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“You will need to screen every patient for depression using the PHQ-9,” my supervisor told me. “Focus on the first two questions and notify the internist of the scores”.

Sounds simple enough. Wait, what is the PHQ-9? What’s an internist?

“Don’t tell me the scores,” the internist instructed me. “Just tell me when the patient is suicidal.”

Ok. Screen everyone. Don’t tell the internist. Watch out for suicide. Is this integration?

My second clinical placement during my doctoral training was at the Snow Hill Medical Center in the eponymous town 30 minutes west of my apartment. The drive through eastern North Carolina was quiet and scenic, interspersed with copses of pine and fields of tobacco.

North Carolina is where the first European Americans experimented with town names. The less creative ones end in -ville or -boro. If I took a wrong turn on my way to Snow Hill, I could end up in Winterville, Farmville, or Tick Bite.

Snow Hill felt like frontier territory, a stark contrast to my first clinical placement at the East Carolina University Family Medicine Department, which resembled a well-established municipality with all the amenities of city life.

This was my first exposure to rural healthcare, to internal medicine, and to universal depression screening. It was also the first time I witnessed integration at an early stage of development.

I enjoyed working with the patients. They were open and generous. I learned to replace clinical mental health terms with more everyday terms like stress, sadness, and life goals.

Sometimes migrant farm workers would visit the clinic with respiratory issues or other ailments. I remember seeing the stains on their fingers from harvesting tobacco leaves. Nicotine exposure. They avoided gloves because it was easier work without them.

The internist was crisp and efficient with his patients. I was amazed at the clinical volume he moved through. The patients admired him.

Just as the internist’s hand touched the door handle to leave the exam room, patients would often voice one last concern. With a practiced smile, the internist would respond, “Please make another appointment, and I’ll be happy to discuss it then. Goodbye!” It was a model of efficiency.

He cared about his patients and staff. Once I shared with him a concern about my left ear. He immediately grabbed an otoscope for a look. “It looks fine. Take some Benadryl and that should help”. It didn’t, but his attention to my need was like medicine.

We screened every patient for depression. This universal screening approach kept us busy and, periodically, led to stepping on toes. Because we screened everyone before their medical visit, the internist did not know which rooms we were in until he opened the door. Sometimes the internist let me stay and other times he shooed me out.

One day another student persuaded the clinic director to designate one of the colored flags hanging above each room as a “mental health” flag. The brown one. From then on, whenever we started our screening, we used the brown flag to communicate with the internist. He learned to temporarily skip those rooms and move onto the next patient. That small change led to more consultation requests.

There were other medical providers besides the internist, including a physician assistant. She consulted with us many times and was interested in our assessments. One day the physician assistant invited me to lunch. I ate pulled pork, coleslaw, and hush puppies. It was a new culinary experience for a Yankee like me.

I talked about my experience moving to the area and starting my doctoral program. The physician assistant talked about her adult kids and ex-husband. “I’m not sure why I’m sharing this with you,” she said at one point. “Maybe it’s because the way you listen.”

Rehab counseling students were placed at the clinic to help patients with substance use concerns (e.g., SBIRT). I enjoyed talking to the students about their training and the SBIRT model. I give them credit for helping make substance use prevention and treatment a significant part of my career.

Toward the end of my time at the clinic, the internist approached my fellow student and asked for recommendations on behavioral medicine textbooks. He wanted to learn more about the connection between physical and mental health. That was a major win.

Integration was new at Snow Hill Medical Center. It was still new to me.  

Reflecting on that time, I see that as I learned more about primary care, the medical team was simultaneously embracing integrated care. While I was building my medical literacy, they were gaining a deeper appreciation for mental health. We were all learning at the same time. I wish I had recognized that truth then.

The early stages of integrating behavioral and physical health services include significant change. Smaller clinics often don’t have access to the training, leadership, and technical assistance required for practice transformation, but they have other resources like a supportive environment and longstanding credibility with the community.

I was lucky to work at Snow Hill. The experience taught me that integration is not just about systems and procedures; it’s about the willingness to learn, adapt, and grow together as a team, regardless of the challenges we face.