Category Archives: Family Medicine Stories

Aligning Our Efforts to Transform the System

Robert Cushman, MD

As a longtime member of the Society of Teachers of Family Medicine (STFM) and the incoming president of the Collaborative Family Healthcare Association (CFHA), I am both excited and a bit anxious about taking on this role at this time, because we are truly at a critical juncture. As health care providers and educators, we offer clinical services in a “system” that is about to either continue making important strides forward toward becoming a true system achieving meaningful outcomes or to slip backward into the free-for-all chaos that has complicated delivering good, patient-centered care for decades. We need to work together as members of STFM and CFHA to navigate through these twists and turns, or plow through some obstacles, so that we, our trainees, and our patients and communities, come out in better shape on the far end.

I want to share one of the “clinical pearls” I learned in my residency, which has served me well as a “compass,” and which I have quoted (with attribution!) many times to my own trainees as I precept them in the hospital and the office. I offer it now because it is applicable beyond the direct patient care process. I can still hear Tom Campbell saying, “When you’re stuck, expand the system.” He of course meant to explore more into the patient’s family and community context, gathering the perspective of some of those folks that make up that social network or enlisting their assistance in changing parts of that context to achieve change for the patient. He also meant to ask for input and additional, new, and different perspectives and suggestions from one’s professional colleagues, both diagnostically and for interventions. This approach has proved hugely valuable to me, repeatedly. And I think the current emphasis on team-based care is a result of a collective recognition that this systemic approach is valuable and more effective than “going it alone.”

I want to challenge us all to continue to “expand the system” in three ways. I want us to expand our concept of teams, to expand our measurements of what we’re doing, and to expand our reach. Let me elaborate briefly on each of these.

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Without Collaborative Care, the PCMH Fails

Gene “Rusty” Kallenberg, MD

I want to tell you a story that is both personal and also parallels the evolution of primary care and collaborative care over the past decade and predicts its future.

I arrived in San Diego to take over the Division of Family Medicine at UCSD in the fall of 2001. I came from “the East” where I had been at George Washington University Medical Center and School of Medicine (GW) for the preceding 20 years.  My clinical primary care practice fortuitously shared a waiting area with the outpatient mental health team. It was a short walk to the therapists’ offices and in the course of wandering over to seek help on various patients I met a clinical psychologist with whom I developed a close working and collegial relationship.  When I needed help with a patient I would seek his counsel and/or refer the patient over to the group with an “Attention Pat” comment on the referral.  I ended up hiring him to be the psychologist in our new family medicine residency program. We did an international consultation together for an Eastern European country’s developing academic family medicine program, and he introduced me to the concept of motivational interviewing, among other things. I began to realize that without this kind of key help the practice of primary care/family medicine would be a lot harder. I began to talk with a psychiatrist who headed the 3rdyear clerkship about deeper collaboration, but then circumstances changed significantly at GW and I decided to move. Long story made short, I ended up taking up the leadership of the UCSD Division of Family Medicine.

One of the most pleasant and propitious surprises on arrival was that there was an outstanding group of academic PhD marriage and family therapists (MFT) from the University of San Diego (USD) who were in discussions with our UCSD Psychiatry Department about transferring their activities to UCSD from the Sharp Family Medicine Residency which, unfortunately, was winding down to closure. Todd Edwards and JoEllen Patterson were the dynamic duo I was privileged to meet.  Unfortunately, these discussions were mired down with our Psych folks in what seemed like a circular and non-progressing research-oriented discussion. Being the new kid on the block, I was able to ingratiate myself with the Chair of Psychiatry and got him to “let our people go” and actually set up a clinical operation where we could deliver co-located care along with directly observed behavioral science teaching sessions (fondly referred to as “BS Sessions”) within our family medicine offices.

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A Case for Interprofessional Exchange in Family Medicine

Courtney Kasun, RN, MNSc

One year ago, I began teaching in an interprofessional student clinic.  The student clinic itself had been around for decades, staffed by students in our family medicine clerkship.  However, after a recent campus-wide push for more interprofessional education across health care disciplines, we began adding nursing and pharmacy students to our clinic and having all the students see patients as an interprofessional team.

I was slotted in as the nursing faculty at the last minute when it became evident the previously planned upon faculty member had too many obligations to manage.  Having not been in on the planning meetings,  I had no idea what to expect from the whole experience.  I was nervous and hoped I would be able to contribute something meaningful to our team and to the education of our students.  Little did I know how profoundly this experience would change my life.

One of the first insights we try to give our students in this clerkship is the chance to learn about the other’s professional training,  education,  scope of practice, and ethics.  In the first ever clerkship of interprofessional clinic, we too, as faculty, were learning things we never knew about our professional colleagues, despite having been licensed practitioners for years.  I gained a better understanding of the nuances of medical education, which has been helpful.  More importantly,  I learned from family physicians what makes family medicine different.

In formal nursing education we don’t learn much about physicians, their training, or the differences between specialties. Really, we don’t learn much formally about physicians at all. What we learn about you as a profession is what you teach us. The attitudes of nurses and the ways in which they collaborate with physicians are largely shaped by the early career encounters they have with doctors.

Nursing graduates leave school with a basic understanding of different medicine specialties; we know cardiologists deal with hearts, orthopods with bones, and so on and so forth. However, we don’t graduate with a knowledge of the subtleties or ethos of different specialties. Among the least clear distinctions for nursing is the difference between internal and family medicine. Most of us would be able to tell you that family medicine takes care of kids in addition to adults. Beyond that the distinction is vague.

Imagine my excitement and surprise when I found out how much family docs care about prevention and social determinants of health. Beyond just caring for your patients, you are concerned with public health and that, often, family physicians make their medical practice an extension of social justice principles. These are things that nurses dig. These are aspects that are foundational to to nursing’s world view.

Learning about and aligning with family medicine has renewed the purpose and passion in my professional nursing career. I was previously opposed to pursuing my advanced practice degree in family practice, perceiving that a family nurse practitioner (FNP) degree was only for nurses who want to work in “Minute Clinics” at chain pharmacies. However, since spending time working with family physicians, I decided an FNP is the advanced practice route for me and that I wanted to get the background in prevention and public health that would help prepare me to stand up with family docs and work for change in our health care system.

In addition, I have become a vocal advocate for the specialty of family medicine, as have many of my nursing students who have come through our interprofessional clinic. Three of our nursing students from last year are new graduates who are helping to open a brand new inpatient family medicine unit at our academic health center. Their lives have been changed through exposure to your mission, and they tell everyone who will listen — and even some who don’t want to— about how amazing family medicine is.

What we, as nurses, learn about medicine, or family medicine, is what you teach us. In taking the time to show us the soul of family medicine, you will mobilize your greatest advocates.