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Using Direct Observation for Team Development and Collaborative Training

Posted By Larry Mauksch, Thursday, August 15, 2013

This is the first post in a series of "blasts from the past". These classic posts will highlight issues that are just too important to collect dust in the archives. The series will be off and on for the next several weeks. Enjoy!

(This piece was originally posted on September 6th, 2009)

A great way to flounder or fail in system change is to avoid relationship development between team members. When we examine efforts to integrate collaborative designs, relationship development is often given short shrift or completely overlooked. For example, the recently published initial evaluation results from the medical home National Demonstration Project found team function suffered (Nutting et al, Ann Fam Med 2009;7:254-260). One way to build teamwork is to use direct observation of day-to-day practice. I have been experimenting with this strategy for 15 years and below I will share some experiences.

Since we began the mental health internship in collaborative care within our Family Medicine Residency in 1996, the first month for the new intern is spent shadowing residents and faculty. Observing helps the intern learn about the challenges of family practice and it spawns many new relationships. Our residents and medical students observe one another regularly as well.

In 1998 I was invited to spend a year training providers, serving patients and designing a system of care in an indigent primary care clinic. During the first half of the year I regularly observed the primary care providers, teaching them interview and primary care psychotherapy skills and forming relationships. My behavioral health practice grew rapidly. A few years before I arrived a local agency had placed a counselor in the clinic. Six months later the counselor was withdrawn due to lack of referrals despite being in a clinic where 50% of the patients had one or more mental disorders. Looking back, it appears that little was done to create relationships with this new team member.
Collaboration is hard won without adequate relationship development ... It takes time.

In my work with health care organizations to train primary care teams to be more efficient and effective in communication with patients, a standard portion of training is peer observation. When the lack of team coordination between medical assistants and physicians became a common theme, I began asking physicians how often they had observed their medical assistants or if medical assistants had observed them. The answer was almost always the same—team observation had never occurred. I began having these dyads observe one another and discuss how to increase the quality and efficiency of patient flow. These primary care dyads or "teamlets” (see Bodenheimer, Ann Fam Med, 2007, 5:547-461) immediately began dissecting day-to-day processes to improve systems of care.

Collaboration is hard won without adequate relationship development. One way of forming relationships is to curiously watch each other provide patient care. It takes time. Trainees need to be sensitive to how feedback is delivered and remember that watching someone else promotes observation of one’s self.

Many of you have other strategies to promote team development or perhaps use similar approaches. What experiences have you had where team development went really well or stumbled?

Larry Mauksch

Larry Mauksch is a Senior Lecturer in the Department of Family Medicine, University of Washington School of Medicine, in Seattle, Washington and a consultant and trainer for health care system transformation. He has spent the last 26 years training medical students, residents, mental health professionals, practicing physicians and nurses in interviewing skills, team development, and the diagnosis and management of mental disorders. He is a core faculty in the Washington State Department of Health, Medical Home Collaborative, serves on the Society of Teachers of Family Medicine (STFM) program committee and on the Council of Academic Family Medicine Competency Measurement Task Force. He is the past chair of the Collaborative Family Health Care Association and of the STFM Group on Physician Patient Interaction. Mr. Mauksch has provided faculty development on communication training to medical schools and residency programs across the United States. He has developed patient centered communication training programs catered to the needs of specific organization using inside champions as role models and collaborators.


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We now return to our regularly scheduled programming

Posted By Matthew P. Martin, Tuesday, August 13, 2013

The blogs have taken a small break this summer to soak up the sun, grab some Italian ice, and pass the baton from one editor to the next. Randall Reitz has been the editor and energy behind CFHA’s blogs since the first maiden voyage on August 31st, 2009. Since that time there have been exactly 178 posts on the flagship CFHA blog. The second blog, Families and Health, was first launched on November 18th, 2011 and has produced 80 blog posts. The subjects have ranged from "Collaborative Care Needs a Theme Song” to "Dejected Views on Family Hating”. Truly, the blog contributors have been creative and productive!

As I have recently thought about the CFHA blogs, I have paused to ask myself this question: if a blog piece is posted on the internet and only a few people read it, is it still worthwhile? The answer is a resounding: YES! First, blog writing helps us to improve our own writing. Most of us have been trained in technical writing, but blog writing is a whole other creature. It requires fresh, creative thinking and expression that can stretch our minds and abilities. Second, blog writing helps us to connect with and inspire each other. Think of how you feel after a conference. For me, my mind is overflowing with ideas after I connect with like-minded colleagues post-conference. In one sense, social media helps us to sustain those relationships and energy beyond the conference hall.

Third, we leave a digital footprint on the vast Internet landscape when we write blogs. When people search for information on collaborative and integrated care, we want them to find and read our blogs. Fourth, blog writing helps us to craft our "brand voice”. We are involved in the selling of a brand, a product called collaboration. We can practice using our "voice” through written expression and dialogue. Honestly, it’s not always easy explaining the power and practice of collaborative care. I only get silence and blank stares when I describe what I do to my grandparents. Imagine being able to sell collaboration to a stranger during a thirty-second elevator ride. That is the value of blog writing.

