Monthly Archives: November 2011

Primary Care/Primarily Caring (III)

“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.

Copyright © 2011 by Paul E. Stepansky.  All rights reserved.

Primary Care/Primarily Caring (II)

“Procedure skills are essential to the definition of a family physician,” announced the Group on Hospital Medicine and Procedural Training of the Society for Teachers of Family Medicine (STFM) in a Group Consensus Statement published in 2009.  And what’s more, “Provision of procedural care in a local setting by a family physician can add value in continuity of care, accessibility, convenience, and cost-effectiveness without sacrificing quality” (Fam. Med., 398:403, 2009).  True enough.  But does this normative claim square with reality?

The fact is that primary care physicians (PCPs) of today, with rare exceptions, cannot be proceduralists in the manner of my father’s postwar generation, much less the generations that preceded it.  Residency training has to date failed to provide them with a set of common procedural skills.  As of 2006, the College of Family Physicians of Canada did not even evaluate procedural skills on the Certification Examination in Family Medicine (Can. Fam. Physician, 52:561, 2006).  Unsurprisingly, many family physicians, in Canada and elsewhere, do not find themselves competent  “in the skills that they themselves see as being essential for family practice training” (Can. Fam. Physician, 56:e300, 2010; Aust. Fam. Physician, 28:1211, 1999; BMC Fam. Practice, 7:18, 2006).

Nor is there an easy way of remedying the procedural lacunae in primary care medicine.  Efforts to infuse family medicine residency programs with procedural training run up against the reality, ceded by educators, that “Many privileging committees currently use specialty certification and/or a minimum number of procedures performed . . . to award privileges to perform procedures independently” (Fam. Med., 398:402, 2009).  In one recent study, Canadian family medicine residents who took “procedural skills workshops” during their residencies were found no more likely than other residents to employ these skills when they entered private practice (Can. Fam. Physician, 56:e296, 2010).  More than a decade earlier, a procedurally gifted family physician in rural south Georgia reported a case series of 751 colonoscopies out of a series of 1,048 performed over a nine-year period.  The practitioner, who acquired all his endoscopic training (including 80 supervised procedures) and experience while in solo practice, had results that were fully equal to those of experienced gastroenterologists; indeed, his results were exemplary.  Still, he experienced difficulty obtaining colonoscopic privileges at a small community hospital in his own town (J. Fam. Practice, 44:473, 1997).  My own family physician performed sigmoidoscopy on me in the early 90s.  A decade later I asked her if she was still doing the procedure.  “No,” she replied, because she was no longer covered for it by insurers.  “And it’s too bad,” she added, “because I liked doing them.”  I recently inspected a simple skin tag on the neck of one of my sons.  “Why don’t you have your family doctor whisk it off?” I asked.  “Actually,” he replied, “she referred me to a plastic surgeon.”

It is the same story almost everywhere.  The “almost” refers to rural training programs which, especially in Canada, produce family physicians with significantly greater procedural competence than their urban colleagues (Can. Fam. Physician, 52:623, 2006).  This tends to be true in the U.S. as well, especially in those rural areas where access to specialists is still limited.  But even rural family physicians here have been found to vary greatly in procedural know-how, with a discernible trend away from the use of diagnostic instruments.   In the mid-90s, a random sample of 403 rural FPs in eight midwestern and western states found that 57% performed sigmoidoscopy, but only 20% performed colposcopy (examination of vaginal and cervical tissue with a colposcope) and fewer than 5% performed nasopharyngoscopy (examination of the nasal passages and pharynx with a laryngoscope) (J. Fam. Practice, 38:479, 1994).  In his illuminating Afterword to The Last Family Doctor, my brother David Stepansky recounts the trend away from procedural competence during his internal medicine residency of the 70s:

“. . . internal medicine residents had traditionally received routine training in certain invasive procedures such as spinal taps, thoracenteses (to remove fluid from the chest cavity) and paracenteses (to remove fluid from the abdomen), and insertion of central intravenous catheters.  Although I was trained in these procedures and had some opportunity to perform them, my experience was limited, compared to the training of internal medicine residents who preceded me by only a few years.  There arose the general understanding that such technical procedures were best left to those who performed them frequently and well – a concept that is now broadly applied throughout healthcare.”

