Let’s Put the Family Back in Family Medicine

Portrait by Norman Rockwell
Portrait by Norman Rockwell
5-7-13-005
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

 

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

silverthawwilted

Be Open for Business

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Astonishing material and revelation appear in our lives all the time. Let it be. Unto us, so much is given. We just have to be open for business.
~Anne Lamott from Help Thanks Wow: Three Essential Prayers

 

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same abandoned Montana schoolhouse as above a few years later (this photo by Joel DeWaard)

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I have the privilege to work in a profession where astonishment and revelation awaits me behind each exam room door.

In a typical busy clinic day, I open that door 36 times, close it behind me and settle in for the ten or fifteen minutes I’m allocated per patient.  I need to peel through the layers of a person quickly to find the core of truth about who they are and why they’ve come to me.

Sometimes what I’m looking for is right on the surface: in their tears, in their pain, in their fear.  Most of the time, it is buried deep and I need to wade through the rashes and sore throats and coughs and headaches to find it.

Once in awhile, I can actually do something tangible to help right then and there — sew up a cut, lance an abscess, splint a fracture, restore hearing by removing a plug of wax from an ear canal.

Often I find myself giving permission to a patient to be sick — to take time to renew, rest and trust their bodies to know what is best for a time.

Sometimes, I am the coach pushing them to stop living sick — to stop hiding from life’s challenges, to stretch even when it hurts, to get out of bed even when not rested, to quit giving in to symptoms that can be overcome rather than overwhelming.

Always I’m looking for an opening to say something a patient may think about after they leave my clinic — how they can make better choices, how they can be bolder and braver in their self care, how they can intervene in their own lives to prevent illness, how every day is a thread in the larger tapestry of their lifespan.

Each morning I rise early to get work done before I actually arrive at work,  trying to avoid feeling unprepared and inadequate to the volume of tasks heaped upon the day.   I know I may be stretched beyond my capacity, challenged by the unfamiliar and stressed by obstacles thrown in my way.  It is always tempting to go back to bed and hide.

Instead, I go to work as those doors need to be opened and the layers peeled away.  I understand the worry, the fear and the pain because I have lived it too.   I am learning how to let it be, even if it feels miserable.  It is a gift perhaps I can share.

No matter what waits behind the exam room door,  it will be astonishing to me.

I’m grateful to be open for business.  The Doctor is In.

 

brokenbarn

cabincentra

Preparing the Heart: Fighting the Long Defeat

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He has dwelt in the West since the days of dawn, and I have dwelt with him years uncounted . . . and together through ages of the world we have fought the long defeat.
~J.R.R. Tolkien from The Lord of the Rings

 

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lonefirt

It is only 10 days before we bid farewell to autumn and accept the arrival of the winter solstice signaling the long slow climb back to daylight. This giving-way to the darkness has felt like a defeat we may never recover from.

Yet the sunset becomes a startling send-off for fall, coloring Mt. Baker and surrounding an almost full moon with purple in the eastern sky. Our farm, for a deceptive few minutes, appears rosy and warm in crisp subfreezing weather. Then all becomes gray again, and within an hour we are shrouded in thick fog which ices the asphalt as darkness fell.  It becomes a challenge to avoid the deep ditches along our country roads, with the white fog line being the critical marker preventing potential disaster.

The ever present evening fog this time of year cloaks and smothers in the darkness, not unlike the respiratory and gastrointestinal viruses that have hit many households hard this week. Plenty of people have been vomiting, feverish, coughing and snuffling, unable to leave the bathroom or see past the ends of their swollen noses, as if the fog descended upon them in an impenetrable gray cloud. It is an unwelcome reminder of our vulnerability to microscopic organisms that can defeat us and lay us low in a matter of hours, just as a sudden freezing fog can lure us to the ditch. We are forced to stay put, our immune systems fighting back at a time when there are dozens of responsibilities vying for attention in preparation for the holidays. Little gets accomplished other than our slow wait for healing and clarity–at some point the viral fog will dissipate and we can try climbing back into life and navigating without needing the fog lines as guides.

Ditches have been very deep for some folks recently, with the diagnosis of cancers and devastating surgeries swallowing up their light and joy. Despite profound losses and pain, people courageously continue to fight, climbing their way out of the darkness to the light.

The day’s transition to night becomes bittersweet: these bright flames of color herald our uneasy future sleep after fighting the long defeat on this soil.

The sun “settles” upon the earth and so must we.

Be at ease, be comforted, put down the heavy burden and rest. We can celebrate, with chorus and gifts, the arrival of brilliant light in our lives. Instead of darkness overcoming us, our lives become illuminated in glory and grace.

The Son has settled among us.

 

Sure on this shining night of star-made shadows round,
kindness must watch for me this side the ground,
on this shining night, this shining night

The late year lies down the north
All is healed, all is health
High summer holds the earth,
hearts all whole
The late year lies down the north
All is healed, all is health
High summer holds the earth, hearts all whole
Sure on this shining night,
sure on this shining, shining night

Sure on this shining night
I weep for wonder wand’ring far alone
Of shadows on the stars
Sure on this shining night, this shining night
On this shining night, this shining night
Sure on this shining night
~from James Agee’s poem

O magnum mysterium,
et admirabile sacramentum.
Ut animalia viderent Dominum natum,
iacentem in praesepio:
Beata Virgo, cujus viscera meruerunt portare
Dominum Christum
Alleluia

 

snowyweed

snowycloudmountain

Refusing to Pledge an Oath to Life

loneleaf

It is…the refusal to take the oath of loyalty to life…
The man who kills a man kills a man.

