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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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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