Monday, May 16, 2016

Relationships in Primary Care

Matthew Gartland, MD
Resident in Medicine and Pediatrics at Massachusetts General Hospital
In the days before I left for Chiapas, Mexico, I spoke several times to one of my primary care patients. I called him at home one night and he answered the phone out of breath, speaking in short quiet sentences, and gasping to catch his breath during long pauses. He had been experiencing progressive shortness of breath and anxiety over the past 2 weeks, but had not called the office or come to the clinic because he was afraid to go to the hospital. He had lived alone since his wife died and I had tried unsuccessfully over the past several months to arrange elder services to make visits to his home. After convincing him to go to the emergency room that night I visited his room and we talked about a range of topics – his family, the care he wanted at the end of his life, and my upcoming trip to Mexico.

This patient represents many of the best and most challenging elements of primary care in residency. He and I have developed a strong relationship that extends beyond the exam room at the clinic. This has helped me to guide him in what will likely be the last months of his life. On the other hand, I have struggled to address his diabetes and anxiety, chronic diseases that deeply impact his quality of life. It has been even harder to change social issues such as his isolation and loneliness.

In Chiapas I had the privilege to work with Compañeros en Salud (Partners in Health sister organization in Mexico) in two communities, Salvador Urbina and Soledad, in the mountains of southern Mexico. There I witnessed the delivery of primary care by young, passionate Mexican physicians, or pasantes. We saw many patients who reminded me of my experiences with primary care in Boston. I was able to share lessons learned in my few years of training, but beyond that I saw novel approaches to address the challenges of delivering equitable and comprehensive primary care to the poor of Chiapas.

Soledad is a town of about 1200 people spanning a large valley almost a mile above sea level. There I worked with with Monse, a pasante who had been living in Soledad for a little more than 3 months.

Almost every night we walked the hills making home visits. One evening we saw a pregnant woman and convinced her to deliver in a regional hospital rather than at home. Another we paid a house call to a patient recovering after a hysterectomy. On my last night in town we climbed to the house of a child with epilepsy having increased seizures.

One visit stands out in my memory. A 16 year-old girl suffering from panic attacks and anxiety came to the clinic after school. The pasante had created an environment in her clinic to welcome patients struggling with mental health issues. The young girl unburdened herself over the course of a 30-minute visit. We discussed her symptoms and educated her about anxiety. We put together a therapeutic plan — regular visits to the clinic, relaxation techniques and avoidance of triggers, a trial of a medication, and even tutoring sessions with Monse on Saturdays to reduce the stress of school and provide another safe space for her to share her feelings. After seeking the patient’s permission, Monse and I then went to her home later that day to discuss the visit with the girl’s parents. We sat in their kitchen drinking tea and advised them on how to guide their daughter through a tough adolescence.

To me this represented the essence of being a community doctor. Monse is part of a group of 10 amazing pasantes supported by the resources of the Mexican government and Compañeros en Salud. They are stationed in small rural communities where they tackle the growing burden of non-communicable chronic diseases like diabetes, hypertension, and hyperlipidemia. The organization is also introducing novel approaches to heavily stigmatized disorders such as depression and anxiety using community health workers, support groups, and physician home visits to reach the poorest and most vulnerable members of these communities.

The work is not without significant challenges, many reminiscent of my own experiences in Boston. Patients miss appointments, get confused about how to take medications, and struggle to make changes in their unhealthy lifestyles. But the organization has created a strong infrastructure and tapped into the energy and dedication of young physicians and the passion of local staff and community health workers to address these challenges.  

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