So now we return to your regularly scheduled blogging. I am very grateful to Randall and all the other contributors who have helped over the past four years. We plan to continue posting on a weekly basis. Over the next several weeks while we gain momentum, we will post a combination of new and classic ("oldies but goodies”) blog posts. As the next editor, I actually hope that you will not hear from me very often. In fact, just forget that I am the editor and enjoy the blogs. Before you do forget who the editor is, let me make two announcements. First, we have a live survey that we invite you to complete for the sake of improving the blogs. Please click here for the survey. Second, if you have any writing itches that can be scratched by contributing to the blogs, please contact me through my email address below. Happy blogging!

Matt Martin, PhD, LMFT is a licensed marriage and family therapist and current Director of Applied Psychosocial Medicine at the Duke/Southern Regional AHEC Family Medicine Residency Program in Fayetteville, NC. He is current editor of both CFHA blogs. His research interests include integration of behavioral health services in primary care settings, behavioral science curriculum development, family-centered primary care, and self-awareness development in family medicine residents. Email:

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A View from the Other Side: One MFT's Story of Family, Illness and Loss

Posted By Shelley L. Meyers, Saturday, June 22, 2013

Some time ago, I wrote this "open letter" to a master's level Marriage and Family Therapy ethics class. I was the teaching assistant at that time and thought that the family crisis I had just experienced would be relevant and applicable to many of the issues discussed in class. I am not sure why, but I never sent the letter. I actually forgot about writing it until recently when I was searching my computer for documents related to my current doctoral course in Medical Family Therapy. My hope is that my story will facilitate discussion about some of these issues and possibly provide some additional insight into the experience of a family dealing with a loved one's terminal illness. I recognize that the events may not be typical or standard procedure and do not wish to imply that they are; this is one person's perspective.

An open letter to the Fall 2011 MFT Ethics Class:

I wanted to share a personal experience with you all that highlights some of the recent issues you have been studying in class regarding ethics in general, as well as medical family therapy and end-of-life issues. Please note that I asked for permission from those mentioned below prior to sharing this with you and also changed some names.

A little background info… my husband is from Canada, and the majority of his family live in the province of British Columbia. In early to mid-October my mother-in-law Heather had some medical tests done as she was losing a great deal of weight and had little appetite for foods other than liquids. On October 19th, we were informed that she had cancer but the exact type was undetermined. It was in her lung, liver and lymph nodes but the source would need to be determined via biopsy in order to figure out the course of treatment (you learn a lot about cancer during these times). When we first learned that she was ill, we planned a visit at Christmas since both my husband and I would be out of school for break and he would have some time off from work. When we got information about the extent of her illness, we purchased tickets to fly out on November 5th. The oncologist told us that "you might want to come sooner”, which is obviously NOT a very good sign, and we rushed to fly out on Friday, October 28th.

By this time, Heather has been admitted to the hospital and a biopsy was done on Thursday the 27th (yes, that’s right…8 days after the diagnosis). We were told that we were "lucky” that it had been moved up a day earlier to Thursday as it was originally going to take place on Friday. So, we wait for results that, honestly, probably wouldn’t matter. At this point, Heather was very ill and any potential treatment would most likely cause more harm than good. During all of this, Heather’s family doctor had told her that she had three weeks to live. We didn’t realize this conversation between the doctor and Heather had taken place until later.

My husband Shayne and I saw Heather in the hospital on Saturday the 29th. She looked ill and fatigued, but not as sickly as I had been expecting considering the diagnosis. Shayne’s sister Connie and her husband were there as well. Connie had been bearing much of the burden of this situation as she lived in the same town as their mom and was spending time at doctor’s appointments and at the hospital. She and her husband Andy also have one adult and two younger children at home and had to manage their normal family responsibilities. Shayne, Connie and I spent as much time as possible with Heather at the hospital. Andy, Heather’s sister, and the kids were there quite often as well. Heather was in a room with another patient who also had visitors often (and usually loud) which made things awkward at times.

We also had a meeting during that weekend (in the TV lounge, but at least no one else was in there) with Heather’s family doctor. Obviously we had some questions. One thing I asked the doctor was why she (the generalist) was the one explaining the diagnosis and possible outcomes rather than the oncologist (the specialist). She became very defensive, appeared to be insulted, and said that she was trying her very best to help Heather, that she was working tirelessly, that she was here on the weekend to meet with us….etc. etc. Her tone and her defensiveness surprised and angered me. A few minutes later I felt the need to excuse myself from the conversation and wander the hospital stairwells, eventually finding the "Sacred Space” room (similar to a chapel). After some crying and yelling, I composed myself and returned. By that time, the family doctor had gone to check on something and I spoke with Connie. Connie told me that she had asked the doctor a question regarding the biopsy procedure. The doctor became teary-eyed, then began talking about how horrible it was for her to lose her dad.

