Tag Archives: William Stepansky

What Do Nurse Practitioners Practice?

Posted on August 22, 2014 | Leave a comment

What should the nurse practitioner’s “scope of practice” be  and how autonomously should she or he be allowed to practice within that scope?  A half century after the first advanced training programs brought nurses into the ranks of clinical providers, these two questions continue to bedevil nursing, medicine, insurance companies, and state legislatures.  The crucial role of nurse practitioners in modern health care delivery, their ability to provide primary care, and the satisfaction of patients who receive this care – these facts are well-established and, for me at least, beyond dispute.

But questions of scope of practice and practice prerogatives (including prescribing privileges) remain contentious, and different state legislatures have codified different answers.   I have no desire to enter debates that will likely continue at medical, nursing, and legislative levels for some time to come.  But let me offer one historian’s perspective on a few aspects of these knotty issues.

The expansion of nursing’s role in the direction of specialized clinical expertise occurred in an amazingly brief stretch of time.  In 1955, The American Nurses Association (ANA) approved a legal definition of nursing practice that prohibited “acts of diagnosis and prescription of therapeutic or corrective measures,” and it was only seven years later, in 1962, that it held its first clinical sessions at its annual convention.[1]  Even then, until 1968, the ANA’s Code for Professional Nurses framed the nurse’s professional responsibilities in terms of the nurse’s relationship to physicians.[2]  Yet, by the mid-60s, spearheaded by reforms in nursing education then underway, the term “nurse practitioner” came into use.  It conveyed a nurse with “specialized expertise,” often in hospital settings, that grew out of additional training beyond the three years of hospital-based training that led to state licensure as a Registered Nurse.

“Specialized expertise” is an evocative but imprecise term.  In nursing, it initially conveyed expertise in one or another aspect of hospital-based care.  In the early 1900s, nurses acquired expertise as x-ray technicians and microscopists, and then again in the 1930s, they “specialized” in monitoring polio patients in their iron lungs.  During World War II, nurses both on the front lines and in stateside hospitals began to perform venipunctures to administer fluids intravenously; after the war, they continued to do so, and some  became specialized IV  therapists, performing and monitoring  IVs all along their units.

But in postwar America it was especially the new technologies brought to bear in treating acutely ill patients that elicited nurse specialization.  Self-evidently, we needed critical care nurses, obstetrical nurses, and dialysis nurses able to exercise independent judgment and initiate (or discontinue) treatments in exigent circumstances, in what the historian Margaret Sandelowski terms “emergent life-threatening conditions.”  By the 1960s, as Sandelowski observes, the new “machinery of care” had fostered a more collegial and collaborative relationship between physicians and nurses.[3]  But this machinery  – vital function monitors, cardiac monitors, electronic fetal monitors, and the like – was integral to medical care in the hospital.  These monitors were not invented by nursing scientists as extensions of nursing care; they were instruments of improved hospital care whose design, manufacture, and intended use fell within the domain of physicians and the medical model.

The nomenclatural challenge proved even greater when advanced nursing practice left the hospital setting and became office-based, especially in the realm of primary care.  Historians of nursing such as Julie Fairman tend to collapse the distinction between hospital-based specialty nursing and independent “nursing practice” in a global narrative of nursing’s coming-of-age in the four decades following the end of World War II.  The storyline of professional self-becoming involves new forms of collegial collaboration between individual nurses and physicians, which, over time, empowered the nursing profession to liberate itself from the bondage of organized medicine, with its long-held belief in the subordinate role of nurses as physician extenders.  What tends to be glossed over is the phenomenology of “expertise” in relation to different professional activities.  Expertise in the implementation of technologically driven, hospital-based monitoring – with the diagnostic and treatment prerogatives associated with it – is not the same as the expertise that inheres in being a “practitioner” of medicine.

Or is it the expertise that inheres in being a “practitioner” of nursing?  In her illuminating history of the nurse practitioner movement in America, Fairman delineates the inter-professional tensions congealed in this question.  Even  Loretta Ford and Henry Silver, she points out, who collaboratively developed the first (pediatric) nurse practitioner training program at the University of Colorado in the mid-1960s, used different, politically laden terminology to describe exactly what kind of nonmedical practitioner they were training.  For the pediatrician Silver, the new provider would be a “nurse associate”; for the nurse educator Ford, she or he would be a “nurse practitioner.”[4]

And the linguistic-cum-political tension was played out in different pairs of descriptors.  Nurse practitioners saw themselves as “taking on” diagnostic and treatment activities traditionally reserved for physicians, whereas physicians saw themselves as “delegating” certain medical tasks to nurses.[5]  The need to define the nurse specialist’s prerogative to diagnose and treat illness as  something other than “medical”  was at the heart of the American Nurses Association’s need to distance itself from another nonmedically trained practitioner who emerged at this same moment in  American history:  the Physician Assistant.  PAs were precisely what newly empowered clinical care nurses, at least in the eyes of their professional organization, did not want to be: a Physician Assistant rather than an autonomous Nurse Practitioner.[6]

In the realm of independent practice, this claim is highly problematic, since diagnosis and treatment of illness is not nursing “practice” in any historically meaningful sense of the term; rather, diagnosis and treatment have always fallen to the physician, as the word “physician” has been understood since the beginning of the thirteenth century, when Anglo-Normans gathered the Latin “physicus” and the French “physic” into the English “physic,” from which the word  “physician” as a medical practitioner came in to use later in the century.  It is easy to see how nursing practice can envelop sophisticated technological skills that are teachable and learnable.  But the art of diagnosis and treatment – and the qualities of learned judgment[7] that fall to this task – have always been the province of medicine.

