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.

access-healthcare-doctor-and-doll
portrait by Norman Rockwell
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portrait by Norman Rockwell

 

Taking a Moment (or a day) to Rest

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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.

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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.

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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.

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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.

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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.

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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.

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Managing the Flamingo

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photo by Chris Duppenthaler
Lewis Carroll Illustration
Lewis Carroll Illustration

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.

 

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photo by Chris Duppenthaler
photo by Chris Duppenthaler

Coughing Round the Clock

‘Tis the season to be coughing…

It no longer takes an epidemiologist looking at absenteeism rates in schools to predict the start of influenza season.  For several years now there have been sophisticated models using search engine terms to monitor increasing incidence of febrile cough illness in regions of the world as well as sentinel clinics reporting on influenza-like illnesses.

Or just ask a primary care clinic what its waiting room sounds like these days — a chorus of coughs, high, low, dry, moist, choking, barking, hacking, gagging, wheezing.  In our clinic, every patient is handed a surgical mask at the reception desk, whether coughing or not, with the explanation “for your protection and others’.”   A sea of blue masked faces glances up every time the nurse comes to call a patient back to an exam room.

In reality, it isn’t that clear how effective simple disposable masks are in preventing the spread of viral illness, but they are likely better than using nothing in crowded symptomatic people on public transportation, in a classroom, or a clinic waiting room.  Masks do make it more difficult to touch facial mucus membranes with contaminated hands if you can remember not to rub your eyes.

So we are in the thick of it now, with patient volumes up 30% over the usual load with extra staffing needed to manage the increased phone calls and electronic messaging.   We do rapid flu tests for those patients who fit criteria for Tamiflu treatment, otherwise, we are primarily looking for those at risk for flu complications, all the while trying to make the miserable a little less miserable.  Otherwise the usual self-treatment advice applies, especially stay home, stay home, stay home.

Once the fever and body aches subside,  one little residual symptom is usually left behind: a post-viral cough serves as a humbling reminder of the persistence of influenza inflammation and irritation in the respiratory tract.  Although no longer infectious by ten days after onset of illness, the cough can last up to three weeks or more, no matter what the patient does or takes.  It can be round the clock, interrupting everyone’s sleep from a constant tickling pressure in the trachea and a sensation of heaviness in the chest.   Although this cough is unlikely a risk to spread infection to others, it certainly sounds to others like a potential threat, so wearing a mask is advised as a courtesy and a reminder to protect others at all costs.

Has modern medicine found an answer to the plague of post-viral cough, other than preventing the whole illness to begin with by vaccinating for influenza?  Dropping out of polite society for three weeks isn’t possible for most people. Post-influenza patients must allow their bodies time to heal from a major insult that required a significant immune system response but most of us do need to get back to work and school.

What’s a doctor to do?

Antibiotics certainly aren’t the solution and never have been, but historically they (and a narcotic cough suppressant) were the easiest prescription for physicians to write for a tired and frustrated patient.  The aisle in local pharmacies for “Cold/Flu Remedies” seems to lengthen annually with new combination over-the-counter products.  Heavily marketed items vanish quickly off the shelves as people search in vain for relief.   Every imaginable combination of menthol, eucalyptus, and honey-lemon has been tried and tried again.   Probably chicken soup is still just as effective as anything else.

This is a time for tried and true wisdom:  this too shall pass.

Just please don’t pass it to others.

Palmed Off on the Unwary

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Nothing seems to please a fly so much as to be taken for a currant;
and if it can be baked in a cake and palmed off on the unwary, it dies happy.
~Mark Twain

Returning to clinic after time off for a summer break, I worry I’m like a fly hiding among the black currants hoping to eventually become part of the currant cake.  Just maybe no one will notice I don’t quite fit back in.

In thirty three years of practice, even after bearing three children and going through several surgeries, I’ve not been away from patients for more than twenty consecutive days at any one time.  This is primarily out of my fear that, even after a few weeks, I will have forgotten all that I’ve ever known and if I were to actually return to see patients again, I would be masquerading as a physician rather than be the real thing.   A mere fly among the currants palmed off on the unwary.

Those who spend their professional lives taking care of others also share this concern if they are truly honest: if a patient only knew how much we don’t know and will never know, despite everything we DO know, there would really be no need for us at all, especially in this day and age of accurate (and some terribly inaccurate) medical information at everyone’s fingertips.  Who needs a physician when there are so many other options to seek health care advice, even when there are a few flies mixed in?

As I walk back into an exam room to sit with my first patient after my time away, I recall over thirty years of clinical experience has given me an eye and an ear for subtlety of signs and symptoms that no googled website or internet doc-in-the-box can discern.  The avoidance of eye contact, the tremble of the lip as they speak, the barely palpable rash, the fullness over an ovary, the slight squeak in a lung base.  These are things I am privileged to see and hear and make decisions about together with my patients.  This is no masquerade; I am not appearing to be someone I am not.  This is what I’m trained to do and have done for thousands of days of my life.   No need for the unwary to fear.

The hidden fly in the currant bush of health care may be disguised enough to be part of the cake that an unwary patient might gobble down to their ultimate detriment — but not this doctor.  I know I’m the real thing, perhaps a bit on the tart side, but offering up just enough tang to be what is needed.

And I will die happy doing this.

 

 

Good Medicine

photo by Josh Scholten
photo by Josh Scholten

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

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.

 

Spicy Feet

photo of bee on a lemon blossom by Nate Gibson

“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’s ability to become pollinator and pollen gatherer simultaneously, facilitating new fruit from the blossom as well as making sweet honey that carries the spicy essence of the flower touched.

As a physician, I wish I might be as transformative in the work I do every day.  I carry with me tens of thousands of patients I’ve seen over thirty years of medical practice.   There is no way I can touch another human being without keeping some small part of them with me–a memory of an open wound or the scar it left behind, a word of sorrow or gratitude, a grimace, a tear or a smile.  Each 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 carries a spicy vitality, even in their illness and dying, that is unforgettable and still clings to me.  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.

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.  Their story becomes part of my story, adding to my skill as a healer, and never to be forgotten.

Physicians do have blessings in the work they do, you know, and if they don’t they should, for they are dusted with stories from a million patients visited.

Nothing could smell as spicy and nothing could taste as sweet.