Category Archives: Primary Care

Procedural Rural Medicine

Posted on March 22, 2013 | Leave a comment

“Primary care practice in the future may be more akin to an Amish barn-raising than care delivered by the fictional Marcus Welby.” – Valerie E. Stone, et al., “Physician Education and Training in Primary Care” (2010)[1]

Current proposals to remedy the crisis in primary care, especially among those Americans living in small, rural communities, are politically correct (or, in the case of J-1 waivers for foreign-trained physicians, ethically unacceptable) gestures.  Small adjustments in Medicare reimbursement schedules for physicians serving the underserved and unenforceable mandates by state legislatures that public medical schools “produce” more primary care physicians are all but meaningless.  Rural medicine programs at a handful of medical colleges basically serve the tiny number of rural-based students who arrive at medical school already committed to serving the underserved.  Such programs have had little if any impact on a crisis of systemic proportions.  If we want to pull significant numbers of typical medical students into primary care, we must empower them and reward them – big time.  So what exactly do we do?

  1. We phase out  “family medicine” for reasons I have adduced and replace it with a new specialty that will supplement internal medicine and pediatrics as core primary care specialties.  I term the new specialty procedural rural medicine (PRM) and physicians certified to practice it procedural care specialists.  Self-evidently, many procedural rural specialists will practice in urban settings.  The “rural” designation simply underscores the fact that physicians with this specialty training will be equipped to care for underserved populations (most of whom live in rural areas) who lack ready  access to specialist care.  Such care will be procedurally enlarged beyond the scope of contemporary family medicine.
  2. Procedural care specialists will serve the underserved, whether in private practice or under the umbrella of Federally Qualified Health Centers, Rural Health Centers, or the National Health Service Corps. They will  complete a four-year residency that equips all rural care specialists to perform a range of diagnostic and treatment procedures that primary care physicians now occasionally perform in certain parts of the country (e.g., colposcopy, sigmoidoscopy, nasopharyngoscopy), but more often do not.  It would equip them to do minor surgery, including office-based dermatology, basic podiatry, and wound management.   I leave it to clinical educators to determine exactly which baseline procedures can be mastered within a general four-year rural care residency, and I allow that it may be necessary to expand the residency to five years.  I further allow for procedural tracks within the final year of a procedural care program, so that certain board-certified procedural care specialists would be trained to perform operative obstetrics whereas others would be trained to perform colonoscopy.[2] The point is that all rural care proceduralists would be trained to perform a range of baseline procedures.  As such, they would be credentialed by hospitals as “specialists” trained to perform those procedures and would receive the same fee by Medicare and third-party insurers as the “root specialists” for particular procedures.
  3. Procedural care specialists will train in hospitals but will spend a considerable portion of their residencies learning and practicing procedurally oriented primary care in community health centers.  Such centers are the ideal venue for learning to perform “specialty procedures” under specialist supervision; they also inculcate the mindset associated with PRM, since researchers have found that residents who have their “continuity clinic” in community health centers are more likely to practice in underserved areas following training.[3]
  4. On completion of an approved four- or five-year residency in procedural rural medicine and the passing of PRM specialty boards, procedural care specialists will have all medical school and residency-related loans wiped off the books. Period.  This financial relief will be premised on a contractual commitment to work full-time providing procedural primary care to an underserved community for no less than, say, 10 years.
  5. Procedural care specialists who make this commitment deserve a bonus. They have become national resources in healthcare.  Aspiring big league baseball players who are drafted during the first four rounds of the MLB draft, many right out of high school, typically receive signing bonuses in the $100,000-$200,000 range.  In 2012, the top 100 MLB draftees each received a cool half million or more, and the top 50 received from one to six million.[4]  I propose that we give each newly trained procedural care specialist a $250,000 signing bonus in exchange for his or her 10-year commitment to serve the underserved.  Call me a wild-eyed radical, but I think physicians who have completed high school, four years of college, four years of medical school, and a four- or five-year residency program and committed themselves to bringing health care to underserved rural and urban Americans for 10 years deserve the same financial consideration as journeymen ball players given a crack at the big leagues.
  6. Taken together, the two foregoing proposals will make a start at decreasing the income gap between one group of primary care physicians (PCPs) and their colleagues in medical subspecialties and surgical specialties.  This gap decreases the odds of choosing primary care by nearly 50%; it is also associated with the career dissatisfaction of PCPs relative to other physicians, which may prompt them to retire earlier than their specialist colleagues.[5]
  7. I am not especially concerned about funding the debt waiver and signing bonuses for board-certified procedural care specialists.  These physicians will bring health care to over 60 million underserved Americans and, over time, they will be instrumental in saving the system, especially Medicare and Medicaid, billions of dollars.  Initial costs will be a  drop in the bucket in the context of American healthcare spending that consumed 17.9% of GDP in 2011.  Various funding mechanisms for primary care training – Title VII, Section 747 of the Public Health Service Act of 1963, the federal government’s Health Resources and Services Administration, Medicare – have long been in place, with the express purpose of expanding geographic distribution of primary care physicians in order to bring care to the underserved.  The Affordable Care Act of 2010 may be expected greatly to increase their funding.

————

These proposals offer an alternative vision for addressing the crisis in primary care that now draws only 3% of non-osteopathic physicians to federally designated Health Professional Shortage Areas and consigns over 20% of Americans to the care of 9% of its physicians.  The mainstream approach moves in a different direction, and the 2010 Macy Foundation-sponsored conference, “Who Will Provide Primary Care and How Will They Be Trained,” typifies it.  Academic physicians participating in the conference sought to address the crisis in primary care through what amounts to a technology-driven resuscitation of the “family practice” ideology of the late 1960s.  For them, PCPs of the future will be systems-savvy coordinators/integrators with a panoply of administrative and coordinating skills.  In this vision of things, the “patient-centered medical home” becomes the site of primary care, and effective practice within this setting obliges PCPs to acquire leadership skills that focus on “team building, system reengineering, and quality improvement.”

To be sure, docs will remain leaders of the healthcare team, but their leadership veers away from procedural medicine and into the domain of “quality improvement techniques and ‘system architecture’ competencies to continuously improve the function and design of practice systems.”  The “systems” in question are healthcare teams, redubbed “integrated delivery systems.”  It follows that tomorrow’s PCPs will be educated into a brave new world of “shared competencies” and interprofessional collaboration, both summoning “the integrative power of health information technology as the basis of preparation.”[6]

When this daunting skill set is enlarged still further by curricula addressing prevention and health promotion, wellness and “life balance” counseling, patient self-management for chronic disease, and strategies for engaging patients in all manner of decision-making, we end up with new-style primary care physicians who look like information-age reincarnations of the “holistic” mind-body family practitioners of the 1970s. What exactly will be dropped from existing medical school curricula and residency training programs to make room for acquisition of these new skill sets remains unaddressed.

I have nothing against prevention, health promotion, wellness, “life balance” counseling, and the like. Three cheers for all of them – and for patient-centered care and shared decision-making as well.  But I think health policy experts and medical academics have taken to theorizing about such matters – and the information-age skill sets they fall back on – in an existential vacuum, as if “new competencies in patient engagement and coaching”[7] can be taught didactically as opposed to being earned in the relational fulcrum of clinical encounter.  “Tracking and assisting patients as they move across care settings,” “coordinating services with other providers,” providing wellness counseling, teaching self-management strategies, and the like – all these things finally fall back on a trusting doctor-patient relationship.  In study after study, patient trust, a product of empathic doctoring,  has been linked to issues of compliance, subjective well-being, and treatment outcome.  Absent such trust, information-age “competencies” will have limited impact; they will briefly blossom but not take root in transformative ways.

I suggest we attend to first matters first.  We must fortify patient trust by training primary care doctors to do more, procedurally speaking, and then reward them for caring for underserved Americans who urgently need to have more done for them.  The rest – the tracking, assisting, coordinating, and counseling – will follow.  And the patient-centered medical home of the future will have patient educators, physician assistants, nurse practitioners, and social workers to absorb physicians’ counseling functions, just as it will have practice managers and care coordinators to guide physicians through the thicket of intertwining  information technologies.  We still have much to learn from Marcus Welby – and William Stepansky – on the community-sustaining art of barn-raising and especially the difference between barns well and poorly raised.

[1] Quoted from “Who Will Provide Primary Care And How Will They Be Trained?”  Proceedings of a conference chaired by L. Cronenwett & V. J. Dzau, transcript edited by B. J. Culliton & S. Russell (NY:  Josiah Macy, Jr., Foundation, 2010), p. 148.

[2] The prerogative to develop specialized knowledge and treatment skills within certain areas has always been part of general practice, and it was explicitly recommended in the Report of the AMA Ad Hoc Committee on Education for Family Practice (the Willard Committee) of 1966 that paved the way for establishment of the American Board of Family Practice in 1969.  See N.A., Family Practice: Creation of a Specialty (American Academy of Family Physicians, 1980), p.  41.

[3] C. G. Morris & F. M. Chen, “Training residents in community health centers:  facilitators and barriers,” Ann. Fam. Med., 7:488-94, 2009; C. G. Morris, et al., “Training family physicians in community health centers,” Fam. Med., 40:271-6, 2008; E. M. Mazur, et al., “Collaboration between an internal medicine residency program and a federally qualified health center: Norwalk hospital and the Norwalk community health center,” Acad. Med., 76: 1159-64, 2001.

[5] “Specialty and geographic distribution of the physician workforce:  What influences medical student & resident choices?”  A publication of the Robert Graham Center, funded by the Josiah Macy, Jr. Foundation (2009), pp. 5, 47; “Who Will Provide Primary Care And How Will They Be Trained” (n. 1), p. 140.

[6] “Who Will Provide Primary Care And How Will They Be Trained”(n. 1), pp. 147, 148.

[7] Ibid, p. 151.

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Posted in Family Doctors, Then & Now, Health Care Reform, Healthcare Delivery Systems, Primary Care, Procedural Rural Medicine, Rural Medicine

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Re-Visioning Primary Care

Posted on January 2, 2013 | Leave a comment

Existing approaches to the looming crisis of primary care are like Congressional approaches to our fiscal crisis.  They have been, and will continue to be, unavailing because they shy away from structural change that would promote equity.  I suggest the time has come to think outside the financial box of subsidization and loan repayment for medical students and residents who agree to serve the medically underserved for a few years.  Here are my propositions and proposals:

