Monthly Archives: January 2012

Professionalism

–David Loxterkamp

 The family doctor is a hybrid in the field of medicine. We perform the generalist’s role with specialists’ ambitions. We are amateurs (from the Latin amator) who love our labor and shoot more from the hip than from the sights of expert opinion. We still consider medicine a vocation, or calling, and thus remain open to duty that lies beyond the roles for which we’re prepared. And, we remember that professionals are those who profess something publicly about what they believe.

I have listened to the professions of Trappist monks at New Melleray, Gethsemani, and New Clairvaux abbeys. Not only do they commit themselves to the religious life (in the vows of poverty, chastity, and obedience) but pledge to live in one place (the vow of stability) in order that grace, working through community, may move them (by a conversion of manners) closer to God.

Family doctors, too, understand that our high incomes distort our perceptions of the poor; money tests our personal values and stands between patients and their access to medical care. Chastity reminds us to be respectful of the intimacies we guard and faithful to those who are marginalized by the loss of insurance or physical well-being. We remain obedient to a higher authority—the precepts of science and a moral conduct befitting our profession. We realize that patient care is not portable and that the doctor who lives among his mistakes and prejudices becomes a healthier person less prone to severity in the judgment of patients or peers. Lastly, family doctors are inevitably changed by the patients they serve. The merely responsible physician, tempered by mercy and groomed by grace, adds to the stock of moral credibility that has sustained our profession over the millennia.

 What I am trying to describe is a doctor who is more than the sum of his or her parts, more than a tally of screening tests and minor procedures and patient encounters scored over the course of a career. We might more easily see that a rabbi or minister is not only master of ceremonies but a person praised as a man of God. We know that a teacher is more than a conveyor of facts and proctor of exams but someone dedicated to the channeling of curiosity in the pursuit of truth. So, too, family doctors, who through the blur of ICD-9 and CPT codes will finally rest in those relationships that define and sustain their work.

(Excerpted from A Vow of Connectedness: Views from the Road to Beaver’s Farm, The Country Doctor Revisited (KSU, 2010) and Family Medicine (2001) used with the permission of the author)

 Dr. Loxterkamp wrestles with big issues. He does not use the word, but the physician is a healer– he/she takes a vow much like a monk or holy man. Medicine is more than science, but the art. There is an understanding between the patient and the physician that the physician will practice in the best interest of the patient, not simply for his or her own reward. Dr. Loxterkamp believes that physicians are called to something greater than simply an occupation.  What are your thoughts on this? In today’s production and profit oriented health care systems is this even possible?

 Dr. Loxterkamp admits that in family medicine we often shoot from the hip.  That may be heresy in the world of evidence based medicine. We have reflected on this in other posts–balancing the art and science, balancing the evidence and what makes sense for the patient. How do you see the health professionals you work with blend what the evidence tells us and caring for patients where there is no evidence to guide us? Are we shooting from the hip? Is there more to it than this or are we fooling ourselves?

 Dr. Loxterkamp suggests that in small communities we “live among our mistakes.”  In small communities we cannot hide. What does it mean to live among your mistakes?  How does one reconcile that a medical mistake may harm someone?  Perhaps after all we are our own worst critics? Sometimes community members can be quite forgiving of the doctor’s foibles and even look past what might be poor care because they value their relationships with the physician.  How does a physician stay honest to the profession and his oath to care for his/her community despite the current incentives in health care, depite the fact that we are human and will make mistakes?

Read Dr. Loxterkamp’s entire essay in Family Medicine

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A Vow of Connectedness–part 1

–David Loxterkamp

 I have known Beaver for a dozen years. He is a member of my parish, a patient in our practice, the host of our son’s summer camp excursions, and a grandfather figure for my daughter, who helps with the summer milking. His daughter-in-law once worked in our medical office. He and Dr. Hughes forged their friendship years ago in Tim’s two-man racing shell. One of Beaver’s sons married the next door neighbor (she had been among my children’s favorite babysitters).

