Category Archives: Family Doctors, Then & Now

Exit the Family Doctor

Posted on June 13, 2013 | Leave a comment

WHERE’S the good old family doctor, with

his microscopic bills,

With his bag of plasters, powders, and those

evil-tasting pills?

How our troubles used to lighten and our

aches and pains abate,

When his shabby horse and buggy tied up

at the old front gate!

________

Now it’s Doctor This for measles and it’s

Doctor That for mumps,

And it’s Doctor What-You-Call-Him when

it’s just a case of dumps;

If it’s only common colic, just as plain as

plain can be,

To a hospital you’re hustled for some

surgicality.

________

Comes the twentieth century doctor in a

spotless limousine,

Sealed hermetically in it — clothed “germproof”

to microbes keen.

Or, more truly, this great doctor will not

come at all to you —

In an office he’s receiving—”Office hours

from one to two.”

________

And it’s Doctor This for left eye and it’s

Doctor That for right,

And it’s Doctor What-You-Call-Him if

you’re crosswise in your sight;

When you need some fancy glasses just

to see more than you ought,

To Berlin you’re shipped instanter to that

famous Doctor Whaught.

________

He can amputate bad tempers, he can

make good folks of bad,

He’ll immune you from diseases that you

never could have had.

Yes, time’s come when it’s expected, just

to keep you ” middling fair,”

You must know the specialistic docs of

all the kinds there are.

________

Oh, it’s Doctor This for ” eetises” and

Doctor That for ” ites,”

And it’s Doctor What-You-Call-Him when

you’re seeing things o’nights.

Each will treat one ” error ” only,

will these modern unionists,

Then divide your woes with twenty other

waiting specialists.

— The Washington Post, February 17, 1910, p. 6.

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Posted in Doctor-Patient Communication, Family Doctors, Then & Now, General Practice

“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?

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.
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.
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]
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.
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.
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]
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.

[4] http://www.85percentsports.com/2012/06/08/mlb-draft-signing-tracker/

[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

Tagged health care reform, medical procedures, Patient-Centered Medical Homes, William Stepansky

The Paradox of Generalist Specialists

Posted on February 4, 2013 | Leave a comment

General practitioners of medicine (GPs), the medical heroes of World War II, returned home only to find their medical standing at their local hospitals in jeopardy. Specialization made great inroads during the war years, and, while the GPs were fighting the war in Europe, many hospitals reclassified their staff physicians on the basis of specialist qualifications. GPs of course were low men on the totem pole, and some found that the very hospitals where they had worked before the war had rescinded their surgical privileges after the war. Stanley R. Truman, the first Secretary of the American Academy of General Practice and chronicler of its founding, recalled this very situation at his own Merritt Hospital in Oakland, CA. “Some of these men had gone away with major surgical privileges,” he later recalled, “and had been assigned leading surgical responsibilities here and overseas. They were furious when they came home and found themselves in ‘Class A’ [the lowest rung of the hospital hierarchy, in which surgery could only be performed after consultation and under supervision].” One day in late 1945, Truman continued,

I met Harold Maloney who had just come back. He was one of our leading general practitioners; a fine doctor and surgeon; a member of the American College of Surgeons and in ‘Class A.’ We had previously talked about an organization of general practitioners; and this day, in talking the situation over again, we agreed that an organization was urgent.[1]

And so the GPs organized, first into the General Practitioners Association of Truman’s Alameda County; then in 1945 into the Section on General Practice of the American Medical Association; and finally in 1947 into the American Academy of General Practice (AAGP). The organizers and officers of the AAGP, who assumed the burden of promoting the new organization and encouraging the formation of local chapters, made no bones about the reason for its existence . It was not about “family practice,” “comprehensive care,” “total patient care,” or any of the other buzzwords that were invoked in the discussions two decades later that led to the creation of the American Board of Family Practice in 1969. It was about power pure and simple, and power in postwar America meant the power to treat one’s patients in the hospital, including patients who required operative obstetrics and major surgery.

Returning GPs, who, as General Medical Officers, had met wartime needs at both ends of the specialty spectrum – in psychiatry and in surgery – were aghast at rumors that certain stateside hospitals – perhaps their own hospitals – planned to limit their staffs to board-certified medical specialists by the early 50s. Was this their reward for exemplary service to the nation? “Since the second World War,” intoned the AAGP’s first President, Paul Davis, in 1948, the GP “has been discriminated against in many cases, and had his professional standards encroached upon.” In 1953, two of New York’s leading GPs recollected: “It was as if the hospitals were about to put up signs reading: ‘If you’re a general practitioner, keep out!” A few years later, Eric Royston, another prominent AAGP booster, recalled the postwar feeling among GPs of being discriminated against in their medical associations “and being pushed to the periphery in the metropolitan hospitals.”[2] The AAGP would come to the rescue; it would have the strength of numbers,[3] which meant it would have the power. The AAGP’s resolve to keep GPs in the hospitals and put scalpels back in their hands was baldly stated in Article II of the its constitution, which set forth this organizational objective: “To preserve the right of the general practitioner to engage in medical and surgical procedures for which he is qualified by training and experience.”[4]

