As the last line of defense in soccer, the goalkeeper holds a privileged position. She’s the one who can see the whole field unfolding in front of her, and she’s the one who must come up with big plays when the game is on the line. When I was a goalkeeper, I lived for the pressure, drama and chance to be the one to make the big plays for my team.
I spent the summers of my childhood at soccer camps, and it was there that I first heard a new perspective on goalkeeping. We were sitting in a half-empty college classroom on a humid New England summer night when a white-haired coach approached the blackboard. “Goalkeepers at the highest level don’t have to make the big plays,” he said. “In fact, they don’t have to make many plays at all. Forget the statistics about how many saves a keeper makes in a game — that’s meaningless. The best goalkeepers in the world can actually prevent the dangerous shots from being taken in the first place.”
I’d never heard this idea before, and twelve-year-old me remained unconvinced. After all, we spent most of camp practicing how to make those big saves. Besides, throwing yourself through the air was the fun part, the part that teammates, coaches, and fans loved. What was the point of goalkeeping if not to feel like a superhero? I filed the coach’s words away but spent the remainder of the summer practicing my dives.
Eventually, my penchant for throwing my body around caught up to me, and a series of injuries found me retired from soccer and scrambling for what to do next. I stumbled into a staff role at a student-run homeless shelter on campus, and there I found a community, sense of purpose and desire to learn what I could do to better serve the guests I met. After graduation, I spent two years with the Boston Health Care for the Homeless Program as an outreach case manager for a panel of high-risk patients. I walked beside my patients as they navigated the primary care clinics, emergency rooms, shelter systems and social services of the city. From this position, I saw the health care system through the eyes of some of the most vulnerable members of the community, and what I saw surprised me.
I saw patients ending up in the emergency room again and again for the same problems. I saw redundant work, repeated tests, siloed resources and fragmented care. I saw passionate providers who went above and beyond for their patients but were pushed to burnout by lack of time and resources. I saw a system that readily reimbursed for a transplant or amputation but not for the creative care and problem solving that could have prevented such a drastic procedure in the first place.
However, amid the problems, I saw incredible potential. The shelter-based primary care clinic made the transition from a traditional care delivery model into a patient-centered medical home and began to engage patients who had previously fallen through the cracks. Our organization put an emphasis on case management and gave primary care teams the ability to work with patients on social needs outside of the clinic walls. The public health commission organized regular meetings across the city and across health and law enforcement professions to coordinate the care of the city’s most vulnerable residents. Within the broken system, I found a community of passionate, creative, mission-driven people who were fighting to put patients’ health first.
Ever since I stopped playing soccer, I had been searching for a new outlet where I could feel the same intensity and sense of purpose that I enjoyed in the goal. I thought I would find it in the fast-paced excitement of the emergency room or the high-stakes performance that surgery demands. However, at some point during my experience with Health Care for the Homeless, the coach’s words came back to me: “The highest-level goalkeepers aren’t the ones making the impressive saves. The best goalkeepers are the ones who can read the game as it unfolds, anticipate what is going to happen next, adjust their positioning and effectively communicate with their teammates to prevent the dangerous shots from being taken in the first place.”
Suddenly, it clicked. High-quality medicine isn’t about dramatic life-saving surgeries or specialty procedures. It’s about figuring out ways to see potential problems, make small adjustments and work with the patient and entire medical team to prevent life-threatening problems from happening in the first place. Often, these interventions are far from glamorous, and they center not on technology but on relationships. It’s about building trust with your patient through the gift of a clean pair of socks, getting to know the emergency department social worker who sees your patient weekly, and creating a space where members of the team can collaborate on a care plan. This is medicine at its highest level, and this is what I believe primary care has the potential to be.
Our health care system is built around the dramatic saves. We need the highly trained specialists and advanced technology of tertiary care centers to make the big plays, since every shot can’t be prevented. However, this can’t be the basis of the system. The point of health care isn’t cutting-edge procedures. It’s healthy patients. All care must be in service of this larger goal. We need a system that rewards outcomes, and I believe my generation of primary care leaders is positioned to lead the charge.
Alexandra Millet is a medical student who blogs at Primary Care Progress.
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