Favorite Rural and FP at this link
The following are collected during the year from various internet and email sources. Some are from personal experience. They are included for your reflection and use as family practice educators.
Lederer in Time to Heal states that physicians are a product of the society that we live in. We live in a society of instant gratification. Few if any want to accept responsibility for their actions. Good patient care demands constant vigilance on the part of patient and physician. Often, in the process of good care, doctors and patients will be at odds with one another. I like what Lee Golusinski, MD had to say:
"When patients get upset and say I am being parental and coercive by doing this, I remind them that there are three names on each bottle of medication: the patient's, mine, and the pharmacist. We all have responsibilities on this team, and if one of us is not meeting those responsibilities (such as monitoring INRs for patients on coumadin), I will not take on the risk they bring by not meeting their responsibilities."
When patients weren't blaming physicians, they were blaming managed care. Physicians often sat at table with insurance companies. Many of us have felt that we were in the following situation: "Look around the table. If you don't see a sucker, get up, because you're the sucker." Amarillo Slim
This was a year of exploring values, of pondering the very heart of family practice. Family practice means caring for patients and sacrifice of one’s self for another. Service, service, service!
Chris Shearer noted the following: The more we limit ourselves from our patients (no call, no hospital etc.) I believe the less relevant we become. Other words of wisdom came from Dan Sontheimer: I am not sure if call is intended to have educational value. Although it sometimes does, call is more about the responsibilities of patient care. Its teaching value is in preparing learners for the demands that may be placed...am wondering more and more if we are losing something. "
We are losing something. In a perfect world folks would get sick at convenient times; they don't. If being available for our patient's sicknesses is important then call is a necessary experience and a necessary learning experience. We must learn to be compassionate and also effective when our body tells us we'd shouldn't "care" (or at least someone already awake can care for me). The real question is how much call do we need to master this. Have we forgotten the underserved that brought us to creation. Family practice graduates choosing rural locations continue at the same 600 per year. This is no different now than shortly after our re-creation. It has occurred even though we have tripled the numbers of fp graduates. Graduate numbers choosing urban poverty locations are on the decline in recent years. Have we become part of those who exploit rather than those who contribute? Are we increasing the experiences that will lead our graduate to choose underserved locations? Are we using our influence at medical schools to get the right kind of students admitted? Will be able to exert enough pressure on medical schools to change before they lose all public support?
The relationship between patients needing services and students needing experience should be mutually beneficial, but unfortunately, sometimes service-learning clinics become an exploitation of the poor. Learning on the poor presents ethical questions discussed by George Orwell in his essay, "How the poor die." However as Arthur Fournier says in an editorial,
"The more that volunteers practice differently than their colleagues who treat the poor at most teaching hospitals, the more these services will make a difference. When service learning works, patient satisfaction and learner satisfaction are mutually intertwined, which may explain why such a brief exposure to service learning in a homeless clinic so profoundly promotes future volunteerism." Fournier AM Service Learning in a Homeless Clinic. Journal of General Internal Medicine. April, 1999:14(4):258-259.
Isn't this one of the things we all got involved in family medicine to do. Didn't we want medical schools to do more than just impart technical skills?
Family practice is about standing up for values. While addressing a highly motivated group of young scientists Albert Einstein said, "Gentlemen, try not to become men of success. But rather, try to become men of value."
