Depression in the Discipline of Family Medicine: Will We Isolate or Reach Out?

At this 25th anniversary, we are indeed at a crossroads in Family Medicine. Many studies and meetings are being held. Decisions are being made, but is this a good time to make these important decisions. Good physicians will instruct depressed patients not to attempt to make critical decisions when they are depressed, if they can possibly do so. It certainly seems that we are a discipline in depression. Should we make such decisions? Better yet, how to we get out of depression.

We all have seen many of our patients go through trying times. Patients in such situations can choose to isolate themselves or they can go for help. Will Family Medicine choose the same isolation or will we reach out?

There are times in the course of nations and institutions when crises basically reduce aspirations to piles of ashes. There are many interpretations of such times. To some this would be called a setback – a time to ride things out until the good times return. Others would use the time to complain and blame. They would point out conditions and situations, offering little in the way of a positive effort. Still others would use such a time to prosper their own agenda, knowing that sometimes in crises, they can get attention as others get more desperate. Yet another group would see this as a time for self-examination. They would take a good look at where they have been and where they hope to go. In a human sense, this is what many of us are doing in Family Medicine. It certainly beats the other options, but we face even more difficult challenges. Will we alter the basic core beliefs of Family Medicine to become more like our dysfunctional health care system? Will we continue to cater to inappropriately demanding patients while countless others fall victim to maldistribution of resources.

I think that there is a way that we can stick with our core beliefs, continue to teach those beliefs to others, and work to improve the distribution of resources. We have yet in Family Medicine to embrace two key areas. Study of these two areas could lead to vital allies and sources of inspiration that would lead us out of depression.

Underserved - Overview and Models

The area most easily addressed is that of the needs of the underserved. We should work with state and federal programs to align ourselves and our training programs with these sources of funds so that our trainees can do a better job of caring for the underserved and so our clinics can continue to develop new sources of revenue.

Many of our patients face overwhelming conditions. Here are just a few recent examples from my practice:

• One couple with diabetes, lipids, hypertension, etc. had the ceiling in their public housing unit fall in on them with injuries. They moved once. Two other locations had drug trafficking. They will again try to move to another location. Each move seems to make their diabetes more difficult to control.

• Another patient with mental illness lost her disability. It took her 2 years and lots of help from a nephew to get back on.

• When gambling came into Iowa just across the river from us, delinquencies on public housing rental doubled from 4% to 8 % in a matter of months. We all know who is more likely to lose from such situations.
• Violence is the rule rather than the exception in many neighborhoods. Some police officers fail to honor protective orders making my patient’s diabetes impossible to control. Personal connections in the community were able to restore some measure of vigilance.
• Some clinics are even hiring lawyers to address some of these areas.

• Another patient made it off Medicaid and had 2 cars and were about ready to buy a house. A workers injury and the failure of workers compensation took her cars, her finances, and delayed her recovery for 2 years. It reduced her to dependency on the state and family again. Fortunately she has a family to help her. The next has none.

• This family has held together for years as the mom made critical efforts to stay sober. Now they face a major crisis. Her bills are way overdue and the utilities have been shut off. When this happened before, the state took her kids away. She is beyond consolation. She pays more for water and natural gas each month that I do in a rental location one fifth the size of my house. She has breast cancer and requires regular care and expensive work ups. She was forced to return to work, but is missing several days a month to care for her asthmatic son with ADHD. She suspects her 11 year old son’s failing grades are due to drugs. More kids drop out than graduate from the schools in the area. Oh, and by the way, the state just took her Medicaid away. I was able to help personally and through an agency to get the gas and water back on, but this is not a long term solution. Her main problem is that she tends to get depressed and isolated. Sound familiar?

There seems to be no hope for some patients, but each of the patients above have had good functional times. In many cases a church stepped in and helped. Sometimes a family member has made the difference. Even the most desperate cases have received help from prison-based ministries.

What can we in Family Medicine do to help the hopeless?

• We can make calls and work with social workers, agencies, and churches.

• Using Asset-based Resource Development we can match up community resources to those in need of support. Some patients do this on their own. Others need some coordination. A clinic can be the focal point of such efforts. Clinics also can get needed help to improve services and decrease expensive costs, such as personnel costs. Community members can be volunteer assistants for the clinic. Others can help with check in, counseling, coordination of services, etc. Using this approach may do more than decrease costs. Since these are often key community members, it is natural that they will come to the clinic and encourage other community members. Churches are "community" as well and working with churches in underserved areas can be most rewarding.