  1. We should redefine “primary care” in a way that gives primary care physicians (PCPs) a fighting chance of actually functioning as specialists. This means eliminating “family medicine” altogether.  The effort to make the family physician (FP) (until 2003, the “family practitioner”) a specialist among specialists was tried in the 70s and by and largely failed – not for FP patients, certainly, but for FPs themselves, who, by most accounts, failed to achieve the academic stature and clinical privileges associated with specialist standing.  It is time to face this hard fact and acknowledge that the era of modern general practice/family medicine, as it took shape in the 1940s and came to fruition in the quarter century following World War II, is at an end.  Yet another round of financial incentives that make it easier for medical students and residents to “specialize” in family medicine will fail.  “Making it easier” will not make it easy enough, nor will it overcome a specialist mentality that has been entrenched since the 1950s.  Further policy-related efforts to increase the tenability of family medicine, such as increasing Medicare reimbursement for primary care services or restructuring Medicare to do away with primary care billing costs, will be socioeconomic Band-Aids that cover over the professional, personal, familial, and, yes, financial strains associated with family medicine in the twenty-first century.  Vague and unenforceable “mandates” by state legislatures directing public medical schools to “produce” more primary care physicians have been, and will continue to be, political Band-Aids.[1]
  2. As a society, we must re-vision generalist practice as the province of internists and pediatricians.  We must focus on developing incentives that encourage internists and pediatricians to practice general internal medicine and general pediatrics, respectively.  This reconfiguring of primary care medicine will help advance the “specialty” claims of primary care physicians.  Historically speaking, internal medicine and pediatrics are specialties, and the decision-making authority and case management prerogatives of internists and pediatricians are, in many locales, still those of specialists. General internists become “chief medical officers” of their hospitals; family physicians, with very rare exceptions, do not.  For a host of pragmatic and ideological reasons, many more American medical students at this juncture in medical history will enter primary care as internists and pediatricians than as family physicians.
  3. Part of this re-visioning and reconfiguring must entail recognition that generalist values are not synonymous with generalist practice.  Generalist values can be cultivated (or neglected) in any type of postgraduate medical training and implemented (or neglected) by physicians in any specialty. There are caring physicians among specialists, just as there are less-than-caring primary care physicians aplenty.  Caring physicians make caring interventions, however narrow their gaze.  My wonderfully caring dentist only observes the inside of my mouth but he is no less concerned with my well-being on account of it.  The claim of G. Gayle Stephens, one of the founders of the family practice specialty in the late 1960s, that internists, as a class, were zealous scientists committed to “a mechanistic and flawed concept of disease,” whereas family physicians, as a class, were humanistic, psychosocially embedded caregivers, was specious then and now.[2]  General internists are primary care physicians, and they can be expected to be no less caring (and, sadly, no more caring) of their patients than family physicians.  This is truer still of general pediatrics, which, as far back as the late nineteenth century, provided a decidedly patient-centered agenda for a cohort of gifted researcher-clinicians, many women physicians among them, whose growth as specialists (and, by the 1920s and 30s, as pediatric subspecialists) went hand-in-hand with an abiding commitment to the “whole patient.”[3]
  4. We will not remedy the primary care crisis by eliminating family medicine and developing incentives to keep internists and pediatricians in the “general practice” of their specialties.  In addition, we need policy initiatives to encourage subspecialized internists and subspecialized pediatricians to continue to work as generalists.  This has proven a workable solution in many developed countries, where the provision of primary care by specialists is a long-established norm.[4]   And, in point of fact, it has long been a de facto reality in many smaller American communities, where medical and pediatric subspecialists in cardiology, gastroenterology, endocrinology, et al. also practice general internal medicine and general pediatrics.  Perhaps we need a new kind of mandate:  that board-certified internists and pediatricians practice general internal medicine and general pediatrics, respectively, for a stipulated period (say, two years) before beginning their subspecialty fellowships.

Can we remedy the shortage of primary care physicians through the conduits of internal medicine and pediatrics?  No, absolutely not.  Even if incentive programs and mandates increase the percentage of internists and pediatricians who practice primary care, they will hardly provide the 44,000-53,000 new primary care physicians we will need by 2025.[5]  Nor will an increase in the percentage of medical students who choose primary care pull these new providers to the underserved communities where they are desperately needed.  There is little evidence that increasing the supply of primary care physicians affects (mal)distribution of those providers across the country.  Twenty percent of the American population lives in nonmetropolitan areas and is currently served by 9% of the nation’s physicians; over one third of these rural Americans live in what the Health Resources and Services Administration of the U.S. Department of Health and Human Services designates “Health Professional Shortage Areas” (HPSAs) in need of primary medical care.[6]  Efforts to induce foreign-trained physicians to serve these communities by offering them J-1 visa waivers have barely made a dent in the problem and represent an unconscionable “brain drain” of the medical resources of developing countries.[7]  The hope that expansion of rural medicine training programs at U.S. medical schools, taken in conjunction with increased medical school enrollement, could meet the need for thousands of new rural PCPs is not being borne out.  Graduating rural primary care physicians has not been, and likely will not be, a high priority for most American medical schools, a reality acknowledged by proponents of rural medicine programs.[8]

Over and against the admirable but ill-fated initiatives on the table, I propose two focal strategies for addressing the primary care crisis as a crisis of uneven distribution of medical services across the population:

  1. We must expend political capital and economic resources to encourage people to become mid-level providers, i.e., physician’s assistants (PAs) and nurse practitioners (NPs), and then develop incentives to keep them in primary care.  This need is more pressing than ever given (a) evidence that mid-level practitioners are more likely to remain in underserved areas than physicians,[9] and (b) the key role of mid-level providers in the team delivery systems, such as  Accountable Care Organizations and Patient-Centered Medical Homes, promoted by the Patient Protection and Affordable Care Act of 2010.  Unlike other other health care providers, PAs change specialties over the course of their careers without additional training, and since the late 1990s, more PAs have left family medicine than have entered it.  It has become incumbent on us as a society to follow the lead of the armed forces and the Veterans Health Administration in exploiting this health care resource.[10]  To wit, (a) we must provide incentives to attract newly graduated PAs to primary care in underserved communities and to pull specialty-changing “journeyman PAs” back to primary care,[11] and (b) we must ease the path of military medics and corpsmen returning from Iraq and Afghanistan into PA programs by waiving college-degree eligibility requirements that have all but driven them away from these programs.[12]  Although the Physician Assistant profession came into existence in the mid-1960s to capitalize on the skill set and experience of medical corpsman returning from Vietnam, contemporary PA programs, with few exceptions, no longer recruit military veterans into their programs.[13]
  2. Finally, and most controversially, we need a new primary care specialty aimed at providing comprehensive care to rural and underserved communities.  I designate this new specialty Procedural Rural Medicine (PRM) and envision it as the most demanding – and potentially most rewarding – primary care specialty.  PRM would borrow and enlarge the recruitment strategies employed by the handful of medical schools with rural medicine training programs.[14]  But it would require a training curriculum, a residency program, and a broad system of incentives all its own.

In the next installment of this series, I will elaborate my vision of Procedural Rural Medicine and explain how and why it differs from family medicine as it currently exists.

[1] D. Hogberg, “The Next Exodus: Primary-Care Physicians and Medicare,” National Policy Analysis #640 (http://www.nationalcenter.org/NPA640.html); C S. Weissert & S. L. Silberman, “Sending a policy signal: state legislatures, medical schools, and primary care mandates,” Journal of Health Politics, Policy and Law, 23:743-770, 1998.

[2] G. G. Stephens, The Intellectual Basis of Family Practice (Tucson, AZ: Winter Publishing, 1982), pp. 77, 96.

[3] See E. S. More, Restoring the Balance: Women Physicians and the Profession of Medicine, 1850-1995 (Cambridge: Harvard University Press, 1999), pp. 170-72.  Edith Dunham, Martha Eliot, Helen Taussig, Edith Banfield Jackson, and Virginia Apgar stand out among the pioneer pediatricians who were true generalist-specialists.

[4] See W. J. Stephen, An Analysis of Primary Care: An International Study (Cambridge: Cambridge University Press, 1979) and B. S. Starfield, Primary Care: Concept, Evaluation and Policy (Oxford : Oxford University Press, 1992).

[5] The percentile range denotes the different protocols employed by researchers.  See M. J. Dill & E. S. Salsberg, “The complexities of physician supply and demand: projections through 2025,” Association of American Medical College, 2008 (http://www.innovationlabs.com/pa_future/1/background_docs/AAMC%20Complexities%20of%20physician%20demand,%202008.pdf); J. M. Colwill, et al., Will generalist physician supply meet demands of an increasing and aging population?  Health Affairs, 27:w232-w241, 2008;  and S. M. Petterson, et al., “Projecting US primary care physician workforce needs:  2010-2025,” Ann. Fam. Med., 10: 503-509, 2012.

[6] See the Federal Office of Rural Health Policy, “Facts about . . . rural physicians” (http://www.shepscenter.unc.edu/rural/pubs/finding_brief/phy.html ) and J. D. Gazewood, et al., “Beyond the horizon: the role of academic health centers in improving the health of rural communities,” Acad. Med., 81:793-797, 2006.  In all, the federal government has designated 5,848 geographical areas HPSAs in need of primary medical care (http://datawarehouse.hrsa.gov/factSheetNation.aspx).

[7] These non-immigrant visa waivers, authorized since 1994 by the Physicians for Underserved Areas Act (the “Conrad State 30” Program), allow foreign-trained physicians who provide primary care in underserved communities for at least three years to waive the two-hear home residence requirement.  That is, these physicians do not have to return to their native countries for at least two years prior to applying for permanent residence or an immigration visa.  On the negative impact of this program on health equity and, inter alia, the global fight against HIV and AIDS, see V. Patel, “Recruiting doctors from poor countries: the great brain robbery?, BMJ, 327:926-928, 2003; F. Mullan, “The metrics of the physician brain drain,” New Engl. J. Med., 353:1810-1818, 2005; and N. Eyal & S. A. Hurst, “Physician brain drain:  can nothing be done?, Public Health Ethics, 1:180-192, 2008.

[8] See H. K. Rabinowitz, et al., “Medical school programs to increase the rural physician supply: a systematic review,” Acad. Med., 83:235-243, at 242:  “It is, therefore, unlikely that the graduation of rural physicians will be a high priority for most medical schools, unless specific regulations require this, or unless adequate financial resources are provided as incentives to support this mission.”

[9] U. Lehmann, “Mid-level health workers: the state of evidence on programmes, activities, costs and impact on health outcomes,” World Health Organization, 2008 (http://www.who.int/hrh/MLHW_review_2008.pdf).

[10] R. S. Hooker, “Federally employed physician assistants,” Mil. Med., 173:895-899, 2008.

[11] J. F. Cawley & R. S. Hooker, “Physician assistant role flexibility and career mobility,” JAAPA, 23:10, 2010.

[12] D. M. Brock, et al., “The physician assistant profession and military veterans,” Mil. Med., 176:197-203, 2011.

[13] N. Holt, “’Confusion’s masterpiece’:  the development of the physician assistant profession,” Bull. Hist. Med., 72:246-278, 1998; Brock, op cit., p. 197.

[14]H. K. Rabinowitz, et al., “Critical factors  for designing programs to increase the supply and retention of rural primary care physicians,” JAMA, 286:1041-48, 2001; H. K. Rabinowitz, et al., “The relationship between entering medical students’ backgrounds and career plans and their rural practice outcomes three decades later,” Acad. Med., 87:493-497, 2012; H. K. Rabinowitz, et al., “The relationship between matriculating medical students’ planned specialties and eventual rural practice outcomes,” Acad. Med., 87:1086-1090, 2012.

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Posted in Family Doctors, Then & Now, Health Care Reform, Healthcare Delivery Systems, Primary Care, Rural Medicine

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Wanted: Primary Care Docs

Posted on November 26, 2012 | Leave a comment

“It will readily be seen that amid all these claimants for pathological territory there is scarcely standing-room left for the general practitioner.” – Andrew H. Smith, “The Family Physician” (1888)

“The time when every family,   v         rich or poor, had its own family physician, who knew the illnesses and health of its members and enjoyed the confidence of the upgrowing boys and girls during two or three generations, is gone.” – Abraham Jacobi, “Commercialized Medicine” (1910)

“More recent investigation shows that almost one-third of the towns of 1,000 or less throughout the United States which had physicians in 1914 had none in 1925. . . . it will be seen at a glance that the present generation of country doctors will have practically disappeared in another ten years.” – A. F. van Bibber, “The Swan Song of the Country Doctor” (1929)

“But complete medical care means more than the sum of the services provided by specialists, no matter how highly qualified.  It must include acceptance by one doctor of complete responsibility for the care of the patient and for the coordination of specialist, laboratory, and other services.  Within a generation, if the present situation continues, few Americans will have a personal physician do this for them.” – David D. Rutstein, “Do You Really Want a Family Doctor?” (1960)

“Whoever takes up the cause of primary care, one thing is clear: action is needed to calm the brewing storm before the levees break.” – Thomas Bodenheimer, “Primary Care – Will It Survive?” (2006)

“Potential access challenges”—that’s the current way of putting the growing shortage of primary care physicians (PCPs).  Euphemism melodious of care incommodious. Aggravated by the 33 million Americans shortly to receive health insurance through the Patient Protection and Affordable Care Act of 2010 – health insurance leads to increased use of physicians – the chronic shortage of primary care physicians is seen as a looming crisis capable of dragging us back into the medical dark ages.  Medical school graduates continue to veer away from the less remunerative primary care specialties, opting for the  well-fertilized and debt-annihilating verdure of the subspecialties.  Where then will we find the 51,880 additional primary care physicians that, according to the most recent published projections,[1] we will need by 2025 to keep up with an expanding, aging, and more universally insured American population?

