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Identity and Archetype in Family Medicine

Posted By Caroline Dorman, Thursday, May 23, 2013
Developing a Professional Identity

Caroline's post is the 3rd installment in this series. Click here to read the first, second, and third posts.
 

How and where does a family medicine doc optimize care for her patients?

How does she develop a professional identity that is robust enough to last through her life and career?


Family Medicine is a field of archetypal legends. My archetypes came from the wild west: Dr. Quinn Medicine Woman and the Lone Ranger. I wanted to be the one person who could see my patients' needs clearly and save the day by treating them promptly and properly. An admirable fantasy in many ways, this egocentric professional identity requires subsuming of a physician’s own family and personal needs in order to function as a superhero for patients.

My own career and ongoing development of professional identity is an example of this process. Having been "called" to rural medicine, I practiced in a town of 7000 after residency. I assumed care of every patient in the ED who was bereft of a provider. I delivered ALL of my patients’ babies...including canceling vacations in order to do so. I ran group visits for Diabetes in the evening rather than eating at home. After four years of practice, 4000 of the 7000 people in town considered me their physician.

My partners, LPNs and MAs were allowed to assist in patient care but never, in my mind, to lead.That was because I also assimilated the other family medicine archetype: the superstar quarterback. This approach to my professional identity led to disillusion and exhaustion. For a time, my commitment to working 90-120 hours a week in order to accomplish all of this was well rewarded with the ego boost of being considered the best. Patients were led to expect 24 hour attention from me and I was destined to disappoint. My own physical health suffered.

Family Medicine is a field of archetypal legends.

My archetypes came from the
wild west: Dr. Quinn Medicine Woman and the Lone Ranger.

While some may consider this approach to be patient centered, it was in fact physician-centered because it did nothing to ensure the stability and consistency necessary for ongoing patient-centered care. Rather, it fostered an unrealistic dependency. The care was focused on the physician because the patients were focused on the physician.

In contrast, with the PCMH model and the collaborative care setting, patients are able to expect just as much from their health care provider team. Indeed, their expectations are much more realistic because the responsibility is shared and thus, ideally, its provision is much more robust.

Mental health providers are better trained overall to resist the quarterback role in their patients' lives. Their ability to share this approach with family physicians in the collaborative care setting, and to model the conducive behavior for them, is one of the many arguments in favor of collaborative care. Nonetheless, individual practitioners do often isolate themselves from a patient's care team. They may find themselves shouldering a quantity of responsibility for the patient's well being that they cannot maintain and that would be more patient-centered if shared with others.

I’ve concluded that the characteristic, whether inherent or learned, most helpful for collaborative family physicians is humility. Humility allows the practitioner to relinquish the superhero role. Rather than being the brains of the operation, or quarterback...we act more like a fullback. We clear the way for our patients to reach their own goals. We cooperate with each other so that our personal strengths are put to the best use.

In so doing, we allow time for a continued personal identity that parallels our professional identity. Time spent fostering professional and personal relationships creates a more robust and, therefore, a more long-lived professional career.

So, I can assert without exaggeration, that collaborative care saved my identity as a full-spectrum family physician. Without team-based care I was faced with choosing between my full-spectrum practice and the rest of my life. With collaboration I can foster my identity without jettisoning the rest of my life.

There is one caveat to this success story, however. I was forced to reconsider my Dr Quinn Medicine Women archetype. Unfortunately, collaborative care is mostly impossible to practice in rural America. The financial models and operational supports don’t yet exist in towns of 7000 people. So, I moved to a larger town where I practice in a residency setting that has the advantages that can sustain collaboration.

As to the previous blogs:

I agree with Dr Reitz's hypothesis that collaborative clinicians benefit from extroversion, self-direction and multitasking (I’ll call this constellation of attributes ESM). Nonetheless, I would suggest that these habits are generally chosen and self-fostered over a period of time. Even if we scrutinize the successful old-timer rural family doc we see, in many cases, some form of tight knit team that includes perhaps, his wife, nurse, assistant and patients. Even the most introverted, task-focused among us (like these old-timey doctors we want to emulate) can and do develop some degree of ESM over time in order to better serve their patients.

The question, then, is the rate at which an individual provider maximizes her ESM by experiencing Chickerings vectors of identity development and how able she is to continue to experience them over time so as to hone their practice more and more to her patients’ benefit.

At St Mary’s Family Medicine Residency, our faculty and residents foster our skills in a collaborative setting wherein providers who see themselves as fullbacks quickly become the most adept at allowing patients to run their own medical lives. As a member of the patients team we block for them, accept handoffs at times, and occasionally run ahead for a pass.

 

Caroline Dorman

Dr. Dorman joined the faculty of St Mary’s Family Medicine Residency after practicing nine years in Craig, Colorado. She completed medical school at the University of Oregon and her residency at St Mary’s. In recognition for her work in rural medicine, she was the 2009 Colorado Family Physician of the Year



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Randall Reitz says...
Posted Friday, May 31, 2013
Caroline, reading your post led me to make a connection to Jeffrey Ellison's blog, the 3rd in the professional identity series. Jeffrey observed that some psychologists discourage a career in integrated care because it is less complex than other branches of psychology and can easily be practiced by someone with less training.

This seems like a parallel to criticisms of family medicine as simple medicine that could easily be carried out by midlevel practitioners. Your points about the challenges and complexities of full-spectrum family medicine highlight the fallacies of both arguments. Primary care, especially with the rigors of full-spectrum and integrated practice, demands a comprehensive knowledge and skill base that far exceeds partialist practice. It is demanding enough to require a team approach. And you will always be the humble quarterback of my team.
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Michael Redd says...
Posted Thursday, June 20, 2013
As a new member of CFHA, I appreciated your comments. I agree with you, that collaborative, integrated practice needs a good level of humility to really work. Humility to relinquish that superhero role (that you can't do everything), humility to recognize the many things we have yet to learn in the biopsychosocial-spiritual realms, and humility to accept and seek out other providers for their unique knowledge and skills (not to mention humility to recognize and adapt for cultural differences in patients and their families). Though I recognize that this humility doesn't come easy for most practitioners, the team approach seems so important I hope we find better ways of teaching and eliciting this kind of attitude towards providing health care.

My question is about training as well. It seems that one avenue to coming to this attitude is the difficult professional/personal experiences you discuss, but I'm wondering if you think that this is the kind of attitude that can be taught? If so, how?
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