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 had happened many times before, but it always took me by surprise.
Always in the midst of great stress, wading waist-deep in trouble and sorrow, as doctors do, I would glance out a window, open a door, look into a face, and there it would be, unexpected and unmistakable. A moment of peace.
The light spread from the sky to the ship, and the great horizon was no longer a blank threat of emptiness, but the habitation of joy. For a moment, I lived in the center of the sun, warmed and cleansed, and the smell and sight of sickness fell away; the bitterness lifted from my heart.
I never looked for it, gave it no name; yet I knew it always, when the gift of peace came. I stood quite still for the moment that it lasted, thinking it strange and not strange that grace should find me here, too. Then the light shifted slightly and the moment passed, leaving me as it always did, with the lasting echo of its presence. In a reflex of acknowledgment, I crossed myself and went below, my tarnished armor faintly gleaming. ~Diana Gabaldon – Claire’s observations from Voyager
I’ve known this moment of peace in the midst of my work; it comes unexpectedly after a day of immersion in troubles and anguish. As I leave the clinic and breathe in a sudden rush of fresh air, and as I drive down our country road as the sun is setting, I remember that for all of us, the sick and the not-yet-sick, there still are moments of grace and beauty.
It isn’t all sad, it isn’t all anxious, it isn’t all anguish. The moment may be brief, it may be elusive.
But it is there. And I seek it out every day.
(written with gratitude to author Diana Gabaldon for her insights into the complex workings of an innovative physician’s mind in her Outlander series of novels, for Caitriona Balfe‘s insightful characterization and understanding of Claire and for Sam Heughan‘s sensitive portrayal of the man who loves her beyond the boundary of time in Starz’ Outlander – if you don’t know these stories yet, you should.)
“This is another day, O Lord…
If I am to stand up, help me to stand bravely.
If I am to sit still, help me to sit quietly.
If I am to lie low, help me to do it patiently.
And if I am to do nothing, let me do it gallantly.”
— Kathleen Norris citing the Book of Common Prayer
This day is the wrap-up to my twenty-eighth academic year working as a college health physician, the most demanding so far. Despite budget challenges, inadequate staffing, a higher severity of illness in a patient population with burgeoning mental health needs, our staff did an incredible job this year serving students and their families with the resources we do have. Reaching this day today is poignant: we will miss the graduating students we have gotten to know so well over four or five years, we watch others leave temporarily for the summer, some to far away places around the globe, and we weep for those who have failed out, given up or fallen away from those who care deeply about them, some never to return to school again.
In my work I strive to do what is needed when it is needed no matter what time of the day or night. There are obviously times when I fall short– too vehement when I need to be quiet, too urgent and pressured when I need to be patient, too anxious to do something/anything when it is best to courageously do nothing. It is very difficult for any doctor to choose to do nothing but I vowed in my own graduation ceremony over forty years ago to “First do no harm.” And I’ve tried hard to live up to that vow.
In a sense I graduate as well on this last day of the school year– only not with cap and gown and diploma in hand. Each year I learn enough from each patient to fill volumes, as they speak of their struggles, their pain, their stories and sometimes hearing, most tragically, their forever silence.
I honor our students and their families on this day, sharing the blessings from us who work toward the goal of sending them healthier and better equipped and joyful into the rest of their lives.
I’ve been really miserable for three days and need that 5 day antibiotic to get better faster.
Ninety eight percent of the time these symptoms are due to a viral infection and will resolve without antibiotics.
But I can’t breathe and I can’t sleep.
You can use salt water rinses and a few days of decongestant nose spray to ease the congestion.
But my face feels like there is a blown up balloon inside.
Try applying a warm towel to your face.
And I’m feverish and having sweats at night.
Your temp is 99.2. You can use ibuprofen or acetominophen to help the feverish feeling.
But my snot is green.
That’s not unusual with viral upper respiratory infections.
And my teeth are starting to hurt and my ears are popping.
Let me know if that is not resolving in a week or so.
But I’m starting to cough.
Your lungs are clear so breathe steam, push fluids and prop up with an extra pillow.
But sometimes I cough to the point of gagging. Isn’t whooping cough going around?
Your illness doesn’t fit the timeline for pertussis. You can consider using an over the counter cough suppressant.
But I always end up needing antibiotics. This is like my regular sinus infection thing.
There’s plenty of evidence they can do more harm than good. They really aren’t indicated at this point in your illness and could have nasty side effects.
But I always get better faster with antibiotics. Doctors always give me antibiotics.
Studies show that two weeks later there is no significant difference in symptoms between those treated with antibiotics and those who did self-care without them.
But I have a really hard week coming up and I won’t be able to rest.
This could be your body’s way of saying that you need to evaluate your priorities.
But I just waited an hour to see you.
I really am sorry about the wait; we’re seeing a lot of sick people with this viral thing going around.
But I paid a $20 co-pay today for this visit.
We’re very appreciative of you paying promptly on the day of service.
But I can go down the street to the walk in clinic and for $130 they will write me an antibiotic prescription without making me feel guilty for asking.
I wouldn’t recommend taking unnecessary medication that can lead to bacterial resistance, side effects and allergic reactions. I truly believe you can be spared the expense, inconvenience and potential risk of taking something you don’t really need.
So that’s it? Salt water rinses and wait it out? That’s all you can offer?
Let me know if your symptoms are unresolved or worsening in the next week or so.
So you spent all that time in school just to tell people they don’t need medicine?
I believe I help people heal themselves and educate them about when they do need medicine and then facilitate appropriate treatment.
I’m going to go find a real doctor who will listen to me.
A real doctor vows to first do no harm. I know you want something different than I’m offering you and I wish you the best as you recover.
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.
