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It's Not About the Nail
- 1. “It’s Not About the Nail” Marsha Johnson, MSW, LCSW
- 8. Camden Coalition of Healthcare Providers a very important person I met on a very important day that I will never forget
- 21. Attachment
Editor's Notes
- So, I am going to start off this morning with a brief video that I think you will enjoy. When I first saw this video, I thought “Wow” this really gets at the heart of where we are in the healthcare movement. I’m going to talk to you about how the “it’s not about the nail” concept applies not only to our patient work, but to the systems change work of healthcare reform more broadly.
- So, I’d like to share a bit about my professional journey. We’ll come back to the nail in a bit. So, I am trained as a clinical social worker and started my career as a psychotherapist providing co-located behavioral health services in a federally qualified health center in Philadelphia, Pennsylvania. My work was doing traditional hour long psychotherapy sessions that continued for as long as the patient remained engaged in care. I had a lot of time to explore and learn many deep things about the lives of patients and how so many of these experiences were the underpinning for how they felt both emotionally and physically. They invited me into their world and helped me to understand their perspectives and experiences. I learned about their birth, their educational journey, where they had lived and with whom they had lived throughout their lives, their spiritual beliefs, who mattered to them most, what chronic diseases they dealt with and an overall picture of their emotional health and wellbeing.
- While I was enjoying my work and felt I was providing a valuable service to my clients, it was not enough. I was one of two clinical social workers at a health center that served 10,000 patients. Despite filling my schedule weekly, at any given time I had about 50-60 people on a waiting list. Our attempts to serve the population were backfiring and we adopted a model of integrated behavioral health that would radically change how I worked with patients. My role shifted from doing psychotherapy with health center patients to a role as an embedded behavioral health consultant on the primary care team. It was an exciting time because there was a great opportunity to learn on a multidisciplinary team. There was tremendous crosspollination and I learned so much about the medical side of things. As a consultant on the medical team, my visits were now about 20-30 minutes in length. I saw some patients only once and others a handful of times. Sometimes I saw a patient for a few visits a year over many years. I no longer had the experience of sitting with patients for an hour or doing a full biopsychosoical assessment. So, while I used to be very expansive with my patients gathering significant information about their lives, their thoughts, their experiences and their fears and their wishes, I began gather small pieces of information and move quickly through a brief assessment, some dialogue and care planning with the patient. The cross-pollination was in full effect and I began to adapt to my new environment and my new role. I began to feel the pressure that my primary care colleagues felt when they had 20 minutes with a patient and had to accomplish so many things in this brief amount of time not knowing when or if they might see the patient again. Along these lines, I began to work more and more like a primary care provider and less and less as what I knew to be a clinical social worker. That adaptation resulted in new knowledge, skills and relationships and it also resulted in me becoming more prescriptive, rushed and outcome-focused…My professional life and work was becoming more and more about the nail.
- I started seeing nails wherever I went and I had a toolbox full of hammers for each nail. If the nail was smoking, my hammer was a quitline and some patches. If the nail was depression, my hammer was an anti-depressant or cognitive behavior therapy techniques If the nail was insomnia, there were sleep aids or progressive muscle relaxation If it was panic, there was diaphragmatic breathing Sometimes I really liked these hammers. In one fell swoop I could check a box, solve a problem. I could fix things. It felt good and I felt competent.
- The hammers were great. They eliminated ambiguity. They eliminated the discomfort of the space of not knowing of feeling unsure. They eliminated the places where I felt hopeless, lost or ineffective. Everything became a nail because the hammer felt so right in my hand. There were problems called nails and there were solutions in the form of a hammer.
- Everything could get wrapped up with a big bow. Let’s face it. Checklists, protocols, and evidence-based practice make us feel like we have wrapped things up with big bows. Such security, such simplicity. My life as a behaviorist on the primary care team was feeling manageable and busy. Lots of nails everywhere…so many things to “fix”...and then something happened.
- I met someone who changed me… I was sitting one afternoon in the provider office working on some notes, when one of my primary care colleagues came in and said, “Marsha, I have this patient who needs to talk to you.” Now, I know that when my colleague says this, it can often mean I need you to see this patient and the patient could be anywhere from reluctant, resigned to downright annoyed that they have to talk to me. So, I asked her to tell me about her patient.
- The PCP said “Well, here’s the deal. Mayda is in her late fifties and she is a mess. She has diabetes, a bunch of complications, heart disease, her blood pressure is uncontrolled and she is STILL smoking. She already has one leg amputated and I am afraid that if she doesn’t start taking care of herself, she is going to lose the other one. Will you see her and talk with her about quitting smoking? She says she wants to quit and knows it is really affecting her health. So, I agreed to meet her and went to the exam room where I typically met with patients. In a minute or two, Mayda came into the room in a wheelchair, wheeled in by her daughter. She smiled politely and we settled in. My colleague informed me that Mayda preferred to speak Spanish and could I situate myself in such a way that her daughter could read my lips because she was hearing impaired. I felt a slight wave of anxiety thinking about speaking in my second language, making sure I spoke so the daughter, opposite Mayda, could read my lips. I was also hoping to use some motivational interviewing skills that I had learned in a training the week prior. Deep breath.