Heather’s illness began to progress. She was noticeably weaker and having difficulty with breathing. On Monday the 31st, we met with the oncologist with Heather at her bedside as well as…in the hallway outside of Heather’s room. She discussed Heather’s prognosis with us and mentioned the possibility of hospice care. My husband and I had originally planned to return home to Pittsburgh the following weekend and asked about the feasibility of coming back for another visit with my mother-in-law, maybe near the Christmas holiday. The oncologist looked at me and said, "we’re talking a few days to a few weeks”. Of course the entire conversation was extremely emotional for the whole family, but excruciatingly painful for Shayne and Connie. As for me, I felt trapped and helpless. I have never felt as useless as I did in those moments when I had no way to "fix” the situation or ease the pain. I also struggled with the practical questions that came up for me…. had anyone asked Heather about her plans? What if she did die soon? What would she want? How does all this stuff happen? Would we have enough time? How do we pay for all of this? Who do we call? Of course, my stomach churned at the thought of even bringing up any of these issues.

So, Monday the 31st was Halloween night. Shayne and Connie wanted to stay with their mom overnight at the hospital. Andy wanted to spend as much time as possible there too. The kids went trick-or-treating that night, so I waited for them at the house until their dad got there. Later I returned to the hospital and stayed with Shayne and Connie.

By late Monday or early Tuesday, Heather was not able to clearly communicate. She slept almost constantly, and when she was "awake”, it was difficult to tell if she was able to understand what was happening around her. The nurses told us that most likely she had some awareness, so we continued to talk to her, stroke her gently and hold her hand. They were able to move her to a private room, which was very helpful.

There’s another twist to the story. Shayne has a 12-year old son, Brian, who lives about three hours’ drive from this town. Brian has an older sister, Ariel, who is 17. She is not Shayne’s biological daughter, however he has always been a father-figure to her. I called their mother Vanessa to explain the most recent circumstances though she was already aware that Heather was ill. Vanessa said that she was allowing the children to make the choice as to whether or not they wanted to see Heather. She said that they had a very difficult time when her [Vanessa's] father died from cancer nine years ago. She also said that Brian really didn’t feel comfortable coming and that Ariel was "on the fence”. I tried very hard to maintain my composure. I said that I was only relaying the information, however I would not want anyone to have regrets later should they miss this opportunity to see her. She said she would call me back. She called a short time later and said that Ariel would take a bus the next morning and that Vanessa's brother and sister-in-law would be picking her up as they lived in this town. I made the assumption that Brian was still not going to be coming. I didn’t ask.

Later in the day on Tuesday we realized that the nurses no longer came in at regular intervals to check Heather’s vital signs (no, she did not have the machine that continually monitors them). We made the assumption they were "telling us without actually telling us” that there was little time left. Shayne and Connie barely left their mother’s side, even hesitating to go get something to eat. That evening (Tuesday) I went back to Corinna’s house and gathered some supplies. Most of the immediate family was jammed into that hospital room…me, Shayne, Connie, Andy, and Heather’s sister, Aunt Rose. Connie’s oldest son Darrin stayed as well and fortunately we were able to find friends to watch the younger boys. There was one recliner-type chair in the room and a couple of regular chairs. I found a yoga mat in Connie’s linen closet that I brought along with some blankets and pillows. We tried to sleep at least a little bit. I napped on the yoga mat for a little while but later went to the TV lounge to sneak some sleep on a sofa. Aunt Rose went to the lounge too, and everyone else stayed in Heather's room.

Wednesday morning, 3 am, Darrin comes into the lounge. He said, "She’s gone”. I felt my stomach churn (and actually still do as I write this) and a sense of panic accompanied by horrible guilt. I so desperately wanted to support my husband and in the moment he would need me the most I wasn’t there. Damn! I was so angry with myself and thought about that part in the Bible where Jesus tells the disciples (my paraphrase), "Geez, couldn’t you guys stay awake for even an hour???”

I hurried to the room. The sadness was almost tangible; the crying and wails of despair broke my heart. The guilt I already felt was intensified by my relief that Heather’s struggle was now over. I had prayed that if God didn’t see fit to heal her could He at least take her home quickly. My prayer had been answered. I know now and I even knew then that I did not "want” her to die, but I still felt awful.

After some time a few of us looked at each other having absolutely no idea what to do next. I went to the nurse’s station to ask and was given the necessary information. Eventually we gathered our things and left Heather’s room, an experience that felt somewhat odd and…. I don’t know… callous? Disrespectful? We waited for the doctor to arrive and make the "official” pronouncement. She arrived, spoke with us briefly and then finally, we all went back to the house. At about 7 am I called Vanessa and gave her the news. Ariel did not take the bus to her aunt and uncle’s house at that point. Vanessa asked me to keep her informed about any memorial plans.

Obviously we now had a lot to do, including planning for a memorial and other preparations. This is a difficult process in any situation, but it becomes even more stressful when little has been discussed or prepared in advance. It’s also a very expensive undertaking. Heather had a very limited income and a sparse life insurance policy. Of course, none of us have much extra income either so there was the added stress of figuring out how we were going to pay for all of this. We finally made the necessary decisions at the funeral home then worked quickly to prepare a memorial service.