But all did not go as planned. Although the AAGP stabilized the GP’s hospital status as it existed before the war, it could not protect GPs from the continuing development of specialty medicine, which increasingly took place in hospitals and entailed ever more sophisticated procedures and interventions. Specialty encroachment of GP hospital privileges might be slowed but never halted. And along with the organizational support came the stigma, which is exactly what the AAGP sought to prevent. In the late 40s, many GP-surgeons resisted joining the AAGP lest — publicly identified as GPs – they have their surgical privileges rescinded. On the other hand, the few GP residency programs that proved successful in the early 60s, mostly in California, were those that taught surgery and permitted GP residents to perform major operations.[5] It was all about surgery, all about procedures, all about treatment-related prerogatives within the hospital.

Of course, the AAGP could not prevail, given the great impetus to specialization provided by the war. When, in the mid-1960s, efforts to upgrade the status of the generalist centered around creation of a new residency-based specialty, “family practice,” it was no longer a matter of surgical privileges within the hospital. No, family practice would be a new and different kind of specialty, one less concerned with procedures and surgeries than with holistic, patient-centered, intergenerational caregiving. The retreat from proceduralism was codified in the “Core Content” of family practice adopted by the AAGP in 1966. The family practitioner (FP) of the future, it held, would assume “comprehensive and continuing responsibility” for his or her patients. This meant that family practice would be a “horizontal specialty” that cut across the other specialties. It would fall back on “function” rather than a “body of knowledge.”[6]

What was lost in the new rhetoric of patient-centered caregiving was the very thing that mattered so much to the AAGP two decades earlier: safeguarding the GP’s prerogative to perform those procedures and interventions that fell within the domain of the practicing (as opposed to the caring) generalist. The proponents of family practice could no longer hope to wrest control of a piece of the medical pie, so they elaborated a new – and, they fervently hoped, specialized – gloss on the pie in its entirety. This amounted to proposing a “sort of a focus”[7] for the residency-trained FP of the future. What FP proponents and educators failed to do was delineate in a conventional manner the procedural correlates of the FP’s “focus” – the things that all FPs would be trained to do that qualified as specialist interventions, not just attitudinal correlates of caregiving that meshed with their person-centered ideology.

The question-begging nature of early definitions of family practice is nowhere more evident than in the matter of surgery. By the mid-60s, the founders of family practice realized full well that the American College of Surgeons would never cede residency-trained family practitioners the prerogative to perform major operations in the hospital. Furthermore, adding insult to injury, the AAGP was beset with a schism within its own ranks: there were GPs who did considerable surgery (including operative obstetrics) and GPs who did not. The former believed family practice should include a strong surgical component; the latter did not. The former were concerned about the exclusion of surgery from “modern” family practice, and for this reason they opposed the development of a family practice specialty board through the early 60s. The pragmatic (non)solution to this quandary was simply to leave the issue open. The AAGP’s vision of the new family practice specialist, as spelled out in its “Core Content” position paper of 1966, assigned family practitioners the nebulous domain of “applicable surgery,” meaning that “the physician in family practice should be trained to do the types and kinds of surgery he would be required to perform after graduation.”

There is irony in this nebulous manifesto: the very effort to transform old-style general practice into specialized family practice hinged on a willingness to fall back on a pre-1930s notion of specialization in which generalists would somehow know, in advance of practice, what kinds of techniques they would need to master for their future work. They would then “pick up” these techniques during residency or after residency in the world of everyday practice and occasional postgraduate courses. Family practice, in these mid-60s deliberations, increasingly looked like a specialty that was not only “different,” but antithetical to the very meaning of specialization. That is, if family practice is a medical specialty of any kind, then all FP residents should receive common training in a range of diagnostic and treatment procedures that, in their totality, add up to specialist interventional care. The willingness to localize procedural skills, to leave it to individual practitioners and/or training programs to determine which skills would be “appropriate” to practice, was a nod to the surgical specialists, whose advanced training and control of hospitals was shored up by the postwar climate of opinion. But it had the paradoxical effect of marginalizing the family practitioner out of the gate: once you begin localizing the procedural, hands-on component of any specialty, medical or otherwise, you risk gutting the specialty, cutting away the shared procedural content that coalesces into expert knowledge and sustains a common professional identity. What kind of specialty leaves it to the individual to fill in the procedural content of the specialty as he or she proceeds through training and practice?

