Category Archives: Primary Care

My Doctor, My Friend

Posted on January 10, 2012 | Leave a comment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.

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Posted in Doctor-Patient Communication, Nineteenth-Century Medicine, Primary Care, Psychoanalysis

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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 19th  and well into the 20th century.  It was in the home of the patient, after all, that the physician could actually experience the psychosocial “systems” that entered into the patient’s illness:  the patient’s personality, but also the patient as spouse, parent, sibling, son or daughter, all apprehended within the dynamics of a living family system.  And of course there was the home environment itself, a psychosocial container of medically salient information.  Wise clinicians of the early 20th century did not need the assistance of a biopsychosocial model to understand the role of the house call in cultivating the physician’s biopsychosocial sensibility.  Here is Harvard’s Francis Peabody in “The Care of the Patient” (1927):

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

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

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

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

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

Addendum

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

Copyright © 2011 by Paul E. Stepansky.  All rights reserved.  Photo copyright © 2011  by Michael D. Stepansky.  All rights reserved.

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

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Primary Care/Primarily Caring (IV)

Posted on December 8, 2011 | 1 comment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Primary Care/Primarily Caring (III)

Posted on November 29, 2011 | Leave a comment

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

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

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

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

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

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

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

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

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

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Primary Care/Primarily Caring (II)

Posted on November 18, 2011 | Leave a comment

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

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

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

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

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

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

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

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

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

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Primary Care/Primarily Caring (I)

Posted on November 4, 2011 | 1 comment

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

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

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

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

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

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

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

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

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

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Posted in Family Doctors, Then & Now, Primary Care