Efforts to upgrade the procedural competence of PCPs have an air of remediation about them.  After all, in the United States the residency-based “family practice” specialty came into being in 1969, but the development of a core list of procedures that all family medicine residents should be able to perform awaited the efforts of the STFM’s Group on Hospital Medicine and Procedural Training in 2007.  And this effort, in turn, followed a spate of research over the past decade from the United States, Canada, Australia, New Zealand, and The Netherlands suggesting that “the procedural skill set expected of new family or general practice physicians is not being adequately taught in residency or registrar programs” (Can. Fam. Physician, 56:e298, 2010).  Finally, these efforts run up against the simple reality that the majority of overworked PCPs are content to refer their patients to specialists for procedures, and that the majority of patients expect to have procedures performed by specialists.  Implicitly if not explicitly, patients have come to embrace the difference between procedural training (and the experience that comes from applying a procedure occasionally in a generalist setting) and the mastery associated with routine use of a procedure in a specialty or hospital setting.  Exceptions to the rule, like the eminently competent FP colonoscopist mentioned above or the skilled FP proceduralists profiled in Howard Rabinowitz’s Caring for the Country: Family Doctors in Small Rural Towns (2004) or the dwindling number of FPs who simply make it their business to perform procedures, serve to underscore the rule.

“The history of medicine,” declaimed the internist W. R. Houston in 1937, “is a history of the dynamic power of the relationship between doctor and patient.” Houston’s address to the American College of Physicians, which, in published form, is the classic article “The Doctor Himself as a Therapeutic Agent” (Ann. Int. Med., 11:1416, 1938) left no doubt about the kind of interactions that powered the doctor’s agency.  “What the patient most imperatively demands from the doctor,” he wrote, “is, as it always was, action.”  And action, in Houston’s sense of the term, always referred back to “the line of procedure,” to the act of doing things to and for the patient.  The performance of a medical procedure, as Houston well knew, made the doctor the representative of modern scientific medicine.  It was the doctor’s calming scientific authority channeled through his or her sensory endowment, especially sight and touch.  We now know more:  That the laying on of hands, even if mediated by medical instruments, activates contact touch, an inborn biological pleasure that, through symbolic elaboration, may come to represent affection and strength (Arch. Int. Med., 153:929, 1993).   Psychoanalysts would say that a basic physiological pleasure is amplified by an idealizing transference.

Houston, of course, delivered his address before World War II and the growth of specialization that accompanied it and followed it.  In America of the 30s, patients might still expect their personal physicians to know and to implement the “line of procedure,” whatever the ailment.  What are we to make of his dictum in our own time?  Absent the kind of procedural glue that bonded GPs and patients of the past, how can today’s PCPs come to know their patients and provide physicianly caring that approximates the procedurally grounded caring of their forebears?  Contemporary PCPs not only manage their patients; they also care for them.  But, given the paucity of procedural interventions,  of actually doing things to their patients’ bodies, what more can they do to make these patients feel well cared for?  Educators have proposed different ways of reinvigorating doctor-patient relationships, and I will address them in future postings.

Copyright © 2011 by Paul E. Stepansky.  All rights reserved.

Primary Care/Primarily Caring (I)

Can contemporary primary care physicians, or PCPs, actually be family physicians in the strong, traditional sense of the term? I’m referring not to scope of practice per se but to something  more subjective and tenuous: the quality of caring.

Among the generation of American GPs who trained during and immediately after World War II, the quality of caring was anchored in hands-on doctoring: it was instrumental and procedural. The family doctor was a good listener and explainer, but he or she listened and explained preparatory to doing things to the patient, to “doctoring” the patient’s body.  In The Last Family Doctor, my tribute to my father’s medicine and the medicine of his cohort of postwar American GPs, I underscore the manual aspect of their doctoring. From the late 40s through the 70s, American GPs not only prescribed, ordered tests, and referred; they doctored through a laying on of hands (with all that entails). To be sure, there were far fewer procedures than today, and even specialty procedures were far less enmeshed in exotic technology.  For this very reason, a highly motivated family doctor – a family doctor who, like my father, was both academically oriented and mechanically gifted – could acquire broad procedural competence across a range of specialties simply by reading the journal literature, taking postgraduate courses, and receiving hands-on instruction by surgical specialists on various office-based interventions.

