Relational Family Medicine

Bob-- What do you mean by "relational?" --Chris Ryan

Robert Bowman wrote: Law and medicine may be similar in many areas, but the selection and perspectives of the grads are quite different. Law is relational and externally focused, that is why lawyers rule. Insurance companies are even more relational, hiring the best of a variety of professions to keep their ruling position. Of course by doing so, most insurance companies and professionals live far from reality in terms of health care, the legal system, etc. Medicine is internally focused and non-relational. . . .

Relational Areas

Proper perspective Importance of connections Priority on relationships

Understanding of systems, especially systems as designed vs those as implemented in reality

Regarding Traditional Medicine and Medical Education

Perspective is that med and med ed can handle it all internally. Med needs little outside direction or guidance and is surprised when advice is ignored or challenged. No dialog means disaster.

Med and med ed thinks that connections are really not a problem. Too busy for consults and communications, even to those who graduated from our medical school or those that decide health benefits and plans. Communities really don't matter much other than as a source of education (usually considered inferior) and done in a way that is disruptive to the community (too short, no return on investment of time and energy), too inflexible, or too flexible (not meeting educational goals). Med centers surrounded by communities of poverty, with little connections between and little progress in such areas in decades if not centuries. Med ed is even more difficult, with folks that do feel that they communicate and connect and they do in many ways, but curricula, environment, student product, and health systems do not change.

Medicine feels that relationships are subservient to medical demands. Med ed has fewer and fewer relationships with students with each passing year.

Systems not really important in med and med ed, after all if perspective and connections are off, why understand systems.

Family Medicine - read all of these as FM having a tendency toward this area as compared to others

Perspective - Tendency toward a proper balance between patient, practitioner, and health system

Connections - are everything, between doctor and patient, doctor and family, doctor and community, doctor and other doctors, health system. Working in a medical system that does not value connections or communication and is highly impersonal and anonymous is most distressing.

Systems are important, but few tools given to work in these areas during medical education. Fortunately those coming later to medical careers (that tend to be FP), often lend a hand. With decline in medical education, tough enough to get educated in the medical end just too start out. Even tougher to move beyond learning medication to practical and patient-oriented application, working with public or community health, practice management, understanding insurance or health policy, relationships between social and educational and medicine.

It is frustrating that there are so many systems to understand to be able to do the best job as an FP. Later when you know much more after working with a broad range of patients and systems, especially when you go beyond patient experiences and explore, such as taking time to talk to teachers and social workers and business owners and workers and a wide variety of people. Despite this great breadth of knowledge, experience, and problem solving, no one seems to listen to you, even those of us in family medicine.

It is even sadder that we have learned so much about a broad range of issues and areas that are bankrupting our states and communities, with few willing to listen to us or even explore some of the areas that we have identified as problems. Few have been granted the privilege that we have in FP of meeting so many across our society. In the mean time those most devoted to addressing such needs, teachers, FP, public servants, and a wide variety of other service-oriented folks, are burdened with more tasks, more castaways, and less resources.

FPs are those that treasure, those that accept responsibility, those that continue to relate against all odds.

Example - was asked to speak to an AMA med student group about medical liability crisis with OB GYN, ER, 2 trauma surgeons. Ob-Gyn doc painted gloom and doom and tried to recruit students to Republican party, trauma surgeons and ER doc had stories and access concerns. I had done some thinking before and during regarding who was in the room (M-1 and M-2 and a few M-3) and what impact this had on them. I discussed the concerns I had about their medical education, how liability conspired with patient discontinuity to keep them from actually making medical decisions and doing the direct (supervised) patient care that would build their confidence and career. I noted that we had made no progress in recent recorded history in liability. Constant conflicts and battles had us no closer to a "cure" and medical quality was even a greater concern. I felt that we were not working well with liability insurance companies, especially when it was in their best interest to work with us and keep the same if not lowered rates (the low incidence rate and low costs of even doing higher risk things like OB, but at low volume). I noted some of the ways that FP folks were meeting coverage. I noted that for some areas, such as OB, we might have maxxed out medical cost benefits and should explore major causes of infant mortality such as lack of education, smoking, drugs, family situations, job training, etc. Our focus on high risk medical care may be taking away from other segments of society.

I am not sure I was much better received than the other folks, but it was certainly a different perspective. I think that this is a major contribution of family medicine. Sadly we are most often used to pacify than to purify.

Another student spent a day in the office with me and many of my "relational" patients happened to come in that day. Turns out that her concept of medicine fit with my practice and she got the reassurance that she needed to continue to pursue medicine. How many others lack that extra boost that can only be experienced in our offices with our patients and our form of care?