Let’s Put the Family Back in Family Medicine

Portrait by Norman Rockwell
Portrait by Norman Rockwell
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portrait by Norman Rockwell

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.

Sincerely,

Emily Gibson, M.D.

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portrait by Norman Rockwell
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portrait by Norman Rockwell

 

Turn Aside and Look: Remembering the Air of Childhood

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I wanted to treat feelings that are not recognized as afflictions and are never diagnosed by doctors. All those little feelings and emotions no therapist is interested in,
because they are apparently too minor and intangible.
The feeling that washes over you when another summer nears its end.
Or when you recognize that you haven’t got your whole life left to find out where you belong.
Or the slight sense of grief when a friendship doesn’t develop as you thought,
and you have to continue your search for a lifelong companion.
Or those birthday morning blues.
Nostalgia for the air of your childhood.
Things like that.

~Nina George from The Little Paris Bookshop

 

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A white vase holds a kaleidoscope of wilting sweet peas
captive in the sunlight on the kitchen table while

wafting morning scent of pancakes
with sticky maple syrup swirls on the plate,

down the hall a dirty diaper left too long in the pail,
spills over tempera paint pots with brushes rinsed in jars after

stroking bright pastel butterflies fluttering on an easel
while wearing dad’s oversized shirt buttoned backwards

as he gently guides a hand beneath the downy underside
of the muttering hen reaching a warm egg hiding in the nest

broken into fragments like a heart while reading
the last stanza of “Dover Beach” in freshman English

Just down the hall of clanging lockers
To orchestra where strains of “Clair de Lune” accompany

the yearning midnight nipple tug of a baby’s hungry suck
hiccups gulping in rhythm to the rocking rocking

waiting for a last gasp for breath
through gaping mouth, mottled cooling skin

lies still between bleached sheets
illuminated by curtain filtered moonlight just visible

through the treetops while whoosh of owl wings
are felt not heard, sensed not seen.

Waking to bright lights and whirring machines
the hushed voice of the surgeon asking

what do you see now, what can you hear, what odor,
what flavor, what sensation on your skin

with each probe of temporal lobe, of fornix
and amygdala hidden deep in gray matter

of neurons and synaptic holding bins of chemical transmitters
storing the mixed bag of the past and present

to find and remove the offending lesion that seizes up
all remembrance, all awareness

and be set free again to live, to love, to swoon at the perfume
of spring sweet peas climbing dew fresh at dawn,

tendril wrapping over tendril,
the peeling wall of the garden shed

no more regrets, no more grief
no more sorrow.

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Sending the Light

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I want you to read this some day, 恵真
our new little Emma Sophia:
as you took your first breath in the dark of the night
so far away from this farm where your father grew up,
we bid farewell to the sun here
so God could bring it glowing to your first day in Japan,
that misty island where your mother grew up.

Your birth blesses so many all over this earth
and proves that war from two generations ago
exists only in history books now,
now love digs so deep in the genes
it overcomes what has come before.

You have sent the sun back today to us,
brand new grandparents,
to rise pink over this snowy morning,
and we will send it back to you tonight
to wake you for your second day
resting calm in the arms of your loving family.

Each day from now on
may we always return the Light you sent
and send it forth to shine on you.

 

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To Feel the Hem of Heaven

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Your days are short here; this is the last of your springs.
And now in the serenity and quiet of this lovely place,
touch the depths of truth, feel the hem of Heaven.
You will go away with old, good friends.
And don’t forget when you leave why you came.

~Adlai Stevenson, to the Class of ’54 Princeton University

icyrose

I was eight years old in June 1963 when the Readers’ Digest arrived in the mail inside its little brown paper wrapper. As usual, I sat down in my favorite overstuffed chair with my skinny legs dangling over the side arm and started at the beginning,  reading the jokes, the short articles and stories on harrowing adventures and rescues, pets that had been lost and found their way home, and then toward the back came to the book excerpt: “The Triumph of Janis Babson” by Lawrence Elliott.

Something about the little girl’s picture at the start of the story captured me right away–she had such friendly eyes with a sunny smile that partially hid buck teeth.  This Canadian child, Janis Babson, was diagnosed with leukemia when she was only ten, and despite all efforts to stop the illness, she died in 1961.  The story was written about her determination to donate her eyes after her death, and her courage facing death was astounding.  Being nearly the same age, I was captivated and petrified at the story, amazed at Janis’ straight forward approach to her death, her family’s incredible support of her wishes, and especially her final moments, when (as I recall 54 years later) Janis looked as if she were beholding some splendor, her smile radiant.

”Is this Heaven?” she asked.   She looked directly at her father and mother and called to them:  “Mommy… Daddy !… come… quick !”

And then she was gone.  I cried buckets of tears, reading and rereading that death scene.  My mom finally had to take the magazine away from me and shooed me outside to go run off my grief.  How could I run and play when Janis no longer could?  It was a devastating realization that a child my age could get sick and die, and that God allowed it to happen.

Yet this story was more than just a tear-jerker for the readers.  Janis’ final wish was granted –those eyes that had seen the angels were donated after her death so that they would help another person see.  Janis  had hoped never to be forgotten.  Amazingly, she influenced thousands of people who read her story to consider and commit to organ donation, most of whom remember her vividly through that book excerpt in Readers’ Digest.  I know I could not sleep the night after I read her story and determined to do something significant with my life, no matter how long or short it was.  Her story influenced my eventual decision to become a physician.  She made me think about death at a very young age as that little girl’s tragic story could have been mine and I was certain I could never have been so brave and so confident in my dying moments.

Janis persevered with a unique sense of purpose and mission for one so young.  As a ten year old, she developed character that some people never develop in a much longer lifetime.  Her faith and her deep respect for the gift she was capable of giving through her death brought hope and light to scores of people who still remember her to this day.

