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.
It may not be rabbit season or duck season but it definitely seems to be doc season, especially as the next version of the American Health Care Act is unveiled today. This (and the Affordable Care Act which preceded it) is not about patients — it is about how to keep doctors and the health care industry under reasonable cost control and maintain some semblance of quality service.
Physicians are lined up squarely in the gun sights of the media, government agencies and legislators, as well as our employers and coworkers, not to mention our own professional organizations, our Board Certifying bodies, and our dissatisfied patients, all happily acquiring hunting licenses in order to trade off taking aim. It’s not enough any more to wear a bullet proof white coat. It’s driving doctors to hang up their stethoscope much earlier than they expected just to get out of the line of fire. Depending on who is expressing an opinion, doctors are seen as overcompensated, demanding, whiny, too uncommitted, too over-committed, uncaring, egotistical, close-minded, inflexible, and especially, and most annoyingly – perpetually late.
One of the most frequent complaints expressed about doctors is their lack of sensitivity to the demands of their patients’ schedule. Doctors do run late and patients wait. And wait. And wait some more. Patients get angry while waiting and this is reflected in patient (dis)satisfaction surveys which are becoming one of the tools the industry uses to judge the quality of a physician’s work and character as well as their salary compensation. It is considered basic Customer Service 101.
I admit I’m one of those late doctors. I don’t share the reasons why I’m late with my patients as I enter the exam room apologizing for my tardiness. Taking time to explain takes time away from the task at hand: taking care of the person sitting or lying in front of me. At that moment, they are the most important person in the world to me. More important than the six waiting to see me, more important than the several dozen emails and calls waiting to be returned, more important than the fact I missed lunch or need to go to the bathroom, more important even than the text message from my daughter from school or the worry I carry about my dying mother.
I’m a salaried doctor, just like more and more of my primary care colleagues these days, providing more patient care with fewer resources. I don’t earn more by seeing more patients. There is a work load that I’m expected to carry and my day doesn’t end until that work is done. Some days are typically a four patient an hour schedule, but most days my colleagues and I must work in extra patients triaged to us by careful nurse screeners, and there are only so many minutes that can be squeezed out of an hour so patients end up feeling the pinch. I really want to try to go over the list of concerns some patients bring in so they don’t need to return to clinic for another appointment, and I really do try to deal with the inevitable “oh, by the way” question when my hand is on the door knob. Anytime that happens, I run later in my schedule, but I see it as my mission to provide essential caring for the “most important person in the world” at that moment.
The patient who is angry about waiting for me to arrive in the exam room can’t know that I’m late because the previous patient just found out that her upset stomach was caused by an unplanned and unwanted pregnancy. Perhaps they might be more understanding if they knew that an earlier patient came in with severe self injury so deep it required repair. Or the woman with a week of cough and new rib pain with a deep breath that could be a simple viral infection is showing signs of a pulmonary embolism caused by oral contraceptives. Or the man with blood on the toilet paper after a bowel movement finding out he has sexually transmitted anal warts when he’s never disclosed he has sex with other men, or the woman with bloating whose examination reveals an ominous ovarian mass, or finding incidental needle tracks on arms during an evaluation for itchiness, which leads to a suspicion of undiagnosed chronic hepatitis.
Doctors running late are not being inconsiderate, selfish or insensitive to their patients’ needs. Quite the opposite. We strive to make our patients feel respected, listened to and cared for. Most days it is a challenge to do that well and stay on time. For those who say we are being greedy, so we need to see fewer patients, I respond that health care reform and salaried employment demands we see more patients in less time, not fewer patients in more time. The waiting will only get longer as more doctors hang up their stethoscopes rather than become a target of anger and resentment as every day becomes “doctor season.”
Patients need to bring a book or catch up on correspondence, bring knitting, schedule for the first appointment of the day. They also need to bring along a dose of charitable grace when they see how crowded the waiting room is. It might help to know you are not alone in your worry and misery.
But your doctor and health care team is very alone, scrambling to do the very best healing they can in the time available.
I’m not hanging my stethoscope up anytime soon though some days I’m so weary by the end, I’m not sure my brain between the ear tips is still functioning. I don’t wear a bullet proof white coat since I refuse to be defensive. If it really is doctor season, I’ll just continue on apologizing as I walk into each exam room, my focus directed to the needs of the “most important person in the whole world.”
And that human being deserves every minute I can give them.
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.
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
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.
