This painting by French realist Julien Dupre` resonated with me this past week. I know well the feeling of pulling against a momentum determined to break free of the strength I can muster to keep it under control. This is what my life often feels like, both on the farm and at work. It seems I am barely hanging on, at times losing my grip, my feet braced but slipping beneath me.
The full-uddered cow in the painting is compelled to join her herd in a pastoral scene just across the creek, but the milk maid must resist the cow’s escape. For the cow’s benefit and comfort, she must be milked. The cow has another agenda. She has snapped her rope tie, almost pulled up the stake, and in a show of strength and determination, the maid braces to pull a much larger animal around to retie her and restore things to how they were.
The action suggests the maid may succeed, but the cow’s attention is directed far afield. She doesn’t even feel the tug on her halter. We’re not fully convinced the cow won’t suddenly pull loose and break away from the maid’s grip, leaping the stream, tail raised straight in the air like a flag of freedom.
Right now, as spring advances rapidly with grass growing thick in the pastures, our horses can smell that richness in the air. Sometimes this tug of war takes place when my plan is different than the horse’s. The fields are too wet for them to be out full time yet, so they must wait for the appropriate time to be released to freedom. The grass calls to them like a siren song as I feed them their portion of last summer’s uninviting hay. They can pull my shoulders almost out of joint when they are determined enough, they break through fences in their pursuit of green, they push through stall doors and lift gates off hinges. Right now I’m barely an adequate counterbalance to the pursuit of their desires and I struggle to remind them I’m on the other end of their lead rope.
Each day I try too hard to restore order in my life, on the farm, in the house, in my clinic, with my patients and coworkers, with my family. I want to pull that cow back around, get her tied up and relieved of her burden of milk so that it can nurture and replenish others. Sometimes I hang on, only to be pulled along on the ground, roughed up in the process. Sometimes I just let go and have to try to catch that cow all over again.
Once in awhile I successfully get the cow turned around and actually milked without a spill.
I’ve held on. I’ve got a grip.
And maybe, just maybe, I will make cheese….
Drying inward from the edge. ~Edna St. Vincent Millay “Ebb”
I wondered if that was how forgiveness budded;
not with the fanfare of epiphany,
but with pain gathering its things,
and slipping away unannounced in the middle of the night. — Khaled Hosseini from The Kite Runner
My mother was 58 when my father left her for a younger woman. For weeks my mother withered, crying until there were no more tears left, drying inward from her edges.
It took ten years, but he returned like an overdue high tide.
She was sure her love had died but somehow forgiveness budded, that dry pool refilled with water somewhat cooler to the touch, yet more amazing, overflowing in its clarity.
Here is the fringey edge where elements meet and realms mingle, where time and eternity spatter each other with foam. ~Annie Dillard from Holy the Firm
Heaven and earth are only three feet apart,
but in the thin places that distance is even smaller.
A thin place is where the veil that separates heaven and earth is lifted
and one is able to receive a glimpse of the glory of God.
An April evening of swirling drama in the sunset clouds~
just enough illumination
to witness the fringe of heaven just beyond.
An open letter to the American Board of Family Medicine (ABFM):
Yesterday I chose to sit for my sixth (and I hope final) Family Practice Board ten year Maintenance of Certification (MOC) examination, having now practiced as a Board Certified Family Physician for the past 34 years and intending to work a few more years. I want to share my experience taking this examination your organization prepares, promotes, and uses at high cost to determine which physicians meet the standards of Family Medicine, as stated on your website:
Family medicine is the medical specialty that provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system, and every disease entity. When you or a family member needs health care or medical treatment, you want a highly qualified doctor dedicated to providing outstanding care. When you choose a doctor who is board-certified, you can be confident he or she meets nationally recognized standards for education, knowledge, experience, and skills to provide high quality care in a specific medical specialty.
After my experience today, I am deeply disappointed in your vision of what a “highly qualified” Board Certified Family Physician needs to demonstrate on a MOC examination in order to meet “nationally recognized standards”.
As a medical student educated at the University of Washington during the early years of a newly organized family medicine specialty in the late seventies, I was inspired by the physicians who were our teachers and mentors in the art and science of caring not just for the individual, but their family system as well. I then had the privilege of family practice residency training at one of the most progressive health maintenance organizations in the country (Group Health Cooperative in Seattle) where my teachers were not only excellent family physicians who were deeply involved with training residents, but actively involved in caring for their own patients as well. In addition, one of my best teachers at Group Health was a full time non-physician behavioral health specialist who taught us how to understand a patient’s experience of their illness and how an excellent family doc makes a difference in a patient’s sense of well-being.
