education, I look back weeks, rather than years, to re-experience my foibles. A recent experience with my physician faculty colleagues is still poignant. My residency program director has tasked me with building a culture of introspection and feedback sharing among the faculty. Additionally, I have been introducing the physician faculty to the same therapy models that I teach residents. This led to a faculty development session during which I presented the basic concepts of narrative therapy to my colleagues.
It was a complete disaster.
To demonstrate strength-based and problem-based narratives, I shared a perceived strength and weakness from my own residency teaching. I then requested that the others do the same in a small group discussion. My colleagues struggled to grasp the concepts, were uncomfortable with the requested disclosure about their teaching, and disliked sharing the problem-based narrative second (asserting that it negated the strength-based narrative). There was not an elegant way to close the discussion and the following day a dear colleague described it using an f-word combination that I was not previously aware existed.
Here are my take home lessons from the experience:
- Behavioral science faculty are trained in environments rich in collegial feedback and self-disclosure. Because the same is not always true in medical training—tread very lightly.
- Clearly distinguish between education and therapy, and always choose the former over the latter in collegial settings.
- When introducing new curricular elements, test-drive it with a smaller group first.
- Don’t give up: seek to understand what didn’t work, apologize for unintended consequences, and then recalibrate.
On a much brighter note, last weekend was our annual residency retreat. While mountain biking in Moab (a perk of living where we do) one of the residents joked that he didn’t want to hear any medical talk or offer any medical treatments during their time-off: "If you break your arm, the only person who is going to help you is Randall”. And then a chorus of jokes gave me soothing reassurance regarding the positive impact I have had:
- Resident A: "Think about a time when your broken arm wasn’t present, how was that day different?”
- Resident B: "Suppose that I see you 6 months from now and your arm has healed itself, what will have happened to make that possible?”
- Faculty Member C: "On a scale of 1 to 10 how much does that arm hurt? What change could make it 1 point better?”
- Resident D: "Let’s suppose that when you wake up in camp tomorrow you discover that a miracle has happened and the broken arm doesn’t bother you anymore…”
Their solution-focused sarcasm was healing to my heart.
I'm a Doctor, Not a Business Expert
Neil Korsen, MD, Family Physician
Maine Medical Center
MaineHealth has had a Mental Health Integration program since 2006 and has done pilot work with several dozen practices. We have learned our share of lessons over the years by making mistakes and figuring out what doesn’t work.
One early mistake we made has to do with how we start a behavioral health clinician working in a practice. Our initial thinking was that starting with a small amount of time (1/2 day per week) minimized the financial risk and therefore should lead to the service working financially. We could then gradually grow the service as the clinician got busier.
The problem with this approach is that, if a clinician is not in the practice very often, it is hard for them to become part of the team. It is also hard for primary care providers and staff to remember when the clinician is in the practice, so they are less likely to think about referring a patient for integrated services. Given that many primary care providers work less than full time, it is possible that some will never even cross paths with the integrated clinician, making it even less likely that they will refer patients. We now believe that there is a minimum of about 16-20 hours per week needed for the integrated clinician to become a member of the team and for the primary care team to develop the new habits necessary for them to make good use of the clinician and to develop and build the integrated service.