Let me fast-forward a bit. We pulled together a beautiful service for Heather which was held on Saturday morning, November 5th…coincidentally, the day we had originally planned to arrive in Canada. After the service, which in large part was scheduled based on our plans to fly back home that Saturday night, we had lunch with several family members and friends including Vanessa, Ariel and Brian. We then had to make a 6-drive back to Seattle, return the rental car and catch our red-eye flight back to Pittsburgh which included a lovely layover in New York at JFK.

So, why in the world am I writing all of this (and, honestly, there is MUCH more but this experience is emotionally exhausting)? Well, it may sound strange but I thought of your class several times during all of this. So many issues seemed to arise that were either potential ethical dilemmas or blatantly obvious ethical mishaps. In addition to the ethical issues involved, there were numerous times that I shook my head and thought about how things could have been done differently from a therapeutic standpoint. How could a MFT have approached the situation in a more helpful way? How could MFTs help to educate medical personnel so that they might better serve their patients and their families?

These are some of the questions and thoughts I had and wanted to share with you. Even if you never "answer" me back, I thought it would be a rare opportunity for you to enter the world of one particular client/family and consider the ways in which you might encounter these issues in your own work. I hope that as you contemplate some of these things you find it useful.

· How do you feel about giving clients information about "how much time they have left"? Is it helpful, ethical, honest? Is it potentially harmful?

· How can you respectfully bring up issues such as terminal illness or funeral arrangements/plans with clients and families?

· What is the role of hospital staff when it comes to providing information to clients and families? If it is "bad news", should they leave that to a therapist? Where should they talk? With/without the "patient"?

· How can hospitals provide more respectful and compassionate care for families without incurring a great deal of expense?

· Think about the dilemmas faced by blended families. What is the role of the non-parent spouse (me) in this kind of situation? How involved should this person be regarding communication with their current spouse's ex?

· How much decision-making power should a parent give to a child? What are your thoughts about Vanessa's perspective regarding the children visiting their grandmother?

· How would you address the intense feelings of guilt experienced by someone who lost a loved one, including the "I should/could have done more" statements?

Tags:  family medicine  family therapy  oncology  primary care  terminal illness 

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I Believe That Behavioral Science Faculty Face an Uphill Battle

Posted By Molly Clark, Thursday, June 20, 2013

I Believe Series Logo

The "I Believe" series is a month-long co-blog on behavioral science education in partnership with the Society of Teachers of Family Medicine (STFM). Please check back each week.


I believe that although behavioral science faculty can have years of training, experience, and can add so much to the improvement of our patients, we continue to have an uphill battle in proving our value within medical settings. As I recruit people to our program, I make the statement that Family Medicine is like working with family for me and feels as comfortable as home. I am fortunate to work with some of the best people I know personally and professionally. In addition, I have met some great people from around the United States who work in Family Medicine and share similar attributes as my colleagues. However, my experiences have not always been a happy and easy.

Although I came into a program with prior experience within Family Medicine and there had been an established behavioral medicine program, I was faced with the challenge of having to prove my expertise and value to our residents. My strategy was to set boundaries and stick with them at all costs. In my first year, I received evaluations from the residents that ranged from "she is extremely helpful” to "she is not welcome here.” In my second year, I was met with slightly more challenges. While providing feedback during resident check outs, some residents would sit to where I was completely to their backs as they presented a case. My evaluations included comments such as, "you’re not a real doctor” or "you’re not welcome in the physician lounge because you are not a fact you should not be considered faculty.”

While those are not pleasant experiences, I think one of the worst experiences was when I sat down for lunch in the physician lounge and residents either left or the ones coming in sat in a different area. There were times I would go to my office, sit down and feel completely ineffective. I hate to admit it, but there were times I cried. All the while, my physician faculty stood beside me, supported me and told me that this would get better. They asked for my input, consulted me when the residents would not, and gave me more responsibilities.

As I am completing the lecture,
I recognize an old familiar
feeling, stare into the audience
and realize that I might as well be promoting the sell of snake oil.

In subsequent years, things began to change. I started to receive pages from residents and curbside consults to ask me my thoughts about their patients. I was even asked by a resident if they could do a rotation with me. My evaluations began to include comments of "excellent,” "extremely helpful,” and "wished I could see her more in clinic but I know she has other duties.” In one of my more recent experiences, a resident asked me what they should do for a patient’s joint pain. When I responded that I was a psychologist and not a physician, the resident laughed and said "oh, yeah, I forgot.”

I’ve grown to have relationships at the medical center across physician specialties and seemingly have a positive reputation. So, as I am feeling confident that I have overcome bias and have proven my worth as a member of the interdisciplinary team, I walk proudly to another medicine department to give a lecture on physician wellness. As I am completing the lecture, I recognize an old familiar feeling, stare into the audience and realize that I might as well be promoting the sell of snake oil as a cure for various medical ailments. I sigh and go back to the Department of Family Medicine, where I feel at home and am satisfied with my accomplishments. I’ll leave the job of establishing the value of interdisciplinary care in that discipline to another individual and hope they will one day be as valued there as I am in Family Medicine.

