Category Archives: family medicine

Local Medical Doctors: State-of-the-Art Healers

–Gwen Wagstrom Halaas

In an emergency room in Cambridge, Massachusetts, at Harvard Medical School, I first heard the acronym “LMD.” As a medical student, this was one more acronym to add to my brain, already swimming with acronyms and millions of bits of information. I soon realized that LMD was the house staff’s term of derision for the local doctors whose patients they were presenting. This was news to me, that other doctors would not respect their peers. Maybe I was naive, coming from Minnesota where we are “all above average.” This realization dulled the shiny image of the medical mecca that I had the privilege of experiencing.

Moving back to Minneapolis, I managed to escape this attitude for a while, training in a hospital where the family of family doctors was the valued source of patients and referrals. This attitude resurfaced as my peers joined practices in small communities in Minnesota, and I would hear them complain about how they were treated by the urban consultants.

On my rural rotation in Homer, Alaska, I was first introduced to the amazing level of care rendered in a rural setting. While on call one evening in the hospital, a man with chest pain arrived in the emergency room. He was quickly evaluated, treated with streptokinase, stabilized, and put on a Lear jet to Anchorage.

This was months before anyone in the big city of Minneapolis was considering thrombolysis for acute MIs (heart attacks). I bragged about this experience and others on my return to the city. They looked at me like I must be hallucinating.

In my professional journey, I first started my own family practice on the skyway downtown—a very old-fashioned general practice in a fancy setting in St. Paul. From there I traveled through combinations of practice, teaching and managing the business of health care until I found myself directing a program that taught medical students the basics of medicine by immersing them in rural community practices. Again face to face with LMDs, I marveled at the innovative ways they cared for families and communities. These “hick” towns have helicopters, digital X-rays, telemedicine, electronic health records, robot consultants, medication vending machines, and approaches to care that are on the cutting edge. Their state-of-the-art facilities are patient-centered healing environments.

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

It always surprises me that this term of derision is still alive today. You’d think that our dependence on each other for referrals and consults would have fostered more respect. But 30 years later, I still hear students talk about some of the same derogatory comments I heard about primary care in the 1980s.

It takes a lots of smarts to know a little about the wide range of health care issues patients face today. It also requires a lot of wisdom to know your limits and when to ask for help. Some personalities may be better suited to the wide swath of general knowledge and others may do better with deep and narrow. Pay attention to what you hear and remember, putting down someone else certainly helps one feel better about his or herself.

 

Avoid medical-speak

From Good Will

–Donald Kollisch

“Like a sponge,” Elwin was thinking, sitting in his father’s old chair. “The doctor said my lungs are filled up like a sponge that they need to wring out.”

He pictured a large sponge—the kind his father used to use to wipe down the horses after a full day’s work, knobby and heavy and dripping in his hands. Elwin held the image in his mind as he tried to clear his laboring lungs. Some sections were softer and more supple; others were stiff and scarred. Water was stuck in the stiffer cavities so he wasn’t able to squeeze it out. That was what made his breathing fast and shallow—the way it had been ever since he’d come in from moving the John Deere into the barn.

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

Elwin was a retired farmer. His doctor gave him a concrete image to understand his congestive heart failure. Avoiding medical-speak is important. Sometimes when we are new to medicine we like to use the big words to impress or friends and colleagues. When presenting to attendings and preceptors we are supposed to use the proper medial terms. But when explaining illness to patients medical-speak doesn’t work.  Translate medical lingo into concepts and images your patients will understand. That may vary depending on a patient’s culture and experience. In the above story, Dr. Kollisch was talking to an old farmer –he understood sponges and water and washing his draft horses. One of the magical moments in talking with patients is when your patient helps you identify the image that makes sense to him or her.  Share one of those moments with us if you can. . .

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

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.

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.

Thank God for My Ass

–Therese Zink

I am not referring to my backside, although I do have a well developed gluteus
maximus due to my stocky German build and fifteen miles of running every week. My ass is Jimmy, a shy miniature donkey (think Shrek’s pal) who has been the companion of my horse, Indy, on my twenty-acre farm for almost four years. Recently Jimmy saved my ass. Please pardon my crass language, but it is the truth.

At about eight one evening, my cell phone chimed as I was driving home.
The local nursing home needed help with an elderly gentleman who had been
admitted three days earlier. My partner had given him some furosemide late
that afternoon for congestive heart failure, but Mr. Olson was still edematous
and very short of breath. “The family is upset and wants me to do something,”
the nurse reported. “His hemoglobin is four and his potassium is six. Will you
talk with the daughter?”

A hemoglobin this low would require a transfusion of several units of blood,
and the potassium suggested kidney failure. “Sure,” I responded. Not wanting
to be the student who lost her homework, I said, “But I don’t know him. Please
read me his diagnoses and tell me what meds he’s on.”