Here we have a central dilemma of family medicine. I invoke it here in support of the need for a new kind of generalist physician who is procedurally empowered in the manner of GPs of the 1940s and 50s. We need to oscillate back to generalists who can do many things and away from generalist physicians who hypothetically know their patients “better” but are increasingly content to “coordinate” their care. The family practice movement failed because it sought the impossible: to create a new kind of specialty that would not delimit expertise in treatment-specific ways.

The family practitioner of the 1970s was to be an interpersonally embedded, empathically attuned, total-patient provider. He or she was to provide comprehensive care that was intergenerational, mind-body care. Proponents of the movement spent years debating what “comprehensive care” meant, and ultimately had to beg the question. The result was a medical specialty that, until recently, lacked consensually agreed on procedural requirements. The semantically strained, even oxymoronic, vision of a non-specialty specialty, a specialty that rejected specialist values, was an amalgam of 1960s counterculture, the social sciences, and a dash of psychoanalytic object relations theory (per Michael Balint), all abetted by the dearth of “personal physicians” and the emergence in the 1970s of the patient rights movement. Family practice was of its time – it was entirely admirable and terribly ill-fated. This is why only eight percent of non-osteopathic medical students now choose to “specialize” in it.[8] It is also why some top-tier medical schools — Harvard, Yale, Johns Hopkins, Columbia, and Cornell, among them — do not even have departments of family medicine.

If we are to address the primary care crisis within rural America, we need a new kind of doctor – call them specialists in procedural rural medicine (PRM) or rural care proceduralists (RCPs) – who can actually take care of people in rural settings where specialists are sparse. Such physicians will not do many things, certainly not the kinds of surgeries that GP-surgeons of the postwar era felt within their province. But they will be trained to do much more than the majority of contemporary family physicians. Their connection with their patients will rely less on prescribing and coordinating than on what W. R. Houston, in his justly celebrated address to the American College of Physicians of 1937, termed “the line of procedure.”[9] We need primary care physicians who do things to their patients’ bodies. Such physicians will “touch” their patients in the dual sense of activating an inborn biological pleasure (contact touch) and allowing such pleasure, through symbolic elaboration, to become a touchstone of a trusting doctor-patient relationship.[10] A renewal of procedural medicine will not make indifferent caregivers caring, but it will fortify in the realm of action what Houston termed the “dynamic power” of the doctor-patient relationship. It will make it easier for caring doctors to doctor.

In the next essay in this series, we will look further at procedural rural medicine and how it would differ from family medicine as it currently exists.

[1] S. A. Truman, The History of the Founding of the American Academy of General Practice (St. Louis: Green, 1969), p. 16.

[2] P. A. Davis, “The American Academy of General Practice,” Southern Med. J., 41:651-55, 1948, at p. 654; W. C. Allen & S. A. Garlan, “Educational motivation in the field of general practice,” NY State J. Med., 53:1243-1245, 1953, at p. 1243; E. A. Royston, “The American Academy of General Practice: its origin, objectives, growth and outlook,” S. Afr. Med., J., 30:298-99, 1956.

[3] The AAGP had well over 2,000 members by the end of 1947, the year of its founding. By 1968, membership had grown to 30,000. Truman, op cit., pp. 54, 60.

[4] N.A., Family Practice: Creation of a Specialty (American Academy of Family Physicians, 1980), p. 34; Truman, op cit., p. 43.

[5] Family Practice: Creation of a Specialty, op. cit., pp. 12, 20.

[6] Family Practice: Creation of a Specialty, op. cit., pp. 37-38.

[7] Family Practice: Creation of a Specialty, op. cit., p. 42.

[8] W. S. Biggs, et al., “Entry of US medical school graduates into family medicine residencies: 2011-2012,” Fam. Med., 44:620-626, 2012.

[9] W. R. Houston, “The doctor himself as a therapeutic agent,” Ann. Int. Med., 11:1416-1425, 1938.

[10] See, for example, N. S. Lehrman, “Pleasure heals: the role of social pleasure—love in its broadest sense—in medical practice,” Arch . Intern. Med., 1993;153:929–934. Contemporary physicians writing about primary care have little to say about the salience of the laying on of hands – even when mediated by instrumentation – as a component of care-giving that mobilizes patient trust. But there is much to be gleaned from contiguous literature, e.g., G. Pohl, et al., “’Laying on of hands’ improves well-being in patients with advanced cancer,” Support Care Cancer, 15:143-151, 2007; S. Jain, et al., “Healing touch with guided imagery for PTSD in returning active duty military: a randomized controlled trial,” Mil. Med., 177:1015-1021, 2012; and T. Jones & L. Glover, “Exploring the psychological processes underlying touch: lessons from the Alexander technique,” Clin. Psychol. Psychother., Nov., 2012 (Epub ahead of print).

