Five minute read

“She was visibly upset while she talked about the confrontation with her brother,” I said. “And then suddenly she stood up, arms wide open, asking for a hug.”

“And what did you do?” my clinical supervisor asked.

“What else could I do? I gave her a hug!”

My supervisor smiled. “I want you to present this case on Monday to the rest of the team.”

After two years of doctoral coursework and clinical placements, I was hired as a pre-doctoral intern at the Concord Hospital Family Health Center in New Hampshire. My wife and I rented an apartment just a mile south of the clinic. The bike ride to work was vigorous, with a climb up the hill, but the ride home was an easy coast back down. During snowstorms, my wife would drop me off.

The Family Health Center is a primary care clinic with a family medicine residency program. The clinic building is a former teaching nurse dormitory adjacent to the hospital. Underground, a tunnel connects the clinic to the hospital, making hospital consults easier during the winter. I used the tunnel even during the spring.

After becoming an expert in universal depression screening at my doctoral program, I was relieved of screening duty for the internship. I rarely worked on the clinic floor. All my patients were referred to me by the medical clinicians and social workers. Names just appeared on my schedule and patients came to my counseling office.

All consults were managed by one of four clinical social workers, each assigned to a specific nursing station. My role was to provide psychotherapy, and referrals flowed into my schedule as effortlessly as my bike ride downhill after work. Interestingly, the clinic used the same electronic health record system (GE Centricity) as my previous placement.

How was the clinical supervision? It was excellent. Every Monday, the entire behavioral healthcare team gathered for group supervision, a meeting I eagerly anticipated. The team included master’s and doctoral students, like myself, as well as fully licensed clinicians. We took turns presenting cases using a reflecting team approach.

Once, I presented a case about a woman recovering from a traumatic relationship and unemployment. I shared with the team that, during our last session, my patient became so overwhelmed that she suddenly stood up and asked for a hug. I agreed, feeling a mix of shock and empathy. The reflecting team relished dissecting my case and discussing the ethical boundaries involved.

Another time a patient with a history of incarceration and PTSD brought two cans of soda, one for me and one for him. I expressed my appreciation and told the patient I would drink it later. He seemed displeased that I was not enjoying the soda with him.

I brought this up during supervision that week. My supervisor and I spent most of the session talking about ethics and boundaries in psychotherapy. It was a great discussion. Soon after the soda session, another patient brought me an entire pizza she had baked in her food truck. By then, I knew exactly how to handle the situation.

I was amazed by the high level of integration and multidisciplinary care across the clinic. For the first time, I worked alongside social workers, psychologists, psychiatrists, and mental health counselors. I completed hospital rounds and consulted on inpatient cases.

I once co-led a Centering Pregnancy group with a family medicine resident and also co-facilitated a support group for patients living with congestive heart failure. My co-leader, a registered nurse, taught me invaluable lessons about emotional support and patient empowerment. Additionally, I was part of a team of clinicians who developed an innovative, team-based group visit model for patients after hospital discharge.

I felt comfortable and cozy at my internship. Sure, my clinical and teaching skills grew, but it was the culture that wrapped around me like a warm blanket. Everyone seemed happy to work there and perfectly understood my role and capacity. As David Byrne’s lyrics go, “And you may ask yourself, ‘Well, how did I get here?’”

“Culture eats strategy for breakfast” is a remark attributed to Peter Drucker. The employees at the Family Health Center had shared values and beliefs about integration. These beliefs translated into everyday collaborative practices. This culture of collaboration influenced every aspect of how employees interacted, made decisions, and approached patient care. I can’t recall a single employee who didn’t embrace collaboration as a core value.

Clinic leaders were both approachable and passionate about their work. Reflecting on it now, I realize that this culture was the foundation of their integrated care model’s long-term success. Just as a tree with strong roots bends with the wind without breaking, a clinic with a robust culture can navigate change smoothly, ensuring sustained success and growth.

Integration naturally varies at each facility, and these differences should reflect the clinic’s culture and community needs. In Concord, I entered a clinical environment that had been carefully and purposefully shaped over the previous 20 years. The systemic collaboration I experienced there didn’t develop overnight.

My internship taught me valuable lessons that I carry into my work today. I now guide newly integrated clinics in harnessing the powerful influence of their culture. I encourage practice managers and leaders to foster systemic collaboration at every level of the organization and to prioritize ongoing clinical training and supervision.