Tag Archives: medical procedures

You Touch Me

Etymologically, the word “touch” (from the old French touchier) is a semantic cornucopia.  In English, of course, common usage embraces dual meanings. We make tactile contact, and we receive emotional contact.  The latter meaning is usually passively rendered, in the manner of receiving a gift:  we are the beneficiary of someone else’s emotional offering; we are “touched” by a person’s words, gestures, or deeds.  The duality extends to the realm of healthcare:  as patients, we are touched physically by our physicians (or other providers) but, if we are fortunate, we are also touched emotionally by their kindness, concern, empathy, even love.  Here the two kinds of touching are complementary.  We are examined (and often experience a measure of  contact comfort through the touch)  and then comforted by the physician’s sympathetic words; we are touched by the human contact that follows from physical touch.

For nurses, caregiving as touching and being touched has been central to professional identity.  The foundations of nursing as a modern “profession” were laid down on the battlefields of Crimea and the American South during the mid-nineteenth century.  Crimean and Civil War nurses could not “treat” their patients, but they “touched” them literally and figuratively and, in so doing, individualized their suffering.  Their nursing touch was amplified by the caring impulse of mothers:  they listened to soldiers’ stories, sought to keep them warm, and especially sought to nourish them, struggling to pry their food parcels away from corrupt medical officers.  In the process, they formulated a professional ethos that, in privileging patient care over hospital protocol, was anathema to the professionalism associated with male medical authority.[1]

This alternative, comfort-based vision of professionalism is one reason, among others, that nursing literature is more nuanced than medical literature in exploring the phenomenology and dynamic meanings of touch. It has fallen to nursing researchers to isolate and appraise the tactile components of touch (such as duration, location, intensity, and sensation) and also to differentiate between comforting touch and the touch associated with procedures, i.e., procedural touch.[2]  Buttressing the  phenomenological viewpoint of Husserl and Merleau-Ponty with recent neurophysiologic research, Catherine Green has recently argued that nurse-patient interaction, with its “heavily tactile component” promotes an experiential oneness:  it “plunges the nurse into the patient situation in a direct and immediate way.”  To touch, she reminds us, is simultaneously to be touched, so that the nurse’s soothing touch not only promotes deep empathy of the patient’s plight but actually “constitutes” the nurse herself (or himself) in her (or his) very personhood.[3]  Other nurse researchers question the intersubjective convergence presumed by Green’s rendering.  A survey of hospitalized patients, for example, documents that some patients are ambivalent toward the nurse’s touch, since for them it signifies not only care but also control.[4]

After World War II, the rise of sophisticated monitoring equipment in hospitals pulled American nursing away from hands-on, one-on-one bedside nursing.  By the 1960s, hospital nurses, no less than physicians, were “proceduralists” who relied on cardiac and vital function monitors, electronic fetal monitors, and the like for “data” on the patients they “nursed.”  They monitored the monitors and, for educators critical of this turn of events, especially psychiatric nurses, had become little more than monitors themselves.

As the historian Margarete Sandelowski has elaborated, this transformation of hospital nursing had both an upside and a downside.  It elevated the status of nurses by aligning them with postwar scientific medicine in all its burgeoning technological power.  Nurses, the skilled human monitors of the machines, were key players on whom hospitalized patients and their physicians increasingly relied.  In the hospital setting, they became “middle managers,”[5] with command authority of their wards. Those nurses with specialized skills – especially those who worked in the newly established intensive care units (ICUs) – were at the top of the nursing pecking order.  They were the most medical of the nurses, trained to diagnose and treat life-threating conditions as they arose.  As such, they achieved a new collegial status with physicians, the limits of which were all too clear.  Yes, physicians relied on nurses (and often learned from them) in the use of the new machines, but they simultaneously demeaned the “practical knowledge” that nurses acquired in the service of advanced technology – as if educating and reassuring patients about the purpose of the machines; maintaining them (and recommending improvements to manufacturers); and utilizing them without medical supervision was something any minimally intelligent person could do.