Lawrence Silverberg posted the following: Relational values: THE FAMILY IN MEDICINE, PROCESS OR ENTITY? by Lynn Carmichael Persons who establish a relationship characterized by affinity, intimacy, reciprocity, and continuity may feel that they are a family. This feeling is not based on factors such as sharing a common household or being parents. Rather it is based on the process or the relationship itself which has the above four characteristics. Primary care physicians will note that these four elements are familiar and are often found in the relationships they develop with patients in their practice. If unappreciated by the physician while practicing, the overwhelming sense of loss one experiences when leaving practice confirms their existence. The existence of such relationships comes about because of the context of general medical practice. Only in a few of the encounters the physician has with a patient is there a progressive disorder in which the medical model is applicable. In the majority of encounters the physician and the patient are participants in a social function that is based on process rather than outcome. Success rides on the rights and duties of the participants rather than on utilitarian value judgements such as what is-the greatest good-for the greatest number. 1. Marinker,Marshall. The Family in Medicine. Proceedings of the Royal Society of Medicine 69:115-124,1976. 2. Ransom,D.C., and Vandervoort,H.E., The Development of Family Medicine: problematic trends. JAMA,225: 1098-1102,1973. 3. Carmichael,L.P. Competencies in the Relational Model. Presented at the Annual Meeting, Society of Teachers of Family Medicine, New Orleans, Louisiana, April 2,1976.
Other discussions debated the essence of the family physician:
Woah...don't read too much into that statement. I was merely saying that many patients do not look for a deep, intimate relationship with their family physician. They want a caring, compassionate person - but they also want competence. Of course there are many in all of our practices who need much more. All I was trying to say was that if we don't also provide high quality, highly organized, and highly competent service along with our continuity, compassion, and caring, we aren't doing our jobs. Mark Ebell MD, MS, Editor, Journal of Family Practice
Caring vs competence, or caring and competence? An optimist thinks that this is the best possible world. A pessimist fears that this is true. Are we optimists or pessimists? Are we overcome, or overcomers? How much of a friend can we be to patients, and how much should we be objective? Should we join the family as a distant relative, or remain an observer?
"Regarding the tolerance of many physicians to the psycho-emotional and spiritual pressures of sharing the intimacy, the fears, the loss, the suffering, etc. of patients: epidemiologic evidence suggests that physicians suffer from mental health disorders (especially substance use disorders) more so than other professionals. Is that tolerating the pressure? Sure, but not in a sustainable way." Or, as Yeats put it, "Too long a sacrifice can make a stone of the heart..." Robert E. Garrett, MD
Have we developed hearts of stone? Can we continue to sacrifice? Are we giving in to a society that says sacrifice is bad and progress and excess is good?
Many of us thought the battle for Family Practice was over. We are finding that the battles have just begun.
It has reminded me of the comment made by Steve Bogdewic one day in a faculty meeting where we were all complaining about how unappreciated we were by our Dean, how we all busted our butts with no additional resources or institutional support, etc. He basically reminded all of us that Family Medicine is still very much the new kid on the block in academic medical centers, that we are basically still on the Conestoga Wagons crossing the Great Plains eating sourdough hard tack and drinking bad coffee, wishing we were in San Francisco drinking great wine and eating Pacific Salmon. We bought a small model of one of those Prairie Schooners and placed it on our conference table for every one of our faculty meetings after that just to remind us of the need to be patient while we fight off the Indians, endure cold nights out on the plains on our way West. Michael L. Parchman, M.D.
It is a hard road that we have had to travel. Family practice has survived creation and vision, it must survive revision and complacency:
It's easier to fight for one's principles than to live up to them. Even if you are on the right track, you'll get run over if you just sit there. Lord, when I am wrong, make me willing to change; when I am right, make me easy to live with. So strengthen me that the power of my example will far exceed the authority of my rank. Pauline H. Peters
Do we have the courage and determination to go beyond the fight and live up to our principles in patient care, in teaching, in role modeling, in research, in negotiation, in the political process?
To some degree this is a leadership issue, but perhaps in a larger sense, the efforts of the faculty are most important. Are family practice faculty motivated to do what it takes to reform and improve health care in this nation?
Don Weston, MD, Vice Chancellor of Health Care in West Virginia, noted this in discussions regarding the creation of a new medical school when he said, "As faculty we want to be this free spirit, with emphasis on the free but not much on the spirit."
