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….
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.
Experiencing the present purely is being emptied and hollow; you catch grace as a man fills his cup under a waterfall. ~Annie Dillard from Pilgrim at Tinker Creek
I am often unprepared for the rush of challenges each clinic day brings and lately far into the night.
Each call, each message, each tug on my arm, each box of kleenex handed over, each look of hopelessness — I empty continuously throughout the day to try to fill the deep well of need around me. If I’m down and dry, hollowed to the core with no more left to give, I pray for more than I could possibly deserve.
And so it pours over me, torrential and flooding, and I only have a mere cup to hold out for filling. There is far more cascading grace than I can even conceive of, far more love descending than this cup of mine could ever hold, far more hope ascending from the mist and mystery of doctoring, over and over again.
I am never left empty for long. The hollow is hallowed, filled to the brim and spilling over.
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
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
Here dies another day During which I have had eyes, ears, hands And the great world round me; And with tomorrow begins another. Why am I allowed two? ~G.K. Chesterton
Even on a Saturday,
usually catch-up on
everything I didn’t get done at work this week,
or cleaning house or barn at home,
instead today is spent
in state-mandated training
on suicide assessment and care.
Even though twenty times every day
I ask someone: can tell me about your thoughts about ending your life?
there is more to learn
and to teach others.
I’ve been allowed
to do my best
to be present
and maybe as this day dies
there will come
when I can help someone
choose to live another day.
In a futile attempt to erase our past, we deprive the community of our healing gift. If we conceal our wounds out of fear and shame, our inner darkness can neither be illuminated nor become a light for others. ~Brennan Manning from Abba’s Child: The Cry of the Heart for Intimate Belonging
Jesus is God’s wounded healer: through his wounds we are healed. Jesus’ suffering and death brought joy and life. His humiliation brought glory; his rejection brought a community of love. As followers of Jesus we can also allow our wounds to bring healing to others.
Our own experience with loneliness, depression, and fear can become a gift for others, especially when we have received good care. As long as our wounds are open and bleeding, we scare others away. But after someone has carefully tended to our wounds, they no longer frighten us or others….We have to trust that our own bandaged wounds will allow us to listen to others with our whole being. That is healing. — Henri Nouwen from Bread for the Journey
There are unconcealed and transparent wounds all around me today. Our yard is frozen in time with glaze ice entrapping newly budded twigs alongside glass-like showcases of old dead weeds. Some forty foot trees are bent over in half, their tops brushing the ground, burdened with such a heavy load. During the northeast wind last night we heard crack after crack as branches gave way, unable to sustain in such conditions.
This morning, in the illumination of day light, it looks like a tornado hit the yard — broken branches and wounded trees everywhere. The wind continues and the temperatures stay sub-freezing. Winter is not done messing with us yet.
It is conditions like earthquakes, hurricanes, tornadoes, floods, firestorms and silver thaws that remind us how little control we have over our environment and how much control it has over us. Being unable to walk anywhere outdoors that isn’t coated with ice is a humbling, helpless feeling. Yet I’m grateful for the reminder of our helplessness and woundedness. We dwell in this often hostile world and try to steward it, but we adapt to it, not the world adapting to us. We cannot stop the frozen rain from falling, but must wait patiently for the southerly winds to blow.
In fact, the warming and healing will come. Soon will I listen out our back door to the south, and hear the frozen trees in our woods knocking their branches together in a noisy cacophony as the south wind warms the ice, causing chunks to drop from the branches, clattering and clacking their way to the ground.
…from stony frozen silence of the wounded to animated noisemakers with a steady puff of warm wind.
…from bleeding to bandaged thanks to the warmth of family, a friend, a neighbor.
At times when I’m iced over –
rigid in my opinions, frozen in emotion, silent and cocooned –
the approach of a warm touch, an empathetic word, or heartfelt outreach breaks me free.
Perhaps I remain frostbitten around the edges, but I am whole again, grateful for the healing of the warm wind.
It was 1978 and I was a third year medical student when my friend was slowly dying of metastatic breast cancer. Her deteriorating cervical spine, riddled with tumor, was stabilized by a metal halo drilled into her skull and attached to a scaffolding-like contraption resting on her shoulders. Vomiting while immobilized in a halo became a form of medieval torture. During her third round of chemotherapy, her nausea was so unrelenting that none of the conventional medications available at the time would give her relief. She was in and out of the hospital multiple times for rehydration with intravenous fluids, but her desire was to be home with her husband and children for the days left to her on this earth.
Her family doctor, at his wit’s end, finally recommended she try marijuana for her nausea. My friend was willing to try anything at that point, so one of her college age children located a using friend, bought some bud and brought it home.
Smoking, because of its relatively rapid effects, didn’t do much other than make her feel “out of it” so that she was less aware of her family, and she hated that the entire house reeked of weed, especially as she still had two teenage children still at home. Her nausea prevented her from eating marijuana mixed into food.