As we drown in the overwhelm of modern day health care duties, most physicians I know, including myself, fail to follow their own advice. Far too many of us have become overly tired, irritable and resentful about our work load. It is difficult to look forward to the dawn of the next work day.
Medical journals and blogs label this as “physician burn-out” but the reality is very few of us are so fried we want to abandon practicing medicine. Instead we are weary of being distracted by irrelevant busy work from what we spent long years training to do: helping people get well, stay well and be well, and when the time comes, die well.
Instead we are busy documenting-documenting-documenting for the benefit of insurance companies and to satisfy state and federal government regulations. Very little of this has anything to do with the well-being of the patient and only serves to lengthen our work days –interminably.
Today I decided to take a rare mid-week day off at home to consider the advice we physicians all know but don’t always allow ourselves to follow:
1) Sleep. Plenty. Weekend and days-off naps are not only permitted but required. It’s one thing you can’t delegate someone else to do for you. It’s restorative and it’s necessary.
2) Don’t skip meals because you are too busy to chew. Ever. Especially if there is family involved.
3) Drink water throughout the work day.
4) Because of 3) go to the bathroom when it is time to go and not four or even eight hours later.
5) Nurture the people (and other breathing beings) who love and care for you because you will need them when things get rough.
5) Exercise whenever possible. Take the stairs. Park on the far side of the lot. Dance on the way to the next exam room.
6) Believe in something more infinite than you are as you are absolutely finite and need to remember your limits.
7) Weep if you need to, even in front of others. Holding it in hurts more.
8) Time off is sacred. When not on call, don’t take calls except from family and friends. No exceptions.
9) Learn how to say no gracefully and gratefully —try “not now but maybe sometime in the future and thanks for thinking of me”.
10) Celebrate being unscheduled and unplanned when not scheduled and planned.
11) Get away. Far away. Whenever possible. The back yard counts.
12) Connect regularly with people and activities that have absolutely nothing to do with medicine and health care.
13) Cherish co-workers, mentors, coaches and teachers that can help you grow and refine your profession and your person.
14) Start your work day on time. End your work day a little before you think you ought to.
15) Smile at people who are not expecting it, especially your co-workers. Smile at people who you don’t think warrant it. If you can’t get your lips to smile, smile with your eyes.
16) Take a day off from caring for others to care for yourself. Even a hug from yourself counts as a hug.
17) Practice gratitude daily. Doctoring is the best work there is anywhere and be blessed by it even on the days you prefer to forget.
The chief difficulty Alice found at first was in managing her flamingo: she succeeded in getting its body tucked away, comfortably enough, under her arm, with its legs hanging down, but generally, just as she had got its neck nicely straightened out, and was going to give the hedgehog a blow with its head, it would twist itself round and look up in her face, with such a puzzled expression that she could not help bursting out laughing: and when she had got its head down, and was going to begin again, it was very provoking to find that the hedgehog had unrolled itself, and was in the act of crawling away…. Alice soon came to the conclusion that it was a very difficult game indeed. ~Lewis Carroll from Alice in Wonderland
Navigating the U.S. health care system these days reminds me of Alice’s dreamscape game of Wonderland croquet. A physician is given a flamingo mallet and a hedgehog ball and ordered — by the Queen at the risk of having one’s head lopped off — to go play, but the mallet won’t cooperate and the ball keeps unrolling itself and crawling away. Just like any day in a medical clinic, a doctor’s time is spent trying to manage their flamingo and the patient gets tired of waiting, so gets up and leaves. At least Alice gets a good giggle out of it, but the reality in health care causes more tears than laughter. We are playing a very difficult game of changing rules and equipment.
The flamingo in the doctor’s hands could represent the increasingly time-consuming requirement now to search over 68,000 ICD-10 diagnosis codes rather than the previous 14,000 ICD-9 codes. Or the requirement to search for a 10 digit NDC number for any prescription medicine sent electronically to a pharmacy. Or the “meaningful use” criteria that regulate mandatory data collection and reportage on patients to the Federal Government in order to receive full payment for Medicare or Medicaid billings. Or the newly updated HIPAA and HITECH electronic security requirements to ensure privacy. Or the obligations to the new Accountable Care Organization that your employer has joined. Or the Maintenance of Certification hoops to jump through in order to continue to practice medicine. The exasperated and uncooperative “managed” flamingo keeps curling itself around and looking at us with a puzzled expression: just what is it you were supposed to be trained to do? is there actually a patient to pay attention to in all this morass of mandates?
And the poor hapless hedgehog patient is just rolled up in a ball waiting for the blow that never comes, for something, anything that might look like health care is about to happen. Instead there are unread Notices of Patient Privacy to sign, as well as releases to share medical information to sign, agreements to pay today’s co-pay and tomorrow’s deductible and whatever is left unpaid by Affordable Care Act insurance, passwords to choose for patient portals, insurance portals, lab portals and healthcare.gov. It might be easier and less painful to just crawl away and hide from that bumbling physician who can’t seem to get her act together.
I wish I were laughing, but I’m not. As both physician and patient, it’s getting harder and harder to play the game that is no game at all. The threat of losing credentialing in an insurance plan, or getting poor ratings on anonymous online physician grading sites, or being inexplicably dropped from a provider list, or too unproductive to remain in an employer medical group, or losing/forgoing board certification is like a professional beheading. We keep trying to juggle the flamingo motivated by those threats, all the while ineptly managing the managed care system, and hoping the patient won’t walk away out of sheer frustration.
It’s hard to remember why I’m in the game at all. I think, at least I hope, I wanted to take care of people, heal their illnesses and help them cope with life if they can’t be healed. I wanted to provide compassionate care.
It is enough to make a doctor cry. At least we can meet our patients at the Kleenex box and compare notes, and maybe, just maybe, we’ll find enough common ground to even share a laugh or two.