 One can be seduced into politics by the notion that popularity, moral righteousness, and a good grasp of the playing field are a guarantee for success. So, soon after establishing myself in medical practice, I joined the parish council, spoke up at hospital staff meetings, and ran for the school board. Mine was a voice for family practice values. I helped children become more involved in church worship, opposed screening programs that reduced health care to a commodity, and supported neighborhood schools that fostered strong relationships between teachers and the wider community. In these and other debates, I was frequently on the losing side. You might have thought that medicine—where the patient’s struggle against mortality is conceded from the start—would have prepared me for poor outcomes. Even in victory, the politician is left with a compromised and transitory gain. He must cherish the political process more than the final vote—likewise, the doctor’s reward, which lies in a love of his or her patients and the provision of good care rather than in any false hope of transforming the misery that parades past his or her door.

 Change

Is the family doctor an agent of social or political change? Perhaps some of us will shape and leverage the national debate. More will run for elected office in our home state or municipality. The rest will do their part by maintaining the connections that are severed in patients’ lives during the course of their disease, despair, addiction, or aging. For them, the doctor holds the flicker of hope, the reassuring hand, a mirror of their self-worth, and sense of dignity. Through our own lives, we model the possibility of change.

 I have saved only a few of my patients. I have seen alcoholics give up the bottle, wives flee the battering hand, the morbidly obese shed an elephant riding on their backs. But most of what the doctor accomplishes is infinitesimally small, barely a quiver, broad and trickling like the St. John’s River for those who are succored in the watershed of our care. We are stewards of a human ecology. Our practices are strengthened by diversity, interdependence, and the desire for our mutual long-term survival. We are caretakers of what Robert Putnam calls “social capital.” The wife of a patient of mine, home dying of lung cancer, recently said to me, “Dr. Loxterkamp, I just feel better knowing that you drive by my house every morning.”

 (Excerpted from A Vow of Connectedness: Views from the Road to Beaver’s Farm, The Country Doctor Revisited (KSU, 2010) and Family Medicine (2001) used with the permission of the author)

Read the entire selection

 Dr. Loxterkamp reflects on how intertwined our lives are with those of our patients in rural communities—babysitters, role-models, etc. In other selections, we have talked about how our patients are often our friends and the importance of figuring out how to create boundaries. Post January 2nd. Here Dr. Loxterkamp explores the big fish in a little pond phenomenon of the local doctor.  For some physicians this may be a “fish bowl” experience where everyone knows his or her business in a way that is unpleasant. For other physicians this may be a one of the benefits of a small community where he or she can be a leader and a role model in the community, a mover and shaker, even politically involved. Others look up to him/her for his/her opinions, ask for money, support, etc. Some personalities may be better suited to the ‘big fish in a small pond’ experience. Think about the health professionals in the community where you are rotating—where do they fall on this continuum??

 This being elevated to a pedestal, the accumulation of power and prestige can go to one’s head.  The national media is filled with the stories of celebrities and politicians who “have fallen from grace, ” who think they can live by different rules. Dr. Loxterkamp does not use the word humility, but he hints at it when he warns about: “false hope of transforming the misery that parades past his or her door” and “I have saved only a few of my patients.”

We are reminded that although others may look up to us, we still live by the same rules as anyone else.  Like anyone else in the community we are human, we each have our strengths and weaknesses, and our challenges– we each must live by the same rules.

 Finally, Dr. Loxterkamp reminds us that as healers we have the opportunity and privilege of giving others support and comfort during the journey of life. This is a privilege. During the years of practice in a community one sees births, health, illnesses and deaths and all the ups and downs in between. He reminds us to appreciate the gift of the intimate view into the human struggle of our patients.

 Reflect on the role of the physicians or health professionals (nurse, pharmacist, health care administrator, chiropractor) in your community. What have you noticed about the respect they do or do not garner from others? How do they respond to the privilege of walking with others? Please do not share identifying characteristics.

White Coat at Midnight

–Richard M. Berlin

This morning my best friend

will come with his chain saw

and ax, and we’ll cut down

the ash where a barred owl

perched last night and hooted

his four note song. We’ll split it

and stack it into cords, and I’ll be

thinking about midnight

in January when the air is twenty

below zero and the northern

lights shimmer purple and blue.

My Defiant woodstove will be

burning today’s work at 700,

and I’ll be warm enough to open

a window wide and listen

again for owls and the calls

of coyotes yipping at the moon,

my monogrammed white coat

draped on a peg, washed

whiter by the moonlight,

hanging around for the next

moment of healing, like winter

waiting for the earth’s heart to thaw.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Dr. Berlin, a western Massachusetts psychiatrist, is a gifted poet and observer of nature. Many of us who practice rural share the same love of the land as our patients. Watching the changes of nature both restores us and reminds us of the constancy of change in our lives. This careful attention to detail, much like mindfulness practice where you appreciate each moment and don’t get too far ahead or behind yourself, is in itself healing.