As a result of those role models in my training and education, I have devoted my four decade career to family medicine in a variety of primary care roles — as a physician with a full spectrum practice in the inner city, as a director of a family planning clinic as well as a community health center for indigent and homeless patients, as an occupational health clinician for industry, as a community inpatient behavioral health and “detox” doctor for our local hospital, as a forensic examiner for hundreds of child sexual abuse evaluations, as a college health physician, and as an administrator. I have had the privilege to work with an immense variety of patients in diverse clinical settings, and only family medicine specialty training could have prepared me for that.
I believe in my specialty and the incredible versatility it offers to the physicians who choose it and to the patients who benefit from care by clinicians who are trained to work with the whole person, not just one aspect of their health. I believe in those who practice a “womb to tomb” approach in providing continuity of care for an individual throughout their life cycle. I believe in the opportunities within my specialty for some clinicians to concentrate only on certain aspects of patient care (geriatric care, palliative/hospice care, emergency medicine, hospitalist care, adolescent medicine, sports medicine, addiction care, behavioral health, etc)
I no longer believe, based on the contents of the MOC examination, the American Board of Family Medicine is living up to its commitment to its paying physician constituents. Board Certification is no longer an “option” for us but an economic necessity for our ongoing professional employment, credentialing and privileging.
First, I knew my preparation for this exam would need to be more rigorous than for previous exams as my current practice exclusively manages patients’ behavioral health issues given the current lack of psychiatric consultant availability or affordability. As family physicians often do, we must step up and become the specialist our patients need when no other specialist is available. I no longer see the full spectrum of life cycle medical issues so the many hours of review I did for the exam was necessary, extensive and time-consuming, even though I will not ever practice full spectrum family medicine again.
Second, the experience of taking the examination at a regional “testing center” goes beyond standard airport security humiliation: having my eye glasses inspected in case they contained a camera, my wedding ring looked at, my pockets turned inside out, my sleeves pulled up, my ankles and socks uncovered, being “wanded” for metal hidden on my body, my wrist watch locked up with my purse and cell phone — this happened not just once but after every break, even to go to the bathroom.
Third, the exam itself in no way measured the diversity of skills required of an excellent family physician. Over three hundred multiple choice questions each providing a few data and clinical points about a particular patient and based on that limited information, the test taker is asked to choose the “best” evidence-based treatment option or “most likely” diagnosis. Absent are the nuances of patient demeanor in the exam room or how they respond on history-taking, the subtleties of a hands-on physical assessment. No information was provided about whether this particular patient has a family involved in their care, or what finances they have to afford the “best” treatment option when insurance won’t cover, or their willingness to comply with what is recommended. A phone app could easily answer these exam questions with a search that takes less than twenty seconds yet our cell phones were taken away and locked up. Your test content implies a family physician has to know all the details, the numbers, and the drug interactions committed to memory without the benefit of the technology tools we, along with many of our patients, use every day.
An excellent family physician can easily look up the “guidelines” and the “evidence based treatment” for a medical diagnosis, but beyond that must know how best to work with a particular patient given all the variables in their life impacting their health and well being.
Less than 5% of the exam questions dealt with any behavioral health issues when mental health concerns can be more than 50% of the issues brought to us in any given appointment. There was minimal mention about the dynamics of family support, or insurance/financial stressors or relationship conflicts, or the many social justice issues impacting patient health. There were no questions involving LGBTQ patients. There were few questions about the impact of the current epidemic of substance abuse and addiction contributing to our patients’ premature deaths. There was nothing that dealt with how to encourage and inspire patient compliance with our recommendations. There were no questions dealing with ethical decision making, or how to keep the computer screen from coming between the clinician and the patient, or how to maintain humanity in medical practice.
Fourth, I left that examination feeling very discouraged that the (all younger) family physicians who sat with me in that testing center are facing future years of this kind of superficial yet onerous assessment of their skills. They are likely reluctant to “rock the boat” in questioning how our specialty has devolved to this but I am not. I want to see this improve within my professional lifetime.