A special predicament of nursing concerns the impact of monitoring and proceduralism on a profession whose historical raison d’être was hands-on caring, first on the battlefields and then at the bedside.  Self-evidently, nurses with advanced procedural skills had to relinquish that most traditional of nursing functions: the laying on of hands.  Consider hospital-based nurses who worked full-time as x-ray technicians and microscopists in the early 1900s; who, beginning in the 1930s, monitored  polio patients in their iron lungs; who, in the decades following World War II, performed venipuncture as full-time IV therapists; and who, beginning in the 1960s, diagnosed and treated life-threatening conditions in the machine-driven ICUs.  Obstetrical nurses who, beginning in the late 1960s, relied on electronic fetal monitors to gauge the progress of labor and who, on detecting “nonreassuring” fetal heart rate patterns, initiated oxygen therapy or terminated oxytocin infusions – these “modern” OB nurses were worlds removed from their pre-1940s forebears, who monitored labor with their hands and eyes in the patient’s own home.  Nursing educators grew concerned that, with the growing reliance on electronic metering, nurses were “literally and figuratively ‘losing touch’ with laboring women.”[6]

Nor did the dilemma for nurses end with the pull of machine-age monitoring away from what nursing educators long construed as “true nursing.”  It pertained equally to the compensatory efforts to restore the personal touch to nursing in the 1970s and 80s.  This is because “true nursing,” as understood by Florence Nightingale and several generations of twentieth-century nursing educators, fell back on gendered touching; to nurse truly and well was to deploy the feminine touch of caring women.  If “losing touch” through technology was the price paid for elevated status in the hospital, then restoring touch brought with it the re-gendering (and hence devaluing) of the nurse’s charge:  she was, when all was said and done, the womanly helpmate of physicians, those masculine (or masculinized) gatekeepers of scientific medicine in all its curative glory.[7]  And yet, in the matter of touching and being touched, gender takes us only so far.  What then of male nurses, who insist on the synergy of masculinity, caring, and touch?[8]  Is their touch ipso facto deficient in some essential ingredient of true nursing?

As soon as we enter the realm of soothing touch, with its attendant psychological meanings, we encounter a number of binaries.  Each pole of a binary is a construct, an example of what the sociologist Max Weber termed an “ideal type.”  The question-promoting, if not questionable, nature of these constructs only increases their heuristic value.  They give us something to think about.  So we have “feminine” and “masculine” touch, as noted above.  But we also have the nurse’s touch and, at the other pole, the physician’s touch.  In the gendered world of many feminist writers, this binary replicates the gender divide, despite the historical and contemporary reality of women physicians and male nurses.

But the binary extends  to women physicians themselves.  In their efforts to gain entry to the world of male American medicine,  female medical pioneers adopted two radically different strategies.  At one pole, we have the touch-comfort-sympathy approach of Elizabeth Blackwell, which assigned women their own  feminized domain of practice (child care, nonsurgical obstetrics and gynecology, womanly counseling on matters of sanitation, hygiene, and prevention).  At the opposite pole we have the research-oriented, scientific approach of Mary Putnam Jacobi and Marie Zakrezewska, which held that  women physicians must be physicians in any and all respects.  Only with state-of-the-art training in the medical science (e.g., bacteriology) and treatments (e.g., ovariotomy) of the day, they held, would women docs achieve what they deserved:  full parity with  medical men.  The binary of female physicians as extenders of women’s “natural sphere” versus female physicians as physicians pure and simple runs through the second half of the nineteenth century.[9]

Within medicine, we can perhaps speak of the generalist touch (analogous to the generalist gaze[10]) that can be juxtaposed with the specialist touch.  Medical technology, especially tools that amplify the physician’s senses –  invite another binary.  There is the pole of direct touch and the pole of touch mediated by instrumentation.  This binary spans the divide between “direct auscultation,” with the physician’s ear on the patient’s chest, and “mediate auscultation,” with the stethoscope linking (and, for some nineteenth-century patients, coming between) the physician’s ear and the patient’s chest).

Broader than any of the foregoing is the binary that pushes beyond the framework of comfort care per se.  Consider it a meta-binary.  At one pole is therapeutic touch (TT), whose premise of a preternatural human energy field subject to disturbance and hands-on (or hands-near) remediation is nothing if not a recrudescence of Anton Mesmer’s “vital magnetism” of the late 18th century, with the TT therapist (usually a nurse) taking the role of Mesmer’s magnétiseur.[11]  At the opposite pole is transgressive touch.  This is the pole of boundary violations typically, though not invariably, associated with touch-free specialties such as psychiatry and psychoanalysis.[12]  Transgressive touch signifies inappropriately intimate, usually sexualized, touch that violates the boundaries of professional caring and results in the patient’s dis-comfort and dis-ease, sometimes to the point of leaving the patient traumatized, i.e., “touched in the head.”  It also signifies the psychological impairment of the therapist, who, in another etymologically just sense of the term, may be “touched,” given his or her gross inability to maintain a professional treatment relationship.