- So, I introduced myself and Mayda told me that she had been smoking for decades and had tried to quit a couple of times including once about twenty years ago when she moved from Puerto Rico to Philadelphia with her youngest daughter to join her two adult children. She said she was never able to quit for more than a day or two in all the times she had tried. She really wanted to quit smoking but felt that So I began to ask Mayda about what activities she enjoyed because that when people start planning to quit smoking, it can be helpful to think about ways that distraction could help them down the road when they decide to quit. Mayda began by telling me that she really used to enjoy reading but
- Then Mayda’s face lit up and she said. Oh I used to have birds, I had cockatiels when I was in Puerto Rico when I was young. These birds were like my babies. I fed them by hand sometimes, I talked to them, they perched on my shoulder and I spent so much time with them. I hardly put them in their cages because I loved spending time with them. I asked Mayda if she had thought about getting a bird at all. She said no and smiled a broad smile and then said but I would love to have one. I turned to her youngest daughter who lived with Mayda and I knew helped Mayda around the house quite a bit. I said, “What are the chances of your mom getting a bird?” The daughter smiled and said I think that would be fine. I can help her. So, that concluded our visit. Mayda was getting a bird. You can imagine the look on the provider when I returned to the office and stated that Mayda was not going to quit smoking at this point. Instead, she was going to get a bird. As silly as it seemed, I knew that until I understood the complexity of the losses Mayda had endured and how smoking had become her companion, her moment of pleasure and enjoyment in the day, there was no way I was going to be able to help her. Understanding complexity is important in healthcare these days
- Our ability to understand and treat medical complexity is astounding. We can do things like filter people’s blood outside their body and put it back in while they sit and talk to a friend. We can give people artificial hearts and artificial lungs. Now I really want to make the point that there are nails in healthcare. Right? Sometimes a nail is really appropriate and a hammer is what we need. There have been any number of times that I was grateful for myself, for my family and for patients that there were hammers and people who were tremendously talented about using them. When my daughter has an asthma attack, I want the hammer. I know that getting to know her is not what matters in that moment. There is nothing wrong with nicotine replacement and breathing exercises as ways to stop smoking. They can be tremendously useful tools in helping someone change their life. Sometimes it really is about the nail. But in healthcare today---we are beginning to notice new kinds of complexity that we are having trouble grappling with. We are going to have to expand and flex for the situations that don’t call for a hammer…the situations that can’t be so easily fixed yet still cause or worsen disease, suffering and pain.
- Now people are dying of this
- And this
- And this
- And because there’s tons of people involved in a complex patient’s care---and no single person seems to have the full story
- Times have changed from my early understandings of healthcare. This is a picture of Dr. Griesy. I grew up in rural Northern MN and this was my family doctor. He delivered me and he was the care provider for my mother, my siblings, my father, my grandparents, my aunts and uncles and cousins. He knew the story of my family very well. He knew that my great-grandparents came to the US from Sweden and Norway at the turn of the century. He knew that to my grandparents it was still a bone of contention whether you were Swedish, Norwegian, Finnish, Polish or Danish. I bagged his groceries at my uncle’s store, I saw him at church and I went to school with his children. To be honest, he probably knew more than he wanted to about the various families in our community. At the end of the day, he was the carrier of many families’ stories of both tragedy and joy.
- It is time for the pendulum to swing back around to the time when we were able to really know our patients and when relationship was at the foundation of the work. This swing isn’t about individual providers deciding to spend an hour with each patient and making managers, patients and colleagues furious with them. I imagine some of you out there are thinking, “Yeah sure. I am going to go back to my practice and talk with my patients about childhood pets. That will go over real well.” The pendulum swing is not about what we do as individuals. It is about a fundamental shift in healthcare delivery that relies on new tools, new approaches and new evidence. We need teams of people who talk with each other to address complexity. We need to consider the impact of housing on the health and well-being of patients and quite frankly what role we play in healthcare to address the myriad of social complexities that get in the way of health and healing.
- There are people in healthcare who are starting to recognize the important of relationships…of knowing the stories of our patients‘ lives.
- Knowing the importance of what has happened in their lives and what impact this has had on them
- We are going to have to think about attachment…which is the study of our relational blueprints...how we learn to relate to ourselves and others comes into play. Not only how our patients relate to us but how we relate to them.
- The reality is that Mayda reminded me that I need to put down the trusty hammer and stop looking for nails when I was talking with her. I needed to pick up a new tool…that new tool I needed in that conversation was the archaeology brush. It is the tool that helps reveal what lives underneath, what never makes it onto a problem list and what drives so much of what we see in healthcare today. The brush helps me to see the shape and dimension of someone’s life. And while the work might take more time and I might get impatient at times, I can’t intervene or support in a way that is meaningful or has any bearing on a patient’s life when I resist seeing the whole picture and look for boxes to check.
- I never saw Mayda again and I don’t know what ever happened with cigarette smoking or with the bird because I moved on to a new workplace shortly after my visit with her. I do know, however, that no part of my training or the reading of a book or journal would have ever prepared me to know that getting a cockatiel would be part of a care plan for smoking cessation. That part of the story only lived in Mayda. Mayda’s story changed my story and now her story has touched you. Thank you everyone and thank you Mayda.