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Observations from a Living Laboratory of Collaborative Family Medicine

Posted By Tina Runyan and James B. Anderson, Thursday, February 28, 2013

"Collaborative care is done in many ways, by many people, in many settings—it is not ‘just one thing.’”

-C.J. Peek

Collaborative care promises not only opportunity to care for patients more holistically, it also provides a living laboratory for training practitioners across disciplines. Notwithstanding the vastly different training paradigms across disciplines, integrated settings offer rich opportunities to borrow and exchange ideas from the training traditions of other disciplines. Narrative medicine has been a time-honored component of family medicine residency training as a mechanism to enhance reflection, self-awareness, and process nuances of the physician-patient (or trainee) relationship. Analogous to "A Piece of My Mind” in JAMA, U Mass Family Medicine hosts a Thursday Morning Memo comprised of personal vignettes submitted by faculty, residents, and medical students; the popularity of the essays is demonstrated by a distribution list that has grown to over 450 readers. Included here are three reflective essays grounded in collaborative care practice and training.

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 The Three Questions

I made it to my car before I broke down in tears. I had just come from the hospital having seen a young woman in the hospital with acute fatty liver disease who nearly died in childbirth a few weeks earlier. I felt as tightly pulled in so many directions as the skin atop a snare drum. I was supposed to be home an hour ago and my daughter had already called twice. I had a grant report due by five o’clock, and too many e-mails in my in-box asking about something due or overdue. I felt as if I was letting everyone down and I couldn’t wait for the day to come to a close so I could just lie in bed and read stories to my children. And then it came to me … the three questions. One of the favorite stories in my home is a children’s adaptation of Leo Tolstoy’s short story about a little boy who poses three questions to the wise old turtle because he often finds himself unsure if he is doing the right thing.

The three questions are:

1. When is the best time to do things?

2. Who is the most important one?

3. What is the right thing to do?

All I knew about the woman I went to see in the hospital was a little bit of history about her disease, the medical events to date, and that she was refusing to see her baby which was concerning to all involved in her care and upsetting her family. There was worry about severe post-partum depression or psychosis. I entered the room to find a listless and soft-spoken woman with dull yellow eyes, too weak to reach for her water glass. Her husband and soul mate of 20 years, steadfast by her bedside for weeks, left us alone to talk.
Reflective writing and the use of narrative medicine can offer nascent practitioners a glimpse into the humanities of their
mentors and peers, help break down barriers across disciplines, and cultivate mutual respect.

She didn’t start with "the story.” Instead, she told me all about the life she and her husband had built together. She told me about her family. She described her longstanding uncertainty and the numerous conversations she and her husband had about whether to even have children. She told me about her birthing classes and her labor plan with a doula and her hopes for the baby’s first hours after delivery. She cried. She detailed the weeks leading up to the diagnosis and C-section and her emotions towards her obstetrical doctors. She explained how defeated she felt and how she does not have the stamina to even sit upright in a chair for any length of time. I tried not to cry. She kept telling me how dismissed she has felt and how no one was listening to her -- everyone was saying how good she looked and she still felt as rotten today as a few weeks ago when she nearly died.

An hour and a half later as I stood to leave, she looked me tearfully in the eye and asked "Will you come see me tomorrow?” Even though I was feeling time slip through my hands like dry sand, I looked right back and said "Of course I will.” So as I sat in my car it was exquisitely clear that the best time to do things was now, in this only moment we know to be certain, the most important one is the one you are with, and the right thing to do is to do good for the person you are with. I took a deep breath and took comfort in knowing I was exactly where I needed to be this afternoon. My drive home was serene. And the bedtime story that night goes without saying.

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On a cold winter morning with the plows finally moving for the first time this winter, I set off for the long drive to the Barre Family Health Center. Despite a long weekend, I felt a bit sluggish starting the day, perhaps because of the random text message that woke me early in the morning threatening to turn me into the police because of repeated harassing messages (I didn’t do it, I swear!).

I went through my morning, seeing a typical panel of behavioral health patients at the health center: A woman struggling to control her weight and mood following bariatric surgery, recurrent major depression, a middle-aged couple struggling to save their marriage, and a newly referred patient adjusting to her newly prescribed suboxone while also trying to find a way to re-narrate her life while free of drugs. While I felt some sense of competence and satisfaction after seeing this variety of patients, I also felt tired. After this clinical session, I entered into our monthly panel of meetings. As they do at times, the meetings bled into each other in my head. Finally, we got to the last meeting of the day—the providers meeting.

The meeting was led by our chief resident, who is pregnant. Earlier this month, she found out she had been accepted to join a prestigious fellowship program. In the middle of the meeting, she was pulled out by our lead nurse to tend to a patient who had been unexpectedly added to her schedule. Her colleague and fellow resident seamlessly took over the lead of the meeting. Towards the end of the gathering, I had the chance to present a project that my mentor and I are trying to initiate at the health center.