Learn more about Dr. Berlin’s writing

Learning from an Amish Birth

–Emily Kroening

Finally the day was done; I’d been up 36 hours and could not bear the thought of doing one more thing . . . my cell phone chimed. Rita, the midwife said, “One of the Amish families is in labor at home. They usually go quickly. Meet me in the hospital parking lot; I’ll be loading my blue van.”

Twilight yielded to darkness, as Rita and I followed the four-lane asphalt road through town, merged to two-lane blacktop, then twisted through a network of gravel roads. The night was inky black; no moon, no stars, only the occasional spotlight at an “English” farm. The agreement between the Amish community and the clinic was that if an Amish woman would come into the clinic for an initial prenatal visit, then she would receive home visits from the midwives for the duration of her pregnancy and could deliver at home as long as there were no complications. Women who had several children often had an Amish lay midwife handle the delivery. “But we are the couple’s quick transportation to the hospital if something goes wrong,” Rita said. “Since Amish don’t have phones, someone has to run to a neighbor’s to call for help. Otherwise it’s horse and buggy.”

Rita turned her van into a farm and the headlights outlined a small frame house. A lantern’s golden glow lit the front window. “Watch your step,” Rita warned. I stepped cautiously over frozen piles of horse manure and jagged ruts in the driveway as we unloaded the van, stacking our tubs on the front porch.

Herman, the husband, welcomed us at the door. He was tall and muscular, his woolly beard stretched past his collar. We wiped our feet on a small dmat and entered the kitchen. The house smelled like supper, something with tomatoes and onions. A wood stove, with a pile of logs nearby, radiated a toasty warmth.

Rita introduced me to Ann, who labored in the rocking chair next to the stove. She wore a white linen gown, the typical undergarment, and a white bonnet, a kapp. Her mother was busy drawing water for tea from the pump that protruded from the corner of the cement kitchen floor. Edward, Herman and Ann’s one year-old son, hid among the folds of his grandmother’s traditional blue dress.

Rita and I accompanied Ann into the adjoining bedroom. A double bed with a rough wooden headboard, an oak dresser with an oil lamp, and the baby crib were tucked into the small space. Herman had built the crib for Edward. After checking her vitals, I helped Ann stretch out on the bed. Her uterus tightened with a contraction. Rita reassured Ann that her contractions were good. We listened for the familiar dlup, dlup, dlup . . . of the baby’s heartbeat. A rate of 140, perfect. I gloved my hand and checked Ann’s cervix. It was open to three centimeters and the length had thinned halfway. This would be a long night, but the novelty held my weariness at bay.

The bedroom was pleasantly warm. An alarm clock perched on the dresser cast a monumental shadow on the wall. Rita handed it to me and told me to set the alarm every fifteen minutes, the interval for checking the baby’s heartbeat. The clock was the old-fashioned kind with a large clock face and metal ringer on the top. The key in the back grated as I wound it, setting the time: 8:30. Its soft ticking faded into background as we set up our theater: baby pack, instrument pack, sterile gloves, oxygen—just in case. We lay a plastic sheet over the mattress, letting it drape to the floor and covered it with towels.

We settled into routine. Grandmother entertained Edward and busied herself around the kitchen where Herman rested in a rocker near the stove with Rita nearby in a straight-back chair. In between contractions Ann and I talked about our lives. We were the same age—24. Ann took off her kapp and pulled pins from her coiled hair, releasing long blonde curls much like my own. Although they spoke German at home, Ann’s English had only the hint of an accent. Born down the road, she attended school through eighth grade. Then she worked for a neighboring family as a helper, caring for children and assisting with household chores. “Are you married?” she asked me.

I shook my head. “Right now my focus is to get through medical school. Then maybe I’ll have time to think about having a family.”