The historical claim enfolds an epistemic claim, a claim about the nature of different kinds of knowledge.  Nursing knowledge, as codified in Florence Nightingale’s Notes on Nursing: What It Is and What It is Not (1859) and the British and American training programs that adopted her model in the 1870s and thereafter, has never been coextensive with medical knowledge.  For  Nightingale and her cohort of nursing educators, it remained a “gendered” (read: womanly) knowledge of comfort care; such care drew on sanitary science and scientifically informed  bedside observation, both infused with a maternalistic sensibility.[8]  Whether or not the knowledge base that subtends such patient-centered caring is something other than medical knowledge (as Nightingale believed) or a neglected subset of medical knowledge, is beside the point. And the point is this:  The kind of “knowledge and skills”[9] that enter into independent clinical practice – “knowledge and skills” that, to be sure, nurse practitioners and other nonmedical providers can acquire to some extent  – are by their nature medical.  This is why the struggle of nurse practitioners to obtain state licensure that permits them to “practice” without medical supervision has been halting and may never succeed entirely.

It is not simply a matter of power in the sense of Foucault, of organized medicine’s ability to withhold, control, and/or regulate entry into the world of practice.  It is because the science of clinical evaluation, diagnosis, and treatment that emerged in postbellum America was vested in the medical profession, not in the nascent nursing profession.  In the final three decades of the nineteenth century, we behold the paradigm shift in medicine that historians endlessly write about:  Medicine became scientific medicine, and this shift, with its associated educational and organizational changes, coincided with the emergence of a “profession” in the modern sense of the term.  The physician, not his (then) helpmate nurse, was part of the profession vested with the scientific understanding of illness and the cultural authorization to act on this understanding by diagnosing and treating it.[10]

The foregoing helps explain why, in retrospect, the ANA’s insistence that pediatric nurse practitioners retain the prerogative to delineate their own scope of practice was foredoomed.  ANA leaders sought to contest a notion of “practice” that, by the early 1970s, was incontestable.  And the pediatric nurse practitioners knew as much.  Like their nurse anesthetist forebears, who formed the National Association of Nurse Anesthetists in 1932,[11] they walked away from the ANA and formed their own professional association, the National Association of Pediatric Nurse Associates and Practitioners (NAPNAP) in 1973.  And the NAPNAP, without further ado, accepted affiliation with the American Academy of Pediatrics, realizing that the ANA’s insistence on complete autonomy for nursing was self-defeating.  The pediatric nurses, if not the ANA leaders, realized that such insistence militated against the idea of team practice, of a pediatrician, pediatric nurse practitioner, and nurse working together, and it contravened the reality that, in all such cases, the pediatrician would be the leader of the team.[12]

The dilemma for nurse practitioners is that they have spent  over a half century trying to define themselves by what they are not.  They are not physicians.  They are not physician assistants or associates.  They are not general nurses who lack advanced postgraduate training and specialty licensure.  So what exactly are they?

In the late 1950s and 1960s, nurse educators like Esther Brown and Hildegard Peplau sought to fill in the lacuna by articulating a new basis for nurse practitioner expertise.  In so doing, they adopted the same orientation as the founders of the “family practice” specialty movement during the same time.  That is, they sought to equate the nurse practitioner’s “expert clinical practice”  with a psychosocial sensibility and an ability to provide holistic psychotherapeutic care.  Social science course work and psychodynamic training, they hoped, would move the nursing practitioner away from medicine and toward this new kind of nursing expertise.

That Brown and Peplau spearheaded this effort in nurse education is hardly surprising, given their respective backgrounds.  Brown, a social anthropologist on the staff of the Russell Sage Foundation, authored Nursing for the Future (1948), a Foundation report that advocated university-based nurse training schools in the service of a vague psychosocial vision of nursing care.  The nurse of the future, she wrote, would “complement the patient by supplying what he needs in knowledge, will, or strength to perform his daily activities and also to carry out the treatment prescribed for him by the physician.”  Peplau, the founder of psychiatric nursing, followed an M.A. at Columbia’s Teachers College, where she completed the first course in advanced psychiatric nursing, with psychoanalytic training at New York’s William Alanson White Institute.[13]  She believed that psychiatric nurses should function as psychotherapists, and, implicitly, that all nurses should bring a broad psychosocial, really a psychotherapeutic, orientation to their work.  Were Brown, Peplau, and their associates successful in reforming nursing training in a manner that subserved a new kind of nursing identity?   No, certainly not in the manner they envisioned.  And further, at the time their educational reforms were introduced in the nursing schools of large public universities, there were serious problems: Graduates overfed with the new social science curriculum were simply unprepared to assume the responsibilities of nursing practice.[14]