Desperate times called for desperate measures. I simmered the marijuana in a small amount of water to soften it, then combined it with melted butter. That mixture was chilled until it was solid and I molded multiple bullet size suppositories, which were kept in the freezer until needed for rectal administration. Although we never could warm up the suppositories to a temperature that was comfortable for her without them melting into unusable marijuana mush, she found that she could get relief from the nausea within twenty minutes of inserting the frozen marijuana butter rectally. It worked, without her feeling as stoned as the smoked marijuana.
My actions, though compassionate, were also illegal and if my medical school had found out I was acting as an apothecary, preparing an illicit drug for use for a non-FDA approved indication, I could have lost my student standing and future profession. I don’t regret that I did what I could to help my friend when she needed it. Subsequent studies have confirmed the efficacy of marijuana, in various forms, for nausea from HIV and chemo, muscle spasm from multiple sclerosis and quadra- and paraplegia, some types of chronic pain, and glaucoma, yet it has never been seen by the medical community a first line drug for any of those conditions. During my professional career, I have prescribed Marinol, the FDA approved pill form of cannabis in a few cases where it was warranted because of the refractory nature of the patient’s symptoms, for indications that are supported by controlled clinical studies. This made sense and like most medications, it worked for some, not for all with varying degrees of side effects.
And now, nearly 40 years later, marijuana is readily available everywhere in every imaginable form — smokeable, vapeable, edible, drinkable — in states like ours with legalized recreational use, the shops are on nearly every corner as ubiquitous as the coffee stands. Our society is split into the users and the abstainers and those who can’t stand the stuff as they know what it has done to their lives.
If you believe the growing number of vocal marijuana promoters, marketers and profiteers, cannabis can ease almost any condition under the sun and make life liveable again. It is a fine example of not so modern snake oil, as it has been around for thousands of years, except now we have state legislative bodies and through initiatives, the voters, putting their stamp of approval on it for recreational purposes, and as a medical therapy without the regulations or scrutiny we require of any other substance. For a mere $5 gram, relief is as close as the corner store thanks to the collective wisdom of our citizenry.
As a physician working daily with adolescents and young adults in a college health center, there is no question retail marijuana is now the cannabis equivalent to the growing market for artisan beers and local microbreweries. There are distinct brands and strengths to attract users of all types and needs. Yet one thing hasn’t changed with legalization: marijuana is not for everyone, particularly not for young developing brains, particularly not for the mentally ill nor the pregnant.
Patients who have enormous antipathy for the pharmaceutical industry or for government agencies responsible for studies of drug safety and effectiveness seem to lose their skepticism when confronting the for-profit motivation of marijuana growers, brokers and storefront sellers. After all, isn’t this a free market system now happily unconstrained by the need for proof for safety or efficacy? The most attractive product at the best price to the consumer wins. We are now revisiting the devastation to our societal health and well being thrust upon us decades ago by the tobacco industry. And we thought we were winning that battle of making cigarettes socially unacceptable and unwelcome.
Cannabis use has become as normalized as tobacco or alcohol to the point of some parents smoking or ingesting THC with their adolescent and adult children as part of holiday gatherings, special family events (Super – Bowl, anyone?) and evenings-at-home “wind-down” routines. It is a challenge for a clinician to question the judgment of a parent who sees no problem in their 18 year old using marijuana to help sleep or reduce their stress level or ease the pain of their knee injury, especially since that is exactly what the parent is doing themselves.
Although I see marijuana as the “least” of the problem recreational drugs, not as physically devastating nor fatal in overdose as nicotine, alcohol, benzodiazepines, methamphetamines, or opiates, I’ve still seen it ruin lives and minds. In its twenty first century ultra high concentrated version, far more powerful than the weed of the sixties and seventies, it just makes people so much less alive and engaged with the world. They are anesthetized to all the opportunities and challenges of life. You can see it in their eyes and hear it in their voices. In a young person who uses regularly, which a significant percentage choose to do in their fervent belief in its touted “safety”, it can mean more than temporary anesthesia to the unpleasantness of every day hassles. They never really experience life in its full emotional range from joy to sadness, learning the sensitivity of becoming vulnerable, the lessons of experiencing discomfort and coping, and the healing balm of a resilient spirit. Instead, it is all about avoidance and getting high.
Marijuana often exhibits paradoxical effects and is unpredictable even in experienced users. It is a common factor in the history of adolescents and young adults with persistent depressive and anxiety disorders, paranoia, recurring dissociative episodes and psychosis. Beyond the mental health impacts, there is frequent morning anxiety, irritability, nausea and abdominal discomfort in some regular users, sometimes to the point of vomiting, which prompts the user ingest even more marijuana to “help improve appetite”. This is part of the symptom spectrum of cannabinoid hyperemesis syndrome as GI workups, antiemetics and other meds fail to help until marijuana use is discontinued completely.
So, as in most things, buyer beware. Don’t be snowed by the marketing and promotion designed to sell the most product to the most people. The profit motive is still alive and well in this country, no matter the cost to the individual.
Even when — especially when– selling a potentially toxic weed. After all, what’s the matter with a little paranoia among friends?