A wind has blown the rain away and blown the sky away and all the leaves away, and the trees stand. I think, I too, have known autumn too long. ~e.e. cummings
Be obscure clearly. ~E. B. White
As a family doctor in the autumn of a forty year career, I work at clarifying obscurity about the human condition daily, dependent on my patients to communicate the information I need to make a sound diagnosis and treatment recommendation. That is hard work for my patients, especially when they are depressed and anxious on top of whatever they are experiencing physically.
There is still much unknown and difficult to understand about psychology, physiology and anatomy. Then throw in a disease process or two or three to complicate what appears to be “normal”, and further consider the side effects and complications of various treatments — even evidence-based decision making isn’t equipped to reflect perfectly the best and only solution to a problem. Sometimes the solution is very muddy, not pristine and clear.
Let’s face the lack of facts. A physician’s clinical work is obscure even on the best of days when everything goes well. We hope our patients can communicate their concerns as clearly as possible, reflecting accurately what is happening with their health. In a typical clinic day we see things we’ve never seen before, must expect the unexpected, learn things we never thought we’d need to know, attempt to make the better choice between competing treatment alternatives, unlearn things we thought were gospel truth but have just been disproved by the latest double blind controlled study which may later be reversed by a newer study. Our footing is quicksand much of the time even though our patients trust we are giving them rock-solid advice based on a foundation of truth learned over years of education and training. Add in medical decision-making that is driven by cultural, political or financial outcomes rather than what works best for the individual, and our clinical clarity becomes even further obscured.
Forty years of doctoring in the midst of the mystery of medicine: learning, unlearning, listening, discerning, explaining, guessing, hoping, along with a little silent praying — has taught me the humility that any good clinician must have when making decisions with and about patients. What works well for one patient may not be at all appropriate for another despite what the evidence says or what an insurance company or the government is willing to pay for. Each person we work with deserves the clarity of a fresh look and perspective, to be “known” and understood for their unique circumstances rather than treated by cook-book algorithm. The complex reality of health care reform may dictate something quite different.
The future of medicine is dependent on finding clarifying solutions to help unmuddy the health care decisions our patients face. We have entered a time of information technology that is unparalleled in bringing improved communication between clinicians and patients because of more easily shared electronic records. The pitfall of not knowing what work up was previously done can be a thing of the past. The risk and cost of redundant procedures can be avoided. The time has come for the patient to share responsibility for maintenance of their medical records and assist the diagnostic process by providing online symptom and outcomes follow up documentation.
The benefit of this shared record is not that all the muddiness in medicine is eliminated, but that an enhanced transparent partnership between clinician and patient develops, reflecting a relationship able to transcend the unknowns.
So we can be obscure with clarity. Our lives depend on it.
Now a red, sleepy sun above the rim Of twilight stares along the quiet weald, And the kind, simple country shines revealed In solitudes of peace, no longer dim. The old horse lifts his face and thanks the light, Then stretches down his head to crop the green. All things that he has loved are in his sight; The places where his happiness has been Are in his eyes, his heart, and they are good. ~Siegfried Sassoon from “Break of Day”
I am growing older along with my horses. I think of them out to pasture throughout my workday as I continue to climb in the harness to pull the load as fast and hard as I can muster, returning home in the evening sore and weary.
I think of them with the morning sun on their withers, the green blades under their feet, as they search for the sweetest tender patch to munch.
They remind me to bring the calm of the pasture inside to balance the noise and bustle and troubles found in the clinic. There still is peace and light to be found; I have only to look for it.
“To practice medicine with good spirit does not mean to be in a place where there is no noise, trouble or hard work. It means to bring your calm and loving heart right into the midst of it.” from www.theheartofmedicine.org
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In my rush to get from there to here I missed some things. The solitary song of the chickadee; the play of winter light on kitchen walls; the smell of fresh-raked leaves; the summer days of childhood, stretched slow from dawn to dusk, no need to know the date or time, only the sound of a silver swung bell to call me in for supper.
Could I re-learn to navigate by phases of the moon, the ebb and flow of tides, the rhodies budding out today before the fall’s first snow? Could I re-learn to take my waking slow? ~Ted McMahon, M.D. “Slow Season”
I took an unscheduled landing while wheelbarrowing hay to our horses in the field yesterday morning.
In my rush to get from there to hereI missed some things.
I stumbled on uneven ground and fell hard, badly injuring my elbow. Finishing chores afterward was a challenge and a necessity, wrapping my broken wing up tight in my jacket, doing what was needed before my husband came home to take me to the ER where good people who know me took great care of me.
Of those so close beside me, which are you?
God bless the Ground! I shall walk softly there,
And learn by going where I have to go.
Even though no bones were broken, it was dislocated, so my elbow (and I) needed to be put back together. The miracle of “conscious sedation” IV medication let my body “think” I was awake – I was surrounded by a swirling round of voices telling me to take deep breaths and constantly reassuring me–while the ER doctor and nurse put traction on my arm and shoulder, then twisting and turning my elbow back into proper position with a “clunk”. I was blissfully unaware of the tugging and torque, paying attention only to the swirling sounds in my head, then waking slow to find my arm splinted and wrapped from mid-humerus to fingers — all fixed but now typing is also slow.
This shaking keeps me steady. I should know.
What falls away is always. And is near.
I’m walking more carefully now, paying attention to exactly where my feet land and what is around me.
The ground is near yet still can be a hard and abrupt landing;
I celebrate the good clinicians who put broken people back together again.
“Bees do have a smell, you know,
and if they don’t they should,
for their feet are dusted with spices from a million flowers.” ― Ray Bradbury, Dandelion Wine
I admire the honey bee as pollinator and pollen gatherer simultaneously, facilitating new fruit from the blossom as well as taking away that which will become sweet honey tasting of the spicy essence of the flower touched.