_______________________

 My father, William Stepansky, whose remarkable postwar career in family medicine has been woven into many of these essays, was a pharmacist before he was a physician.  He entered Philadelphia College of Pharmacy and Science in 1940, but his education was interrupted by induction into the army in March, 1943, several months before he completed his junior year.  He had not begun pharmacy college with the intention of attending medical school – this seemed an utterly far-fetched dream for the son of poor Russian émigrés who fled the Pogroms in 1921 and struggled to raise a family in the Jewish enclave of South Philadelphia.  His own mother thought him foolish for entering college and crazy (meshuga) when he mentioned his interest in medicine.  In 1946, after two years of service as a surgical technician on the battlefields of France, Belgium and Germany and an additional six months as a laboratory technician in Pilzen, Czechoslovakia, he returned to Philadelphia, where he completed his pharmacy training in 1947.  Only then, with the G.I. Bill in place, did he allow himself to envision a career in medicine, and following an inventive series of initiatives, he gained admittance to Jefferson Medical College, where he joined the freshman class in the fall of 1948.[15]

My father not only retained an active pharmacy license throughout his career, but actually “practiced” pharmacy out of his Trappe office.  He maintained an impressive inventory of basic and not-so-basic drugs, and he concocted, among other things, the marvelous “red medicine” of which I have written.  He became a staff research clinician for McNeil Labs and later participated in clinical drug trials with the Psychopharmacology Research Unit of the University of Pennsylvania.  Pharmacy training certainly proved helpful to him and his rural patients, but it was not at the core of his professional identity.  He was not a “pharmacist practitioner” or an “advanced practice pharmacist.”  He was a physician, a general practitioner of medicine.

Perhaps it is time for the nurse practitioner profession to dispense with the “nurse” appellation altogether.  These men and women are not professional nurses as the notion of nurse professionalism took shape over 150 years, even though they come to  medical “practice” through nursing training and the patient-centered values it instills.  But additional clinical training of several years duration beyond the R.N. or B.S.N. level, I suggest, takes them out of the realm of nursing practice altogether.   So, with a nod to perduring intra- and inter-professional politics, let’s cast aside the terms “medical,” “physician,” “nurse,” and “nursing” altogether, and come up with something more accurate.  Advanced practice nurses should henceforth be designated “licensed clinical providers” or “licensed clinical practitioners,” with the appropriate specialty designation appended to their licenses, e.g., “licensed clinical provider – primary care” or “licensed clinical provider – nephrology” or “licensed clinical provider – oncology.”  There, I’ve said it.  These designations are accurate and neutral and therefore certain to please no one.

 __________________

[1] J. Fairman, Making Room in the Clinic:  Nurse Practitioners and the Evolution of Modern Health Care (New Brunswick:  Rutgers University Press, 2008), pp. 119-21.

[2] L. Freitas, “Historical roots and future perspectives related to nursing ethics,” J. Prof. Nurs., 197-205, 1990, at 202.

[3]  M. Sandelowski, Devices and Desires:  Gender, Technology, and American Nursing (Chapel Hill: University of North Carolina Press, 2000), pp. 127-28.

[4] Fairman, Making Room in the Clinic, p. 91.

[5] J. Fairman, “Delegated by default or negotiated by need?:  physicians, nurse practitioners, and the process of clinical thinking,” in E. D. Baer, et al., Enduring Issues in American Nursing (NY:  Springer Pub., 2002), pp. 309-333, at p. 323.

[6] Fairman, Making Room in the Clinic, pp. 95ff.

[7] N.B. I do not understand “clinical judgment,” with its reliance on mentoring and tacit knowing, in the same way Fairman understands “clinical thinking,” viz., as a process or skill set. See Fairman, “Delegated by default,” pp. 311-12 and Making Room in the Clinic, p. 187.

[8] For a wonderful popular exposition of  Nightingale’s vision of the nurse transposed to the Bellevue Hospital Training School in the early 1880s,  see F. H. North, “A new profession for women,” The Century, 25:30-37, 1882.

[9] Fairman, “Delegated by default,” p. 323.

[10] These brief remarks allude to, without doing justice to, the brilliant analysis of Thomas Haskell on the emergence of modern professions in postbellum America.  See T. L. Haskell, The Emergence of Professional Social Science:  The American Social Science Association the the Nineteenth-Century Crisis of Authority (Baltimore: John Hopkins, 2000 [1977]), pp. 68-74, 91-121, and passim.

[11] K. Koch, “Agatha Hodgins, Lakeside Alumnae Association, and the founding of the AANA,” AANA Journal, 73:259-62, 2005.

[12] Fairman, Making Room in the Clinic, pp. 175-80.

[13] On Peplau’s graduate training at Teacher’s College and the William Alanson White Institute, see B. J. Callaway, Hildegard Peplau: Psychiatric Nurse of the Century (NY:  Springer Pub., 2002), pp. 167-91.

[14] Dominique Tobbell documents the perceived deficiencies of 1960s graduates of the UCLA and University of Minnesota nursing schools, where the new curriculum was implemented,  in “’Coming to grips with the nursing question’:  the politics of nursing education reform in 1960s America,”  Nurs. Hist. Rev., 22:37-60, 2014.