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Posted in Family Doctors, Then & Now, General Practice, Medicine in WWII, Procedural Rural Medicine

Tagged AAGP, primary medical care, specialization, W.R. Houston

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:

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]
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.
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]}
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:

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 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]
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

Tagged nurse practitioners, physician assistants, primary medical care

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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Posted in Family Doctors, Then & Now, Medical Instruments, Medical Technology, Old & New, Primary Care

Tagged cardiac catheterization, doctor patient relationship, G.Gayle Stephens, Harvey Cushing, incubator, retinology, sphygmomanometer, stethoscope

Naming the Pain

Posted on August 29, 2012 | 1 comment

I always begin my “Medicine and Society” seminar by asking the students to identify as many of the following terms as they can and then to tell me what they have in common: nostalgie; railway spine; soldier’s heart (aka effort syndrome or Da Costa’s syndrome); puerperal insanity; neurasthenia; hyperkinetic syndrome; irritable bowel syndrome; ADHD; chronic fatigue syndrome; and fibromyalgia.

The answer, of course, is that they are not diseases at all but broadly descriptive syndromes based on self-reports. In each and every case, physicians listen to what patients (or, in the case of children, parents or teachers) tell them, and then give a diseaselike name to a cluster of symptoms for which there is no apparent biomedical explanation.

The fact that such conditions have existed throughout history and the appreciable symptomatic overlap among them surprise some students but not others. I like to point out especially the virtual mapping of neurasthenia, a syndrome “identified” by the pioneer American neurologist George Beard in 1869, on to contemporary notions of chronic fatigue syndrome and fibromyalgia. For Beard the symptoms of neurasthenia include mental and physical fatigue, insomnia, headache, general muscular achiness, irritability, and inability to concentrate. What have we here if not the symptoms of chronic fatigue syndrome and fibromyalgia, with the only difference, really, residing in the biomedically elusive cause of the symptoms. Whereas neurasthenia was attributed by Beard and other nineteenth-century neurologists to nervous weakness, i.e., “debility of the nerves,” the contemporary variants are ascribed to a heretofore undetected low-grade virus.

The same mapping chain applies to stomach and digestive discomfort. Long before the arrival of “irritable bowel syndrome,” for which there has never been a basis for differential diagnosis, there were terms like enteralgia, adult colic, and that wonderfully versatile eighteenth- and nineteenth-century medical-cum-literary condition, dyspepsia. Before children were “diagnosed” with ADHD, they were given the diagnosis ADD (attention deficit disorder) or MBD (minimal brain dysfunction), and before that, beginning in the early 1960s, the same kids were diagnosed with hyperactivity (hyperkinetic syndrome). Military medicine has its own chronology of syndromal particulars. Major building blocks that lead to our understanding of combat-related stress and its sequelae include PTSD, during America’s war in Vietnam; combat fatigue and war neurosis during WWII; shell shock and “soldier’s heart” during WWI; and nostalgie during the Napoleonic Wars and American Civil War.

The functionality of neurasthenia and its modern descendants is that they are symptomatically all-inclusive but infinitely plastic in individual expression. It is still a blast to read Beard’s dizzying catalog of the symptoms of neurasthenia in the preface to Modern American Nervousness (1881). Here is a small sampling:

Insomnia; flushing; drowsiness; bad dreams; cerebral irritation; dilated pupils; pain, pressure, and heaviness in the head; changes in the expression of the eye; asthenopia [eye strain]; noises in the ears; atonic voice; mental irritability; tenderness of the teeth and gums; abnormal dryness of the skin, joints, and mucous membranes; sweating hands and feet with redness; cold hands and feet; pain in the feet; local spasms of muscles; difficulty swallowing; convulsive movements; cramps; a feeling of profound exhaustion; fear of lightning; fear of responsibility; fear of open places or closed places; fear of society; fear of being alone; fear of fears; fear of contamination; fear of everything.[1]

This same model, if less extravagant in reach, pertains to chronic fatigue syndrome and fibromyalgia. Any number of symptoms point to these conditions, but no single clustering of symptoms is essential to the diagnosis or able to rule it out. In the world of global syndromes, the presence and absence of specific symptoms serve equally well as diagnostic markers.[2]

As many historians have pointed out, the development and marketing of new drugs plays a significant role in the labeling (and hence medicalizing) of these syndromes. From time immemorial, young children, especially boys, have had a hard time sitting still in school and focusing on the task before them. But it was only with the release of Ritalin (methylphenidate) in the early 1960s that these time-honored developmental lags (or were they simply developmental realities?) were gathered into the diagnosis “hyperkinetic syndrome.”