Molly Clark

Molly Clark is currently an Assistant Professor and Fellowship Director in the Department of Family Medicine at the University of Mississippi Medical Center (UMMC). She received her doctoral training in Counseling Psychology at the University of Southern Mississippi, completed her residency at the University of Missouri-Columbia, and fellowship in Health Psychology at the University of Mississippi Medical Center. She also holds an appointment in the Department of Human Behavior and Psychiatry at the UMMC. Dr. Clark’s area of specialty is in behavioral medicine with particular interests in obesity, sleep, and mood disorders in primary care. She also has an interest in teaching and training medical students and residents. She has a number of publications and national presentations in these areas of interest.

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I believe that Behavioral education in Family Medicine is the domain of the courageous and resilient

Posted By Corey Smith, Thursday, June 13, 2013

I Believe Series Logo

The "I Believe" series is a month-long co-blog on behavioral science education in partnership with the Society of Teachers of Family Medicine (STFM). Please check back each week.


I believe that Behavioral education in Family Medicine is the domain of the courageous and resilient. Behavioral Scientists, the "Lone Wolf” of medical education, are asked to educate residents (often with little support) in areas sometimes antithetical to their students’ previous 4 years of medical school.

Example: Motivational Interviewing. Teaching a group of intelligent over achievers, who recently finished training aimed at increasing their comfort with giving "orders,” that giving "orders” might be the worst choice they could make? Bring it on.

On my first day in my current position, I participated in a 3 hour didactic involving the placement of first year residents into groups, with nametags labeled "Stars,” "Champions” and "Winners,” competing to properly identify OARS statements. What courage to attempt such a novel approach! Three years, and many frustrating didactics later, I see how an experienced and effective psychologist might come to the conclusion, "You know what? Let’s put name tags on these yahoos and see what happens.”
Over the last three years
I have faced resistance
to the concept of
Motivational Interviewing
the likes of which would
rival the "300 Spartans” at
the battle of Thermopylae.

Over the last three years I have faced resistance to the concept of Motivational Interviewing the likes of which would rival the "300 Spartans” at the battle of Thermopylae. I began with my own resistance and maintenance of a strict adherence to teaching the concepts of MI in a way more suited to those attending a day-long workshop. My first clue the car had gone off the rails occurred when, during a group meeting, a first year resident flatly refused to participate in a role play. Awkward. Resilience points: check. Next, I enlisted the assistance of the most behaviorally-friendly physician faculty member I could find because, "sometimes doctors think they can only learn from other doctors.” The first statement from the residents upon seeing one of their own in our behavioral meeting: "What are YOU doing here, checking up on us?” Hmmmm…

Finally, a revelation: "Why don’t we ask the residents how they want to learn this?” Brilliant!! (I really wish I could take credit for this…) The residents wanted to have a free form discussion of common problems and how they might address them (i.e., smoking cessation, weight loss, leaving an abusive partner, etc.). "But that’s not MI!!!” I protested. Knowing my colleague was better suited for this task than I, It has taken courage to give up the reins. However, watching her execute her wisdom and skill as a teacher made the development of resilience from constant tongue biting to avoid the over insertion of MI terminology more palatable. (I’m barely even allowed to speak its’ name!)

At the time of publication, we have met four times with each cohort of residents and our wonderfully helpful "Physician Mole.” I find the conversations helpful in building rapport and camaraderie surrounding difficult areas of potential change and see hope for the future. In true MI form, I rolled with the resistance and sought opportunities to model and educate residents on the Spirit of MI. It is far too early to evaluate the effectiveness of our modality, nor have I found the method of teaching this important skill that will define our curriculum, but we have become more resilient teachers and maintained the courage of our convictions. We can’t go back now anyway; I lost the name tags.

Corey Smith

Dr. Smith is the Director of Behavioral Health at the Lincoln Family Medicine Center and has held that position for three years. He loves to travel, exercise and spend time with friends and his fiancée.

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I Believe There's No Such Thing as Work-Life Balance

Posted By Katherine Fortenberry, Friday, June 7, 2013

I Believe Series Logo

The "I Believe" series is a month-long co-blog on behavioral science education in partnership with the Society of Teachers of Family Medicine (STFM).  Please check back each week.


I believe there’s no such thing as work-life balance. I think this every morning when I leave for work, watching my two-year-old son press his face against the front window and wave at me as I back down the driveway. It comes up again at work, as I guiltily feel relieved when a patient cancels and I have an unexpected half hour to work on a behavioral science presentation for residents. There is always somewhere else that I should be, and something else that I should be working on.

As a working mother who has been a chronic perfectionist and overachiever, the pressure is always there. If I’m not careful, this pressure turns into guilt. I miss my son’s doctor’s appointment, and I can’t translate his toddler-speak as easily as I think I should be able to. At work I fall hopelessly behind in answering emails, while wondering when I’ll have time to submit that paper for publication. It’s easy to start berating myself for not being more efficient, for not accomplishing more at work, and then not getting home in time to start dinner.

As the Behavioral Science Educator in our Family Medicine Residency Program, I teach work-life balance. Residents vent in support group about the endless patient demands, of long nights, of stress in their marriages, of their own emotional struggles. So I encourage them to focus on their goals, to reflect on the things they’re grateful for, and put their energy toward what they value most. Take steps to change what stressors can be controlled, and learn to release the ones that cannot.
I hear these words as I say them to our residents, and I resolve yet again to start taking my own advice.