The metallic bell of the alarm clock interrupted our conversation. Rita peered in while I listened for the baby’s heartbeat. It continued to be strong. With an intense contraction, Ann moved onto her hands and knees. Laboring quietly and moaning occasionally, she did not ask for pain meds. After each contraction, I wiped her forehead with a washcloth, then massaged her boney shoulders, ropey biceps, and firm back. She was smaller than I, probably stronger as well, from physical labor. She talked of doing laundry in tubs by hand and tending the garden. My world was suspended as I shared these intimate moments with her. Her world—set apart from my 21st century life of e-mail, iPods, and cell phones. Only the metronomelike click of the clock and the periodic chime of the bell marked time…

Read the version published in Family Medicine, February 2008

(Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

During her rural elective in medical school, Dr. Kroening rotated at a clinic/hospital that served the Amish community. The clinic/hospital was able to negotiate an agreement with the Amish community that worked for both. The Amish were able to continue home births with back-up for emergent problems and the medical folks were reimbursed and able to work within their malpractice/liability constraints. This is an example of serving your community—working out an agreement that respects the needs of all involved. During this birth Dr. Kroening experienced the world of someone her age, from a very different culture, who lived a very different life: doing laundry in tubs, tending a garden, caring for children, living without electricity or computers versus e-mail, iPods, and cell phones. Such experiences can be life altering for us—the opportunity to step back and examine and appreciate people who have very different lives and perspectives from our own. This is one of the gifts of medicine—the privilege of sitting on the sidelines of the lives of others. We may ask ourselves: How do we partner with them? How do we encourage them? How do we help them heal themselves? How are we touched by the interactions?  Reflect on patient encounters that provided you with a bird’s eye view into a world different from the one you know. Feel free to share it, but preserve the privacy of the individuals involved.

We are rural.

–Dr. Tom Bibey

 The landscape may be in evolution, but some things never change. Spring planting will come around every year, and some of our patients will sit on the front porch and smoke cigarettes because that is what they do. Yeah, our patients eat too much at times and don’t exercise enough, and maybe they aren’t all that sophisticated, but don’t diss ’em. They are our patients. We are them, and they are us. We don’t talk bad about our own.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

 In rural health care we often live in community with our patients. As we’ve discussed in other posts, this poses challenges for confidentiality and privacy. [See October 3rd post] Familiarity can breed tolerating the status quo as well as understanding the underlying dynamics and issues that need to be addressed to help patients problem solve and make better choices in their lives. Sometimes a fresh perspective brings new energy and ideas. Often clinics like having students for those reasons. A new set of eyes can ask the same old question from a different angle, a mind fresh from training shares new information and new thinking. 

 There is value to understanding what cannot and will not change. It can save us lots of energy and head banging when working with patients. It is our job to present options to patients, but ultimately their choices are their own. There may be ramifications to those choices,  but it is the patient who has the power to change his/her behavior or his/her situation.  Understanding Prochaska and DiClemente’s http://www.motivationalinterview.org/ stages of change can help during patient care. The Transtheoretical model was developed in the 1970’s based on different psychological theories about how people make and adapt to changes in their lives. An individual cycles through various stages when deciding to change a problem behavior.  Precontemplation—you don’t think you have a problem; Contemplation—realize you do have a problem and examine the pros and cons to making a change; Preparation—gathering the tools and support to make a change; Action—actively taking steps to change a behavior; Maintenance—continue the change for more than six months.  Of course, patients cycle through contemplation and action and even maintenance repeatedly. Think of a person who quits smoking, loses weight or starts an exercise program.

 As a provider, when a patient is in precontemplation, it is my job to remind him/her that his/her behavior is a problem. “Losing even five pounds could make a big difference for your blood pressure control…” I won’t waste my words or time about how to do it if he/she isn’t really interested in making a change. If I receive the response, I like my cigs, doc, the I remind them with humor –“I wouldn’t be doing my job if I didn’t bother you about our cigs.” Humor almost always. When a patient is actively weighing the pros and cons, then it is worth my time to talk about the supports available for the behavior change–quitting smoking, exercise, etc. However, instead of lecturing, motivation interviewing helps the patient explore their assets and blocks for altering the behavior.

 Think about patients you’ve seen. Who was or was not ready to change his/her behavior? It is the new year, a time that many people take stock and make resolutions to change. Some will be successful, some will not.

Share the story without using identifying information.  Did the provider or nurse you worked with do a particularly good job of addressing behavior change with the patient? If so, tell us about it. If not, what could they have done differently that would have taken a motivational interviewing approach.