"Collaborative care is done in many
ways, by many people, in many settings—it is not ‘just one thing.’”
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.
_ _ _
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
2. Who is the most important
3. What is the right thing to
|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.
_ _ _
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.
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.
_ _ _
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.
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.
_ _ _
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.
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 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.|