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Looking for Batman in Primary Care

Posted By Patrick McFarlane, Thursday, April 16, 2015



"I like batman,” she said

baring her chest to reveal a dishevelment of a tattoo

of the famous Gotham call for assistance

that police commissioner Gordon would shine into the sky.

"I’m really into werewolves too.”

She wears a sweatshirt with the same logo like an echo,

layers of a symbol of the superhero she seeks,

and the superpowers she hopes for.

I asked her why she likes these superheroes,

And she said I don’t know, I just do.

When she tells me how her orbit was fractured

   by an ex-boyfriend,             

and how her mother was an addict who allowed

her using friends into her bedroom as a child

it all made sense.

If, as we are told, 40-70% of all primary care visits are related to underlying psychosocial issues 1 and if the resident physicians are right that 80% of the job is health education and they get to do that only 25% of the time 2, then that leaves 55% of the time that the physician isn't able to respond to which is perhaps the foundation of the patient problem; or to use the metaphor of the opening poem, Batman doesn't show up when called.

Batman is supposed to show up and fix the problem when called. When Batman doesn't show up, or when people don’t know how to call Batman, patients go to the emergency room or urgent care, or get referred to specialty care at great cost both in terms of cost and morbidity.  

Ted Epperly, Former President American Academy of Family Physicians (AAFP) in his plenary at the annual AAFP Program Directors Workshop in March 2015 eloquently described a future of team based care with patient metrics allowing multidisciplinary staff to work at the top of their license responding to patient needs with physician’s concentrating on the most concerning patients and their broad presentations, with incentives for ‘doing what it takes’ to keep people well and out of our emergency system. The technology exists already to electronically interact with patients to determine levels of risk, find the highest risk patients and to educate and connect with patients who are well.  This is Batman stuff.

Arguably, asking patients about what has happened to them, how they think about it impacting their medical needs and what they want is du rigueur, a standard of practice in a patient centered medical home world.  As we move toward a firmer foundation under the expectation that providers inquire in order to address risk in a preventative care model, payment models that support and reward such intervention must be adequately supported. We will know that is the case when providers are able to 100% take the time that each patient requires.

The patient in the poem above is seeking what she failed to get from her family:  a sense of attachment, belonging, and safety.   The medical setting is certainly a poor substitute for what she didn't get, but it can provide a societal foundation for, as Epperly suggests 1, doing what it takes. Part of what it takes is knowing the patient well and diminishing the shame and loneliness that sets up the superhero dynamic. 

By taking time and leveraging the provider relationship with the patient,  we remind the patient that they in fact are their own superhero as a survivor and that preventative care models can be leveraged to improve health outcomes that matter to all of us.   It is a new model of care that disperses with the superhero dynamic and takes the whole patient into account (family, community and environment) which will move the patient toward better health and away from mythic medicine.


Patrick McFarlane, MSW, MA, MSN-APRN is Faculty and Director of Behavioral Medicine at the Eastern Maine Medical Center’s Family Medicine Center and Residency Program.   He has worked in integrated health since writing a HRSA Office of Rural Health grant for integrating rural primary care in Western Michigan  in 1998.  He has two boys,  Isaiah and Ben, and loves to Kayak in the cold North Atlantic around Penobscot Bay in Maine and it’s many tributaries.   His research interests including addressing issues of violence and poverty in primary care and reflective practice.  


1. Epperly, Ted (2015) AAFP Program Directors Workshop Conference Plenary.  Kansas City, MO. 


2. McFarlane, Patrick (2015)   Resident Focus group in Transition to Office Practice Systems. Bangor, ME. National Ambulatory Medical Survey 2008 Survey Tables.  CDC, Mental Health workgroup  Atlanta, GA.

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