I hear these words as I say them to our residents, and I resolve yet again to start taking my own advice. And sometimes I can successfully do this. Yet other times, I compose emails in my head as I rock my son to sleep. Or a patient’s struggles sparks one of my own worries, and I find my mind drifting off into my own troubles. Then my work life and my personal life collide into each other, and I wonder what kind of hypocrite I am that I presume to tell our residents how to live their lives better.

Perhaps I should admit to myself that I can’t achieve balance. Maybe part of me will always want to be in the other part of my life, somehow both working more and spending more time with my family. It hurts to think that I may never be able to spend all the time I want with my son. But I know fighting this guilt won’t help. Instead I focus on changing my relationship with it, and remind myself that even if there isn’t enough time, wishing to be in the other part of my life only takes me away from where I am now. So I close my eyes and I focus on the feel of my son’s soft hair against my cheek. I focus on the pain in my patient’s voice. I slowly take a deep breath. This is my only moment.


Katherine Fortenberry
Katie Fortenberry is a licensed clinical psychologist and the behavioral health coordinator at the University of Utah Family Medicine residency program. She received her bachelor’s degree from The University of Alabama, and her master’s degree and Ph.D. in clinical and health psychology from the University of Utah. Dr. Fortenberry completed her pre-doctoral internship at the Memphis VAMC, and a postdoctoral fellowship in primary care psychology at the University of Mississippi Medical Center. Her professional interests include psychological adjustments to chronic health conditions with a focus in diabetes, as well as cognitive-behavioral and interpersonal approaches to treating anxiety and depression in the primary care setting. In her leisure time, Dr. Fortenberry enjoys hiking, camping, and exploring Utah with her husband, son, and dog.

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Pediatrics, Integrated care, and the Family-Centered Medical Home

Posted By Karen Schetzina, Friday, June 7, 2013
Developing a Professional Identity

Karen's post is the final installment in this series.
Click here to read the first, second, third, and fourth posts.

I appreciate the opportunity to comment as the final post in this series from my perspective as a pediatrician and medical educator. Reading the comments of Drs. Reitz and Bishop and Mr. Ellison has provided me as a medical provider with greater insight into the challenges that psychology and family therapy colleagues may experience as part of an integrated primary care health team. This type of dialogue is important. In addition to developing one’s own professional identity, understanding each others’ roles and perspectives are keys to functioning effectively in interprofessional teams.

Acquiring effective written and oral communication skills and developing a common language among disciplines (and familiarity with our different dialects) is also essential. Even in the inpatient environment, where everyone is providing care under one roof and mostly within the same room, care can be uncoordinated if communication among providers, patients, and family members is poor.

I share the opinions that educators should do more to ensure that trainees develop broader skills, experience a range of clinical models, and be afforded early educational opportunities that are interprofessional and collaborative. Spreading innovations and improvements within groups, including educational reform within institutions, can be challenging however, due to the characteristics of the innovation itself, the willingness or ability of those involved to adopt the changes, and the organizational culture and infrastructure to support change.

This series has provided a stimulating discussion of the evolution of professional identity, influence of provider personality on practice style, balancing tradition with innovation, and the value of inter-professional collaborative training experiences.

An international commission of professional and academic leaders in medicine, nursing, and public health recently published a framework in the journal Lancet for transforming health science education that is relevant to this discussion. The commission called for educational reform to improve health systems, including "interprofessional and transprofessional education that breaks down professional silos while enhancing collaborative and non-hierarchical relationships in effective teams” (Frenk et al 2010).
The current prevalence of behavioral risks and chronic conditions and associated demands on our health system calls for training professionals and fostering systems for integrated care. Providing team-based, integrated care with nurses, physician, psychologists and other health professionals within the primary care setting can help in achieving the goal of a family-centered medical home and improve patient outcomes. Institutions, including ours, are beginning to develop and expand interprofessional academic health science curricula to address cross-cutting relevant core competencies including roles & responsibilities, interprofessional communication, teams & teamwork, and values & ethics.

Leadership from institutional officials and educators as well as influence from health system employers under pressure to demonstrate improvements in care delivery by their health care teams may continue to drive this educational reform.

I would like to thank my fellow bloggers and readers for their comments. This series has provided a stimulating discussion of the evolution of professional identity, influence of provider personality on practice style, balancing tradition with innovation, and the value of interprofessional collaborative training experiences. I look forward to similar discussions with colleagues around integrated care in the future.

Karen Schitzina

Karen E. Schetzina, MD, MPH, FAAP is Associate Professor and Director of Community Pediatrics Research in the Department of Pediatrics at East Tennessee State University Quillen College of Medicine.

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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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A Graduate Student Perspective of Professional Identity Development

Posted By Jeffrey Ellison, Thursday, May 16, 2013
Developing a Professional Identity
Jeff's post is the 3rd installment in this series. Click here to read the first and second posts.