These binaries invite further scrutiny, less on account of the extremes than of the shades of grayness that span each  continuum.  Exploration of touch is a messy business, a hands-on business, a psycho-physical business.  It may yield important insights but perhaps only fitfully, in the manner of – to invoke a meaning that arose in the early nineteenth century – touch and go.


[1] See J. E. Schultz, “The inhospitable hospital: gender and professionalism in civil war medicine,” Signs, 17:363-392, 1992.

[2]  S. J. Weiss, “The language of touch,” Nurs. Res., 28:76-80, 1979; S. J. Weiss, “Psychophysiological effects of caregiver touch on incidence of cardiac dysrhythmia,” Heart and Lung, 15:494-505, 1986; C. A. Estabrooks, “Touch in nursing practice: a historical perspective: 1900-1920,” J. Nursing Hist., 2:33-49, 1987; J. S. Mulaik, et al., “Patients’ perceptions of nurses’ use of touch,” W. J. Nursing Res., 13:306-323, 1991.

[3] C. Green, “Philosophic reflections on the meaning of touch in nurse-patient interactions,” Nurs. Phil., 14:242-253, 2013; quoted at pp. 250-251.

[4] Mulaik, “Patient’s perceptions of nurses’ use of touch,” pp. 317-318.

[5] “Middle managers” is the characterization of the nursing historian Barbara Melosh, in “Doctors, patients, and ‘big nurse’: work and gender in the postwar hospital,” in E. C. Lagemann, ed., Nursing History: New Perspective, New Possibilities (NY: Teachers College Press, 1983), pp. 157-179.  

[6] M. Sandelowski, Devices and Desires:  Gender, Technology, and American Nursing (Chapel Hill: University of North Carolina Press, 2000), p. 166.

[7] On the revalorization of the feminine in nursing in the Nursing Theory Movement of the 70s and 80s, see Sandelowski, Devices and Desires, pp. 131-134.

[8] See R. L. Pullen, et al., “Men, caring, & touch,”  Men in Nursing, 7:14-17, 2009.

[9] The work of Regina Morantz-Sanchez is especially illuminating of this binary and the major protagonists at the two poles.  See R. Morantz, “Feminism, professionalism, and germs: the thought of Mary Putnam Jacobi and Elizabeth Blackwell,” American Quarterly, 34:459-478, 1982, with a slightly revised version of the paper in R. Morantz-Sanchez, Sympathy and Science: Women Physicians in American Medicine (Chapel Hill: University of North Carolina Press, 2000 [1985]), pp. 184-202.

[10] I have written about the “generalist gaze” in P. E. Stepansky, The Last Family Doctor:  Remembering my Father’s Medicine (Montclair, NJ: Keynote Books, 2011), pp. 62-66, and more recently in P. E. Stepansky, “When generalist values meant general practice: family medicine in post-WWII America” (precirculated paper, American Association for the History of Medicine, Atlanta, GA, May 16-19, 2013).

[11] Therapeutic touch was devised and promulgated by the nursing educator Delores Krieger in publications of the 1970s and 80s, e.g., “Therapeutic touch:  the imprimatur of nursing,” Amer. J. Nursing, 75:785-787, 1975; The Therapeutic Touch (NY: Prentice Hall, 1985); and Living the Therapeutic Touch (NY:  Dodd, Mead, 1987).  I share the viewpoint of Therese Meehan, who sees the technique as a risk-free nursing intervention capable of potentiating a powerful placebo effect (T. C. Meehan, “Therapeutic touch as a nursing intervention,” J. Advanced Nursing, 1:117-125, 1998).

[12] For a fairly recent examination of transgressive touch and its ramifications, see G. O. Gabbard & E. P. Lester, Boundary Violations in Psychoanalysis (Arlington, VA: Amer. Psychiatric Pub., 2002). 

Copyright © 2013 by Paul E. Stepansky.  All rights reserved.

Advertisements

Procedural Rural Medicine

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

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

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

————

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

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

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

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

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


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

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

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

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

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

[7] Ibid, p. 151.

Copyright © 2013 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.