• We can ally with law schools. Enthusiastic medical and law students can indeed make a difference. Why should we settle for liaisons for mock trials where we will be pitted against one another when we can form up teams to truly help people in need. Both of our students need this before they are socialized away from their original intent to be of service to others.

Part II next time – Embracing the Family

Family Medicine Teaching

An area that we have not yet explored is the area of Family. Over the past 30 years there has certainly been a deterioration of the traditional family. In many ways our problems in health, mental health, education, and other areas can be linked to this decay. This does not mean that there is not great potential for working with those who defend and support the family. Intact families are perhaps our best hope for long term solutions. Family groups and institutions often embrace many of the same values that we do. We share key leaders with such groups. Faith-based government programs actually have some potential in the current administration. Why don’t we explore this further?

Here are a few ideas regarding linkages between Family Medicine and Groups that support the family:

The church is an obvious group although I learned this from a not so obvious source. Eva Salber was a Jewish physician. She studied under Sidney Kark in South Africa and Israel and embraced the concept of COPC. She left her native South Africa for Boston. She did some of the original studies on adolescent smoking. She worked with some of the original Community Health Centers. When she moved to North Carolina, she linked up with key members in black community churches to develop a lay network that referred high risk patients in for care. One of the best learning days I had was a rural minifellowship faculty development experience, sitting at her feet at her home in Chapel Hill listening to her wisdom and experience. Every few STFM meetings, someone presents a similar idea and approach, yet we continue to fail to embrace these efforts or this approach.

Others have similar approaches that are worthy of exploration. Last STFM Barb Doty’s residency program in Alaska presented a powerful session on healing circles. It was my great privilege to attend. Unfortunately there were only a handful who also did so. I must admit my connection with Barb drew me more than the topic. This was short-sighted on my part. During the session, I received great support and advice for some important issues in my family, patients, and career. There are many such traditions, ceremonies, and liaisons to explore that would improve health to some of the most underserved peoples in the United States (or globally). Some of our other residency programs have managed to maintain significant connections to the population that they serve. That Alaska has done so since its origin is most impressive. John Halvorsen’s article in Family Medicine on the Missiological model comes closest to helping us understand how to make minimal changes with maximal result.

Faith-based Community Health Centers - Using the idea of inner city or rural churches in underserved areas, new community health centers could arise from such efforts. The Board Members need to be patients. Why not work with leaders in churches?

Working with Family Organizations - Focus on the Family, Family Life, and other ministries have consistently given advice that would improve parenting and support many of our most troubled patients. Walt Larimore, one of our most respected family physicians, is now working for Focus on the Family. We have many others who share dual memberships in Christian Medical and Dental Association. Wouldn’t this be a good time to explore a closer relationship?

I have been on a Health Professions list serve for the past 4 years. About twice a year an advisor asks for assistance with a student who is a strong Christian, afraid that the medical school will take this the wrong way and not give the student a fair shake. In a recent episode a residency program basically did the same thing to a student with strong beliefs. This white student was already working with the black community and attending a black church. Why are we suspicious of strong Christians? Our country was founded by strong Christians. Perhaps even more important, strong Christians and others with strong service-orientation may offer some solutions to our most pressing problems.

The status of the yearly match dominates our discipline like no other. It seems to us like a yearly confidence vote. There is much more to the match than a popularity contest however. The students that we need to become doctors are not getting into medical school. Religious institutions can show the way. Oral Roberts University was able to graduate 52% into rural practice with an even higher percentage going into primary care and into Family Medicine. Loma Linda was the only school recognized by college health advisors as being open to Christians who wanted to apply. Don Madison wrote an article about service-orientation and admissions to medical school. According to his research, selecting for service-orientation would greatly improve the numbers choosing primary care and family medicine. My studies demonstrated that senior medical students interested in rural practice were twice as likely to volunteer locally and overseas at every level of medical school. The overwhelming choice of these seniors was Family Medicine. Service Orientation

In summary, rather than focus on what is wrong with Family Medicine, we should look at what is right. We have some excellent examples. We have seen successful approaches. We have liaisons with other groups, associations, and organizations to explore. Time to stop wringing our hands and get busy.

Underserved - Overview and Models

Top Priorities For More FP and Rural Docs