Tag Archives: David Stepansky

It Takes a Village in Health Care, Too

It Takes a Village in Health Care, Too

David W. Stepansky, M.D.**

A few weeks ago, while rounding on patients at Phoenixville Hospital, I began to experience a vague tightness in my upper chest as I walked from one nurses’ station to the next.  The pain was fairly mild, but I also became a little sweaty with it.  The symptoms did not cause me to stop and rest, but when I did sit down to write on a chart, the discomfort would subside, only to recur when I began walking again.

As a physician, I well knew what my symptoms might have represented, but being just as susceptible to denial as any other human, I chose to ignore things for a little while, not wanting to believe that I might be experiencing angina.  I knew what would take place as soon as I said anything to anyone and only wanted to forget that it was happening.  I actually went out to my car to drive to the office to start my outpatient hours, again experiencing that same mild but gnawing pressure in my chest.  I sat in my car for a minute or two, just trying to think it all through, when I finally came to the realization that if I was indeed ignoring cardiac symptoms, than I was being very foolish.

Even then, I did not go directly to the emergency room.  Instead, I wandered through the hospital until I found one of my cardiologist partners and told him my story. Of course, from that moment on, I ceased to be a doctor and somewhat begrudgingly became a patient.  I knew from that moment that I would have to  completely relinquish my regular identity and become wholly reliant not only on the judgment and skill, but also on the compassion of the many who then began to care for me.

What happened after that was at once extraordinary and commonplace. Following my evaluation in the emergency room, I was taken directly to the cath lab where a 95% occlusion of my circumflex artery was discovered and uneventfully stented.  I recuperated in the post-op area, was transferred briefly to an inpatient room, and was ultimately discharged at 6:00 PM.  In the aftermath of this whirlwind, surreal day, I found myself at home safe, healed, and marveling with my wife at how I had had my heart fixed from a tiny hole in my wrist.  All that remained was for me to take it easy for a few days, contemplate how my life had changed, and reflect on this stark and jolting recognition of my own frailty.

The care that I received while a patient at the hospital was wonderful – efficient, accurate, and at the same time compassionate and reassuring.  As an attending physician at Phoenixville Hospital for over 30 years, as well as the organization’s CMO and Patient Safety Officer, I have spent countless hours in countless meetings overseeing the hospital’s quality and safety.  Yet experiencing the care provided from this new (and hopefully not oft repeated) vantage point was eye-opening in some unexpected ways.

In particular, I was repeatedly struck by the realization that exemplary health care is truly the sum total of the well-intended, expert actions of a multitude of people.  With due gratitude to, and respect for, the talented physicians who cared for me, their actions would not have been possible without the support of a highly competent and reliable team that comprised both people and machines.  I was repeatedly impressed and comforted by the confident attitudes of nearly everyone I encountered.  Some of these people I knew well and some I had never seen before.  The people who participated in my care, aside from my doctors, included ER nurses, x-ray technicians, laboratory technicians, cath lab personnel, post-op nurses, and telemetry nurses.  But this barely scratches the surface when one considers that the technology brought to bear on me was developed and refined by scores of dedicated individuals whose ultimate purpose was to provide accurate and safe healing to individuals like me.  In many ways, this was a humbling experience, as I must be thankful to a multitude of people, most of whom are actually behind the scenes and will never be known to me.

Many individuals who are involved in the front line of health care, including me, worry about the dehumanizing effect that high technology and specialization has had on patient care.  Doctors and the systems in which they work are so often criticized for being aloof and insensitive to the emotional needs of patients. Health care has become highly business-oriented, often at the expense of the human needs of those for whom the system ostensibly came into being.  Unfortunately, there is much truth to this concern.

However, the realization that I had during my brief hospital stay was that the human aspects of health care can be maintained even in the face of “dehumanizing” technology.  Doctors do less “hand holding” than in the past, but this is at least in part because there is so much more they can do.  Patients expect, and are entitled to, the high technology that modern medicine brings to them,  but they are also  entitled to  the warmth and  caring of the people who deploy that technology on their behalf.  I can happily report that I received both when I was ill.  It was, once again, an eye-opening experience.

The reality is that high-quality health care can only be the result of painstaking design.  The care that I received could never happen were it not for the coordinated actions of hundreds of dedicated individuals.  And so I would like to acknowledge the many people and machines that brought me back to good health.  To my doctors, nurses, technicians and others who provided efficient and compassionate care; to the many people behind the scenes whom I will never know who also contributed to my well-being; and finally to Community Health Systems for providing the structure necessary for all of this to happen – my heartfelt thanks.

Copyright © 2013 by David W. Stepansky.  All rights reserved.

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**Internist David Stepansky is Chief Medical Officer and Patient Safety Officer at Phoenixville Hospital, Phoenixville, PA, and Chair of the Patient Safety Committee of Community Health Systems, Inc., Franklin, TN.

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“Doctor’s Office . . .”

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

Primary Care/Primarily Caring (II)

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

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

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

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

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

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

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

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

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