[15] This paragraph is culled from my memoir of my father’s life and career, P. E. Stepansky, The Last Family Doctor:  Remembering My Father’s Medicine (Montclair, NJ:  Keynote, 2011).

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.

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Injections and the Personal Touch

Posted on April 18, 2014 | Leave a comment

“Fear of the needle is usually acquired in childhood.  The psychic trauma to millions of the population produced in this way undoubtedly creates obstacles to good doctor-patient relationships, essential diagnostic procedures, and even life-saving therapy.”  Janet Travell, “Factors Affecting Pain of Injection” (1955)[1]

It was during the 1950s that the administration of hypodermic injections became a fraught enterprise and a topic of medical discussion.  With World War II over and American psychoanalysis suffusing postwar culture, including the cultures of medicine and psychiatry, it is unsurprising that physicians should look with new eyes at needle penetration and the fears it provoked.

In the nineteenth century, it had been all about pain relieved, sometimes miraculously, by injection of opioids.  Alongside the pain relieved, the pain of the injection was quite tolerable, even minor, a mere afterthought.  But in the mid-twentieth century pain per se took a back seat.  It was no longer about the painful condition that prompted injection.  Nor, really, was it about the pain of injection per se.  Psychodynamic thinking trumped both kinds of pain.  Increasingly, the issue before physicians, especially pediatricians, was about two things:  the anxiety attendant to injection pain and the lasting psychological damage that was all too often the legacy of needle pain.  Elimination of injection pain mattered, certainly, but it became the means to a psychological end.  Relieve the pain, they reasoned, and you eliminate the apprehension that exacerbates the pain and leaves deep psychic scars.

And so physicians were put on notice.  They were enjoined to experiment with numbing agents, coolant sprays, and various counterirritants to minimize the pain that children (and a good many adults) dreaded.  They were urged to keep their needles sharp and their patients’ skin surfaces dry.  Coolant sprays and antiseptic solutions that left a wet film, after all, could be carried into the skin as irritants.  For the muscular pain attendant to deeper injections, still stronger anesthetics, such as procaine, might be called for.  Physicians were also encouraged to reduce injection pain through new technologies, to use, for example, hyposprays and spring-loaded presto injectors.  Injection “technique” was a topic of discussion, especially for intramuscular injections of new wonder drugs such as streptomycin.  To be sure, new technologies and refined technique often failed to eliminate injection pain, especially when a large volume of solution was injected.  But, then again, pain relief was only a secondary goal. The point of the recommendations was primarily psychological, viz., to eliminate “the psychological reaction to piercing the skin.”[2]  It was anticipation of pain and the fear it engendered that jeopardized the doctor-patient relationship.

Psychoanalysts themselves, far removed from the everyday concerns of pediatricians, family physicians, and internists, had little to say on the topic.  They were content to call attention now and again to needle symbolism – invariably phallic in nature – in dreams and childhood memories.  In 1954, the child analyst Selma Fraiberg recalled “The theory of a two-and-a-half-year-old girl who developed a serious neurosis following an observation of coitus.  The child maintained that ‘the man made the hole,’ that the penis was forcibly thrust into the woman’s body like the hypodermic needle which had been thrust into her by the doctor when she was ill.”   Pity this two and a half year old.

Inferences about male sadism and castration anxiety were integral to this train of thought.  In 50s-era psychoanalysis, needle injection could symbolize not only “painful penetration,” but also the sadistic mutilation of a little girl by a male doctor.[3]  One wants to say that such strained psychoanalytic renderings are long dead and buried, but the fact is they still find their way into the literature from time to time, usually in the context of dream interpretations.  Here is one from 1994:

Recently Ms. K mentioned a dream in which she was diabetic and had little packets of desiccated insulin which were also like condoms.  All she needed now was a hypodermic syringe and a needle.  I pointed out the sexual nature of the dream with its theme of penetration; she then remembered that in the dream a woman friend had lifted her skirt and Ms. K had ‘whammed the needle right in’.[4]

Psychoanalytic interpretive priorities change over time, whether or not in therapeutically helpful ways being a perennial subject of debate.  By the 1990s, there was belated recognition that children’s needle phobias really didn’t call for analytic unraveling; they derived from the simple developmental fact that “children are exposed to hypodermic needles prior to their ability to understand what is going on,” and, as such, were more amenable to behavioral intervention than psychoanalytic treatment.  In the hospital setting, in particular, children needed simple strategies to reduce fear, not psychoanalytic interpretations.[5]

In 1950s medicine, psychoanalysis was at its best when its influence was subtle and indirect.  Samuel Sterns’s thoughtful consideration of the “emotional aspects” of treating patients with diabetes, published in the New England Journal of Medicine in 1953, is one such example.  Sterns worked out of the Abraham Rudy Diabetic Clinic of Boston’s Beth Israel Hospital, and he expressed indebtedness to the psychiatrist-psychoanalyst Grete Bibring and other members of her department for “many discussions” on the topic.

