This is the third in a series of collaborative blog posts between the Collaborative Family Healthcare Association and the Society of Teachers of Family Medicine.
Molly Clark, PhD
I believe that although behavioral science faculty can have years of training, experience, and add 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 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 so that 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 physician…in 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.
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.
Deborah Taylor, PhD
One of my greatest professional joys has been my connection to STFM’s Behavioral Science/Family Systems Educator Fellowship (BFEF) steering committee. Most “seasoned” behavioral science educators remember the “jump and build wings on the way down” training model for our discipline. The BFEF is an effort to create a more supportive/less isolated model to increase retention and career satisfaction. As with most acts that appear altruistic, those of us on the steering committee quickly found ourselves experiencing increased energy/enthusiasm and dedication to our work. In promoting a fellowship model of mentorship intended to be an offering, we receive far more than we contribute.
The term “mentor” has its roots in Homer’s epic poem, “The Odyssey.” In this myth, Odysseus, a great royal warrior, has been off fighting the Trojan War and has entrusted his son, Telemachus, to his friend and advisor, Mentor. Mentor has been charged with advising and serving as guardian to the entire royal household. As the story unfolds, Mentor accompanies and guides Telemachus on a journey in search of his father and ultimately for a new and fuller identity of his own. At times, throughout the story, Athene, goddess of wisdom, who presides over all craft and skillfulness, whether of the hands or the mind, manifests herself to Telemachus in the form of Mentor. The account of Mentor in “The Odyssey” leads us to make several conclusions about the activity that bears his name. First, mentoring is an intentional process. Mentor intentionally carried out his responsibilities for Telemachus. Second, mentoring is a nurturing process, which fosters the growth and development of the protégé toward full maturity. It was Mentor’s responsibility to draw forth the full potential in Telemachus. Third, mentoring is an insightful process in which the wisdom of the mentor is acquired and applied by the protégé. Some argue it was Mentor’s task to help Telemachus grow in wisdom without rebellion. Fourth, mentoring is a supportive, protective process. Telemachus was to consider the advice of Mentor, and Mentor was to “keep all safe.”
Barry J. Jacobs, PsyD
In the early 1990s, at the outset of my career as a psychologist in medical settings, I spent 5 years at a physical medicine rehabilitation hospital on what I was sure was a team of perennial all-stars. During our weekly clinical meetings, daily curbside dialogues in the hallways and cafeteria, and co-care in the PT gym and patients’ rooms, I always marveled at the competence, youthful confidence, and innumerable skills of the doggedly optimistic physical and occupational therapists, canny speech therapists, hardy nurses, and street-smart social workers on my assigned squad. At the head of this team was usually a gray-haired, white-coated physiatrist, wizened and patient, offering subtle guidance to team members but generally allowing us to practice our crafts. Not that harmony always reigned. We would have table-pounding debates about treatment plans. Rivalries simmered about who best evaluated cognition or ambulatory status. But the team worked proudly and effectively and patients usually thrived.
I’ve been waxing nostalgic recently about those years because of family medicine’s ostensible move toward team-based care. The patient-centered medical home (PCMH) is intended to be a collaborative, integrated, multidisciplinary place where family physicians work shoulder to shoulder with behaviorists, pharmacists, case managers, social workers, medical assistants, and administrators to deliver improved, cost-effective, chronic disease management. But the culture of family medicine, in my opinion, is not yet team driven. What is second nature in physical medicine rehab is of necessity first nature for us—a new set of spiffy dress-up clothes without the well-worn comfort of habitual garb. I think there is much we can learn from rehab medicine’s decades-long experience with teams:
Multidisciplinary isn’t interdisciplinary. An oft-cited truism in the field of integrating behavioral health services into primary care is that “co-location isn’t integration”—that is, proximity by itself doesn’t lead diverse clinicians to work in tandem toward better patient outcomes. I think this truism extends to team-based care in general. A multidisciplinary PCMH just connotes different disciplines under the same roof, which are working on their own respective and possibly divergent goals. Rehab was distinctly interdisciplinary—different disciplines working on commonly agreed upon goals. I believe that the PCMH likewise needs to be interdisciplinary to best blend the talents and skills of multiple specialists striving together. That means, like rehab, there needs to be processes in place for ongoing team communication and decision making. (An EHR alone won’t suffice.) That means somehow creating team meeting times out of the hectic primary care work flow.