Consider office surgery. When I ask my family physician and others I have met whether or not they do office surgery, they typically evince mild chagrin and reply to this effect: “Only if I have to. It really messes up office hours.” My father’s medicine was different. He learned surgery as a surgical tech on the battlefields of France and Germany; during his rotating internship at a small community hospital in southeastern Pennsylvania; through a post-internship mentorship with a local surgeon; and then during a year-long course on minor surgery at Philadelphia’s Einstein Medical Center in the late 1950s. He did all kinds of office surgery – and he enjoyed doing it. Like countless GPs in agricultural communities of the time, he tended surgically to all manner of farm-equipment wounds. He reattached the first joint of countless fingers and toes. He was skilled at performing nerve blocks. He did successful skin grafts. This was rural general practice in the 50s and 60s. The caring of a family doctor who actually doctors – who treats you and, where possible, fixes you – is different from the caring of a family doctor who exams, prescribes, orders studies, manages risk factors, and coordinates multi-specialty care. In my father’s day, patients felt well cared for; today, more often than not, they feel well managed.

I am not suggesting for an instant that contemporary PCPs do not care about their patients. Of course they do. But fewer and fewer procedural tributaries flow into their caring. Increasingly their training – and the caring it sustains – is cordoned off from the laying on of hands in medically salient ways. So we end up with PCPs who are touted as gatekeepers to the health care system; as “a kind of case manager” or “central coordinators of care” (Acad. Med., 77:2002, p. 771); and, more grandiloquently still, as “an essential hub in the network formed by patients, health care organizations, and communities” (Ann. Int. Med., 142:2005, p. 695). Hmm.

Empirical research suggests that the majority of patients (90% by one account) continue to have trusting relationships with their doctors, and that trust is the “basic driver” of patient satisfaction (Med. Care, 37:510, 1999; Milbank Q., 79:631, 2001).  Patients who trust their doctors tend to have less treatment anxiety and greater pain tolerance (Sci. & Med., 13A:81, 1979); they are more likely over time to be satisfied with the care they receive.  But there are different kinds of trust.  Can the trust associated with managing, coordinating, and being an “essential hub” approximate the trust that grew out of, and was sustained by, a range of doctoring activities – suturing, delivering babies, doing basic dermatology, gynecology, ENT, allergy testing and allergy treatment?

Trust that has bodily moorings tends to be deeper and more sustaining than the disembodied trust of care coordinators, just like the most vital and enduring of the metaphors that enter into our everyday speech  – the “metaphors we live by,” to borrow the title of a classic book by the linguists George Lakoff and Mark Johnson – tend to be rooted in phenomena and relationships in the physical environment. When it came to forging trusting bonds with their patients, my father’s medicine – which lives on among American and Canadian family physicians trained to care for rural and/or underserved populations – had a leg up (indeed, an entire torso up) on contemporary primary care providers. They doctored from infancy onward and from the body outward, so their patients were left not only with the knowledge of being well managed but with the feeling of being well cared for.

Contemporary providers cannot care in the manner of my father’s generation, for their caring is legally, procedurally, and educationally constrained in ways that were alien to GPs of the mid-twentieth cenury.  Like all physicians, PCPs are subject to clinical practice guidelines, treatment eligibility criteria, and reimbursement schedules. Now insurance carriers, relying on credentialing organizations, effectively determine the range of procedures and interventions a given doctor may employ. So in most American and Canadian locales, contemporary PCPs differ from family doctors of my father’s generation because third-parties largely determine the kind of medicine they may even aspire to practice.

These claims admit important exceptions, and we shall discuss them in future blogs. There are PCPs trained to serve rural communities: graduates of Jefferson Medical College’s Physician Shortage Area Program; the University Minnesota School of Medicine’s Rural Physician Associate Program; and the Maine-Dartmouth family medicine residency who work out of Augusta’s Family Medicine Institute.

Copyright © 2011 by Paul E. Stepansky.  All rights reserved.