Dire forecasts about the imminent disappearance of general practitioners or family practitioners or, more recently, primary care physicians have been part of the medical-cum-political landscape for more than a century.  Now the bleak scenarios are back in vogue, and they are more frightening than ever, foretelling a consumer purgatory of lengthy visits to emergency rooms for private primary care – or worse.  Dr. Lee Green, chair of Family Medicine at the University of Alberta, offers this bleak vision of a near future where patients are barely able to see primary care physicians at all:

Primary care will be past saturated with wait times longer and will not accept any new patients.  There will be an increase in hospitalizations and increase in death rates for basic preventable things like hypertension that was not managed adequately.[2]

I have no intention of minimizing the urgency of a problem that, by all measurable indices, has grown worse in recent decades. But I do think that Dr. Green’s vision is, shall we say, over the top.  It is premised on a traditional model of primary care in which a single physician assumes responsibility for a single patient.  As soon as we look past the traditional model and take into account structural changes in the provision of primary care over the past four decades, we are able to forecast a different, if still troubling, future.

Beginning in the 1970s, and picking up steam in the 1980s and 90s, primary care medicine was enlarged by mid-level providers (physician assistants, nurse practitioners, psychiatric nurses, and clinical social workers) who, in many locales, have absorbed the traditional functions of primary care physicians.  The role of these providers in American health care will only increase with implementation of the Patient Protection and Affordable Care Act and the innovative health delivery systems it promotes as solutions to the crisis in healthcare.

I refer specifically to the Act’s promotion of “Patient-Centered Medical Homes” (PCMHs) and “Accountable Care Organizations” (ACOs), both of which involve a collaborative melding of roles in the provision of primary care.  Both delivery systems seek to tilt the demographic and economic balance among medical providers back in the direction of primary care and, in the process, to render medical care more cost-effective through the use of electronic information systems, evidence-based care (especially the population-based management of chronic illnesses), and performance measurement and improvement.  To these ends, the new delivery systems equate primary care with “team-based care, in which physicians share responsibility with nurses, care coordinators, patient educators, clinical pharmacists, social workers, behavioral health specialists, and other team members.”[3]  The degree to which the overarching goals of these new models – reduced hospital admissions and readmissions and more integrated, cost-effective management of chronic illnesses – can be achieved will be seen in the years ahead.  But it is clear that these developments, propelled by the Accountable Care Act and the Obama administration’s investment of $19 billion to stimulate the use of information technology in medical practice, all point to the diminished role of the all-purpose primary care physician (PCP).

So we are entering a brave new world in which mid-level providers, all working under the supervision of generalist physicians in ever larger health systems, will assume an increasing role in primary care.  Indeed, PCMHs and ACOs, which attempt to redress the crisis in primary care, will probably have the paradoxical effect of relegating the traditional “caring” aspects of the doctor-patient relationship to nonphysician members of the health care team.  The trend away from patient-centered care on the part of physicians is already discernible in the technical quality objectives (like mammography rates) and financial goals of ACOs that increasingly pull primary care physicians away from relational caregiving.

The culprit here is time.  ACOs, for example, may direct PCPs to administer depression scales and fall risk assessments to all Medicare patients, the results of which must be recorded in the electronic record along with any “intervention” initiated.  In all but the largest health systems (think Kaiser Permanente), such tasks currently fall to the physician him- or herself.  The new delivery systems do not provide ancillary help for such tasks, which makes it harder still for overtaxed PCPs to keep on schedule and connect with their patients in more human, and less assessment-driven, ways.[4]

So, yes, we’re going to need many more primary care physicians, but perhaps not as many as Petterson and his colleagues project.  Their extrapolations from “utilization data” – the number of  PCPs we will will need to accommodate the number of office visits made by a growing, aging, and better insured American population at a future point in time – do not incorporate the growing reality of team-administered primary care.  The latter already includes patient visits to physician assistants, nurse practitioners, and clinical social workers and is poised to include electronic office “visits” via the Internet.   For health services researchers, this kind of  distributed care suggests the reasonableness of equating “continuity of care” with “site continuity” (the place where we receive care) rather than “provider continuity” (the personal physician who provides that care).

Of course, we are still left with the massive and to date intractable problem of the uneven distribution of primary care physicians (or primary care “teams”) across the population.  Since the 1990s, attempts to pull PCPs to those areas where they are most needed have concentrated on the well-documented financial disincentives associated with primary care, especially in underserved, mainly rural areas .  Unsurprisingly, these disincentives evoke financial solutions for newly trained physicians who agree to practice primary care for at least a few years in what the federal government’s Health Resources and Services Administration designates “Health Professional Shortage Areas” (HPSAs).  The benefit package currently in place includes medical school scholarships, loan repayment plans, and, beginning in 1987, a modest bonus payment program administered by Medicare Part B carriers.[5]

The most recent and elaborate proposal to persuade primary care physicians to go where they are most needed adopts a two-pronged approach.  It calls for creation of a National Residency Exchange that would determine the optimal number of  residencies in different medical specialties for each state, and then “optimally redistribute”  residency assignments state by state in the direction of underrepresented specialties, especially primary care specialties in underserved communities.  This would be teamed with a federally funded primary care loan repayment program, administered by Medicare, that would gradually repay participants’ loans over the course of their first eight years of post-residency primary care practice in an HPSA.[6]

But this and like-minded schemes will come to naught if medical students are not drawn to primary care medicine in the first place.  There was such a “draw” in the late 60s and early 70s; it followed the creation of “family practice” as a residency-based specialty and developed in tandem with social activist movements of the period.  But it did not last into the 80s and left many of its proponents disillusioned.  Despite the financial incentives already in place (including those provided by the federal government’s National Health Service Corps[7]) and the existence of “rural medicine” training programs,[8] there is no sense of gathering social forces that will pull a new generation of medical students into primary care.  Nor is there any reason to suppose that the dwindling number of medical students whose sense of calling leads to careers among the underserved will be drawn to the emerging world of primary care in which the PCP assumes an increasingly administrative (and data-driven) role as coordinator of a health care team.

In truth, I am skeptical that financial packages, even if greatly enlarged, can overcome the specialist mentality that emerged after World War II and is long-entrenched in American medicine.  Financial incentives assume that medical students would opt for primary care if not for financial disincentives that make it harder for them to do so.  Now recent literature suggests that financial realities do play an important role in the choice of specialty.[9]  But there is more to choice of specialty than debt management and long-term earning power.  Specialism is not simply a veering away from generalism; it is a pathway to medicine with its own intrinsic satisfactions, among which are prestige, authority, procedural competence, problem-solving acuity, and considerations of lifestyle. These satisfactions are at present vastly greater in specialty medicine than those inhering in primary care.  This is why primary care educators, health economists, and policy makers place us (yet again) on the brink of crisis.

Financial incentives associated with primary care are important and probably need to be enlarged far beyond the status quo.  But at the same time, we need to think outside the box in a number of ways.  To wit, we need to rethink the meaning of generalism and its role in medical practice (including specialty practice).  And we need to find and nurture (and financially support) more medical students who are drawn to primary care.  And finally, and perhaps most radically, we need to rethink the three current primary care specialties (pediatrics, general internal medicine, and family medicine) and the relationships among them.  Perhaps this long-established tripartite division is no longer the best way to conceptualize primary care and to draw a larger percentage of medical students to it.  I will offer my thoughts on these knotty issues in blog essays to follow.

[1] S. M. Petterson, et al., “Projecting US primary care physician workforce needs:  2010-2025,” Ann. Fam. Med., 10:503-509, 2012.

[2] Quoted in Nisha Nathan, “Doc Shortage Could Crash Health Care,” online at http://abcnews.go.com/Health/doctor-shortage-healthcare-crash/story?id=17708473.

[3] D. R. Rittenhouse & S. M. Shortell, “The patient-centered medical home:  will it stand the test of health reform?, JAMA, 301:22038-2040, 2009, at 2039.  Among recent commentaries, see further D. M. Berwick, “making good on ACOs’ promise – the final rule for the Medicare shared savings program,” New Engl. J. Med., 365:1753-1756, 2011; D. R. Rittenhouse, et al., “Primary care and accountable care – two essential elements of delivery-system reform,” New Engl. J. Med., 361:2301-2303, 2009, and E. Carrier, et al., “Medical homes:  challenges in translating theory into practice,” Med. Care, 47:714-722, 2009.

[4] I am grateful to my brother, David Stepansky, M.D., whose medical group participates in both PCMH and ACO entities, for these insights on the impact of participation on PCPs who are not part of relatively large health  systems.

[5]E.g., R. G. Petersdorf, “Financing medical education: a universal ‘Berry plan’  for medical students,” New Engl. J. Med., 328, 651, 1993;  K. M. Byrnes, “Is there a primary care doctor in the house? the legislation needed to address a national shortage,” Rutgers Law Journal, 25: 799, 806-808, 1994.  On the Medicare Incentive Payment Program for physicians practicing in designated HPSAs – and the inadequacy  of the 10% bonus system now in place – see L. R. Shugarman & D. O. Farley, “Shortcomings in Medicare bonus payments for physicians in underserved areas,” Health Affairs, 22:173-78, 2003 at 177 (online at http://content.healthaffairs.org/content/22/4/173.full.pdf+html) and S. Gunselman, “The Conrad ‘state-30’ program:  a temporary relief to the U.S. shortage of physicians or a contributor to the brain drain,”  J. Health & Biomed. Law, 5:91-115, 2009, at 107-108.

[6]G. Cheng, “The national residency exchange: a proposal to restore primary care in an age of microspecialization,” Amer. J. Law & Med., 38:158-195, 2012.

[7] The NHSC, founded in 1970, provides full scholarship support for medical students who agree to serve as PCPs in high-need, underserved locales, with one year of service for each year of support provided by the government.  For medical school graduates who have already accrued debt, the program provides student loan payment for physicians who commit to at least two years of service at an approved site. Descriptions of the scholarship and loan repayment program are available at http://nhsc.hrsa.gov/

[8] See the rationale for rural training programs set forth in a document of the Association of American Medical Colleges, “Rural medicine programs aim to reverse physician shortage in outlying regions,” online at http://www.aamc.org/newsroom/reporter/nov04/rural.htm.  One of the best such programs, Jefferson Medical College’s Physician Shortage Area Program, is described and its graduates profiled in H. K. Rabinowitz, Caring for the country:  family doctors in small rural towns (NY: Springer, 2004).

[9] See especially the 2003 white paper by the AMA’s taskforce on student debt, online at http://www.ama-assn.org/ama1/pub/upload/mm/15/debt_report.pdf and, more recently, P. A. Pugno, et al., “Results of the 2009 national resident matching program: family medicine,” Fam. Med., 41:567-577, 2009 and H. S. Teitelbaum, et al., “Factors affecting specialty choice among osteopathic medical students, Acad. Med., 84:718-723, 2009.