Psychiatry has been especially willing to accommodate the drug-related charge to syndromize new variants of existing syndromes. “Panic disorder” became a syndrome only after Upjohn released a new benzodiazepine, alprazolam, for which it sought a market within the broad universe of anxiety sufferers. Conveniently, the release of the drug in 1980 coincided with the release of the 3^rd edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM), which obligingly found a place for “panic disorder” (and hence alprazolam) in its revised nosology. DSM-III was no less kind to Pfizer; it helped the manufacturer find a market for its newly released MAOI antidepressant, phenelzine, by adding “social phobia” to the nomenclature.[3]

Critics write about the creeping medicalization of virtually every kind of discomfort, dis-ease, despondency, dysfunction, and dysphoria known to humankind.[4] As a society, we are well beyond medicalizing the aches and pains that accompany everyday life. We are at the point of medicalizing life itself, especially the milestones that punctuate the human life cycle. This is the viewpoint especially of French social scientists influenced by Foucault, who seem to think that the “medicalization” of conception (via, for example, embryo freezing) or the “pharmacologization” of menopause via hormone therapy takes us to the brink of a new de-naturalizing control of biological time.[5]

I demur. What we see in medicalization is less the “pathologization of existence”[6] than a variably successful effort to adapt to pain and malaise so that life can be lived. The adaptation resides in the bi-level organizing activity that fuels and sustains the labeling process. It is comforting to group together disparate symptom clusters into reified entities such as neurasthenia or chronic fatigue syndrome or fibromyalgia. It is also comforting, even inspiriting, to associate with fellow sufferers, even if their fibromyalgia manifests itself quite differently than yours. All can organize into support groups and internet self-help communities and fight for recognition from organized medicine and society at large. These people do something about their pain. And they often feel better, even if they still hurt all over. If nothing else, they have accessed a collective illness identity that mitigates self-doubts and alienation.[7]

But there may be other ways of adapting to chronic pain amplified, all too often, by chronic misery that veers into psychiatric co-morbidity. The problem with adapting to nonspecific suffering by labeling, medicalization, support groups, self-help literature, and the like is the pull to go beyond living with pain to living through the illness identity constructed around the pain. For some there are other possibilities. There is psychotherapy to address the misery, which may or may not prove helpful. There is the stoic resolve, more typical of the nineteenth century, to live with pain without collapsing one’s identity into the pain and waiting for the rest of the world to acknowledge it.[8] There is the pursuit of symptomatic relief unburdened by illness identity and the existential angst that accompanies it. And there is a fourth way that leads back to my father’s medicine.

In the post-WWII era, there were no support groups or self-help literature or internet communities to validate diffuse syndromal suffering. But there were devoted family physicians, many of whom, like William Stepansky, were psychiatrically oriented and had the benefit of postgraduate psychiatric training. A caring physician can validate and “hold” a patient’s pain without assigning the pain a label and trusting the label to mobilize the patient’s capacity to self-soothe. He or she can say medically knowledgeable things about the pain (and its palliation) without “medicalizing” it in the biomedically reductive, remedy-driven sense of our own time.

Primary care physicians who listen to their patients long enough to know them and value them become partners in suffering. They suffer with their patients not in the sense of feeling their pain but in the deeper sense of validating their suffering, both physical and mental, by situating it within a realm of medical understanding that transcends discrete medical interventions.

Am I suggesting that fibromyalgia sufferers would be better off if they had primary care physicians who, like my father, had the time and inclination to listen to them in the manner of attuned psychotherapists? You bet I am. The caring associated with my father’s medicine, as I have written, relied on the use of what psychoanalysts term “positive transference,” but absent the analytic goal of “resolving” the transference (i.e., of analyzing it away) over time.[9] Treating patients with chronic pain – whether or not syndromal – means allowing them continuing use of the physician in those ways in which they need to use him.

A parental or idealizing transference, once established, does two things. It intensifies whatever strategies of pain management the physician chooses to pursue, and it provides the physician with relational leverage for exploring the situational and psychological factors that amplify the pain. Of course, the general physician’s willingness to be used thusly is a tall order, especially in this day and age. It signifies a commitment to holistic care-giving over time, so that issues of patienthood morph into issues of suffering personhood. My father’s psychological medicine – of which contemporary notions of patient- and relationship-centered care are pale facsimiles — could not eliminate the pain of his syndromal sufferers. But it provided them with a kind of support (and, yes, relief) that few contemporary sufferers will ever know.

[1] G. M. Beard, American Nervousness, Its Causes and Consequences (NY: Putnam, 1881), pp. viii-ix.

[2] K. Barker, “Self-help literature and the making of an illness identity: the case of fibromyalgia syndrome (FMS),” Social Problems, 49:279-300, 2002.

[3] D. Healy, The Anti-Depressant Era (Cambridge: Harvard University Press, 1997), pp. 187-189.