For most diabetics, of course, daily injections, self-administered whenever possible, were an absolute necessity.  And resistance to the injections, then as now, undercut treatment and resulted in poor glycemic control.[6]  How then to cope with the diabetic’s resistance to the needle, especially when “the injection of insulin is sometimes associated with a degree of anxiety, revulsion or fear that cannot be explained by the slight amount of pain involved.”[7]

Psychoanalysis provided a framework for overcoming the resistance.  It was not a matter of “simple reassurance” about insulin injections, Sterns observed, but – and it is Bibring’s voice we hear –

Recognition that apparently trivial and unfounded complaints about insulin injections may be based on deeply rooted anxiety for which the patient finds superficial rationalizations enables the physician to be more realistic and tolerant, and more successful in dealing with the problem.

Realism, tolerance, acceptance – this was the psychoanalytic path to overcoming the problem.  Physicians had to accept that diabetics’ anxiety about injections arose from “individual personalities,” and that each diabetic had his or her own adaptively necessary defenses.  Exhortation, criticism, direct confrontation – these responses had to be jettisoned on behalf of the kindness and understanding that would lead to a “positive interpersonal relation.”  This entailed an understanding of the patient’s transference to the physician:

It is particularly apparent that most of the reactions of juvenile diabetic patients to discipline, authoritativeness or criticism by the physician are really identical with their reactions to similar situations involving their parents.

And it included a  like-minded willingness to wrestle with the countertransference as an obstacle to treatment:

Even the occasional display of an untherapeutic attitude by the physician is enough to interfere with the development of a relation that will enable him to obtain maximal cooperation from the patient.  If the physician cultivates awareness of his own reactions to a difficult patient, he will be less easily drawn into retaliation or other negative behavior.[8]

The point of the analytic approach was to lay the groundwork for a “positive interpersonal relation” that would enlist the patient’s cooperation, and “not through anxiety or fear of the disease or the physician, but rather through the wish to be well and to gain the physician’s approval.”[9]  Sympathetic acceptance of the patient’s fears, of the defenses against those fears, of the life circumstances that led to the defenses – this was the ticket to the kind of positive transference relationship that the physician could use to his and the patient’s advantage.

_______________

Sterns’s paper of 1953 remains helpful to this day; it exemplifies the application of general psychoanalytic concepts to real-world medical problems that, as I suggested in the final chapter of Psychoanalysis at the Margins (2009), may breathe new life into a beleaguered profession.  The reasonableness of Sterns’s recommendations stands in contrast to the insular irrelevance of  George Moran’s “Psychoanalytic Treatment of Diabetic Children” (1984), where poor glycemic control among children becomes a “metaphorical expression[s] of psychological disturbance” — framed in terms of “entrenched defensive structures” and “drive derivatives” – that calls for psychoanalytic treatment, sometimes via “prolonged stays” of up to several months in pediatric wards.[10]  And yet, there is something missing from Sterns’s commentary.  Like other writers of his time, he was concerned lest needle anxiety become an obstacle to a good doctor-patient relationship.  Cultivate the relationship through sympathetic insight into the problem, he reasoned, and  the obstacle would diminish, perhaps even disappear.  What he ignored – indeed, what all these hospital- and clinic-based writers of the time ignored – is the manner in which a preexisting “good doctor-patient relationship” can defuse needle anxiety in the first place.

Nineteen fifty three, the year Sterns’s paper was published, was also the year my father, William Stepansky, opened his general practice at 16 East First Avenue, Trappe, Pennsylvania.  My father, as I have written, was a Compleat Physician in whom wide-ranging procedural competence commingled with a psychiatric temperament and deeply caring sensibility.  In the world of 1950s general practice, his office was, as Winnicott would say, a holding environment.  His patients loved him and relied on him to provide care.  If injections were part of the care, then ipso facto, they were caring interventions, whatever the momentary discomfort they entailed.

The forty years of my father’s practice spanned the first 40 years of my life, and, from the time I was around 13, we engaged in ongoing conversations about his patients and work.  Never do I recall his remarking on a case of needle anxiety, which is not to deny that any number of patients, child and adult, became anxious when injection time arrived.  My point is that he contained and managed their anxiety so that it never became clinically significant or worthy of mention.  At the opposite end of the spectrum, I know of elderly patients who welcomed him into their homes several times a week for injections – sometimes just vitamin B-12 shots – that amplified the human support he provided.

Before administering an injection, my father firmly but gently grasped the underside of the patient’s upper arm, and the patient felt held, often in just those ways in which he or she needed holding.  When one’s personal physician gives an injection, it may become, in some manner and to some extent, a personal injection.  And personal injections never hurt as much as injections impersonally given.  This simple truth gets lost in the contemporary literature that treats needle phobia as a psychiatric condition in need of focal treatment.   A primary care physician remarked to me recently that she relieved a patient’s severe anxiety about getting an injection simply by putting the injection on hold and sitting down and talking to the patient for five minutes.  In effect, she reframed the meaning of the injection by absorbing it into a newly established human connection. Would that all our doctors would sit down with us for five minutes and talk to us as friendly human beings, as fellow sufferers, before getting down to procedural business.