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Caring Technology

Posted on October 11, 2012 | Leave a comment

The critique of contemporary medical treatment as impersonal, uncaring, and disease-focused usually invokes the dehumanizing perils of high technology.  The problem is that high technology is a moving target.  In the England of the 1730s, obstetrical forceps were the high technology of the day; William Smellie, London’s leading obstetrical physician, opposed their use for more than a decade, despite compelling evidence that the technology revolutionized childbirth by permitting obstructed births to become live births.[1]  For much of the nineteenth century, stethoscopes and sphygmomanometers (blood pressure meters) were considered technological contrivances that distanced the doctor from the patient.  For any number of Victorian patients (and doctors too), the kindly ear against the chest and the trained finger on the wrist helped make the physical examination an essentially human encounter.  Interpose instruments between the physician and the patient and, ipso facto, you distance the one from the other.  In late nineteenth-century Britain, “experimental” or “laboratory” medicine was itself a revolutionary technology, and it elicited  bitter denunciation from antivivisectionists (among whom were physicians) that foreshadows contemporary indictments of the “hypertrophied scientism” of modern medicine.[2]

Nineteenth-century concerns about high technology blossomed in the early twentieth century when technologies (urinalysis, blood studies, x-rays, EKGs) multiplied and their use switched to hospital settings.  Older pediatricians opposed the use of the new-fangled incubators for premature newborns. They  not only had faulty ventilation that deprived infants of fresh air but were a wasteful expenditure, given that preemies of the poor were never brought to the hospital right after birth.[3]   Cautionary words were always at hand for the younger generation given to the latest gadgetry.  At the dedication of Yale’s Sterling Hall of Medicine, the neurosurgeon Harvey Cushing extolled family physicians as exemplars of his gospel of observation and deduction and urged  Yale students to engage in actual “house-to-house practice” without the benefit of “all of the paraphernalia and instruments of precision supposed to be necessary for a diagnosis.”  This was in 1925.[4]

Concerns about the impact of technology on doctor-patient relationships blossomed again in the 1960s and 70s and played a role  in the rebirth of primary care medicine in the guise of the “family practice movement.”  Reading the papers of the recently deceased G. Gayle Stephens, written at the time and collected in his volume The Intellectual Basis of Family Practice (1982), is a strong reminder of the risks attendant to loading high technology with relational meaning.  Stephens, an architect of the new structure of primary care training, saw the “generalist role in medicine” as an aspect of 70s counterculture that questioned an “unconditional faith in science” that extended to medical training, practice, and values.  And so he aligned the family practice movement with other social movements of the 70s that sought to put the breaks on scientism run rampant:  agrarianism, utopianism, humanism, consumerism, and feminism.  With its clinical focus on the whole person and liberal borrowings from psychiatry and the behavioral sciences, family practice set out to liberate medicine from its “captivity” to a flawed view of reality that was mechanistic, protoplasmic, and molecular.[5]

Technology was deeply implicated in Stephens’ critique, even though he failed to stipulate which technologies he had in mind.  His was a global indictment: Medicine’s obsession with its “technological legerdemain” blinded the physician to the rich phenomenology of “dis-ease” and, as such, was anti-Hippocratic.  For Stephens, the “mechanical appurtenances of healing” had to be differentiated from the “essential ingredient” of the healing process, viz., “a physician who really cares about the patient.” “We have reached a point of diminishing returns in the effectiveness of technology to improve the total health of our nation.”  So he opined in 1973, only two years after the first crude CT scanner was demonstrated in London and long before the development of MRIs and PET scans, of angioplasty with stents, and of the broad array of laser- and computer-assisted operations available to contemporary surgeons.[6]  Entire domains of technologically guided intervention – consider technologies of blood and marrow transplantation and medical genetics – barely existed in the early 70s.  Robotics was the stuff of science fiction.

It is easy to sympathize with both Stephens’ critique and his mounting skepticism about the family practice movement’s ability to realize its goals. [7]  He placed the movement on an ideological battleground in which the combatants were of unequal strength and numbers.  There was the family practice counterculture, with the guiding belief that “something genuine and vital occurs in the meeting of doctor and patient” and the pedagogical correlate that  “A preoccupation with a disease instead of a person is detrimental to good medicine.”  And then there were the forces of organized medicine, of medical schools, of turf-protecting internists and surgeons, of hospitals with their “business-industrial models” of healthcare delivery, of specialization and of technology – all bound together by a cultural commitment to science and its  “reductionist hypothesis about the nature of reality.”[8]

Perceptive and humane as Stephen’s critique was, it fell back on the very sort of reductionism he imputed to the opponents of family practice.  Again and again, he juxtaposed “high technology,” in all its allure (and allegedly diminishing returns) with the humanistic goals of patient care.  But are technology and humane patient care really so antipodal?  Technology in and of itself has no ontological status within medicine.  It promotes neither a mechanistic worldview that precludes holistic understanding of patients as people nor a humanizing of the doctor-patient encounter.  In fact, technology is utterly neutral with respect to the values that inform medical practice and shape individual doctor-patient relationships.  Technology does not make (or unmake) the doctor.  It no doubt affects the physician’s choice of specialty, pulling those who lack doctoring instincts or people skills in problem-solving directions (think diagnostic radiology or pathology). But this is hardly a bad thing.

For Stephens, who struggled to formulate an “intellectual” defense of family practice as a new medical discipline, technology was an easy target.  Infusing the nascent behavioral medicine of his day with a liberal dose of sociology and psychoanalysis, he envisioned the family practice movement as a vehicle for recapturing “diseases of the self” through dialogue.[9]  To the extent that technology – whose very existence all but guaranteed its overuse – supplanted  the sensibility (and associated communicational skills) that enabled such dialogue, it was ipso facto part of the problem.

Now there is no question that overreliance on technology, teamed with epistemic assurance that technology invariably determines what is best, can make a mess of things, interpersonally speaking.  But is the problem with the technology or with the human beings who use it?  Technology, however “high” or “low,” is an instrument of diagnosis and treatment, not a signpost of treatment well- or ill-rendered.  Physicians who are not patient-centered will assuredly not find themselves pulled toward doctor-patient dialogue through the tools of their specialty.  But neither will they become less patient-centered on account of these tools.  Physicians who are patient-centered, who enjoy their patients as people, and who comprehend their physicianly responsibilities in broader Hippocratic terms – these physicians will not be rendered less human, less caring, less dialogic, because of the technology they rely on.  On the contrary, their caregiving values, if deeply held, will suffuse the technology and humanize its deployment in patient-centered ways.

When my retinologist examines the back of my eyes with the high-tech tools of his specialty – a retinal camera, a slit lamp, an optical coherence tomography machine – I do not feel that my connection with him is depersonalized or objectified through the instrumentation.  Not in the least.  On the contrary, I perceive the technology as an extension of his person.  I am his patient, I have retinal pathology, and I need his regular reassurance that my condition remains stable and that I can continue with my work.  He is responsive to my anxiety and sees me whenever I need to see him.  The high technology he deploys in evaluating the back of my eye does not come between us; it is a mechanical extension of his physicianly gaze that fortifies his judgment and amplifies the reassurance he is able to provide.  Because he cares for me, his technology cares for me.  It is caring technology because he is a caring physician.

Modern retinology is something of a technological tour de force, but it is no different in kind from other specialties that employ colposcopes, cytoscopes, gastroscopes, proctoscopes, rhinoscopes, and the like to investigate symptoms and make diagnoses.  If the physician who employs the technology is caring, then all such technological invasions, however unpleasant, are caring interventions.  The cardiologist who recommends an invasive procedure like cardiac catheterization is no less caring on that account; such high technology does not distance him from the patient, though it may well enable him to maintain the distance that already exists.  It is a matter of personality, not technology.

I extend this claim to advanced imaging studies as well.  When the need for an MRI is explained in a caring and comprehensible manner, when the explanation is enveloped in a trusting doctor-patient relationship, then the technology, however discomfiting, becomes the physician’s collaborator in care-giving.  This is altogether different from the patient who demands an MRI or the physician who, in the throes of defensive medicine, remarks off-handedly, “Well, we better get an MRI” or simply, “I’m going to order an MRI.”

Medical technology, at its best, is the problem-solving equivalent of a prosthetic limb.  It is an inanimate extender of the physician’s mental “grasp” of the problem at hand. To the extent that technology remains tethered to the physician’s caring sensibility, to his understanding that his diagnostic or treatment-related problem is our existential problem – and that, per Kierkegaard, we are often fraught with fear and trembling on account of it – then we may welcome the embrace of high technology, just as polio patients of the 1930s and 40s with paralyzed intercostal muscles welcomed the literal embrace of the iron lung, which enabled them to breath fully and deeply and without pain.

No doubt, many physicians fail to comprehend their use of technology in this fuzzy, humanistic way – and we are probably the worse for it.  Technology does not structure interpersonal relationships; it is simply there for the using or abusing.  The problem is not that we have too much of it, but that we impute a kind of relational valence to it, as if otherwise caring doctors are pulled away from patient care because technology gets between them and their patients.  With some doctors, this may indeed be the case.  But it is not the press of technology per se that reduces physicians to, in a word Stephens disparagingly uses, “technologists.”  The problem is not in their tools but in themselves.

[1] A. Wilson, The Making of Man-Midwifery: Childbirth in England, 1660-1770 (Cambridge: Harvard, 1995), pp. 97-98, 127-128.

[2] R. D. French, Antivivisection and Medical Science in Victorian Society (Princeton:  Princeton University Press, 1975), p. 411.

[3] J. P. Baker, “The Incubator Controversy: Pediatricians and the Origins of Premature Infant Technology in the United States, 1890 to 1910,” Pediatrics, 87:654-662, 1991.

[4] E. H. Thomson, Harvey Cushing: Surgeon, Author, Artist (NY: Schuman, 1950), pp. 244-45.

[5] G. G. Stephens, The Intellectual Basis of Family Practice (Kansas City: Winter, 1982), pp. 62, 56, 83-85, 135-39.

[6] Stephens, Intellectual Basis of Family Practice, pp. 84, 191, 64, 39, 28.

[7] E.g., Stephens, Intellectual Basis of Family Practice, pp. 96, 194.  Cf. his comment on the American College of Surgeon’s effort to keep FPs out of the hospital: “There are issues of political hegemony masquerading as quality of patient care, medicolegal issues disguised as professional qualifications, and economic wolves in the sheepskins of guardians of the public safety” (p. 69).

[8] Stephens, Intellectual Basis of Family Practice, pp. 23, 38, 22.  In 1978, he spoke of the incursion of family practice  into the medical school curriculum of the early 70s as an assault on an entrenched power base:  “The medical education establishment has proved to be a tough opponent, with weapons we never dreamed of. . . .We had to deal with strong emotions, hostility, anger, humiliation. Our very existence was a judgment on the schools, much in the same way that civil rights demonstrators were a judgment on the establishment.  We identified ourselves with all the natural critics of the schools – students, underserved segments of the public, and their elected representatives – to bring pressure to bear on the schools to create academic units devoted to family practice” (pp. 184, 187).

[9] Stephens, Intellectual Basis of Family Practice, pp. 94, 105, 120-23, 192.

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“Doctor’s Office . . .”

Posted on June 29, 2012 | Leave a comment

Looking for a new primary care physician some time back, I received a referral from one of my specialists and called the office.  “Doctor’s Office . . .”   Thus began my nonconversation with the office receptionist.  We never progressed beyond the generic opening, as the receptionist was inarticulate, insensitive, unable to answer basic questions in a direct, professional manner, and dismally unable, after repeated attempts, to pronounce my three-syllable name.  When I asked directly whether the doctor was accepting new patients, the receptionist groped for a reply, which eventually took the form of “well, yes, sometimes, under certain circumstances, it all depends, but it would be a long time before you could see her.”  When I suggested that the first order of business was to determine whether or not the practice accepted my health insurance, the receptionist, audibly discomfited, replied that someone else would have to call me back to discuss insurance.

After the receptionist mangled my name four times trying to take down a message for another staff member, with blood pressure rising and anger management kicking in, I decided I had had enough.  I injected through her Darwinian approach to name pronunciation – keep trying variants until one of them elicits the adaptive “that’s it!” — that I wanted no part of a practice that made her the point of patient contact and hung up.

