Born Again A Family Physician

Insert the fp pieces in and connect

Introduction

Physicians have a special role in society. Being a physician means that patients have top priority, even over the needs of the physician. This means that physicians have a unique perspective of going on in the world. Physicians must engage this in order to optimally care for patients. They must not use use this information to their own advantage. Also, they must not be overwhelmed by what they see and care for. When large numbers of physicians belong to each of these categories, the medical world is in chaos.

Charles Dickens has the best beginning to a book in a Tale of Two Cities. "It was the best of times; it was the worst of times." Certainly American Medicine today is in the midst of this irony.

Chapter 1 - Discovery

My name is Bob Bowman, and I am a recovering doctor. This is not a fictitious statement. I have used it several times in meetings. We probably should have regular small group meetings for physicians like they have in Alcoholics Anonymous, but we have not implemented this until recently (See Canada CME). A medical career is a powerful drug and at best I can take in just enough to meet my dependence and not take in too much to have it overwhelm me.

The process of addiction to medicine begins in childhood with parents and teachers. It continues under the influence of doctors when we suffer significant illness and engage doctors for our care. We see the good, caring, almost magical parts of being a physician and we are hooked.

In our quest for a career in medicine we defer relationships in the quest for knowledge and intellectual capacity. A few of us manage to maintain personal growth despite overwhelming odds, but few. If knowledge alone were not enough, then patient care takes over in medical school as a powerful aphrodisiac. It is a great feeling to take care of people and to have them dependent on you. Even before you deserve it you receive respect and admiration. Your superiors praise you for extra efforts and long hours, but this takes a toll on personal and relational growth.

An Episcopal priest in Texas, Father John was the first to take me aside and explain the problem in simple relationship terms that I could understand at the time. "It’s like this. As a priest or doctor, you spend time at the church or hospital helping people and they think you are wonderful. You help out the nurses and staff and they respect and praise you. Of course when you go home, your wife tells you that you forgot to take out the garbage again. You mysteriously find yourself spending more and more time at the clinic and hospital and less and less time at home."

Melvin Konner wrote a great review of the process of becoming a doctor. I read his book during yet another recovery cycle of being a doctor.

I agree with the embarrassing part about AAFP meetings, (is that how this got started?).  But the  question is how do we cultivate or nurture a vision of family medicine, without these things?  Too often, these issues are dismissed as coming from academia, and do not hold for the real world.  I am sure many of you know that  reps are a key source of information for practicing clinicians.  How do we move away from this to another model?  While we might gripe at the AMA for dissing family medicine, what can we do to foster an organization with real values and vision, that serve and hold up to the needs of all of family medicine.

Dan Sontheimer

The Academization of Family Medicine

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 academization 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.