With onboarding our new BHC interns and FM residents, we have had numerous conversations and presentations regarding the importance of integrating a contextual, compassionate approach to healthcare. Regardless of it being delivered by a BHC, by a PCP, by an MA or nurse, providing healthcare in a way that remains curious and compassionate is lifesaving.
During the past week, I had recent college graduate shadowing me in clinic (side note, if you are ever interested in shadowing us at CHCW, let us know; we would love to host you), and we had a true realization of the importance of applying a contextual approach. We saw the patient via a handoff from our terrific pediatrician, and was a teenager that was dealing with weight concerns. Upon entering the exam room, and with the assistance of an MA interpreter, we learned the teenager was living with a solo parent and sibling. Being curious about the living situation, the parent present in the room explained the family had been living separately for the past year due to financial struggles. In a result of this, both parents were working full time, long-hours, in separate states to make ends meet. This context had resulted in the patient being home most of the time by themselves, which, as one’s mind may predict, prompted some difficulties in regulating their diet and incorporating healthy food choices. As we gathered more context, we learned even through a move over the past year and having no social connections other than their parent and one sibling, the patient received straight A’s in school, something they were obviously very proud of. Further, the parent present explained they were trying to exercise with the teenage patient, however, due to work requiring an increase in hours, resulting in working seven days a week, they had not been able to do as much as they were like. During this conversation, the MA and I could tell there was much guilt from the parent for not being as present as they would like with the patient. As we were setting goals, which the patient stated they believed they could do two days a week of gym exercises, the parent stated, “you know, I think I can take him to the gym five days a week.” Before I could even say anything, the MA commented, “you are doing a lot right now, what if we kept it at 2 days a week just to make sure you are not overwhelmed.” The relief on the parent’s face was palpable. My mind predicts the reason for this relief was that the MA, myself, and the student observing, saw their situation, their context, we saw them for who they were. As we ended the visit, agreeing to follow up at the next PCP visit in a month, the parent asked, “are we able to come back to see you even if we don’t have a scheduled visit with the PCP?” Myself and the MA assured, “we are here, anytime, when you need us.”
After the visit, I sat with our student shadower and discussed what all had transpired. Clearly, there were obvious aspects of the visits that went great, us reinforcing the patient for making good grades, us normalizing to the patient the challenges of being away from some of his family for the past year, us setting a SMART goal that had a chance of being completed because we saw them for who they were. And, while those were obvious, the student and I reflected on the less obvious ripple and relational frame that transcended the visit. Specifically, the patient who was congratulated on making grades, had an opportunity to discuss what they liked to do for hobbies, and was validated for missing their family. Instead of the majority of the visit focusing on their weight or something they were doing wrong and needed to improve, the majority of the visit was focused on them as a human and what they were doing well. Instead of developing a relational frame that every time they come into the doctors office they will be criticized for their weight and told the things they need to do more of, they were reinforced for being resilient and their struggles normalized. Then, thinking of the parent in the room, who expressed guilt for not working out more with the patient, even though they were doing more than we could ever expect or ask. That rather than being told they needed to do more, they were told, “we see you, you are doing more than enough, be kind in this moment.” When we think about the visit rippling out to engage both the patient and the parent with the healthcare system, my mind becomes very emotional. We often, as BHCs, do not recognize the life saving interventions that we subtly do. That simply taking a contextual approach and seeing individuals for who they are, rather than just indiscriminately focusing on the presenting concern or what is going wrong, is healing and lifesaving. We know we have a number of behavioral interventions that can do amazing things, and maybe simply taking a contextual approach that honors the individual and where they are does the most important thing, creates relational frames of engagement with the health system. As the MA said after the visit, “they will be back,” and, that, is lifesaving.