Now a brief  letter from a former patient to my father, William Stepansky, at the time of his retirement in 1990 after 40 years of family medicine:  “One only has to sit in the waiting area for a short while to see the care and respect shown to each and every patient by yourself and your staff.”  And this from another former patient on the occasion of his 80th birthday in 2002:

“I heard that you are celebrating a special birthday – your 80th.  I wanted to send a note to a very special person to wish you a happy birthday and hope that this finds you and Mrs. Stepansky in good health.  We continue to see your son, David, as our primary doctor and are so glad that we stayed with him.  He is as nice as you are.  I’m sure you know that the entire practice changed.  I have to admit that I really miss the days of you in your other office with Shirley [the receptionist] and Connie [the nurse].  I have fond memories of bringing the children in and knowing that they were getting great care and attention.”[1]

Here in microcosm is one aspect of the devolution of American primary care over the past half century.  Between my own upset and the nostalgia of my father’s former patient, there is the burgeoning of practice management, which is simply a euphemism for the commercialization of medicine.  There is a small literature on the division of labor that follows commercialization, including articles on the role of new-style, techno-savvy office managers with business backgrounds.  But there is nothing on the role of phone receptionists save two articles concerned with practice efficiency:  one provides the reader with seven “never-fail strategies” for saving time and avoiding phone tag; the other enjoins receptionists to enforce “practice rules” in managing patient demand for appointments.[2]  Neither has anything to do, even tangentially, with the psychological role of the receptionist as the modulator of stress and gateway to the practice.

To be sure, the phone receptionist is low man or woman on the staff totem pole.  But these people have presumably been trained to do a job.  My earlier experience left me befuddled both about what they are trained to do and, equally important, how they are trained to be.  If a receptionist cannot tell a prospective patient courteously and professionally (a) whether or not the practice is accepting new patients; (b) whether or not the practice accepts specific insurance plans; and (c) whether or not the doctor grants appointments to  prospective patients who wish to introduce themselves, then what exactly are they being trained to do?

There should be a literature on the interpersonal and tension-regulatory aspects of receptionist phone talk.  Let me initiate it here.  People – especially prospective patients unknown to staff – typically call the doctor with some degree of stress, even trepidation.  It is important to reassure the prospective patient that the doctor(s) is a competent and caring provider who has surrounded him- or herself with adjunct staff who share his or her values and welcome patient queries.  There is a world of connotative difference between answering the phone with “Doctor’s office,” “Doctor Jones’s office,” “Doctor Jones’s office; Marge speaking,” and “Good morning, Doctor Jones’s office; Marge speaking.”  The differences concern the attitudinal and affective signals that are embedded in all interpersonal transactions, even a simple phone query.  Each of the aforementioned options has a different interpersonal valence; each, to borrow the terminology of J. L. Austin, the author of speech act theory, has its own perlocutionary effect.  Each, that is, makes the recipient of the utterance think and feel and possibly act a certain way apart from the dry content of the communication.[3]

“Doctor’s office” is generic, impersonal, and blatantly commercial; it suggests that the doctor is simply a member of a class of faceless providers whose services comfortably nestle within a business model.   “Doctor Jones’s office” at least personalizes the business setting to the extent of identifying a particular doctor who provides the services.  Whether she is warm and caring, whether she likes her work, and whether she is happy (or simply willing) to meet and take on new patients – these things remain to be determined.  But at least the prospective patient’s intent of seeing one particular doctor (or becoming part of one particular practice) and not merely a recipient of generic doctoring services is acknowledged.

“Doctor Jones’s office; Marge speaking” is a much more humanizing variant.  The prospective patient not only receives confirmation that he has sought out one particular doctor (or practice), but also feels that his reaching out has elicited a human response, that his query has landed him in a human community of providers.  It is not only that Dr. Jones is one doctor among many, but also that she has among her employees a person comfortable enough in her role to identify herself by name and thereby invite the caller to so identify her – even if he is unknown to her and to the doctor.  The two simple words “Marge speaking” establish a bond, which may or may not outlast the initial communication.  But for the duration of the phone transaction, at least, “Marge speaking” holds out the promise of what Mary Ainsworth and the legions of attachment researchers who followed her term a “secure attachment.”[4] Prefacing the communication with “Good morning” or “Good afternoon” amplifies the personal connection through simple conviviality, the notion that this receptionist may be a friendly person standing in for a genuinely friendly provider.

Of course, even “Good morning, Marge speaking” is a promissory note; it rewards the prospective patient for taking the first step and encourages him to take a second, which may or may not prove satisfactory. If “Marge” cannot answer reasonable questions (“Is the doctor a board-certified internist”  “Is the doctor taking new patients?”) in a courteous, professional manner, the promissory note may come to naught.  On the other hand, the more knowledgeable and/or friendly Marge is, the greater the invitation to a preliminary attachment.

Doctors are always free to strengthen the invitation personally, though few have the time or inclination to do so.  My internist brother, David Stepansky, told me that when his group practice consolidated offices and replaced the familiar staff that had worked with our father for many years, patient unhappiness at losing the comfortable familiarity of well-liked receptionists was keen and spurred him to action.   He prevailed on the office manager to add his personal voicemail to the list of phone options offered to patients who called the practice.  Patients unhappy with the new system and personnel could hear his voice and then leave a message that he himself would listen to.  Despite the initial concern of the office manager, he continued with this arrangement for many years and never found it taxing.  His patients, our father’s former patients, seemed genuinely appreciative of the personal touch and, as a result, never abused the privilege of leaving messages for him.  The mere knowledge that they could, if necessary, hear his voice and leave a message for him successfully bridged the transition to a new location and a new staff.

Physicians should impress on their phone receptionists that they not only make appointments but provide new patients with their initial (and perhaps durable) sense of the physician and the staff.  Phone receptionists should understand that patients – especially new patients – are not merely consumers buying a service, but individuals who may be, variously, vulnerable, anxious, and/or in pain.  There is a gravity, however subliminal, in that first phone call and in those first words offered to the would-be patient.  And let there be no doubt:  Many patients still cling to the notion that a medical practice – especially a primary care practice – should be, per Winnicott, a “holding environment,” if only in the minimalist sense that the leap to scheduling an appointment will land one in good and even caring hands.

[1] The first quoted passage is reprinted in P. E. Stepansky, The Last Family Doctor: Remembering My Father’s Medicine (Keynote, 2011), p. 123. The second passage is not in the book and is among my father’s personal effects.

[2] L. Macmillan & M. Pringle, “Practice managers and practice management,” BMJ, 304:1672-1674, 1992; L . S. Hill, “Telephone techniques and etiquette: a medical practice staff training tool,” J. Med. Pract. Manage., 3:166-170, 2007; M. Gallagher, et al.,  “Managing patient demand: a qualitative study of appointment making in general practice,” Brit. J. Gen. Pract., 51:280-285, 2001.

[3] See J. L. Austin,  How To Do Things with Words (Cambridge: Harvard University Press, 1962) and the work of his student, J. R. Searle, Speech Acts:  An Essay in the Philosophy of Language. (Cambridge: Cambridge University Press, 1970).

[4] Ainsworth’s typology of mother-infant attachment states grew out of her observational research on mother-infant pairs in Uganda, gathered in her Infancy in Uganda (Baltimore: Johns Hopkins, 1967).  On the nature of secure attachments, see especially J. Bowlby, A Secure Base: Parent-Child Attachment and Healthy Human Development(New York: Basic Books, 1988) and  I. Bretherton, “The origins of attachment theory: John Bowlby and Mary Ainsworth,” Develop. Psychol., 28:759-775, 1992.

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Empathy, Psychotherapy, Medicine

Posted on March 27, 2012 | Leave a comment

What passes for psychoanalysis in America these days is a far cry from the psychoanalysis Freud devised in the early years of the last century.  A sea change began in the 1970s, when Heinz Kohut, a Vienna-born and Chicago-based psychoanalyst, developed what he termed “psychoanalytic self psychology.”  At the core of Kohut’s theorizing was the replacement of one kind of psychoanalytic method with another.   Freud’s method – which Freud himself employed imperfectly at best – revolved around the coolly self-possessed analyst, who, with surgeon-like detachment, processed the patient’s free associations with “evenly hovering attention” and offered back pearls of interpretive wisdom.  The analyst’s neutrality – his unwillingness to become a “real” person who related to the patient in conventionally sympathetic and supportive ways – rendered him a “blank screen” that elicited the same feelings of love and desire – and also of fear, envy, resentment, and hatred – as the mother and father of the patient’s early life.  These feelings clustered into what Freud termed the positive and negative transferences.

Kohut, however, found this traditional psychoanalytic method fraught with peril for patients burdened less with Freudian-type neurotic conflicts than with psychological deficits of a preoedipal nature.  These deficits gained expression in more primitive types of psychopathology, especially in what he famously termed  “narcissistic personality disorder.”  For these patients – and eventually, in Kohut’s mind, for all patients – the detached, emotionally unresponsive analyst simply compounded the feelings of rejection and lack of self-worth that brought the patient to treatment.  He proffered in its place a kinder, gentler psychoanalytic method in which the analyst was content to listen to the patient for extended periods of time, to affirm and mirror back what the patient was saying and feeling, and over time to forge an empathic bond from which interpretations would arise.

Following Kohut, empathy has been widely construed as an aspect, or at least  a precondition, of talking therapy.  For self psychologists and others who draw on Kohut’s insights, the ability to sympathize with the patient has given way to a higher-order ability to feel what the patient is feeling, to “feel with” the patient from the inside out.  And this process of empathic immersion, in turn, permits the therapist to “observe” the patient’s psychological interior and to comprehend the patient’s “complex mental states.”  For Kohut, the core of psychoanalysis, indeed of depth-psychology in general, was employment of this “empathic mode of observation,” an evocative but semantically questionable turn of phrase, given the visual referent of “observe,” which comes from the Latin observare (to watch over, to guard).   More counterintuitively still, he sought to cloak the empathic listening posture in scientific objectivism.  His writings refer over and over to the “data” that analysts acquire through their deployment of “scientific” empathy, i.e., through their empathic listening instrument.

I was Heinz Kohut’s personal editor from 1978 until his death in the fall of 1981.  Shortly after his death, I was given a dictated transcript from which I prepared his final book, How Does Analysis Cure?, for posthumous publication.  Throughout the 80s and into the 90s, I served as editor to many senior self psychologists, helping them frame their arguments about empathy and psychoanalytic method  and write their papers and books.  I grasped then, as I do now, the heuristic value of a stress on therapeutic empathy as a counterpoise to traditional notions of analytic neutrality, which gained expression, especially in the decades following World War II, in popular stereotypes of the tranquilly “analytic” analyst whose caring instincts were no match for his or her devotion to Freud’s rigid method.

The comparative perspective tempers bemusement at what would otherwise be a colossal conceit:  that psychoanalytic psychotherapists alone, by virtue of their training and work, acquire the ability to empathize with their patients.  I have yet to read an article or book that persuaded me that  empathy can be taught, or that the yield of therapeutic empathy is the apprehension of “complex psychological states” that are analogous to the “data” gathered and analyzed by bench scientists (Kohut’s own analogy).

I do believe that empathy can be cultivated, but only in those who are adequately empathic to begin with.  In medical, psychiatric, and psychotherapy training, one can present students with instances of patients clinically misunderstood and then suggest how one might have understood them better, i.e., more empathically.  Being exhorted by teachers to bracket one’s personal biases and predispositions in order to “hear” the patient with less adulterated ears is no doubt a good thing.  But it  assumes trainees can develop a psychological sensibility through force of injunction, which runs something like:  “Stop listening through the filter of your personal biases and theoretical preconceptions!  Listen to what the patient herself  is saying in her voice!  Utilize what you understand of yourself, viz., the hard-won fruits of your own psychotherapy (or training analysis), to put yourself in her place!  Make trial identifications so that her story and her predicament resonate with aspects of your story and your predicament; this will help you feel your way into her inner world.”

At a less hortatory level, one can provide trainees with teachers and supervisors who are sensitive, receptive listeners themselves and thus “skilled” at what self psychologists like to refer to as “empathic attunement.”  When students listen to such instructors and perhaps observe them working with patients, they may learn to appreciate the importance of empathic listening and then, in their own work, reflect more ongoingly on what their patients are saying and on how they are hearing them say it.  They acquire the ability for “reflection-in-action,” which Donald Schön, in two underappreciated books of the 1980s, made central to the work of “reflective professionals” in a number of fields, psychotherapy among them.[1]  To a certain extent, systematic reflection in the service of empathy may help therapists be more empathic in general.