As a physician, I can only hope to be as transformative in the work I do every day. I carry with me tens of thousands of patients I’ve seen over thirty five years of medical practice. There is no way I can touch another human being without keeping some small part of them with me – perhaps a memory of an open wound or the residual scar it left behind, a word of sorrow or gratitude, a grimace, a tear or a smile.
Each patient is a flower visited, some still in bud, some in full bloom, some seed pods ready to burst, some spent and wilting and ready to fall away. Each patient carries a spicy vitality, even in their illness and dying, that is unforgettable and still clings to me. Each patient changes me, the doctor, readying me for the next patient by teaching me a gentler approach, a clearer explanation, a slower leave-taking. Each patient becomes part of my story, adding to my skill as a healer, and is never to be forgotten.
It has been my privilege to be thoroughly dusted by those I’ve loved and cared for. I want to carry that on to create something wonderful that reflects the spice of living.
In all the woods that day I was the only living thing fretful, exhausted, or unsure. Giant fir and spruce and cedar trees that had stood their ground three hundred years stretched in sunlight calmly unimpressed by whatever it was that held me hunched and tense above the stream, biting my nails, calculating all my impossibilities. Nor did the water pause to reflect or enter into my considerations. It found its way over and around a crowd of rocks in easy flourishes, in laughing evasions and shifts in direction. Nothing could slow it down for long. It even made a little song out of all the things that got in its way, a music against the hard edges of whatever might interrupt its going. ~John Brehm “Passage”
It may be that when we no longer know what to do we have come to our real work,
and that when we no longer know which way to go we have come to our real journey.
Who among us knows with certainty each morning
what we are meant to do that day
or where we are to go?
Or do we make our best guess by
putting one foot ahead of the other
until the day is done and it is time to rest.
For me, I wake baffled each day
that I am allowed
to eavesdrop on heartbeats,
touch tender bellies,
sew up broken skin,
listen to tearful stories
of those no longer wish to live
and those who never want to let go of life.
I wake humbled with commitment
to keep going even when too tired,
to offer care even when rejected.
to keep trying even if impeded.
It is only then I learn that
daily obstacles slow
but cannot stop
the offer of help,
the gift of caring,
the flow of time given freely
which overflows its banks with
my real work and journey
May I wade in deep~
ready to raise my voice
for those who hurt
and sing along.
Due to changes in Fair Housing Act laws, clinicians are experiencing a significant increase in requests from patients for medical documentation to keep emotional support animals with them in “no-pets policy” rental housing. On a college campus, this leads to far more than just two-legged mammals inhabiting dorm rooms. There has been an animal explosion on our University campus with over seventy animals of various types approved as an “ESA” in the residence halls and unknown dozens more who live with their owners off campus yet still frequent campus. Only a small minority of these animals are actually trained and certified as service animals with the right to accompany their owner on public transportation to any public place, including classrooms and eating establishments. The rest are approved only for housing purposes, yet they are regularly showing up in airplane cabins and grocery stores, dressed in little jackets that are easily purchased along with “certification letters” for big prices on the internet. ESAs have become part of the campus and community landscape.
As a relatively outdoorsy, green and tolerant northwest University campus, the presence of animals on our campus has yet to seem like a big deal, but as the animal numbers inevitably increase due to 25% of the college student population nationwide currently eligible for an animal due to a mental health diagnosis, it is becoming a big deal as individuals insist on exercising their civil rights along with their dogs.
And it isn’t always dogs. There are cats, along with the occasional pocketed rat, hamster, guinea pig, flying squirrel, and ferret not to mention emotional support pot bellied pigs, tarantulas, and various types of birds. And at least one snake.
Yes, a snake.
As a physician farmer concerned with stewardship of the patients I treat and the land and animals I care for, I’m emotionally caught and ethically bound in this treatment trend. The law compels clinicians to provide the requested documentation to avoid potential law suits alleging discrimination, yet I’m also concerned for the rights of the animals themselves. I’ve loved, owned and cared for animals most of my sixty two years and certainly missed my pets during the thirteen years I was in college, medical school, residency and doing inner city work (my tropical fish and goldfish notwithstanding). I neither had the time, the money, the space nor the inclination to keep an animal on a schedule and in an environment that I myself could barely tolerate, as stressed as I was. That is not stopping the distressed college student of today from demanding they be able to keep their animals with them in their stress-mess.
As a clinician, I’d much prefer writing fewer pharmaceutical prescriptions and help individuals find non-medicinal ways to address their distress. I’d like to see my patients develop coping skills to deal with the trouble that comes their way without falling apart, and the resilience to pick themselves up when they have been knocked down and feel broken. I’d like to see them develop the inner strength that comes with maturity and experience and knowing that “this too will pass.” I’d like individuals to see themselves as part of a diverse community and not a lone ranger of one, understanding that their actions have a ripple effect on those living, working, eating, riding and studying around them. Perhaps corporate work places, schools and universities should host a collaborative animal center with rotating dogs and cats from the local animal shelter, so those who wish to may have time with animals on their breaks without impacting others who aren’t animal fans, or with potentially life threatening animal dander allergies.
So I find myself reluctantly writing a prescription for a living breathing creature perceived by the law as a “treatment” rather than a profound responsibility that owners must take on for the lifetime of the animal. With great gravity, I always let my patients know an animal is not disposable like a bottle of pills (or a human therapist) when no longer needed and must have a lifelong commitment from its owner beyond a particular time of high personal stress.
Pardon me now while I go take care of my dogs, my cats, by birds, and my horses and yes, my goldfish. They are my joy to support for decades and for as long as they need me.
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.