I myself am more fortunate than most.  For me the very anticipation of an injection has a positive valence.  It conjures up the sights and smells and tactile sensations of my father’s treatment room.  Now in my 60s, I still have in my nostrils the bracing scent of the alcohol he used to clean the injection site, and I still feel the firm, paternal grasp of his hand on my arm at the point of injection.  I once remarked to a physician that she could never administer an injection that would bother me,  because at the moment of penetration, her hand became my father’s.

Psychoanalysts who adopt the perspective of object relations theory speak of “transitional objects,” those special inanimate things that, especially in early life, stand in for our parents and help calm us in their absence.  Such objects become vested with soothing human properties; this is what imparts their “transitional” status.  In a paper of 2002, the analyst Julie Miller ventured the improbable view, based on a single case, that the needle of the heroin addict represents a “transitional object” that fosters a maternal connection the addict never experienced in early life.[11]  For me, I suppose, the needle is also a transitional object, albeit one that intersects with actual lived experience of a far more inspiriting nature.  To wit, when I receive an injection it is always with my father’s hand, life-affirming and healing.  It is the needle that attests to a paternal connection realized, in early life and in life thereafter.  It is an injection that stirs loving memories of my father’s medicine.   So how much can it hurt?

_______________

[1] J. Travell, “Factors affecting pain of injection,” JAMA, 58:368-371, 1955, at p. 368.

[2] J. Travell, “Factors affecting pain of injection,” op. cit.; L. C. Miller, “Control of pain of injection,” Bull Parenteral Drug A., 7:9-13,1953; E. P. MacKenzie, “Painless injections in pediatric practice,” J. Pediatr., 44:421, 1954; O. F. Thomas & G. Penrhyn Jones, “A note on injection pain with streptomycin,” Tubercle, 36:157-59, 1955; F. H. J. Figge & V. M. Gelhaus, “A new injector designed to minimize pain and apprehension of parenteral therapy,” JAMA, 160:1308-10, 1956.  There were also needle innovations in the realm of intravenous therapy, e.g., L. I. Gardner & J. T. Murphy, “New needle for pediatric scalp vein infusions,” Amer. J. Dis. Child., 80:303-04, 1950.

[3] S. Fraiberg, “A critical neurosis in a two-and-a-half-year girl,” Psychoanal. Study Child, 7:173-215, 1952, at p. 180; S. Fraiberg, “Tales of the discovery of the secret treasure,” Psychoanal. Study Child, 9:218-41, 1954, at p. 236.

[4] I. D. Buckingham, “The effect of hysterectomy on the subjective experience of orgasm,” J. Clin. Psychoanal., 3:607-12, 1994.

[5] D. Weston, “Response,” Int. J. Psychoanal., 78:1218-19, 1997, at p. 1219; C. Troupp, “Clinical commentary,” J. Child Psychother., 36:179-82, 2010.

[6] There is ample documentation of needle anxiety among present-day diabetics, e.g., A. Zambanini, et al., “Injection related anxiety in insulin-treated diabetes,” Diabetes Res. Clin. Prac., 46:239-46, 1999 and A. B. Hauber, et al., “Risking health to avoid injections: preferences of Canadians with type 2 diabetes,” Diabetes Care, 28:2243-45, 2005.

[7]S. Stearns, “Some emotional aspects of the treatment of diabetes mellitus and the role of the physician,” NEJM, 249:471-76, 1953, at p. 473.

[8] Ibid., p. 474.

[9] Ibid.

[10]P. E. Stepansky, Psychoanalysis at the Margins (NY: Other Press, 2009), pp. 287-313; G. S. Moran, “Psychoanalytic treatment of diabetic children,” Psychoanal. Study Child, 39:407-447, at pp. 413, 440. 

[11]J. Miller, “Heroin addiction: the needle as transitional object,” J. Amer. Acad. Psychoanal., 30:293-304, 20.

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.

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Procedural Rural Medicine

Posted on March 22, 2013 | 2 comments

“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.

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Posted in Family Doctors, Then & Now, Health Care Reform, Healthcare Delivery Systems, Primary Care, Procedural Rural Medicine, Rural Medicine

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Naming the Pain

Posted on August 29, 2012 | 1 comment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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“Doctor’s Office . . .”

Posted on June 29, 2012 | Leave a comment

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

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

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

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My Father’s Empathy

Posted on June 16, 2012 | Leave a comment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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A Musical Offering

Posted on February 24, 2012 | Leave a comment

“There is no doubt in my mind that the study of music aids in the study of medicine.  The study of one appears to potentiate the other.”                                  ~ F. William Sunderman, M.D., Musical Notes of a Physician (1982)

My father, William Stepansky, whose lifelong passion for violin and string chamber playing is recorded in The Last Family Doctor, holds a singular status in the history of World War II.  He was the only GI in the US Army to join his infantry division at the D-Day staging area in the dripping heat of Yuma, Arizona with a violin in tow.  Wiser minds prevailed, and he sent the violin home, but not before knowledge of his unlikely traveling companion spread throughout the unit.  Here he is in army fatigues playing violin in Germany in the final year of World War II.  The violin in question, a fine mid-eighteenth-century instrument by the Prague maker Thomas Andreas Hulinzky (1731-1788), was the gift of a group of GIs who retrieved it in the vicinity of the famous Hohner Factory in Trossingen, Germany in early 1945.  Apparently knowing about the violin-toting  kid from South Philly who was a surgical tech, they brought the “liberated” fiddle back to his surgical clearing station and offered it to him – but only on condition that he play it for them then and there.