But then the same may be said of any person who undergoes a transformative life experience (even, say, a successful therapy) in which he learns to understand differently – and less tendentiously – parents, siblings, spouses, children, friends, colleagues, and the like.  Life-changing events  — fighting in  wars, losing loved ones, being victimized by natural disasters, living in third-world countries, providing aid to trauma victims – cause some people to recalibrate values and priorities and adopt new goals.  Such decentering can mobilize an empathic sensibility, so that individuals return to their everyday worlds with less self-centered ways of perceiving and being with others.

There is nothing privileged about psychotherapy training in acquiring an empathic sensibility.  I once asked a senior self psychologist what exactly differentiated psychoanalytic empathy from empathy in its everyday sense.  He thought for a moment and replied that in psychoanalysis, one deploys “sustained” empathy.  What, pray tell, does this mean, beyond denoting the fact that psychoanalysts, whether or not empathic, listen to patients for a living, and the units of such listening are typically 45-minute sessions.  Maybe he simply meant that, in the nature of things, analysts must try to listen empathically for longer periods of time, and prolongation  conduces to empathic competence.

Well, anything’s possible, I suppose.  But the fact remains that some people are born empathizers and others not.  Over the course of a 27-year career in psychoanalytic and psychiatric publishing, I worked with a great many analysts and therapists who struck me as unempathic, sometimes stunningly unempathic.  And those who struck me as empathic were not aligned with any particular school of thought, certainly not one that, like self psychology, privileges empathy.

Nor is it self-evident  that the empathy-promoting circumstances of psychotherapy are greater than the circumstances faced day-in and day-out by any number of physicians. Consider adult and pediatric oncologists, transplant surgeons, and internists and gerontologists who specialize in palliative care.  These physicians deal with patients (and their parents and children) in extremis; surely their work should elicit “sustained empathy,” assuming they begin with an empathic endowment strong enough to cordon off the miasma of uncertainty, dread, and imminent loss that envelops them on daily rounds.  Consider at the other end of the medical spectrum those remaining family doctors  who, typically in rural settings, provide intergenerational, multispecialty care and continue to treat patients in their homes .  The nature of their work makes it difficult for them not to observe and comprehend their patients’ complex biopsychosocial states; there are extraordinary empathizers among them.

When it comes to techniques for heightening empathy, physicians have certain advantages over psychotherapists, since their patients present with bodily symptoms and receive bodily (often procedural) interventions, both of which have a mimetic potential beyond “listening” one’s way into another’s inner world.  There is more to say about the grounds of medical empathy, but let me close here with a concrete illustration of such empathy in the making.

William Stevenson Baer graduated from Johns Hopkins Medical College in 1898 and stayed on at Hopkins as an intern and then assistant resident in William Halsted’s dauntingly rigorous surgical training program.  In June, 1900, at the suggestion of Baer’s immediate supervisor, Harvey Cushing, Halsted asked Baer to establish an orthopedic outpatient clinic at Hopkins the following fall.  With no grounding in the specialty, Baer readied himself for his new task by spending the ensuing summer at the orthopedic services of Massachusetts General Hospital and the Boston Children’s Hospital.  At both institutions, many children in the orthopedic ward had to wear plaster casts throughout the hot summer months.  On arrival, Baer’s first order of business was to alter his life circumstances in order to promote empathy with, and win the trust of, these young patients.  To wit, he had himself fitted for a body cast that he wore the entire summer.  His sole object, according to his Hopkins colleague Samuel Crowe, was “to gain the children’s confidence by showing them that he too was enduring the same discomfort.”[2]

Psychotherapists are generally satisfied that empathy can be acquired in the manner of a thought experiment.  “Bracket your biases and assumptions,” they admonish, “empty yourself of ‘content,’ and then, through a process of imaginative identification, you will be able to hear what your patient is saying and feel what she is feeling.”  Baer’s example reminds us that illness and treatment are first and foremost bodily experiences, and that “feeling into another” – the literal meaning of the German Einfühlung, which we translate as “empathy” – does not begin and end with concordant memories amplified by psychological imagination.[3]  In medicine, there is an irremediably visceral dimension to empathy, and we shall consider it further in the next posting.

[1] Donald A. Schön, The Reflective Practitioner: How Professionals Think in Action (NY: Basic Books, 1983); Donald A. Schön, Educating the Reflective Practitioner (San Francisco: Jossey-Bass, 1987).

[2] Samuel James Crowe, Halsted of Johns Hopkins: The Man and His Men (Springfield, IL: Thomas, 1957), pp. 130-31.

[3] The imaginative  component of empathy, which is more relevant to its function in psychotherapy than in medicine, is especially stressed by Alfred Margulies, “Toward Empathy: The Uses of Wonder,” American Journal of Psychiatry, 141:1025-1033, 1984.

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My Doctor, My Friend

Posted on January 10, 2012 | Leave a comment

In a piece several months ago  in the Boston Globe, “Blurred Boundaries Between Doctor and Patient,” columnist and primary care internist Suzanne Koven writes movingly of her patient Emma, whom Koven befriended over the last 15 years of Emma’s life.  “Emma and I met frequently to gossip, talk about books and politics, and trade stories about our lives,” she remarks.  “She came to my house for dinner several times, and my husband and kids joined me at her 90th birthday party.  When, at 92, Emma moved reluctantly into a nursing home, I brought her the bagels and lox she craved – rich, salty treats her doctor had long discouraged her from eating.  Here’s the funny part:  I was that doctor.”

Koven writes perceptively of her initial concern with doctor-patient boundaries (heightened, she admits, by her status as “a young female physician”), her ill-fated efforts to maintain her early ideal of professional detachment, and, as with Emma, her eventual understanding that the roles of physician and friend could be for the most part “mutually reinforcing.”

As a historian of medicine interested in the doctor-patient relationship, I reacted to Koven’s piece appreciatively but, as I confessed to her, sadly.  For her initial concern with “blurred boundaries” and her realization after years of practice about the compatibility of friendship with primary medical care only underscore the fragmented and depersonalized world of contemporary medicine, primary care included.  By this, I mean that the quality of intimacy that grows out of most doctoring has become so shallow that we are led to scrutinize doctor-patient “friendship” as a problematic (Is it good?  Is it bad?  Should there be limits to it?) and celebrate instances of such friendship as signal achievements.   Psychoanalysts, be it noted, have been pondering these questions in their literature for decades, but they at least have the excuse of their method, which centrally implicates the analysis and resolution of transference with patients who tend to become inordinately dependent on them.

My father, William Stepansky, like many of the WWII generation, befriended his patients, but he befriended them as their doctor.  That is, he understood his medicine to include human provisions of a loving and Hippocratic sort.  Friendly two-way extramedical queries about his family, contact at community events, attendance at local weddings and other receptions – these were not boundary-testing land mines but aspects of community-embedded caregiving.  But here’s the rub:  My father befriended his patients as their doctor; his friendship was simply the caring dimension of his care-giving.  What, after all, did he have in common with the vast majority of his patients?  They were Protestants and Catholics, members of the Rotary and Kiwanis Clubs who attended the local churches and coached little league baseball and Pop Warner football.  He was an intellectual East European Jew, a serious lifelong student of the violin whose leisure time was spent practicing, reading medical journals, and tending to his lawn.

And yet to his patients, he was always a special friend, though he himself would admit nothing special about it:  his friendship  was simply the human expression of his calling.  He did not (to my knowledge) bring anyone bagels and lox or pay visits to chat about books or politics, but he provided treatment (including ongoing supportive psychotherapy) at no charge, accepted payment in kind, and visited patients in their homes when they became too elderly or infirm to come to the office.  Other routine “friendly” gestures included charging for a single visit when a mother brought a brood of sick children to the office during the cold season.  And when elderly patients became terminal, they did not have to ask – he simply began visiting them regularly in their homes to provide what comfort he could and to let them know they were on his mind.

When he announced his impending retirement to his patients in the fall of 1990, his farewell letter began “Dear Friend” and then expressed regret at “leaving many patients with whom I have shared significant life experience from which many long-term friendships have evolved.”  “It has been a privilege to serve as your physician for these many years,” he concluded.  “Your confidence and friendship have meant much to me.”  When, in my research for The Last Family Doctor, I sifted through the bags of cards and letters that followed this announcement, I was struck by the number of patients who not only reciprocated my father’s sentiment but summoned the words to convey deep gratitude for the gift of their doctor’s friendship.

In our own era of fragmented multispecialty care, hemmed in by patient rights, defensive medicine, and concerns about boundary violations, it is far from easy for a physician to “friend” a patient as physician, to be and remain a physician-friend.  Furthermore, physicians now wrestle with the ethical implications of “friending” in ways that are increasingly dissociated from a medical identity.  Many choose to forego professional distance at the close of a work day.  No less than the rest of us, physicians seek multicolored self states woven of myriad connective threads; no less than the rest of us, they are the Children of Facebook.

But there is a downside to this diffusion of connective energy.  When, as a society, we construe the friendship of doctors as extramedical, when we pull it into the arena of depersonalized connecting fostered by social media, we risk marginalizing the deeper kind of friendship associated with the medical calling: the physician’s nurturing love of the patient.   And we lose sight of the fact that, until the final two decades of the 19th century,  when advances in cellular biology, experimental physiology, bacteriology, and pharmacology ushered in an era of specific remedies for specific ailments, most effective doctoring – excluding only a limited number of surgeries – amounted to little more than just such friendship, such comfortable and comforting “friending” of sick and suffering people.

And this takes us back to Suzanne Koven, who imputes the “austere façade” of her medical youth to those imposing 19th-century role models “whose oil portraits lined the walls of the hospital [MGH] in which I did my medical training.”  Among the grim visages that stared down from on high was that of the illustrious James Jackson, Sr., who brought Jenner’s technique of smallpox inoculation to the shores of Boston in 1800, became Harvard’s second Hersey Professor of the Theory and Practice of Medicine in 1812, and was a driving force in the founding of MGH, which opened its doors in 1821.  Koven cites a passage from the second of Jackson’s Letters to a Young Physician (1855) in which he urges his young colleague to “abstain from all levity” and “never exact attention to himself.”

But why should absence of levity and focal concern with the patient be tantamount to indifference, coolness, the withholding of physicianly friendship?  Was Jackson really so forbidding a role model?  Composing his Letters in the wake of the cholera epidemic of 1848, when “regular” remedies such as bleeding and purging proved futile and only heightened the suffering of  thousands, Jackson cautioned modesty when it came to therapeutic pretensions.  He abjured the use of drugs “as much as possible,” and added that “the true physician takes care of his patient without claiming to control the disease in all cases.” Indeed he sought to restore “cure” to its original Latin meaning, to curare, the sense in which “to cure meant to take care.”  “The physician,” he instructed his protégé,

“may do very much for the welfare of the sick, more than others can do, although he does not, even in the major part of cases, undertake to control and overcome the disease by art.  It was with these views that I never reported any patients cured at our hospital.  Those who recovered their health before they left the house were reported as well, not implying that they were made so by the active treatment they had received there.  But it was to be understood that all patients received in that house were to be cured, that is, taken care of” [Letters to a Young Physician, p. 16, Jackson’s emphasis].

And then he moved on to the narrowing of vision that safeguarded the physician’s caring values, his cura:

“You must not mistake me.  We are not called upon to forget ourselves in our regard for others.  We do not engage in practice merely from philanthropy.  We are justified in looking for both profit and honor, if we give our best services to our patients; only we must not be thinking of these when at the bedside.  There the welfare of the sick must occupy us entirely” [Letters to a Young Physician, pp. 22-23].

