Bill* stops by the clinic about once a week to use the phone in our lobby. Karen* asked if she could have her mail sent here. Once we bought Daniel* a bag of groceries, and Frank* calls to speak to our nurse every few days because he says, “I’m lonely.”
There is a national push to re-envision our primary care clinics as patient-centered medical homes, with the intention that a patient can get all their medical needs coordinated in one location, thereby minimizing logistic barriers to care, and providing the benefits of continuity care provider relationships. This is a sentiment that has long been embodied by family medicine clinics, for good reason: Strong care relationships, centralization of services, and provision of convenient, effective medical care can lead to better health outcomes.
But some of our patients need more than a medical home. They simply need a home. A place to get their mail. A place to make phone calls. A place to catch up with kind people. Familiar faces. Compassionate listeners. Human beings who care about them as fellow human beings. Personal connections. A friend.
Should primary care clinics serve that role?
Our patients’ intuition is correct: They will find kindness here. Our clinic is a small team of incredibly dedicated, compassionate, thoughtful, skillful caregivers, all committed to providing the best care for our patients so that they can attain and maintain the best of health.
But for many of our patients (the majority of whom are on Medicaid), what they are seeking to heal is far more than their rash, diabetes, or headaches. For many of them, their emotional and psychosocial fabric is completely torn. Their relationships are fractured, their psychiatric conditions severe. Some of them suffer from substance addiction, or debilitating injuries. Some lack the resources to clean and feed themselves. Some have no supportive relationships: no family, no friends, or even worse — family or friends who harm them. And many of our patients lack compassion for themselves.
So they turn to our clinic. A place where every person treats them with respect, listens to their concerns, validates their fears, offers solutions. And thus the dilemma: despite our sincere compassion and commitment to their health, the emotional and personal needs of our patients are beyond the scope of care that we can or should provide as a medical clinic.
In modern American culture, individuals are increasingly isolated and disconnected. It is difficult to pinpoint any one event, trend, or cause: Poverty? Erosion of the extended family? Expansion of technology and social media? Dissolution of urban neighborhoods? The American emphasis on individuality? The opioid epidemic? Untreated mental health disorders? All of these factors, and many others, contribute to our current situation, where people are left without a community to catch them in times of need. No sibling to drive them to their doctor’s appointment, no neighbor to check on their house, no church or school group to notice if anything seems amiss, no friend to call to simply say hello.
A social worker could address certain concerns by connecting patients with social services; unfortunately, like so many other clinics, we do not have a social worker, because of the limited hospital-system budget. A counselor can provide critical psychological support to our patients, and we are fortunate to have such professionals in our clinic. But for many patients, these services cannot fix their profound social isolation, and it is not the role of the clinic or clinician to fill that need. We must be cautious about reaching beyond our professional roles, because despite our best intentions, we may not help them, and we could actually cause harm.
After we bought groceries for Daniel that one time, he started asking for cash. Our staff continues to speak to Frank for hours at a time; sometimes he threatens to do something drastic if we say we have to get off the phone, and he recently asked us to help him acquire a new cat. When Bill uses the phone in the waiting room, sometimes he yells, and sometimes he smells, and sometimes he hits on the receptionists, who handle this well, but the other patients look uncomfortable. Furthermore, these patients often consume significant amounts of time and emotional energy from our clinical team, leading to feelings of burnout.
Our clinic provides exceptional medical care to our patients, but we are not equipped to provide the comprehensive emotional care and social support relationships that our patients so desperately need. When we identify a patient with such needs, and feel the impulse to help, we must recognize the reality of our professional limitations. It is unfortunate that in our desire to help our patients in non-medical ways, sometimes we cause harm by enabling them, perpetuating relationships of dependency, or overextending resources to the detriment of our other patients or even ourselves. Of course, there are some obvious situations where we can draw cleaner boundaries. But it is not so easy to simply stop helping our patients when their needs are so overwhelming, while the community resources are so few.
Societal-level problems require societal-level solutions. We must, as a society, research what cultural, political, and economic pressures have led to the social and emotional isolation that leaves so many people drifting and helpless, with no one to turn to for support but the kind people at their doctor’s office. It is only through such broad self-inquiry that we can, as a country, develop solutions that permeate through all of our communities, down to the individual level, to renew the supportive interpersonal relationships that these days seem fewer and farther between. Of course, such an optimistic vision for the future will take immense time and effort to realize. In the meantime, while our clinic cannot replace the relationships that make up a person’s home, we will keep providing our patients kind, compassionate, and excellent care at our patient-centered medical home.
* Identifying information changed for patient privacy.
Belinda Fu is a family physician.
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