The comments of Dr. Reitz and Dr. Bishop in this series to date bring to mind a recent conversation with several of my fellow graduate students. In this conversation, my peers suggested that: 1) integrated practice is less complex and thus less effective than traditional methods of clinical practice, and 2) mental health providers with sub-doctoral training are qualified to provide collaborative care services, so why would a psychologist want/need to do it?

When I first began writing this post, I had planned to formally rebut my peers’ "misconceptions” of integrated primary care (Had they actually read the research?); to finally set-the-record-straight about integrated primary care (What about psychotherapy? There are plenty of very qualified and competent sub-doctoral level providers with expertise in traditional psychotherapies!); and to prove to everyone that the practice of integrated primary care is actually a worthwhile endeavor (Even for a psychologist!). As I read through the other blog contributors’ posts, however, I began to sense that the conversation that I had with my peers was not about the "facts” of integrated care at all. Instead, this conversation may have been a representation of our divergent professional identities.

But how do students 3, 4, or 5 years into their respective programs develop such different professional identities? In the initial post in this series, Dr. Reitz discussed how trainees pass through Chickering’s seven "vectors” multiple times throughout their educational journeys. In the first years of graduate training, the "identity” that all trainees develop (Chickering’s 4th vector), though broad and rudimentary, is likely fairly uniform across trainees. As trainees undertake more clinical experiences they pass through Chickering’s vectors again and again (e.g., during beginning practicum, advanced practicum, and internship, etc.).
Trainees are particularly
vulnerable to identifying
with the first thing
(i.e. model, theory, etc.)
with which they become
confident and competent.

Through this process, students hone and focus their professional identities based on many factors including personalities, interests, and specific experiences. Inevitably, as a result of this process, students will conclude their training with unique and personally tailored professional identities. Increased job satisfaction, career investment, and productivity are all likely positive side-effects of this process. Additionally, this process promotes variety within our respective fields, thus allowing our fields to remain flexible and adaptive even in this ever-evolving healthcare environment.

Unfortunately, there are also downsides to our increasingly divergent professional identities. In the conversation I described above, neither my peers nor I were able or willing to stray from our narrowly defined professional identities. We took the same classes, participated in the same clinical experiences, worked with the same supervisors, and progressed though the same clinical psychology program, but we seemed to have nothing in common! How could this be? In reading again through the previous posts, I realized that the reason that it may have seemed that we had nothing in common was that, though we had well developed individual professional identities, we had poorly developed group professional identities (e.g., we had only vaguely and narrowly defined concepts regarding what it really to be a clinical psychologist or mental health provider). In other words, we had become so focused on "the trees” that we could not see "the forest.”

I recognize this as a problem specifically within the clinical psychology training process, however, I would bet that the same problem occurs within other fields as well. I hypothesize that this hyper-focus on specialization (i.e., sole focus on developing an individual professional identity) has its roots in the first years of training. When trainees enter graduate school, they typically come from a undergraduate programs where they were likely considered highly competent and top-of-the-class. When they enter graduate school, however, they are again inexperienced "newbies,” who have to prove themselves in a new program. Because of this, trainees are particularly vulnerable to identifying with the first thing (i.e., model, theory, etc.) with which they become confident and competent. Students become fixed on domains in which they are competent instead of continuing to explore new things (i.e., models, theories, etc.) and struggling with incompetence again. Granted not all trainees are seduced in this way, but in my case, it certainly makes sense. My initial practicum experiences occurred in integrated primary care, a setting where I am still exclusively practicing today.

In writing this, I am not trying to suggest that it is not okay to specialize or that it is a necessarily a mistake to become enamored with the first experiences in which you taste confidence and competence.I am suggesting, however, that it is important for trainees to carefully analyze their motivations.I also think that it may be important to rethink the structure of training programs so that they may have introductory experiences (i.e. not just book work) in a wide range of clinical models and theories prior to specialization.As such, I completely agree with Dr. Bishop’s assertion that providing students with inter-professional and collaborative experiences very early in their training may help facilitate the development of a more broadly defined professional group identity.


Jeff Ellison

Jeff Ellison is an advanced student in the clinical psychology Ph.D. program at East Tennessee State University. In his current externship placement he provides behavioral health services to patients presenting in primary care and community health settings across the state of Tennessee via videoconferencing. His research interests include: the integration of primary care and mental health; the use of technology (e.g., videoconferencing) in expanding access to behavioral health care; rural mental health care; and dissemination, implementation, and quality improvement for primary care and mental health settings. In his free time, he enjoys running, hiking, biking, and exploring the outdoors with his family.

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Sound but Flexible Identity Development: A Challenge for Behavioral Clinicians

Posted By Tom Bishop, Thursday, May 9, 2013
Developing a Professional Identity
Tom's post is the 2nd installment in this series.  You can read the first post here.

I certainly appreciate Dr. Reitz’s assertions of a developmental progression in professional identity formation as one prepares to work within integrated care. It does seem intuitive that one would pass through each of Chickering’s seven "vectors” as they progress through training and service as a primary care provider. It is also seems plausible, and very much supported by observances in the field, that there is a personality style, or as Dr. Reitz postulates, a "collaborative identity” that tends to lend oneself in being a good "fit” for serving within integrated care.

