Aligning Our Efforts to Transform the System

Posted on October 23, 2012 by | Leave a comment

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

Posted on October 11, 2012 by | 1 comment

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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As Rosie the Riveter Says: We Can Do It—Collaborative and Facilitative Leadership

Posted on October 4, 2012 by | 1 comment

Jeri Hepworth, PhD,STFM Past President

What a fortunate path I have been on. But it is a path that more of us can take, and that is the core message of this blog post. As a behavioral scientist in family medicine for more than 30 years, I grew up in parallel with the discipline of family medicine and have been part of the community of behavioral science faculty who help family physicians know what it means to care for real people, for families, and to do so collaboratively with other health care professionals. Over time, I felt included and valued in my department, in my medical school, and in our national organizations, especially the Society of Teachers of Family Medicine (STFM). So what a thrill it was to be elected STFM president. But it was not without trepidations.

As STFM President-Elect, I attended my first meeting of CAFM and Working Party. Forgive the funny names, but they represent the Council of Academic Family Medicine organizations (STFM; ADFM, the organization of departments and chairs; AFMRD, the residency directors; and NAPCRG, the primary care researchers). The Working Party includes the CAFM organizations, plus the American Academy of Family Physicians (AAFP), the American Board of Family Medicine, and the AAFP Foundation. Together, the organizations work to ensure coordinated positions and grapple with vision and leadership of family medicine. These meetings represent ideal examples of Covey’s work of being both important and not urgent, of taking the time to consider what family medicine is accomplishing, and very powerfully, what should be the next steps.

Not surprisingly, attending my first meetings of these groups was intimidating. But, on the first morning, I received this email from my husband, Robert Ryder: “You are not a non-physician. You were elected to represent the educators in family medicine. So you represent the future of family medicine. Go do good work.” I must say, I walked a bit taller after that email, and over the last couple of years of leadership within national family medicine, I take these statements very much to heart. And I want others to recognize these truths.

Behavioral science clinicians and educators have the skills needed for leadership in our departments, in our health care systems, in our agencies and policy-making arenas, and in our national organizations and advocacy efforts. We know how to listen and include others. We can elicit divergent views and withstand conflict. We know how valuable it is to include the views of those who feel less powerful in systems. We can tolerate the anxiety that emerges in systems under stress or facing change. We know how to help groups create goals and vision, though we sometimes need help determining whether differences actually emerged. So we know we need collaborators, and generally we know how to play well with others. If we have been successful in working in settings in which our professions were the minority, we have learned these skills. And they are exactly the skills needed for effective leadership.

I truly enjoyed giving talks as president of STFM. Unlike presentations about my work, I learned that I didn’t need to hold back, because I wasn’t talking about me. I was representing something greater than me. To be grandiose, and also accurate, I was able to talk about a future and vision of compassionate, effective health care. It wasn’t a form of bragging about my work or ideas; it became a responsibility to do the best I can to help achieve our common goals. I was given a wonderful platform and support to do so.

And the beat goes on. I will still take the opportunities to advocate for family medicine, for primary care, for integrated health care systems that are focused first on patients and families and that require the collaboration and skills of many. But I also have a commitment to encouraging others to stand up and participate in advocacy and leadership for our common visions. The Collaborative Family Healthcare Association and STFM create wonderful platforms for us to do so. Let’s not waste these opportunities.

This is the first in a series of collaborative blog posts between the Collaborative Family Healthcare Association and the Society of Teachers of Family Medicine.

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