[4] E.g., Peter Conrad, The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders (Baltimore: Johns Hopkins, 2007).

[5] A. J. Suissa, “Addiction to cosmetic surgery: representations and medicalization of the body,” Int. J. Ment. Health Addiction, 6:619-630, 2008, at p. 620.

[6] R. Gori & M. J. Volgo, La Santé Totalitaire: Essai sur la Medicalization de l’Existence (Paris: Denoël, 2005).

[7] Barker, “Self-help literature and the making of an illness identity,” op. cit.

[8] There are some powerful examples of such adaptation to pain in S. Weir Mitchell’s Doctor and Patient, 2^nd edition (Phila: Lippincott, 1888), pp. 83-100.

[9] P. E. Stepansky, The Last Family Doctor: Remembering My Father’s Medicine (Keynote, 2011), p. 86. More than a half century ago, the American psychoanalyst Leo Stone wrote of “the unique transference valence of the physician.” Patients formed transference bonds with their analysts partly because the latter, as physicians, were beneficiaries of “the original structure of the patient-doctor relationship.” Small wonder that Stone deemed the physician’s role “the underlying definite and persistent identity which is optimum for the analyst.” L. Stone, The Psychoanalytic Situation: An Examination of Its Development and Essential Nature (NY: International Universities Press, 1961), pp. 17, 15, 41.

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Posted in Doctor-Patient Communication, Family Doctors, Then & Now, Medicalization

Tagged ADD, ADHD, chronic fatigue syndrome, doctor patient relationship, fibromyalgia, George Beard, hyperactivity, neurasthenia, S. Weir Mitchell, William Stepansky

“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 80^th birthday in 2002:

“I heard that you are celebrating a special birthday – your 80^th. 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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Posted in Attachment Theory, Family Doctors, Then & Now, Medical Office Management, Primary Care

Tagged attachment theory, David Stepansky, J. L. Austin, Mary Ainsworth, phone receptionist, speech act theory, William Stepansky

My Father’s Empathy

Posted on June 16, 2012 | Leave a comment

My late father, William Stepansky, was the most empathic caregiver I have ever known. Until recently, however, I never thought of him that way. Indeed, I never had the sense that he “practiced” medicine one way or another, simply that he lived out his medical calling. I thought nothing of having a father who taped the Hippocratic Oath to his dresser and read it every morning.

My father’s “empathy” did not grow out of medical training; it was the stuff of life experience. His family’s emigration from Russia followed the Hitler-like savagery of the Ukrainian Pogroms that followed World War I. Anti-Semite thugs murdered his grandfather on his own doorstep several years before his father, Pincus, mother, Vittie (then pregnant with him), and older sister, Enta began their uncertain journey to America in 1921. Pincus, a highly decorated Russian war veteran, a member of the 118^th (Shuiskii) Infantry Regiment of the 30^th Infantry Division, was the recipient of what my father termed the Russian equivalent of our own Congressional Medal of Honor. “He was a sergeant,” he would tell me, “but a colonel had to salute him first.” On the battlefield he was wounded three times in the chest and once left for dead. Stripped of his decorations by the bandits who raided his native village of Stavishche, he arrived in the new world penurious and crippled with chest pain.

My father, who was born in Kishinev, Rumania during the first leg of his family’s 1,900-mile journey across continental Europe, was six-months old when they arrived in Boston Harbor. A year later, they left Boston and made their home in the densely Jewish enclave in South Philadelphia. Throughout my life, my father shared two memories of his own father; they attest, respectively, to the positive and negative poles of the wounded soldier-tailor’s dedication to high culture. The first is of Pincus gamely limping across long city blocks with his young son in tow; he was taking his young son, my father, to his weekly violin lesson with his first teacher, the local postman. Pincus never left the music room, and when the lesson was over, he took his son’s violin and lovingly wiped it down with a special cloth brought solely for that purpose.

The second memory is of Pincus imperiously ordering his son to bring his violin and perform whenever neighbors, friends, or relations gathered in the family’s small apartment. A shy, retiring child, my father urgently wanted not to play. But his father’s directives were issued from on high with military-like peremptoriness that brooked neither contradiction nor delay. And so my father got his violin and he played, perhaps through tears, perhaps through rage.

My father, at age 15, watched his father die of heart disease. In February, 1943, having completed his third-year of pharmacy training, he was called up by the army and served as a surgical technician in a medical battalion attached to the 80^th Infantry Division of Patton’s Third Army. In France, Belgium, and Germany, he worked alongside battlefield surgeons who fought to keep wounded GIs alive in a surgical clearing company only a short remove from the front line. I learned a bit about the visceral reality of wound management in the European Theatre during his final years, when I interviewed him and several of his surviving comrades for The Last Family Doctor. The prosaic summary of his duties in his army discharge of January, 1946 – “Removed uncomplicated cases of shrapnel wounds, administered oxygen and plasma, sterilized instruments, bandages, clothing, etc. Gave hypodermic injections and performed general first aid duties” – only hints at this reality.