Koven sees the Hippocratic commitment that lies beneath Jackson’s stern glance and, with the benefit of hindsight, links it to her friendship with Emma. “As mutually affectionate as our friendship was,” she concludes, “her health and comfort were always its purpose.”  Indeed.  For my father and any number of caring generalists, friendship was prerequisite to clinical knowing and foundational to clinical caring.  It was not extramural, not reserved for special patients, but a way of being with all patients.  And this friendship for his patients, orbiting around a sensibility of cura and a wide range of procedural activities, was not a heavy thing, leaden with solemnity.  It was musical.  It danced.

In the early 60s, he returns from a nursing home where he has just visited a convalescing patient.  I am his travelling companion during afternoon house calls, and I greet him on his return to the car.  He looks at me and with a sly grin remarks that he has just added “medicinal scotch” to the regimen of this elderly gentlemen, who sorely missed his liquor and was certain a little imbibing would move his rehab right along.  It was a warmly caring gesture worthy of Osler, that lover of humanity, student of the classics, and inveterate practical joker.  And a generation before Osler, the elder Jackson would have smiled.  Immediately after cautioning the young physician to “abstain from all levity,” he added: “He should, indeed, be cheerful, and, under proper circumstances, he may indulge in vivacity and in humor, if he has any.  But all this should be done with reference to the actual state of feeling of the patient and of his friends.”  Just so.

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Hail the House Call

Posted on December 22, 2011 | Leave a comment

It is now 35 years since George Engel, an internist at the University of Rochester Medical School, formulated his biopsychosocial model of medicine (Science, 196:129, 1977).  Concerned with the reductionism and fragmentation inherent in scientifically guided specialist care, Engel called on his colleagues to locate biomedical interventions on a larger biopsychosocial canvas.  Drawing on the version of general systems theory popular in the 1970s, Engel argued that clinical assessment properly embraced a hierarchy of discrete biological, personal, and transpersonal levels, any combination of which might enter into the meaning of illness, whether acute or chronic.  Even in ostensibly biomedical conditions such as diabetes, cancer, and heart disease, Engel held, it was not simply deranged cells and dysfunctional organs that accounted for pathophysiology.  His model made a strong knowledge-related (i.e., epistemic) claim:  that hierarchically ordered layers of intra- and interpersonal stressors were causal factors in disease as it expressed itself  in this or that person.  It followed for Engel that personality structure; adaptive resources and “ego strength”; psychodynamic conflicts; two-person conflicts; family-related conflicts; conflicts in the workplace – these factors, in various combinations, entered into the scientific understanding of disease.

In devising the biopsychosocial model, Engels was influenced by the psychoanalysis of his day.  It is for this reason that biopsychosocial medicine is typically, and, I believe, erroneously, identified with the kind of “psychosomatic medicine” that analysis gave birth to in the quarter century following World War II (Psychosom. Med., 63:335, 2001). More generally still, it is conflated with psychosocial skills, especially as they enter into doctor-patient communication.  Because Engel’s model is not an algorithm for determining which levels of the patient “system” are implicated in this or that instance of illness, it has been criticized over the years for failing to guide clinical action, including the ordering of therapeutic goals (Comp. Psychiatry, 31:185, 1990).  Self-evidently, the model has proven very difficult to teach (Acad. Psychiatry, 28:88, 2004) and equally difficult to integrate into the conventional medical school curriculum (Psychosom. Med., 63:335, 2001).

These findings are hardly surprising.  It is difficult to teach doctors-in-training how to apply a biopsychosocial model when real-world doctoring rarely places them in regular contact with the transmedical “systems” invoked by the model.  This was not always the case.  Consider the house call, that site of biopsychosocial consciousness-raising throughout the 19th  and well into the 20th century.  It was in the home of the patient, after all, that the physician could actually experience the psychosocial “systems” that entered into the patient’s illness:  the patient’s personality, but also the patient as spouse, parent, sibling, son or daughter, all apprehended within the dynamics of a living family system.  And of course there was the home environment itself, a psychosocial container of medically salient information.  Wise clinicians of the early 20th century did not need the assistance of a biopsychosocial model to understand the role of the house call in cultivating the physician’s biopsychosocial sensibility.  Here is Harvard’s Francis Peabody in “The Care of the Patient” (1927):

“When the general practitioner goes into the home of a patient, he may know the whole background of the family life from past experience; but even when he comes as a stranger he has every opportunity to find out what manner of man his patient is, and what kind of circumstances make his life.  He gets a hint of financial anxiety or of domestic incompatibility; he may find himself confronted by a querulous, exacting, self-centered patient, or by a gentle invalid overawed by a dominating family; and as he appreciates how these circumstances are reacting on the patient he dispenses sympathy, encouragement or discipline.  What is spoken of as a ‘clinical picture’ is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears” [JAMA, 88:877, 1927].

Three decades after Peabody’s lecture, I began riding shotgun when my father, William Stepansky, made his daily round of house calls in rural southeastern Pennsylvania.  Sometimes, especially with the older patients he visited regularly, I came into the house with him, where I was warmly welcomed, often with a glass of milk and home baked treats, as the doctor’s son and travelling companion.  From my time on the road, I learned how my father’s clinical gaze met and absorbed the anxious gazes of family members.  It became clear, over time, that his medical obligation was not only to the patient, but to the patient-as-member-of-a-family and to the family-as-medically-relevant-part-of-the-patient.  In a lecture to the junior class of his alma mater, Jefferson Medical college, in 1965, he made this very point in differentiating the scope of the family physician’s clinical gaze from that of the pediatrician and internist.  Unlike the latter, he observed, the family physician’s interventions occurred “within the special domain of the family,” and his treatment of the patient had to be continuously attentive to the “needs of family as an entity.”  It was for this reason, he added, that “family medicine must teach more than the arithmetic sum of the contents of specialties” (my father’s emphasis).  Here, in the mid-60s, my father posited a medical-interventional substratum to what would emerge a decade or so later, in the realm of psychotherapy, as family systems theory and “structural family therapy.” And then, 12 years before Engels came on the scene, he offered his conception of  “a solid intellectual approach to medicine”:

“To me this means relating the effects of the body systems one upon the other in health and disease through knowledge of the basic sciences – i.e., biochemistry and physiology – through some understanding of the social and environmental stresses on the patient, and finally through insight into the psychological influences of personality structure as it affects health and disease.”

Of course, physicians long before my father and long before Francis Peabody understood that medical treatment of the individual might entail interventions with transpersonal “systems.”  Witness the Victorian physicians of well-off American families of the 1870s and 1880s described by the historian Nancy Theriot (Amer. Studies, 26:69, 1990; Signs, 19:1, 1993; J. Hist. Behav. Sci., 37:349, 2001).  Making home visits to overwrought postpartum women in the throes of what was then termed “puerperal insanity” – we have only the far less evocative “postpartum depression” – these knowing family physicians dissuaded their patients from the drastic surgical interventions available to them (such as ovariotomy).  They recommended instead a change in the family “system” to accommodate the parturient’s urgent need for “time out” from the burdens of household management, childrearing, and husband-pleasing, to which care of a newborn was now superadded.  Is it any wonder that the matrons of these well-run Victorian households became “insane,” and that their insanity took the form, inter alia, of vile language, refusal to dress appropriately, refusal to resume housework, indifference to their children’s daily needs, and even – horribile dictu –  refusal to hold their newborns?  And yet these same women, flouting Victorian conventions with postpartum abandon, often returned to bourgeois sanity after the family physician, with the weight of medical authority, simply prescribed a daily period of solitude when the new mother, perhaps sitting alone in the family garden, was not to be disturbed – not by anyone.  Biopsychosocial intervention aimed at the family “system” was never so elegantly simple.

Interventions of this sort are hardly unknown among contemporary providers, some small percentage of whom continue to visit their patients in their homes.   Further, as one of my correspondents has reminded me, all family medicine residencies employ full-time behaviorists, usually psychologists, who help trainees develop a biopsychosocial model of care. But outside of these programs the biopsychosocial model remains where it has always been – on the fringe of a medical world of fragmented and technology-driven specialist care.  In this sense, it is no different than the house call, which lives on among some 4,000 physicians in the U.S. and through a very few university hospital-based “house call programs.”  But let there be no mistake:  these physicians and these programs are at the far margins of primary care.  When the American Academy of Family Physicians polled its active members in 2008 on the settings in which they saw patients, respondents from urban and rural regions alike reported an average of 0.6 house calls a week.  (My father, in the 50s and 60s, averaged 3-4 a day.)  If this figure represents the rate at which house call-making doctors make house calls, then it is fair to say that the house call has long since ceased to be an intrinsic – and intrinsically humanizing – dimension of primary care.  This is why I pay tribute to the Great American House Call.  It is a relic of an era when biopsychosocial medicine suffused general practice without the aid of a biopsychosocial model.

Addendum

Unbeknown to many, the healthcare reform bill passed by Congress in March, 2010 contains an “Independence at Home Act” that provides physicians with financial incentives to treat their oldest and sickest patients in their homes.  To wit, house call-making doctors will share in cost saving if they can “prove” their in-home care reduced hospital use and left their patients satisfied.   So much for the scientific bona fides of biopsychosocial medicine.  It’s about the money, stupid.

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Primary Care/Primarily Caring (IV)

Posted on December 8, 2011 | Leave a comment

If it is little known in medical circles that World War II “made” American psychiatry, it is even less well known that the war made psychiatry an integral part of general medicine in the postwar decades.  Under the leadership of the psychoanalyst (and as of the war, Brigadier General) William Menninger, Director of Neuropsychiatry in the Office of the Surgeon General, psychoanalytic psychiatry guided the armed forces in tending to soldiers who succumbed to combat fatigue, aka war neuroses, and getting some 60% of them back to their units in record time.   But it did so less because of the relatively small number of trained psychiatrists available to the armed forces than through the efforts of the General Medical Officers (GMOs), the psychiatric foot soldiers of the war.  These GPs, with at most three months of psychiatric training under military auspices, made up 1,600 of the Army’s  2,400-member neuropsychiatry service (Am. J. Psychiatry., 103:580, 1946).

The GPs carried the psychiatric load, and by all accounts they did a remarkable job.  Of course, it was the psychoanalytic brass – William and Karl Menninger, Roy Grinker, John Appel, Henry Brosin, Franklin Ebaugh, and others – who wrote the papers and books celebrating psychiatry’s service to the nation at war.  But they all knew that the GPs were the real heroes.  John Milne Murray, the Army Air Force’s chief neuropsychiatrist, lauded them as the “junior psychiatrists” whose training had been entirely “on the job” and whose ranks were destined to swell under the VA program of postwar psychiatric care (Am. J. Psychiatry, 103:594, 1947).

The splendid work of the GMOs encouraged expectations that they would help shoulder the nation’s psychiatric burden after the war. The psychiatrist-psychoanalyst Roy Grinker, coauthor with John Spiegel of the war’s enduring  contribution to military psychiatry, Men Under Stress (1945), was under no illusion about the ability of trained psychiatrists to cope with the influx of returning GIs, a great many “angry, regressed, anxiety-ridden, dependent men” among them (Men Under Stress, p. 450).  “We shall never have enough psychiatrists to treat all the psychosomatic problems,” he remarked in 1946, when the American Psychiatric Association boasted all of 4,000 members.  And he continued:  “Until sufficient psychiatrists are produced and more internists and practitioners make time available for the treatment of psychosomatic syndromes, we must use heroic shortcuts in therapy which can be applied by all medical men with little special training” (Psychosom. Med., 9:100-101, 1947).

Grinker was seconded by none other than William Menninger, who remarked after the war that “the majority of minor psychiatry will be practiced by the general physician and the specialists in other fields” (Am. J. Psychiatry, 103:584, 1947).  As to the ability of stateside GPs to manage the “neurotic” veterans, Lauren Smith, Psychiatrist-in-Chief to the Institute of Pennsylvania Hospital prior to assuming his wartime duties, offered a vote of confidence two years earlier.  The majority of returning veterans would “present” with psychoneuroses rather than major psychiatric illness, and most of them “can be treated successfully by the physician in general practice if he is practical in being sympathetic and understanding, especially if his knowledge of psychiatric concepts is improved and formalized by even a minimum of reading in today’s psychiatric literature”  (JAMA, 129:192, 1945).