That said, I believe that taking another pass at McDaniels et al (2002) curricular article may provide more clarity to why some clinicians excel at integrated care and embrace innovation over traditional roles. McDaniels comments, "Psychologists-in-training need to develop the skills that solidify their identity as psychologists” and that having a "positive professional identity” would serve one well in working within primary care.

I am led to recall an experience I had with a couple of students in training. They were sharing the tension they experienced in learning the core skills and attributes of what it means to be a psychologist while considering what their work would look like within a primary care setting. They voiced concern that working in an integrated care setting, especially at that start of the training, would be too "narrow,” and limit the development of their clinical skills in some way. I believe that these concerns are closely tied to how one understands what it means to be a "psychologist.”

More recently, the field of psychology has begun gravitating back toward a more comprehensive identity. I say "gravitating back” because Lightner Witmer who is considered by many to be the father of modern clinical psychology understood psychology as collaborative, scientific, and as a catalyst for addressing problems. According to one reference: "Witmer never intended for clinical psychology to become segregated from other helping professions, particularly medicine and school psychology” (Brown, Prime, & Wade, 2012, pg. 1). However, this vision for the field has not been the prevailing image or impetus of training. "Indeed, Witmer envisioned a unified yet multifaceted discipline that possessed many progressive and innovative ideas that were lost or ignored over the course of the 20th century”
(See pg 2 where Brown et al discuss Routh, 1996).
One reason clinicians
may flounder within integrated
care is that they have come to embrace a more "contained” perception of what it means to
be a clinical psychologist,
medical family therapist, social worker, or school psychologist

Put broadly, then, one reason some clinicians flounder within integrated care is that they have come to embrace a more "contained” perception of what it means to be a clinical psychologist, medical family therapist, social worker, or school psychologist, and that perception is inherently independent rather than collaborative.As a corrective, training programs might emphasize the importance of core, foundational skills that would allow a behavioral clinician to collaborate with others rather than become "soloist.” It may also be critical to stress that our training allows us to be good at what we do, and that we are not to become something that we are not. Elliott and Klapow (1997) suggested that "We must broaden the professional options for our trainees by emphasizing behavioral science expertise versus mental health service provision.”

In returning to Dr. Reitz’s discussion of Chickering’s model as providing a means of examining professional identity formation, there is at least one other consideration. Perhaps training and early career experiences are more characteristic of what Erikson and James Marcia described as a time of crisis in one’s sense of occupational and social identity. This period of professional life is fraught with the search of "fit,” growth, conflict, and tension.

While personality is a factor, early career clinicians identification with their profession may be more characteristic in how they have wrestled with what it means to be functioning as a behavioral clinician. Some may have entered into training and work with a great deal of uncertainty and little reflection or consideration (Identity Diffusion), while others may have gone in full throttle with little exploration of what their particular field (e.g., psychology, social work, etc.) could encompass (Identity Foreclosure). Still others may truly be in crisis where they are unsettled and desire more from the work that they are doing, which seems to fit Dr. Reitz reflections on establishing identity (Identity Moratorium).

Perhaps "controlled and supported crisis” is what may be helpful in training and in challenging trainees to consider a broader conception of their discipline. It may be that McDaniel and the other authors were speaking of Identity Achievement when they commented how having a solid identity would prepare one for working within integrated care. They would possess the core understanding, skill set, and commitment for what it means to be a psychologist.

In summary:

  1. The success of a clinician in integrated care is inherently linked to how we portray, teach, and model a comprehensive understanding of what it means to be a particular behavioral health discipline, whether that is a psychologist, social worker, medical family therapist, or any other. Trainers want to foster the development of a sound identity for that discipline.
  2. At the same time, trainers could do better at challenging trainees in developing broader skills and in challenging their notions of what it means to be a psychologist, social worker, etc. It seems that this would be facilitated by having training opportunities that are more inter-professional and collaborative. These opportunities would, perhaps, create conflict and crisis in roles and functioning within an interdisciplinary team.
  3. While personality is certainly a factor in what leads one to consider a career in integrated care, this could be said of any profession, ie…why does one person become a plumber vs an engineer? Perhaps an analogy would be the contrasts of a jazz musician who is classically trained and a musician of another genre of music – they are each well versed in the foundations of their craft, but express these skills in varying ways.

I am certain and hopeful that the next response will challenge many of these premises.


Thomas Bishop

Dr. Bishop joined the faculty at the Johnson City Family Medicine Residency program at ETSU/Quillen Medical School in March of last year after serving several years with Cherokee Health Systems as a Behavioral Health Consultant and pediatric primary care psychologist. Thomas received his Psy.D. in Clinical Psychology from Wheaton College with an emphasis in the integration of psychology and theology, and a Masters degree from Central Michigan in general experimental psychology with an emphasis in brain injury and recovery of function.  His professional and research interest include primary care, rural and organizational health, faith and medicine, positive psychology in medical care, sports psychology, and neuropsychology. Perhaps most important, he and his wife Barb, who is brilliant in math, and have three children, two in college and one that thinks she should already be in college. They are often found together on a trail, running, or camping.

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