My father, so I learned, held down wounded GIs for anesthesia-less suturing, assisted with frontline battlefield surgery, much of which involved amputation, and then, after the day’s work, went outside to bury severed arms and legs. He experienced close fighting in the woods of Bastogne during the freezing winter of 1945, when the techs worked 20-hour shifts to keep up with the inflow of casualties. One can only wonder at the impact of such things on the constitution of a gentle and soft-spoken 22-year-old pharmacy student whose passion, before and after the war, was the violin, and who carried Tolstoy’s War and Peace in his backpack throughout his European tour.

A different man might have emerged from my father’s childhood and wartime experience emotionally constricted, withdrawn, intimidated by authority figures or, obversely (or concurrently) enraged by them. In my father’s case, a lifelong performance anxiety – the legacy of a militaristic father repeatedly ordering him to play violin before visitors — was vastly counterbalanced by an enlarged empathic sensibility that enabled him to understand and contain his patients’ anxieties about their health, their relationships, their ability to love and to work. Wrestling as he did with his own anxieties and memories of the war, which included the liberation of Dachau and Buchenwald, he became a physician who accepted utterly his patients’ prerogative to share their anxieties with him, even to project their anxieties into him. He was, after all, their doctor.

My father was not only an astute diagnostician but also a gifted psychotherapist, and the amalgam of these twin talents was an ability to titrate his disclosures, to tell patients what they needed to know, certainly, but in a manner he thought they could bear. His psychologically attuned approach to patient care is now associated with the paternalism of a different era. But it was also an aspect of his ability, rare among physicians, to diagnose suffering and to discern the limits of this or that patient’s ability to cope with it.[1] This style of practice was wonderfully appreciated by his patients, some of whom, after leaving the area, travelled a distance for yearly appointments with him. No doubt they wanted to experience the “holding environment” of his person.

Premed students who grind away at biology and chemistry have no idea what my father and his cohort of war-tested physicians, many first- and second-generation immigrants, overcame for the privilege of studying medicine. I would not wish his life story – of which I relate only a few particulars here – on any of them. And yet, we might ponder the desirability of subjecting premed students to some muted version of his experience in order to nurture whatever elements of empathic temperament they possess. Specifically, medical educators can take steps to ensure that premeds are not subverted by medicine’s “hidden curriculum” – its institutional pull away from patient-centered values and practices – while they are still in college, especially when they complete their med school applications and present for their interviews. And they can work harder to find clinical teachers who do not endorse shame, humiliation, and intimidation as credible educational strategies for acculturating young doctors into the profession.[2]

If we wish to steer contemporary medical students toward compassionate, or at least adequately sensitive, care-giving – and here I echo what others have said[3] – then we need to provide them with clinical teachers who are dissatisfied with a passive conception of role modeling and actually model discrete and specifiable behaviors in their interactions with patients.[4] Sadly, the literature continues to provide examples of clinical training during medical school and residency that is denigrating, demoralizing, and ultimately desensitizing. We end up with clinical teachers (not all, by any means, but no doubt a good many) who long ago capitulated to the hidden curriculum and devote themselves to readying the next generation of trainees for a like-minded (or better, a survival-minded) capitulation. With this intergenerational dynamic in place, we are at the point of Marshall Marinker’s devastating “Myth, Paradox and the Hidden Curriculum” (1997), which begins: “The ultimate indignity teachers inflict upon students is that, in time, they become us.”[5]

My father and his cohort of med students who trained during and shortly after WWII were resistant to shaming and intimidation. They had experienced too much to be diverted from a calling to practice medicine. But then their teachers too had experienced a great deal, many working alongside their future students – the pharmacists, medics, techs, and GIs – in casualty clearing stations, field hospitals, VA hospitals, and rehab facilities in Europe and America. Teachers emerging from the war years encountered a generation of mature students whose wartime experience primed them to embrace medicine as patient care. And the students, for their part, encountered teachers whose own wartime experience and nascent cold war anxieties tempered budding Napoleonic complexes. High tech medicine, bioethics, and patient rights all lay in the future. Generalists like my father were trained to provide care that was caring; their ministrations were largely “medicinal, manual, and mentalistic, which is to say, psychological.”[6] In the kind of training they received, the notion of castigating as “unprofessional” med students whose patient-centered concerns and queries slowed down the breakneck pace of team rounds – a documented reality these days[7] – would literally have been non-sensical.

