All of us can learn from primary care clinicians, who know that listening, compassion, and connection are the foundations of clinical excellence.
Lifelong Learning in Clinical Excellence | March 12, 2020 | 4 min read
By Colleen Farrell, MD, New York University
Inspired by primary care
When I finished medical school, I was certain I would become a primary care physician. I chose a residency in primary care internal medicine at a public, safety net hospital. Like any internal medicine residency, my program required many months of inpatient and intensive care medicine. What’s unique is that my training also included intensive clinical and didactic experiences focused on the complex, challenging work of primary care. I’ve been surrounded by co-residents and faculty passionate about primary care. Primary care hasn’t been an afterthought in my internal medicine training, but a cornerstone.
I’ve loved my primary care training, but life doesn’t always follow the plan. To my great surprise, I learned during residency that I also love critical care. Something about caring for patients with acutely life-threatening illness has connected with my intellectual and emotional core in a way that providing primary care hasn’t. After much reflection, I’ve decided that in July I’ll say goodbye to the primary care patients I’ve had the privilege of caring for over the last three years and begin fellowship training in pulmonary and critical care medicine.
It was hard telling my primary care faculty about the change in my path. Not because of anything they said—they’ve been unflaggingly supportive—but because I felt like was betraying the mission of primary care. Given our country’s critical shortage of primary care physicians and the widespread underappreciation and undercompensation of primary care, my intention to do primary care had been a statement of my values. But deep down, I know I need to proceed on the career path that feels right to me. I’ve also realized that the values that drew me to primary care don’t have to be limited to that field.
What my primary care mentors taught me
My mentors in primary care have taught me lessons in the art of doctoring that extend far beyond the primary care clinic. From what I’ve observed in medical school and residency, primary care is often at the forefront of humanistic, patient-centered, social justice-informed medicine. I want to share here a few of the lessons my primary care mentors have taught me that I will take with me as I care for patients throughout my career, from the clinic to the ICU.
Meet patients where they are
My primary care training taught me to focus on who the patient is, not just what disease they have. While on a multiple-choice test the treatment plans for two patients might be identical, real life is different. Making a plan with a patient about medication, lifestyle changes, or diagnostic tests is shaped by so many individual factors like patients’ unique personalities, family relationships, work schedules, personal values, religious practices, and more. In primary care, our goal isn’t necessarily to get the “right” answer, but to engage patients in their care and create a non-judgmental and supportive space that they will want to return to.
Care for the family unit
My family medicine rotations as a medical student deeply shaped my orientation toward patients’ families. I learned from physicians who cared for both postpartum mothers and their new babies, who saw multiple members of a big extended family in one evening clinic session. In those interactions, I saw how the health and well-being of family members was deeply interwoven. I’ve often thought of my family physician mentors while in the intensive care unit where our work is not just caring for the critically ill patient, but supporting their family through uncertain and and often devastating times. While the patient in front of me is my primary concern, I recognize that my responsibility to offer compassion and care extends beyond them.
Be there when there’s no fix
In other areas of medicine it’s not uncommon to hear doctors say, “there’s nothing more we can do.” But primary care physicians never “sign off” from a patient’s case. They’re there when there are no surgical options or no more chemotherapy. They help elderly patients maximize their final years. They provide a comforting, familiar presence for patients struggling with chronic stress and illness. My primary care training has instilled in me the belief that we can always provide care, even if only by being present and ready to listen.
Pay attention to your own emotions
Practicing medicine requires tending to one’s own inner experience. My primary care mentors have understood this and modeled it for me. In my residency program, we have regularly scheduled “psychosocial rounds” in which a resident shares a patient interaction that was challenging for emotional, interpersonal, or ethical reasons. The faculty member who leads these discussions encourages us to use our own emotions as an entry point for learning about our patients and ourselves. Emotions often run high in medicine; these sessions have helped me approach my own emotions and the emotions of others with curiosity and understanding. Over time, this practice has helped me cope with the inevitable frustrations and heartaches of medicine and develop more effective communication in difficult moments. It has been a space for me to worry less about my clinical competence and embrace my very human vulnerability.
Though I’m not pursuing my original plan to become a primary care physician, my primary care training has deeply shaped the kind of physician I am and will become. All too often medicine is uncaring, transactional, and impersonal. My primary care training has taught me an orientation to medicine that centers listening, compassion, and connection. I am profoundly grateful to have had primary care mentors who have shown me medicine at its best.
Colleen M. Farrell is a resident in primary care internal medicine at NYU and Bellevue Hospital and an incoming pulmonary and critical care fellow at Weill Cornell Medicine.