One of the attending docs, who has been at the health center since about the time I started pre-school, literally leaned forward in his chair to listen to the project description and offer incredibly insightful and concise advice about how to make it work. This man had been seeing patients all day since 8:30 and still was full of energy. Another doctor, this one a young woman just years out of residency, also provided helpful advice, while making a warm-hearted joke to keep the mood light even after a day full of meetings. Following discussion of the project I am trying to develop, two other docs piped in with their own ideas of how to improve our community, with ideas of a health center-based patient library and ways to help low-SES patients get transportation to and from the health center when they don’t have a car. One of these doctors is a Harvard product who selflessly and tirelessly devotes himself to medicine, the health center, and under-served populations. The other is a very young doctor who manages a full patient panel while running our resident in-patient service and raising a beautiful young daughter on her own.

As I drove home after the long day, I felt happy and inspired, feelings of fatigue from earlier in the day gone. I feel lucky to work with providers who are as energetic as they are competent. Not only do they have strong knowledge of a wide-range of medicine, but they also truly believe in the importance of behavioral and community health for overall patient wellness. As a psychology fellow at the beginning of a career that could have taken many different directions, these doctors and their actions reminded me of the importance of this work, and the privilege it is to work with such outstanding doctors and people.

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This final essay was written jointly written by Tina Runyan, PhD (italics) and High Silk, MD (plain text) about a notorious and divisive patient in our health center, the day after the presidential election this past Fall.

Caring Together

Waking to the news of Obama’s re-election this morning brings rekindled hope for the future of healthcare in the US. Still, the health and well being of many Americans hangs in the balance of a transformed primary care system. This new system of care promotes comprehensive, coordinated, whole-person, and patient-centered care. But let’s not forget quality. Quality as defined by metrics and thresholds chosen by insurance companies and linked to remuneration. As we sit and talk with our patient, looking back and forth from her to each other, we both know that we have accomplished something. Something that would never be detected from the types of quality measures the insurance companies value.

The young woman before us had not identified any with any health care provider in her first 30 years. In fact she had deep disdain for them all! And now, she had bonded with the two of us and was actually making progress on health goals.She had been handed a lot in life - diabetes at a young age, sexual trauma, an anger management issue, being overweight, and a predilection for alcohol. This constellation of health issues had been making life worse for her for years: a miscarriage, relationship issues, uncontrolled sugars and generally dissatisfaction with life. Many tears had been shed in this office; many rants about how unfair life is; many moments of despair and giving up. Now here was a woman sitting up taller than before. She was talking about "getting control of her life". Her tears contained near joy now. Her sugars had come down a little but more importantly, she was feeling good about lifestyle changes. Minimal alcohol,walking frequently, not drinking soda, and eating healthier - she was setting goals to get pregnant understanding fullwell what this would entail.

After the visit, Tina said that I should be proud to have moved her in the right direction over the last 5 years. Sure, I had not given up. Sure, I maintained full respect for her even at her meanest moments. But who was I fooling. This was a team effort. We had seen her back and forth like a ping pong tournament, caring for her week in and week out - listening, empathizing, prodding, tinkering with medications, accepting and congratulating small accomplishments. Together we had helped this woman make progress. We have both always been strong supporters of co-management between primary care providers and behavioral health, but this was the pinnacle. We had worked together, stopped each other in the hallway frequently for consultation and updates, supported one another's ideas and nurtured each other along. The success was not in her HbA1c, in fact we had failed miserably on that front alone. The success was in the transformation of the person, in the teamwork, and in progress and process. There is no quality measure on the scorecard for these outcomes … but there it was. And we sat in that room for a while longer, the three of us - it felt very good. It felt rewarding. It felt like quality care. Our patient felt it too.

PS – I saw our patient today. She is, for the first time since I met her, consistently taking all of her medications and checking her blood sugars. She has not had any alcohol in a couple months. She explained that she chooses not to have any around because she knows she cannot stop at just one drink. And she knows alcohol is not good for the baby she is now carrying. She wanted me to tell Dr. Silk the good news.

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Reflective writing and the use of narrative medicine to process rich and emotionally intense experiences in training and practice are not novel for any of the helping professions. However, sharing those musings, particularly with those in training, can offer nascent practitioners a glimpse into the humanities of their mentors and peers, help break down barriers across disciplines, and cultivate mutual respect. Over time, this cannot help but to shape a culture of interdisciplinary collaborators who find various creative outlets for the emotional experiences intrinsic to the practice of (integrated) medicine. In our Thursday Morning Memos, we have discovered gratifying solace and empathy among one another.

Christine Runyan

Tina Runyan is an associate clinical professor in the Department of Family and Community Medicine at the University of Massachusetts Medical School. She is the Director of an APA accredited, two year Post-doctoral fellowship in Clinical Health Psychology in Primary Care and the behavioral science director for the Worcester family medicine residency. . She recently joined the Board of CFHA and when not writing, practicing, training or talking about integrated care she enjoys being a mom, trail running, and practicing yoga.
James Anderson
James B. Anderson is an assistant professor and licensed psychologist in the Division of General Internal Medicine in the Department of Medicine at the University of Massachusetts Medical School. He is a recent graduate of the APA-accredited, two-year post-doctoral fellowship in Clinical Health Psychology in Primary Care in the Department of Family Medicine and Community Health at UMass (directed by none other than the co-author of this blog, Dr. Christine Runyan). James received his PhD in clinical psychology from Western Michigan University in 2010. When not working on integrated care, he enjoys playing hockey, SCUBA diving, and travel.

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