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?
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
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.
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