What follows is a discussion of the academization of family practice. Segments to be discussed include: doctor/patient relationship, a development of faculty, relationships with medical schools, and relationships within the community.
Family practice owes its origin to "academization". Despite the protests of medical education, a coalition of perceptive and disgusted general practitioners, patients, and legislators built a new specialty. Thus family practice takes its origins from the attitudes of these physicians of the 1950's and 1960's. During that time, America was much more rural and doctors and patients were much closer together.
The doctor-patient relationship is much different today. Often the two are separated by machines, other providers, or even other physicians. Formal study and teaching of the doctor-patient relationship is a novelty rather than a standard. It is no wonder that over 90 % of Americans want a change in the health system. Academics study the relationship to death and do little to integrate it into mainstream medical education. Why should they? There is not yet a National Board exam for communication and compassion. Most training occurs in tertiary hospitals where neither trainee or patient feels comfortable and even these meetings are a brief four or five days. Is it no surprise that the two never truly get to know on another?
In fact, the initial impetus for reimbursement reform was the close relationship between rural doctors and their patients. This intimacy and concern for patients led to much slower rises in doctor fees in rural areas, which then became institutionalized in medicare using the customary, and then was ratcheted up on a percentage basis by Congress. This left rural doctors with far less reimbursement.
Examples of the doctor/patient relationship include dissecting the relationship as locus of control or studying psychosocial issues as disease processes; i.e., the hernia in room 604 becomes the enmeshed family-patient with adjustment disorder. Examples of the effect of academation on faculty include being busy, self-involved, research-involved, advancement-involved, fellowship-involved, complainers vs. people-involved practitioners who would be examples of suburban and rural type practices. Urbanized people are less involved while rural people, are mainly people-involved. In the relationship with medical schools, family medicine is still ostracized and has not bought its academic credibility. Therefore it is still fairly distant from the curriculum and other decision-making processes. Medical schools as a whole, are still very distant from communities and spend very little time satisfying the social needs of this nation. Relationships with communities: urban areas are busy and self-involved. Rural areas are people-involved. Community programs, however, have become increasingly less involved in the welfare of their communities except when politically necessary. Overall, the transit is away from political and into expectations with loss of state and local funding over time. Question: Why is rural good for these areas? Review of the categories of why rural is good. Evidence for the changes: Arkansas' information when their one year general practice rotating internship switched to three years, they had a marked decrease in rural practice choice. Also, when you get groups of students together they work together and interact with one another rather than one-on-one with a role model. Also, an article at the end is Glenn & Hofmeister 'Rural Training Settings', "Journal of Family Practice", 13:3 p. 377, 1981.
Further Examples of What Medical Training Does to Physicians
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Such detachment has long been considered a necessary condition for medical practice. The appropriate stance of physicians vis-à-vis their patients has variously been termed "clinical distance," "detached concern," and "compassionate detachment." 2 Sir William Osler, for example, wrote that physicians should adopt a "judicious measure of obtuseness" by which they become relatively "insensible" to the slings [End Page 222] and arrows of involvement with patients. 3
How can we characterize the tension between subjectivity and objectivity in medicine without using metaphors like distance or barrier? Michael Basch's "empathic understanding" and James Rosenberg and Bernard Towers's "imaginative imitation" begin to capture the dy-namic. 9 I prefer to borrow the words steadiness and tenderness from Thomas Percival, the British Enlightenment physician who developed a set of ethical standards for the Manchester Infirmary.
My first "case story" is "The Steel Windpipe," by Mikhail Bulgakov. This tale comes from a collection, A Country Doctor's Notebook, based on Bulgakov's experience as a district physician in the Ukraine shortly before the Russian revolution. 12 It exemplifies an urgent or explosive doctor-patient interaction, a situation similar in that respect to the one portrayed in Hemingway's "Indian Camp." The protagonist is a young doctor on his first assignment at a rural district hospital. He has just completed medical school and feels terribly incompetent. His anxiety and loneliness are compounded by the fact that his predecessor was well-beloved by both hospital staff and local people. A young girl is brought to the hospital by her mother and grandmother. She is a beautiful child, but with one glance at the "strange cloudiness" in her eyes--which he immediately identifies as terror--the doctor realizes that she is dying (p. 30).
My second case leaves the drama of urgent surgery for a more ordinary situation. In Chekhov's story "A Doctor's Visit," physician Korolyov is called to attend Liza Lyalikov, the daughter of a factory owner in an industrial area outside of Moscow. 15 Liza is chronically ill with "nerves" and suffers from palpitations of the heart.
In a moving essay titled A Fortunate Man, Berger sketches the life and experience of John Sassall, a general practitioner in an economically depressed rural area in England. 16 For Sassall the doctor's central task is an "individual and closely intimate recognition" of the patient: "If the man can begin to feel recognized--and such recognition may well include aspects of his character which he has not yet recognized himself--the hopeless nature of his unhappiness will have been changed."
John Sassal has reflected directly on his own emotional state during encounters with patients. Berger observes that Sassall also tends to lose himself in the doctor-patient interaction. He is acknowledged to be a good doctor "because he meets the deep but unformulated expectation of the sick for a sense of fraternity. He recognizes them." In fact, Sassall talks about trying actually to become each patient. "He does not believe in maintaining his imaginative distance," Berger writes; "he must come close enough to recognize the patient fully." 18 These descriptions of doctors losing themselves in their work bring to mind the state of calm absorption that Bulgakov's young doctor experiences, as well as Korolyov's discovery that he and his patient are "we."
In their classic paper, "Training for Detached Concern," Harold I. Lief and Renée Fox argue that detached concern and empathy, as described above, are in fact synergistic.
Bridging Distance, Connecting Detachment
In her essay "Metaphor and Memory," Cynthia Ozick writes that physicians believe they ought to cultivate detachment from their patients because they are afraid of finding themselves "too frail . . . to enter into psychological twinship with the even frailer souls of the sick." 27 This fear of being overwhelmed by suffering is one pillar upon which the concept of clinical detachment rests. The second pillar is the belief that clear-headed decision making, the ability to weigh probabilities accurately and correct for biases, requires a neutral mental environment. In particular, strong emotions may impair reasoning.
John L. Coulehan is a Professor of Medicine and Preventative Medicine at the State University of New York at Stony Brook, where he is also a Senior Fellow in the Institute for Medicine in Contemporary Society. At Stony Brook he practices general internal medicine and co-directs the medical humanities program. His books include The Medical Interview (with Marian Block) and two volumes of poetry, The Knitted Glove and First Photographs of Heaven.
From
James R. Damos, M.D.
Academic Impacts on Family Physicians