Out of the recesses of my memory, I recalled Janis’ story a few years ago when I learned of a local child who had been diagnosed with a serious cancer.  I could not recall Janis’ name, but in googling “Readers’  Digest girl cancer story”,  by the miracle of the internet I rediscovered her name, the name of the book and a discussion forum that included posts of people who were children in the sixties, like me,  who had been incredibly touched by Janis when they read this same story as a child.  Many were inspired to become health care providers like myself and some became professionals working with organ donation.

Janis and family, may you know the gift you gave so many people through your courage in the midst of suffering, and the resulting hope in the glory of the Lord.  Your days were short here, but you touched the depth of truth and touched the hem of heaven.
~~the angels are coming indeed.

We who have been your old good friends,  because of your story,  have not forgotten how you left us and why you came in the first place.

For excerpts from “The Triumph of Janis Babson”, click here

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Love Stored Up

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the finale this morning
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today’s sunrise at its peak
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As it began this morning

Believe in a love that is being stored up for you like an inheritance, and have faith that in this love there is a strength and a blessing so large that you can travel as far as you wish without having to step outside it.
~Rainer Maria Rilke from Letters to a Young Poet

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The sunrise this morning kept giving and giving, vanquishing the darkness through an illumination that made all things, even the sorry and the plain, beautiful.

So is the love of one person for another, reflecting the Light that illuminates us all, even to the depths of our shadows.

May we too give and give without ceasing, our plainness made beautiful, our shadows no more.

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So God Made a Farmer

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And on the 8th day, God looked down on his planned paradise and said, “I need a caretaker.” So God made a farmer.

God said, “I need somebody willing to get up before dawn, milk cows, work all day in the fields, milk cows again, eat supper and then go to town and stay past midnight at a meeting of the school board.” So God made a farmer.

“I need somebody with arms strong enough to rustle a calf and yet gentle enough to deliver his own grandchild. Somebody to call hogs, tame cantankerous machinery, come home hungry, have to wait lunch until his wife’s done feeding visiting ladies and tell the ladies to be sure and come back real soon — and mean it.” So God made a farmer.

God said, “I need somebody willing to sit up all night with a newborn colt. And watch it die. Then dry his eyes and say, ‘Maybe next year.’ I need somebody who can shape an ax handle from a persimmon sprout, shoe a horse with a hunk of car tire, who can make harness out of haywire, feed sacks and shoe scraps. And who, planting time and harvest season, will finish his forty-hour week by Tuesday noon, then, pain’n from ‘tractor back,’ put in another seventy-two hours.” So God made a farmer.

God had to have somebody willing to ride the ruts at double speed to get the hay in ahead of the rain clouds and yet stop in mid-field and race to help when he sees the first smoke from a neighbor’s place. So God made a farmer.

God said, “I need somebody strong enough to clear trees and heave bails, yet gentle enough to tame lambs and wean pigs and tend the pink-combed pullets, who will stop his mower for an hour to splint the broken leg of a meadow lark. It had to be somebody who’d plow deep and straight and not cut corners. Somebody to seed, weed, feed, breed and rake and disc and plow and plant and tie the fleece and strain the milk and replenish the self-feeder and finish a hard week’s work with a five-mile drive to church.

“Somebody who’d bale a family together with the soft strong bonds of sharing, who would laugh and then sigh, and then reply, with smiling eyes, when his son says he wants to spend his life ‘doing what dad does.'” So God made a farmer.
~Paul Harvey (1978)

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Good farmers, who take seriously their duties as stewards of Creation and of their land’s inheritors, contribute to the welfare of society in more ways than society usually acknowledges, or even knows. These farmers produce valuable goods, of course; but they also conserve soil, they conserve water, they conserve wildlife, they conserve open space, they conserve scenery.
~Wendell Berry

Farmers farm for the love of farming. They love to watch and nurture the growth of plants. They love to live in the presence of animals. They love to work outdoors. They love the weather, maybe even when it is making them miserable. They love to live where they work and to work where they live. If the scale of their farming is small enough, they like to work in the company of their children and with the help of their children.
~Wendell Berry from Bringing it to the Table: Writings on Farming and Food

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The ultimate goal of farming is not the growing of crops, but the cultivation and perfection of human beings.”
~Masanobu Fukuoka 

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photo by Nate Gibson

It is hard for my husband and I to ignore our genetic destiny to struggle as stewards of the land through the challenges of economics and weather. Our blood runs with DNA of dairy farmers, wheat and lentil growers, loggers, cattle ranchers, work horse teamsters, and flower and vegetable gardeners. A farm eventually called us from the city and our professional lives to come back home and care for a piece of ground and its animals. So we heeded and here we remain, some 32 years later, children raised and gone.

Perhaps the call of the farmer genes will bring one of them back to the land.  Because farmers are hand-picked for the job by God Himself.

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As Time is Forgotten

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Only in sleep I see their faces,
Children I played with when I was a child,
Louise comes back with her brown hair braided,
Annie with ringlets warm and wild.

Only in sleep Time is forgotten —
What may have come to them, who can know?
Yet we played last night as long ago,
And the doll-house stood at the turn of the stair.

The years had not sharpened their smooth round faces,
I met their eyes and found them mild —
Do they, too, dream of me, I wonder,
And for them am I too a child?
~Sara Teasdale, 1884 – 1933

 

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Some nights my dreams take me,
like a time traveler,
to those bygone days
when all was simple
and life’s horizons so distant.

Somewhere, sometime,
perhaps in another’s dream,
I am that child again
with goofy grin and freckled face
and in that dream, the horizon,
so near now I can almost touch it,
stretches out forever
as time is forgotten.

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