January 24, 2013

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Within Family Medicine and Community Health, we work hard to integrate behavioral health with primary care. We teach this to our residents and practice it in many of our offices. Behavioral health providers, side by side with primary care physicians, share warm hand-offs, frequent updates and, sometimes, dual visits. This dual reflection on a patient we have cared for together is written by Christine (Tina) Runyan, PhD, clinical associate professor of family medicine and community health and director of the behavioral health fellowship, and me. –Hugh Silk, MD

Caring Together

Waking to the news of Obama’s  re-election this morning brings rekindled hope for the future of health care in the United States. Still, the health and well-being of many Americans hangs in the balance of a transformed primary care system. This new system of care promotes comprehensive, coordinated, whole-person, and patient-centered care. But let’s not forget quality, as defined by metrics and thresholds chosen by insurance companies and linked to remuneration. As we sit and talk with our patient, looking back and forth from her to each other, we both know that we have accomplished something that would never be detected by the types of quality measures the insurance companies value.—T. Runyan

The young woman before us had not identified with any health care provider in her first 30 years. In fact, she had deep disdain for them all! And now, she had bonded with the two of us and was actually making progress on health goals. She had been handed a lot in life—diabetes at a young age, trauma, anger management issue, being overweight and issues with alcohol. This constellation of health issues had been making life worse for her for years: a miscarriage, relationship issues, uncontrolled sugars and general dissatisfaction with life. Many tears had been shed in this office; many rants about how unfair life is; many moments of despair and giving up. Now here was a woman sitting up taller than before. She was talking about "getting control of her life." Her tears contained near joy now. Her sugars had come down a little, but more importantly, she was feeling good about lifestyle changes. Minimal alcohol, walking frequently, not drinking soda, and eating healthier –she was setting goals to get pregnant, understanding full well what this would entail.—T. Runyan and H. Silk

After the visit, Tina said that I should be proud to have moved her in the right direction over the last five years. Sure, I had not given up. Sure, I maintained full respect for her even at her moments of being angry with me and the world. But who was I fooling? This was a team effort. We had seen her back and forth like a ping-pong tournament, caring for her week in and week out, listening, empathizing, prodding, tinkering with medications, accepting and congratulating small accomplishments. Together we had helped this woman make progress. We have both always been strong supporters of co-management between primary care and behavioral health providers, but this was the pinnacle. We had worked together, stopped each other in the hallway frequently for consultation and updates, supported one another's ideas and nurtured each other along. The success was not in our patient’s HbA1c; in fact we had failed miserably on that front alone. The success was in the transformation of the person, in the teamwork, and in progress and process. There is no quality measure on the scorecard for these outcomes—but there it was. And we sat in that room for a while longer, the three of us. It felt very good. It felt rewarding. It felt like quality care. Our patient felt it too.—H. Silk

P. S.—I saw our patient today. She is, for the first time since I met her, consistently taking all of her medications and checking her blood sugars. She has not had any alcohol in a couple of months. She explained that she chooses not to have any around because she knows she cannot stop at just one drink. And she knows alcohol is not good for the baby she is now carrying. She wanted me to tell Dr. Silk the good news.—T. Runyan

Each Thursday, the Daily Voice showcases selected Thursday Morning Memos, reflective essays about clinical experiences written by faculty, alumni, residents and students of the Department of Family Medicine & Community Health and, occasionally, contributors from other departments. Thursday Morning Memos is UMass Medical School’s homegrown version of narrative medicine, in which the authors process their experiences through writing. To learn more, visit: http://www.umassmed.edu/news/articles/2011/personal_stories.aspx.

Related links on UMassMedNow:

Medicine from the heart . . . Tina Runyan

Medical and nursing students focus on veterans

Celebrating primary care by telling stories

Medicine from the heart . . . Hugh Silk: Climbing the mountain