If the every ten year high stakes MOC examination were a surgery, an imaging study or a new medication, it would never pass muster for the ABFM standard of “best practice” and “evidence-based”. That seems ironic for an exam that is designed specifically to measure physicians’ abilities to memorize and recall guidelines, best practices and what is recommended and what is not in certain clinical situations. Over my 30+ years of family medicine, many generally accepted and “evidence-based” medical practices have now been found to be ineffective, or at worse, harmful. So we stop doing them and stop recommending them.
Yet somehow the high stakes MOC exam survives without evidence of benefit and one could argue causes significant harm including the immense cost in money, time and aggravation. I am not advocating for ceasing MOC, but want to see ABFM move on from the once a decade exam to a more frequent open book assessment — help us physicians learn more effectively and more eagerly.
I have worked at a University for three decades and understand the style of learning that results in information “sticking” versus that which is memorized and quickly forgotten, especially when it is not used on a regular basis. As Dr. Robert Centor has cogently commented about the MOC process, there is a difference between “formative” assessment of knowledge which is an ongoing monitoring of knowledge acquisition reflecting a learner’s strengths and weaknesses versus a “summative” assessment which is the high stakes end of the semester (or decade) examination. We want our physicians to be enthusiastic ongoing learners with incentive to keep up on new medical innovation and knowledge. To encourage that we need to launch frequent mandatory open book assessments of knowledge before more and more physicians drop out of the MOC process (and their practices) altogether.
I’m asking the ABFM and its Board members to not be tone deaf to the voices of physicians who are telling you “the emperor has no clothes” when we all have tried for decades to be good Board Certified citizens pretending that all is right and well with the process we are subjected to.
I’m also asking the ABFM and its Board members to reexamine the cost and need for security measures in a strip mall testing center setting which is the equivalent of MRI scanning 10,000 patients to find the one cancer — this would never be an acceptable option on one of your exam questions. Treat us as the professionals we are.
I know why I became a family physician over thirty years ago and it wasn’t to treat patients as demographic data points whose health parameters and decisions must meet “evidence-based outcome measures” so health care entities can be fully reimbursed for the work we do with them.
And so I ask you, on behalf of family physicians who don’t speak up, and on behalf of our patients:
~with your organization leading the way, let’s put the “family” back in family medicine.
~let’s put the doctor/patient relationship back in the forefront of the care we provide for people.
~and let’s stop meaningless multiple choice high stakes MOC examinations in strip mall testing centers and look at what really matters in Maintenance of Certification of family physicians.
April is like the raggedy, wandering gypsy lad of the fairy tale. When he moves, streaks of gold show beneath his torn garments and you suspect that this elfin creature is actually a prince in disguise.
April is just that.
There are raggedy, cold days, dark black ones, but all through the month for a second, for an hour, or for three days at a stretch you glimpse pure gold.
The weeks pass and the rags slip away, a shred at a time. Toward the end of the month his royal highness stands before you. ~Jean Hersey from The Shape of a Year
I avoid mirrors now as I age, knowing I’m clothed in rags, thinning here, thickening there, sagging and stretching, wrinkled and patched up.
Still, if I look closely past the rags and sags, I see the same eyes as my nine year old self peering back at me.
The lightness of youth and freshness may be disguised, but it is still there.
Every once in awhile, I glimpse pure gypsy gold.
I am the rest between two notes, which are somehow always in discord because Death’s note wants to climb over— but in the dark interval, reconciled, they stay there trembling. And the song goes on, beautiful.” ~Rainer Maria Rilkefrom “My Life is Not This Steeply Sloping Hour”
At the end of this past Sunday’s Easter worship, while playing a complicated version of the Doxology on the piano in our church, I hit some wrong notes. Usually I can recover from such mistakes but I lost my way in the music on the page, struggling to recover in time to finish with the undaunted congregation, my fingers trembling to find the right keys.
Waking yesterday, I felt my usual Monday morning uneasiness but even more so: I’m the spot in the middle between discordant notes. There is on one side of me the pressure of catching up from what was left undone through the weekend and on the other side the anticipated demands of the coming week.
Before I even arrive at work, I find myself uneasy in dead center, immobilized by the unknown ahead and the known messiness I’ve left behind.
This moment of rest in the present, between the trembling past and uncertain future, is a precious moment of reconciliation, my Sabbath extended. I must allow myself an instant of silence and reflection and forgiveness before I surge ahead into the week, knowing that on my continuing journey I’ll inevitably hit wrong notes.
But it can be beautiful nevertheless.
Even the least harmonious notes find reconciliation within the next chord. I move from the rest of my Sabbath back into the rhythm of my life, renewed and forgiven.