The man who kills himself kills all men.
As far as he is concerned, he wipes out the world.
~ G.K. Chesterton

impaled

Suicide rates in the United States have increased by 25% since 1999.

Based on the anguish of the patients I see every day,
one after another and another,
over and over again I hear
a too-easy contemplation of suicide,
from “It would be easier if I were dead”
or “no one cares if I live or die”,
or “the world would be better off without me”,
or “I’m not worthy to be here”
to “that is my plan, it is my right and no one can stop me”.

Without us all pledging an oath to life,
willing to lay ourselves down,
to bridge the sorrow and lead the troubled to the light,
there will be no slowing of this trend.

…when there is no loyalty to life, as stressful and messy as it can be,
…when there is no honoring of the holiness of each created being,
…when there is no resistance to the buffeting winds of life,
only a toppling over, taking out everything and everyone in the way,
our sad and hurting world is wiped out by one suicide,
all people killed by one act of self-murder.

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oakleafhydrangea11122

When you’re weary, feeling small,
When tears are in your eyes
I will dry them all
I’m on your side
When times get rough
And friends just can’t be found
Like a bridge over troubled water
I will lay me down
Like a bridge over troubled water
I will lay me down

When you’re down and out
When you’re on the street
When evening falls so hard
I will comfort you
I’ll take your part
When darkness comes
And pain is all around
Like a bridge over troubled water
I will lay me down
Like a bridge over troubled water
I will lay me down

Sail on, silvergirl
Sail on by
Your time has come to shine
All your dreams are on their way
See how they shine
If you need a friend
I’m sailing right behind
Like a bridge over troubled water
I will ease your mind
Like a bridge over troubled water
I will ease your mind
~Simon and Garfunkel

Send Our Roots Rain

redsquare

Justus quidem tu es, Domine, si disputem tecum; verumtamen
justa loquar ad te: Quare via impiorum prosperatur? (Jeremiah 12)

Thou art indeed just, Lord, if I contend
With thee; but, sir, so what I plead is just.
Why do sinners’ ways prosper? and why must
Disappointment all I endeavour end?
    Wert thou my enemy, O thou my friend,
How wouldst thou worse, I wonder, than thou dost
Defeat, thwart me? Oh, the sots and thralls of lust
Do in spare hours more thrive than I that spend,
Sir, life upon thy cause. See, banks and brakes

Now, leavèd how thick! lacèd they are again
With fretty chervil, look, and fresh wind shakes
Them; birds build — but not I build; no, but strain,
Time’s eunuch, and not breed one work that wakes.

Mine, O thou Lord of life, send my roots rain
~Gerard Manley Hopkins  “Thou art indeed just, Lord”

rainstorm

As I look out through a tear-streaked window at the beginning of this dark day,
I feel inadequate to the task before me.

Parched and struggling patients will line my schedule in weeks to come;
they are anxious and already weary and barren, seeking something, anything
to ease their distress in a hostile world.
Preferably an easy pill to swallow.
Nothing that hurts going down.

While others thrive around them,
they wilt and wither, wishing to die.

Lord of Life, equip me to find the words to say that might help.
May it be about more than
genetics, neurotransmitters and physiology.

In this dry season for young lives,
send your penetrating rain to reach them
and those who guide them.
Reach down and shake our roots fiercely
to slake our continual thirst.

1031drops7

The Health of Self-Forgetfulness

begoniared

The nail of each big toe was the horn of a goat.  Thick as a thumb and curved, it projected down over the tip of the toe to the underside.  With each step, the nail would scrape painfully against the ground and be pressed into his flesh.  There was dried blood on each big toe. 

It took an hour to do each big toe.  The nails were too thick even for my nail cutters.  They had to be chewed away little by little, then flattened out with the rasp, washed each toe, dried him off, and put his shoes and socks back on.  He stood up and took a few steps, like someone who is testing the fit of a new pair of shoes. 
“How is it?”
“It don’t hurt,” he said, and gave me a smile that I shall keep in my safety deposit box at the bank until the day I die.

I never go to the library on Wednesday afternoon without my nail clippers in my briefcase.
You just never know.

~Richard Seltzer from “Toenails” from Letters to a Young Doctor

molepaw

notadeaddog

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I know for a while again

the health of self-forgetfulness,
looking out at the sky through
a notch in the valleyside,
the black woods wintry on
the hills, small clouds at sunset
passing across. And I know
that this is one of the thresholds
between Earth and Heaven,
from which even I may step
forth and be free.
– Wendell Berry from “Sabbath Poems”

 

brightnight

Whenever I lose perspective about what I’m trained to do
and who I am meant to serve,
when I wallow in the mud of self-importance
rather than in the health of self-forgetfulness~

I wash out a plug of wax from a deaf ear
and restore hearing
or clip someone’s crippling toenails
so they can step forth in freedom.

I’ve been given these tools for a reason
so need to use them.
You just never know.
.

royalannejune