These appraisals, enlarged by the Freudian sensibility that saturated popular American culture in the postwar years, led to the psychiatrization of American general practice in the 1950s and 60s.  Just as the GMOs had been the foot soldiers in the campaign to manage combat stress, so GPs of the postwar years were expected to lead the charge against the ever growing number of “functional illnesses” presented by their patients (JAMA, 152:1192, 1953; JAMA, 156:585, 1954).  Surely these patients were not all destined for the analyst’s couch.  And in truth they were usually better off in the hands of their GPs, a point underscored by Robert Needles in his address to the AMA’s Section on General Practice in June of 1954.  When it came to functional and nervous illnesses, Needles lectured, “The careful physician, using time, tact, and technical aids, and teaching the patient the signs and meanings of his symptoms, probably does the most satisfactory job” (JAMA, 156:586, 1954).

Many generalists of the time, my father, William Stepansky, among them, practiced psychiatry.  Indeed they viewed psychiatry, which in the late 40s, 50s, and 60s typically meant psychoanalytically informed psychotherapy, as intrinsic to their work.  My father counseled patients from the time he set out his shingle in 1953.  Well-read in the psychiatric literature of his time and additionally interested in psychopharmacology, he supplemented medical school and internship with basic and advanced-level graduate courses on psychodynamics in medical practice.  Appointed staff research clinician at McNeal Laboratories in 1959, he conducted and published  (Cur. Ther. Res. Clin. Exp., 2:144, 1960) clinical research on McNeal’s valmethamide, an early anti-anxiety agent.  Beginning in the 1960s, he attended case conferences at Norristown State Hospital (in exchange for which he gave his services, gratis, as a medical consultant).  And he participated in clinical drug trials as a member of the Psychopharmacology Research Unit of the University of Pennsylvania’s Department of Psychiatry, sharing authorship of several publications that came out of the unit.  In The Last Family Doctor, my tribute to him and his cohort of postwar GPs, I wrote:

“The constraints of my father’s practice make it impossible for him to provide more than supportive care, but it is expert support framed by deep psychodynamic understanding and no less valuable to his patients owing to the relative brevity of 30-minute ‘double’ sessions.  Saturday mornings and early afternoons, when his patients are not at work, are especially reserved for psychotherapy.  Often, as well , the last appointment on weekday evenings is given to a patient who needs to talk to him.  He counsels many married couples having difficulties.  Sometimes he sees the husband and wife individually; sometimes he seems them together in couples therapy.  He counsels the occasional alcoholic who comes to him.  He is there for whoever seeks his counsel, and a considerable amount of his counseling, I learn from [his nurse] Connie Fretz, is provided gratis.”

To be sure, this was family medicine of a different era.  Today primary care physicians (PCPs) lack the motivation, not to mention the time, to become frontline psychotherapists.  Nor would their credentialing organizations (or their accountants) look kindly on scheduling double-sessions for office psychotherapy and then billing the patient for a simple office visit.  The time constraints under which PCPs typically operate, the pressing need to maintain practice “flow” in a climate of regulation, third-party mediation, and bureaucratic excrescences of all sorts – these things make it more and more difficult for physicians to summon the patience to take in, much less to co-construct and/or psychotherapeutically reconfigure, their patients’ illness narratives.

But this is largely beside the point.  Contemporary primary care medicine, in lockstep with psychiatry, has veered away from psychodynamically informed history-taking and office psychotherapy altogether.  For PCPs and nonanalytic psychiatrists alike – and certainly there are exceptions – the postwar generation’s mandate to practice “minor psychiatry,” which included an array of supportive, psychoeducative, and psychodynamic interventions, has effectively shrunk to the simple act of prescribing psychotropic medication.

At most, PCPs may aspire to become, in the words of Howard Brody, “narrative physicians” able to empathize with their patients and embrace a “compassionate vulnerability” toward their suffering.  But even this has become a difficult feat.  Brody, a family physician and bioethicist, remarks that respectful attentiveness to the patient’s own story or “illness narrative” represents a sincere attempt “to develop over time into a certain sort of person – a healing sort of person – for whom the primary focus of attention is outward, toward the experience and suffering of the patient, and not inward, toward the physician’s own preconceived agenda” (Lit. & Med., 13:88, 1994; my emphasis).  The attempt is no less praiseworthy than the goal.  But where, pray tell, does the time come from?  The problem, or better, the problematic, has to do with the driven structure of contemporary primary care, which makes it harder and harder for physicians to enter into a world of open-ended storytelling that over time provides entry to the patient’s psychological and psychosocial worlds.

Whether or not most PCPs even want to know their patients in psychosocially (much less psychodynamically) salient ways is an open question.  Back in the early 90s, primary care educators recommended special training in “psychosocial skills” in an effort to remedy the disinclination of primary care residents to address the psychosocial aspects of medical care.  Survey research of the time showed that most residents not only devalued psychosocial care, but also doubted their competence to provide it (J. Gen. Int. Med., 7:26, 1992; Acad. Med., 69:48, 1994).

Perhaps things have improved a bit since then with the infusion of courses in the medical humanities into some medical school curricula and focal training in “patient and relationship-centered medicine” in certain residency programs.   But if narrative listening and relationship-centered practice are to be more than academic exercises, they must be undergirded by a clinical identity in which relational knowing is constitutive, not superadded in the manner of an elective.  Psychodynamic psychiatry was such a constituent in the general medicine that emerged after World War II.  If it has become largely irrelevant to contemporary primary care, what can take its place?  Are there other pathways through which PCPs, even within the structural constraints of contemporary practice, may enter into their patients’ stories?

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Posted in Family Doctors, Then & Now, General Practice, Medicine in WWII, Primary Care, Psychiatry in Medicine, War & Medicine

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Primary Care/Primarily Caring (III)

Posted on November 29, 2011 | Leave a comment

“The good physician knows his patients through and through, and his knowledge is bought dearly.  Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine.  One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”

– Francis W. Peabody, M.D., “The Care of the Patient” (1927)

Beginning in the 1980s, primary care educators, concerned that newly trained family physicians, freighted with technology and adrift in protocols, lacked people skills, resuscitated an expression coined by the British psychoanalyst Enid Balint in 1969.  They began promoting “patient-centered medicine,” which, according to Balint’s stunning insight, called on the physician to understand the patient “as a unique human being” (J. Roy. Coll. Gen. Practit., 17:269, 1969).  More recently, patient-centered medicine has evolved into “relationship-centered care” (or “patient and relationship-centered care” [PRCC]) that not only delineates  the relational matrix in which care is  provided but also extols the “moral value” of cultivating doctor-patient relationships that transcend the realm of the biomedical.  In language that could just as well come from a primer of relational psychotherapy, these educators enjoin clinicians to embrace the clinician-patient relationship as “the unique product of its participants and its context,” to “remain aware of their own emotions, reactions, and biases,” to move from detached concern to emotional engagement and empathy, and to embrace the reciprocal nature of doctor-patient interactions.  According to this latter, the clinical goal of restoring and maintaining health must still “allow[ing] a patient to have an impact on the clinician” in order “to honor that patient and his or her experience” (J. Gen. Int. Med., 21:S4, 2006).

Recent literature on relationship-centered care evinces an unsettling didacticism about the human dimension of effective doctoring.  It is as if medical students and residents not only fail to receive training in communication skills but fail equally to comprehend that medical practice will actually oblige them to comfort anxious and confused human beings.  So educators present them with “models” and “frameworks” for learning how to communicate effectively.  Painfully commonsensical “core skills” for delivering quality health care are enumerated over and over.  The creation and maintenance of an “effective” doctor-patient relationship becomes a “task” associated with a discrete skill set (e.g.,  listening skills, effective nonverbal communication, respect, empathy).  A recent piece on “advanced” communication strategies for relationship-centered care in pediatrics reminds pediatricians that “Most patients prefer information and discussion, and some prefer mutual or joint decisions,” and this proviso leads to the formulation of a typical advanced-level injunction:  “Share diagnostic and treatment information with kindness, and use words that are easy for the child and family to understand” (Pediatr. Ann., 4:450, 2011).

Other writers shift the relational burden away from caring entirely and move to terrain with which residents and practitioners are bound to be more comfortable.  Thus, we read of  how electronic health records (EHRs) can be integrated into a relational style of practice (Fam. Med., 42:364, 2010) and of how “interprofessional collaboration” between physicians and alternative/complementary providers can profit from “constructs” borrowed from the “model” of relationship-centered care (J. Interprof. Care., 25:125, 2011).  More dauntingly still, we learn of how  relational theory may be applied to the successful operation of primary care practices, where the latter are seen as “complex adaptive systems”  in need of strategies for organizational learning borrowed from complexity theory (Ann. Fam. Med., 8S:S72, 2010).

There is the sense that true doctoring skills (really the human aptitude and desire to doctor) are so ancillary to contemporary practice that their cultivation must be justified in statistical terms.  Journal readers continue to be reminded of studies from the 1990s that suggest an association between physicianly caring and the effectiveness and appropriateness of care, the latter measured by efficiency, diagnostic accuracy, patient adherence, patient satisfaction, and the like (Pediatr. Ann., 40:452, 2011; J. Gen Intern. Med., 6:420, 1991; JAMA, 266:1931, 1991).  And, mirabile dictu, researchers have found that physicians who permit patients to complete a “statement of concerns” report their patients’ problems more accurately than those who do not; indeed, failure to solicit the patient’s agenda correlates with a 24% reduction in physician understanding (J. Gen. Int. Med., 20:267, 2005).

The problem, as I observed in The Last Family Doctor, is that contemporary medical students are rarely drawn to general medicine as a calling and, even if they are, the highly regulated, multispecialty structure of American (and to a somewhat lesser extent, Canadian) medicine militates against their ability to live out the calling.  So they lack the aptitude and desire to be primary caregivers – which is not the same as being primary care physicians – that was an apriori among GPs of the post-WWII generation and their predecessors.  Primary care educators compensate by endeavoring to codify the art of humane caregiving that has traditionally been associated with the generalist calling – whether or not students and residents actually feel called.  My father would probably have appreciated the need for a teachable model of relationship-centered care, but he would also have viewed it as a sadly remedial attempt to transform individuals with medical training into physicians.  Gifted generalists of his generation did not require instruction on the role of the doctor-patient relationship in medical caregiving.  “Patient and relationship-centered care” was intrinsic to their doctoring; it did not fall back on a skill set to be acquired over time.

The PRCC model, however useful in jump-starting an arrested doctoring sensibility, pales alongside the writings of the great physician-educators of the early twentieth century who lived out values that contemporary educators try to parse into teachable precepts.  For medical students and primary care residents, I say, put aside the PRCC literature and introduce them ab initio to writings that lay bare what Sherwin Nuland terms “the soul of medicine.”  I find nothing of practical significance in the PRCC literature that was not said many decades ago – and far more tellingly and eloquently – by Francis W. Peabody in “The Care of the Patient” (JAMA, 88:877, 1927), L. J. Henderson in “Physician and Patient as a Social System (NEJM, 212:819, 1935), W. R. Houston in “The Doctor Himself as a Therapeutic Agent” (Ann. Int. Med., 11:1416, 1939), and especially William Osler in the addresses gathered together in the volume Aequanimitas (1904).  Supplement these classic readings with a healthy dose of Oliver Sacks and Richard Selzer and top them off with patient narratives that underscore the terrible cost of physicians’ failing to communicate with patients as people (such as Sacks’s own A Leg to Stand On [1984] and David Newman’s powerful and troubling Talking with Doctors [2011]), and you will have done more to instill the principles of patient and relationship-centered care than all the models, frameworks, algorithms, communicational strategies, and measures of patient satisfaction under the sun.

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Posted in Family Doctors, Then & Now, General Practice, Medical Education, Primary Care

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