It is no longer about establishing family medicine as a discipline. The battle is much larger. It is about the kind of health care delivered in the United States and our role in shaping the caregiver that will best serve our patients. This is no easy task because the general awareness of these issues is low.
I put a post on Family L a few months ago during our debates on pharmaceutical reps and open scheduling. It was titled "Revise Priorities Before Scheduling." There were hundreds of responses to the pharmaceutical ethics issues, but only a few regarding this post that attempted to get to the heart of the faculty issue. Nearly every department chair struggles with these issues. Do family practice faculty continue to support the efforts of family medicine, the department, and top quality patient care? The post is repeated for reflection:
We need to be doctors first and make this and our clinical activities our top priority. Anything less will not survive. If the clinics do not survive, then we will not be able to teach, research, serve the underserved, etc. Good quality clinics will continue to be able to teach, but mediocre clinics are just not good teaching sites. I suspect that we are doing our residents and their patients a great disservice in this area. We are attempting to make patient care our top priority, again and again. We seem to discover this every few months, but fail to make headway in this area. One of our faculty who is mostly practitioner is doing her MBA now. Regarding recent Jerry Maguire-type memo episodes from myself and others and resultant clinic meetings, she notes that these are temporarily helpful for feeling better, but not much help in the long run without some implementation. Everyone from top to bottom has to have this commitment to quality for it to work. We have far too much to do in our clinics to continue to put the overload on nurses, a few clinic faculty, or key staff that tire and leave (in various ways, transfer, quit, or impairment). This is really the only strategy that works if you plan to care for patients at all. Seems simple, but we have missed the point too long. Our patients deserve the best, our learners deserve the best, and family medicine must have the best in order to survive these turbulent times and come out ahead and influential in the decades to come. Robert C. Bowman, M.D.
I also echo Dr. Bowman's comments on adjusting priorities and "putting patients first." Interestingly, when we've tried to address this issue in faculty development (both inside and outside the institution), it's been a very difficult concept for many in family medicine education to accept. Viki Kaprielian Duke Family Medicine
Will we be like many of our physician leaders who are focusing on dollars and control and position or will we continue to embrace patient care advocacy and teaching values to learners. I will close with the following Family-L quote:
I think what we can all agree upon is that reflection, re-evaluation and change is necessary. Barbara Starfield, as well as many other knowledgeable leaders, has documented that primary care is not delivering on its promise. Our founders are crying out for a new paradigm. Doctors McWhinney, Carmichael, White, those at Keystone, et al. are proposing and airing their ideas. To me, they are not attempting to write in stone, but are raising the bar on future negotiations for a change process. We must consider their words. Times are changing, there are many warning signs, and the public is growing restless. In my opinion, the concepts presented by these leaders can be a beginning point for a new and necessary revolution in family medicine philosophy.
We need to:
1. Rewrite our goals (professional resonance) and look at progressive and unique ways of educating our students to better prepare them for this New World medicine. (ethics bias communication health caresystems)
2. Agree on our battles (Universal health care? Renumeration? Funding? Training? Improvement of quality of care? Relationship with specialists?).
3. Decide how we will join forces with our brothers and sisters (nurse practitioners, physician associates, primary care internists, etc.).
4. Develop a rapid system which constantly provides and updates recommendations on new technology usage and offers unbiased information (especially on medication utilization). In this area, we need a critical look at how we relate to the pharmaceutical industry. We must pursue behaviors which reduce the cost of medications.
5. Emphasizes patients stories and takes a broader look at "biosemiotic thinking (the interpretation of signals and the assignment of meaning to them) and salutogenesis (production and maintenance of health)".
6. Re-energized our mission, our vision and our message.
7. Reach out and connect with our practicing brethren and sistren.
8. We need careful and thoughtful action. We rely on our academic leaders to institute change.
Lead and the warriors will follow.
Lawrence Silverberg
May you and yours have the best of holidays and a valuable new year!
Robert C. Bowman