He obliged them, and the Hulinzky became his violin for the next half century, the instrument that provided his four sons with childhoods suffused with Bach, Mozart, Beethoven, Schubert, Mendelssohn, Brahms, and a host of later Romantics.  We learned standard repertoire through my father’s practicing and chamber rehearsals and performances.  And we played with him ourselves – two pianists, a violinist, and a cellist.   Here is a family trio in action in 1976; this one includes David Stepansky (piano), Alan Stepansky (cello), and William Stepansky (violin).

Why the violin mattered so much to our father and how it entered into the kind of medicine he practiced – I forego these precious bits of biography here.  But I cannot resist commenting on Danielle Ofri’s recent piece, “Music Teachers for Doctors?”, since it stimulates memories of growing up with a  gifted physician-musician in a remarkably musical household.

Picking up on a recent article by the internist Frank Davidoff, Ofri suggests that the critical feedback that performing musicians receive throughout their careers from “teachers, audiences, critics and their own ears” exemplifies the kind of “coaching” that, in parallel fashion, might aid physicians in the “performance” of clinical medicine.  Senior colleagues who observe physicians as they actually practice medicine and provide “detailed feedback,” she suggests, might play the same energizing motivational role as music teachers and coaches who relentlessly critique their students’ performance skills and spur them to higher levels of artistry.

It’s a bit difficult to understand precisely what Ofri and Davidoff mean by the term “performance.”  It seems to be a catchall for clinical competence, of which creative problem solving; emotional engagement;  collaborative sensibility; and enthusiasm for the work are all components.  The greater one’s allotment of these attributes, the better one “performs” clinical medicine.

Davidoff, who observes that most musicians “perform almost exclusively in groups,” is especially taken with the interactive and cognitive yield of group performance.  It inculcates a better sense of “teamwork,” of the “specialization” associated with one’s particular instrument, and of the importance of clinical improvisation, i.e., the wherewithal to deviate from established protocols in response to the needs of “particular patients in particular contexts.”  Ofri, for her part, sees clinical coaching modeled on musical coaching as especially relevant to the creeping complacency, the mid-career “plateaus” to which all-too-human physicians are subject.  Musical-cum-clinical coaching would remind physicians that the quest for “performance” excellence is never ending; it might goad them to further career growth and renewed satisfaction in their work.

Between these two contrasting emphases, I am more aligned with Davidoff, though I question whether the value of group performance is best thought of in terms of an interactional concept such as “teamwork” or a cognitive skill such as improvisation.  The improvement to which “good enough” doctors  should seek ongoing feedback is of a different sort.   What they could really use is a dose of the sensibility associated with chamber music playing, for ensemble work feeds into the art and craft of dialogue, of give and take, of respectful recognition of different voices moving together in accord with the anatomical blueprint provided by a composer.

Rather than provide “coaches” who give physicians feedback to improve their clinical “performance,” let’s take them right to the medicomusical locus itself.  To wit, let’s make instrumental training and chamber performance an integral part of postgraduate clinical training.  And, by way of bringing this utterly fanciful notion back down to earth – or at least within earth’s orbit – let’s give physicians “continuing education” credit both for playing in musical ensembles and for taking seminars and workshops on how to listen to chamber music.

But let’s play out the original fantasy.  What a boon to patients if doctors were obliged to make music among themselves.  Better still if they made music with nonphysicians and best of all if they made music with current or former patients.  In so doing, they might build up tacit knowledge relevant to caring for people rather than diagnosing and treating illnesses.  From chamber playing, they would learn about harmonious interchange, about counterpoint (as Davidoff points out), about respecting intelligent voices other than their own.  Tacit knowledge – the concept comes to us from the Hungarian-British scientist and philosopher Michael Polanyi – by its nature resists articulation among those who possess it.  But, speaking from the outside, let me say that the tacit knowledge I have in mind hovers around the art of doctor-patient communication, of learning to converse with patients in a manner more responsive to individual illness experiences.  Here is my claim:  Chamber music holds the promise of broadening, however tacitly, the physician’s sense of dialogic possibility when he or she is with patients.

Consider chamber music as a special kind of narrative journey.  It is not the hero’s journey that culminates in individual redemption and rebirth but the journey of individual voices conjoined in pursuit of something communal, call it musical truth.  Individual voices assert their authority; they take the lead when called on, enabling other voices to play their supportive roles with greater sensitivity and more perfect ensemble.[1]  The voices interweave and interpenetrate; they invade musical space only to make graceful exits; they weave exquisite filigrees around the melodic inventiveness of others; they learn to yield melodic pride of place, only to reclaim it once again as transformed by other voices.  Out of the dialogue emerges a tapestry whose separate threads merge in single-minded  purpose.  This interpretive solidarity, this playing together, is hemmed in by a composer’s intentions, framed by the compositional traditions and performance practices of a particular time and place.  Absent any single voice, the journey can not be undertaken; there is no tapestry to be woven.