But that was then and this is now. Today medical culture has in key respects become subversive of the ideals that drew my father and his cohort to medicine. And this culture, which revolves around the sacrosanctity of an academic hierarchy that, inter alia, insists on perfection, denigrates uncertainty, privileges outcome over process, and, in the clinical years, engages students adversarially, is far too entrenched to be dislodged with manifestos, position papers, and curricular reforms. What educators can do is seek out medical students whose empowerment derives less from high grades and artfully constructed admissions essays and more from life experience in the trenches – in any trenches. We don’t need to send premeds off to war to make them resistant to the hidden curriculum, but we should encourage premed experience robust enough to deflect its pull and let those of caring temperament develop into caring physicians.

Perhaps we need students who are drawn less to biochemistry than to the vagaries of human chemistry, students who have already undertaken experiential journeys that bring into focus the humanistic skyline of their medical horizons. What Coulehan[8] terms “socially relevant service-oriented learning” should not be confined to residency training. We need more students who come to medicine after doing volunteer work in developing nations; fighting for medical civil rights; staffing rural and urban health clinics; and serving public health internships.[9] And if this suggestion is quixotic, let’s at least have premed students spend the summer before senior year in the trenches, as I proposed in “The Hunt for Caring Med Students.” Such strategies will not create empathic caregivers de novo, but they will nurture the empathic temperament of those so endowed and, one hopes, fortify them a little better against the careerist blandishments of the hidden curriculum. It would be nice if, a generation hence, other sons (and daughters) could write about their fathers’ (and mothers’) special kind of therapeutic empathy.

[1] E. J. Cassell, “Diagnosing suffering: a perspective,” Ann. Intern. Med., 131:531-534, 1999.

[2] J. White, et al., “’What do they want me To say?’: the hidden curriculum at work in the medical school selection process: a qualitative study,” BMC Med. Educ., 12:1-9, 2012; U. H. Lindström, et al., “Medical students’ experiences of shame in professional enculturation,” Med. Educ., 45:1016-1024, 2011; A. H. Brainard & H. C. Brislen, “Learning professionalism: a view from the trenches,” Acad. Med., 82:1010-1014, 2007; P. Haidet & H. F. Stein, “The role of the student-teacher relationship in the formation of physicians,” J. Gen. Intern. Med., 21:S16-20, 2006; Mary Seabrook, “Intimidation in medical education: students’ and teachers’ perspectives,” Stud. Higher Educ., 29:59-74, 2004.

[3] Haidet & Stein, “Role of the student-teacher relationship”; N. Ratanawongsa, et al., “Residents’ perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements,” J. Gen Intern. Med., 21:758-763, 2006; J. Coulehan, “Today’s professionalism: engaging the mind but not the heart,” Acad. Med., 80:892-898, 2005; B. Maheux, et al., “Medical faculty as humanistic physicians and teachers: the perceptions of students at innovative and traditional medical schools, Med. Educ., 34:630-634, 2000; J. H. Burack, et al., Teaching compassion and respect: attending physicians’ responses to problematic behaviors,” J. Gen. Intern. Med., 14:49-55, 1999.

[4] See further Burack, “Teaching compassion and respect,” p. 54.

[5] M. Marinker, “Myth, paradox and the hidden curriculum,” Med. Educ., 31:293-298, 1997, quoted at p. 293; cf. Haidet & Stein, “Role of student-teacher relationship,” p. 3: “The relational processes of the hidden curriculum assure the perpetuation of its content” (authors’ emphasis).

[6] P. E. Stepansky, The Last Family Doctor: Remembering My Father’s Medicine (Keynote, 2011), p. 114.

[7] Brainard & Brislen, “Learning professionalism,” p. 1011.

[8] Coulehan, “Today’s professionalism,” p. 896.

[9] For examples of such physicians and their role in the revitalization of primary care medicine in the 1970s, see Stepansky, Last Family Doctor, pp. 130-133.

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Posted in Empathy, General Practice, Medical Education, Medicine in WWII, Premed Education

Tagged doctor patient relationship, empathy, William Stepansky

Empathy, Psychotherapy, Medicine

Posted on March 27, 2012 | 1 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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Posted in Doctor-Patient Communication, Family Doctors, Then & Now, Primary Care, Psychoanalysis, Psychotherapy

Tagged Donald Schoen, empathy, Harvey Cushing, Heinz Kohut, self psychology, William Baer, William Halsted

Hail the House Call

Posted on December 22, 2011 | 1 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 19^th and well into the 20^th 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 20^thcentury 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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Posted in Family Doctors, Then & Now, General Practice, Primary Care, Psychoanalysis

Tagged biopsychosocial, doctor patient relationship, family doctors, William Stepansky

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A Gift to Children During the Pandemic

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Websites Extraordinaire

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A Revolution In A Tube

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How’s Your Blood Pressure?

It Wasn’t Pretty But It Got The Job Done

The Mighty B-D “Empire”

Organotherapy, anyone?