And so you have a life that you are living only now,
now and now and now,
gone before you can speak of it,
and you must be thankful for living day by day,
moment by moment …
a life in the breath and pulse and living light of the present… ~Wendell Berry
My days are filled with anxious people, one after another after another. They sit at the edge of their seat, struggling to hold back the flood from brimming eyes, fingers gripping the arms of the chair, legs jiggling. Each moment, each breath, each rapid heart beat overwhelmed by panic-filled questions: will there be another breath? must there be another breath? Must this life go on like this in fear of what the next moment will bring?
The only thing more frightening than the unknown is the knowledge that the next moment will be just like the last. There is a serious gratitude deficiency going on here, a lack of recognition of a moment just passed that can never be retrieved and relived. There is only fear of the next and the next so that the now and now and now is lost forever.
Their worry and angst is contagious as the flu.
I mask up and wash my hands of it throughout the day.
I wish a simple vaccination could protect us all from unnamed fears.
I want to say to them and myself:
Stop. Stop this. Stop this moment in time. Stop and stop and stop.
Stop expecting some one, some thing or some drug must fix this feeling.
Stop being blind and deaf to the gift of each breath.
And simply be.
I want to say:
this moment is ours,
this moment of weeping and sharing
and breath and pulse and light.
Shout for joy in it.
Be thankful for tears that can flow over grateful lips
and stop holding them back.
Stop me before I write,
out of my own anxiety,
yet another prescription
you don’t really need.
and be blessed–
in the now and now and now.
A good night sleep, or a ten minute bawl, or a pint of chocolate ice cream, or all three together, is good medicine. ~Ray Bradbury from Dandelion Wine
Most days in clinic we see tears, lots of them. We keep boxes of tissues strategically placed in the exam and consult rooms, as well as the waiting room. Life can seem overwhelming, fear and worry proliferate unchecked and floodgates spillover occurs when just one more thing happens — maybe a failed test, a fight with a family member, a lingering fatigue that just might be some dread disease.
We underestimate how therapeutic a good cry can be, almost as helpful as deep and heart felt laughter. Stress and tension is dissipated, endorphins are released, muscles relax. Holding back tears, like trying not to laugh (think Mary Tyler Moore at Chuckles the Clown’s funeral service) is hard work and cab only make things worse.
So I hand out kleenex like candy and tell my patients to just let it go and flow. I’m an easy crier myself, and will cry at the drop of a hat with very little provocation — a certain hymn in church, a beautiful word picture, a poignant memory, or sometimes in exhaustion and frustration. Tears are a visible tangible connection with what is happening to us and around us and to others. They can be more honest than what we say and do.
When the weeping wanes, I always recommend a good night’s sleep.
A good night sleep, or a ten minute bawl, or a pint of chocolate ice cream, or all three together, is good medicine.
If there is anything I’ve learned in 35 years of my medical career, it’s that I still must “practice” my art every day. As much as we physicians emphasize the science of what we do, utilizing “evidence based” decisions, there are still days when a fair amount of educated guessing and a gut feeling is based on my past experience, along with my best hunch. Many patients don’t arrive with classic cook book symptoms that fit the standardized diagnostic and treatment algorithms so the nuances of their stories require interpretation, discernment and flexibility. I appreciate a surprise once in awhile that makes me look at a patient in a new or unexpected way and teaches me something I didn’t know before. It keeps me coming back for more, to figure out the mystery and dig a little deeper.
I’ve also learned that not all medicine comes in pills or injections. This isn’t really news to anyone, but our modern society is determined to seek better living through chemistry, the more expensive and newer the better, whether prescribed or not. Chemicals have their place, but they also can cause havoc. It is startling to see medication lists topping a dozen different daily pills. Some are life-saving. Many are just plain unnecessary.
How many sleep without the aid of pill or weed or alcohol? Fewer and fewer. Poor sleep is one of the sad consequences of our modern age of too much artificial light, too much entertainment keeping us up late, and not enough physical work to exhaust our bodies enough to match our frazzled and fatigued brains.
How many of us allow ourselves a good cry when we feel it welling up? It could be a sentimental moment–a song that brings back bittersweet memories, a commercial that touches just the right chord of feeling and connection. It may be a moment of frustration and anger when nothing seems to go right. It could be the pain of physical illness or injury or the stress of emotional turmoil. Or just maybe there is weeping when everything is absolutely perfect and there cannot be another moment just like it, so it is tough to let it go unchristened by tears of joy.
And without a doubt, the healing qualities of chocolate are unquestioned by this doctor, however it may be consumed. It can fix most everything that ails a person. at least for an hour or two.
It doesn’t take an M.D. degree to know the best medicine. It just takes a degree of common sense.
Time for bed and time to turn off the light. A good bawl and chocolate will wait for another night.