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A Two Hour Span of Primary Care...

There were two moments during my morning clinic that conveyed the reality of primary care, as well as the importance of ensuring behavioral health providers are in primary care. To set the setting, it was mid-morning, clinic was a-rolling and as I finished a visit, I walked over to one of our medical pods as there was a patient who was coming in that I had not seen in a year or so. Side note, another factor of primary care that we rarely talk about, the longitudinal relationship we get to have with patients. Potentially the only place in health care, primary care allows us to be with patients and their families throughout their entire lives. Episodic care that transcends a lifetime. In any sense, as I was waiting for the MA to come out of the room as she had already TEAMS me that the patient was “excited” to check in with “her BHC,” I noticed one of our medical providers coming out of a visit.

As I often say to our providers and medical team, “what’s good, Dr. Smith (not their name, to help protect PHI)?”

Dr. Smith, “Not a whole lot. I have a visit that needs to turn into a procedure, I have a patient waiting after this one that is a hospital follow-up and going to need an interpreter, and then after that, I have a wound check that I know is not improving. Oh, and I am already 40 minutes behind.”

Those that work in primary care have unfortunately observed this reality regularly, a provider just trying to make it through and survive their hectic clinic. I told him, “we are here for you, man, if you need us (BHCs) to get any of these visits started for you so you can just have a break, let us know.” He nodded and ran to find the tools needed for the procedure.

I entered the handoff and check in on my patient. Patient was doing great, truly was amazing considering their context and what they had been through, not only as a child and throughout their teenage years, but as and adult. The excitement, the pride, and, most importantly, the compassion they were showing towards themselves, it was incredible.

As I wrapped up the visit, I quickly went back to the medical pod to check on that provider. It had been about 15 – 20 minutes and they STILL had not started the procedure. And, their last visit of the morning, had just checked in. As the provider entered the exam room to begin the procedure, myself and another BHC quickly made our way over to an MA and asked if the last visit of the morning, who had seen a BHC two months ago and was coming in for hypertension, had been roomed yet. The MA explained they had not been, they had no rooms to room them, and they were worried if the patient would end up leaving due to how far behind the team had gotten. As another handoff came in that my colleague quickly took, I asked the MA if they would be able to room the patient in my exam room and that I could at least get the visit started for Dr. Smith and potentially work on items related to high blood pressure. She agreed and walked briskly to pick up the patient.

To make an already long-story short, as I entered the room and began talking with the patient, it became obvious there was a larger context for this individual. They conveyed they had two bouts with COVID, one of which they though they may not make it through. This close encounter with mortality had resulted in an increase sense of unease and worry, as they had a family that they were the primary care giver for. Working long hours to provide for their growing family, they impressively had already made lifestyle improvements including reducing soda intake and completely cutting out energy drinks, even though their job required them to travel regularly and the patient indicated, “it can be tiring.” The visit kept coming back to a theme of “my mind just keeps racing,” which appeared to be related to worries about their health and the ripple it could have on their family if there were concerns. As we normalized and discussed the reality of “it would be weird if you weren’t worried about this, as well as interventions, including some mindfulness and relaxation, we made goals regarding exercising with their children (values, values, values) and doing meditation and relaxation with their son, who also has anxiety. I excused myself to go check on how soon the medical provider would be able to see them and pick up the printed out After Visit Summary and learned the PCP was still at least 30 minutes out, and the patient had to get back to work. The nurse, hearing this, said, “you know what, let me go in, let me go over any concerns and see what I can do. Let them know I’ll be there in 5 minutes.”

As I entered the exam room to inform the patient of the situation, they inquired, obviously reflecting they were contemplating the visit we just had, “can I ask you something? Why is it tough to talk about this stuff? I talked to my partner about this in that I just feel overwhelmed, just nervous a lot. I cannot stop it?” My mind smiled at the obvious openness and willingness that was being displayed. As tears filled the patients eyes, they further said, “look I come from (a culture, won’t disclose due to PHI) and no one talks about this stuff. You know, I really think we should.” As we wrapped up the visit, embracing with a handshake that seemed to last a lifetime, I ended with, “my mind says this is corny and, you know, us psychologist, we are corny. More than anything, be kind right now. It is incredible to see what you are doing and this worry and nervous should be here as it reflects the love for family. Again, more than anything right now, be kind.” We both had tears at this time and, as fate would have it, the RN knocked on the door to complete her portion of the visit.

After the visit, I ran to get my scheduled visit that I was 20 or so minutes behind. As I picked them up from the waiting room and expressed gratitude for waiting, they said, “do not worry about it, we know you all are helping people.” Proceeding that visit, I finally made it back to the PCP and asked how they were doing. “Not good, that one patient had to leave before I could see him.” It was clear he didn’t know that we were able to see him and provide a moment with the patient. As I filled him in on the visit and what was happening, his face changed from one of being demoralized to one of relief and hope. It was obvious that he was still bothered about the morning, still feeling that he let the patient down, and, it was something that he was not holding alone, it was something the team held together.

After the morning and I went down to my office to grab a quick bite to eat and, yes, a red bull 😊, my mind began to reflect on the incredible moments that transpired during just a two hour stretch of primary care. The efforts of a team that was striving to help a provide manage their impossible day. The provider having a value of providing high quality care to patients, even though they were running behind. The reminder of the longitudinal relationship we get to have with patients throughout their life time. The experience of working with another id

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