What have we here if not a musical analogue of the kind of narrative competence associated with patient- and relationship-centered medicine?  Interweaving, interpenetrating, entering and exiting, listening to other voices, yielding to other voices, hearing differently because of other voices – aren’t these things at the heart of narrative medicine?

This was the medicine that my father practiced long before scholars decided to study “narrative medicine” as a kind of medicine.  As a violinist, he was especially drawn to Bach, but also to the early and late Romantics, and he could shape a phrase with the same warmth and control with which he helped patients reshape the personal stories they brought to him.  He was a charismatic listener who encouraged his patients to bring him their stories.  But he always listened as their doctor, with the quiet authority to decide on a course of treatment and reassure them all was in hand – because all was in his  mind.  He was, after all, the first violinist, the leader of the quartet.  He knew the score, and he was comfortable taking the lead, both with other chamber players and with his patients.

My father was a man of great modesty and reserve, but his violin always soared with controlled passion.  Just so in medicine:  his personal reserve never diminished the polyphonic textures and expressive sonorities of his medicine, of how he listened to and conversed with his patients and then proceeded to doctor them.

_________________

My father’s model for a life of medicine and music was F. William Sunderman. One of Philadelphia’s premier internists, Sunderman was an accomplished medical researcher at Pennsylvania Hospital.  During the 1930s, he developed new methods for measuring blood cholesterol, glucose, and chloride and invented  the Sunderman Sugar Tube.  During the war, he served as Medical Director of the Manhattan Project, where he developed an antidote for the nickel carbonyl piosoning to which the first atomic bomb assemblers were prone.

Among Philadelphia’s literati, however, Sunderman was best known for integrating medicine and music into a single exemplary life.  The side-by-side entrances of his four-story brownstone at 2210 Delancy Street bore complementary aluminum plaques, one adorned with a caduceus, the other with a lyre and singing bird.  To the former came his patients; to the latter the musicians – eminent scientists and physicians among them – who joined him regularly for chamber music.  Sunderman’s passion for the violin, which in his case was embodied in a collection of exquisite instruments – a Gagliano, a Vuillaume, a Guarnarius – was fast becoming part of Philadelphia’s cultural landscape.

What must Sunderman have thought when, in the fall of 1947, a young war veteran recently graduated from Philadelphia College of Pharmacy wrote him and requested an audience.   The young man, a Jewish immigrant whose parents fled the Russian Pogroms in 1921, knocked on Sunderman’s “musical” door with his GI-liberated Hulinzky in hand.  He announced without fanfare:  “I want to be like you.  My life will be medicine and music.”  And without further ado, my father played for him.  And Sunderman was impressed, both with the young man and with his playing.  And so he endorsed the violinist-pharmacist-serviceman’s application for admission to Philadelphia’s Jefferson Medical College.

Among the area musicians who joined Sunderman for chamber playing on a regular basis was a young cellist and Harvard graduate (class of ’32).  At Harvard, Robert U. Jameson not only played cello but rose to the presidency of the Pierian Sodality, the forerunner of the Harvard-Radcliffe Orchestra.  (In 1941, nine years after Jameson’s graduation, the Orchestra performed his orchestration of  Edward Ballantine’s “Variations on Mary Had a Little Lamb.”)   Now in the real world, Jameson made his living teaching English at The Haverford School on Philadelphia’s Main Line.  An extraordinary teacher who seemed to know his students from the inside out and hence to understand exactly what they needed (viz., how to “coach” them),  Jameson remained a devotee of cello throughout his life.  In the mid-1970s, in failing health but still in the saddle at Haverford, he counted among his students a remarkably gifted young cellist. The two bonded, and the teacher became admiring of his student and warmly supportive of his career aspirations.

The young man played the Saint-Saens Cello Concerto at his teacher’s memorial concert in the spring of 1978, one cellist saluting another, and then moved on to the Curtis Institute, Harvard, and the New York Philharmonic, where he served as Associate Principal Cellist. The cellist, my brother Alan Stepansky, is now Professor of Cello at the Peabody Conservatory and Manhattan School of Music  and a performer and teacher of international stature.

A decade earlier, in the late 1960s, this same Robert U. Jameson took in hand another student who showed  promise as a writer but was in need of the kind of disciplining a chamber-music-playing English teacher could provide. Jameson, a student, like all cellists, of Bach’s Cello Suites, helped him harness luxuriant adolescent prose and understand that restraint is the handmaiden of passion, indeed, that it is the better part of a writer’s valor.  I was that student.  Did Mr. Jameson’s love of cello and chamber playing enter into his understanding of language and his ability to impart, perhaps tacitly, the elements of well-wrought narratives?  Did his instrument help make him the teacher and mentor he was?  Who’s to say it didn’t.

[1] The importance of taking the lead in chamber playing and the manner in which a strong leader enables other players to provide support “with greater sensitivity and more perfect ensemble” – this insight and this wording come from my brother Alan Stepansky.

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

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Posted in Doctor-Patient Communication, General, Medicine and Music, Medicine in WWII, Narrative Medicine

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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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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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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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