It took the nurse several minutes to tick off the list, which included some
dementia and repair of a thoracic aneurysm seven years ago.

“How old is he?” I asked wishing I was not the one on call.

“Eighty-eight,” she informed me. “He’s very sick. DNR-DNI. The family is
pushing me to do something. The daughter is really upset.”

As I drove in the darkness toward home, I took a deep breath and readjusted the
phone next to my ear. My new challenge flashed like a neon sign—the distressed
family of a new patient who I didn’t know. “Any thoughts?” I asked the nurse.

“The daughter is a handful. Good luck.”

“Put the daughter on,” I said and prayed for inspiration.

“This is Janet,” the voice said. “You know me. My husband and I borrowed
your donkey for our church’s Christmas nativity pageant.”

I thanked God for the connection, some place to start this conversation. “Of
course, Jimmy. That was a cold day.” I said and remembered that the shepherds,
kings, even Mary and Joseph, wore snowmobile suits under their cloth costumes. Thick Sorel boots peeked out beneath their flowing robes. Jimmy was insecure without his buddy, Indy. So this manger scene had had a horse and a donkey. Janet and her husband had given me the digital photos that I had cut and pasted into my Christmas letter to family and friends. “I am glad to talk with you again, but I am sorry about the circumstances. Tell me your understanding of what’s going on with your Dad?”

Janet cleared her throat. “My mom cared for him at home for six years. He
started having trouble walking two weeks ago, so I started coming every day
to help her. We decided he needed more than we could do and looked for a
nursing home. There was an opening here, so we moved him last Friday. He’s
gone downhill since.”
I heard the frustration and recrimination in her voice: Why was he doing
worse, not better at the nursing home? “The nurses tell me he has a lot of fluid in his lungs,” I said. “We can help him breathe easier.”
“Can you help him get better?” Janet asked.
Read the rest of the story

First published in JAMA,299:16 (2008):1879–80, used with permission in The Country Doctor Revisited (Kent State University Press, 2010)

Building trust is an important ingredient to the doctor-patient relationship. In the 4 habits model, Dr. Frankel ARTICLE  presents a very practical model for thinking about how to approach the patient. Sometimes trust must be built rapidly, such as in an emergency or crisis. In this story, I was faced with the angry daughter of a patient I did not know. Luckily my miniature donkey gave us a place to start the conversation. If you are on a rural rotation, what have you observed about how doctors and nurses build trust with patients?

End of life decisions–becoming your grandfather’s physician in rural Tennessee

–David McRay
Dr. McRay tells the story of helping his grandfather decide to end dialysis and agreed to be his physician so he could die at home. ..

As his creatinine level rose, his hematocrit fell, he had no choice. With the itching worse and the fatigue incapacitating, if he wanted to feel better—in fact, if he wanted to continue to live—he needed to begin dialysis. He did not understand what was being offered, how it would work or how it would make him feel. The therapy was never described as a form of life support
with all the customary conversations about indications, alternatives, ethics, and options for withdrawal. It was simply the next step in the management of his illness; a step he felt forced to accept but never really did.

The nearest dialysis center was in a town forty-five minutes north. Three days a week, my grandparents would leave home early in the morning and make the trip to greet the staff and submit to “misery,” the word he used to describe the way dialysis made him feel. Miserable though he was, he made the best of the situation, as he had always done with every hardship he encountered in his life and for two and a half years, he drove himself to dialysis most of the time.

A stroke changed everything. He awoke that morning with some troubling weakness and numbness in his right arm and leg. An ambulance trip and brief evaluation in the local hospital emergency room were followed by a transfer to the major medical center in Nashville where my grandfather remained hospitalized for two weeks. He was discharged to a rehabilitation hospital and then an extended care facility. He never suffered from a severe loss of function, but he became dependent, unable to attend to his most basic needs. His dignity was under attack; his spirit broken.

When his wife of sixty-one years passed away in her sleep, he asked, “What will happen if I don’t go back to dialysis?”

“I don’t know” was the only answer I could provide. I had never encountered this circumstance before. I knew he could delay his treatment a day, maybe two. A few days later, I spoke with a nephrologist in my community. She seemed very uncomfortable with the conversation and described the difficult deaths of two patients who chose to stop dialysis during her fellowship. Beyond that she offered little.

Granddad approached this decision in his usual careful and thoughtful manner. We continued our conversation and I tried to answer his many questions. We referenced the Christian Scriptures, talked about his relationship with God, and spoke of the confidence with which he felt he could approach the end of his life. We discussed other situations in which patients make decisions to withdraw life-sustaining medical care such as mechanical ventilation and tube feedings. He concluded that for him discontinuing renal dialysis was similar to discontinuing mechanical ventilation in the face of an irreversible, terminal illness. His kidneys had failed and would not recover. His life was without joy and now devoid of the experiences that had given it rich meaning for almost eight decades. Existence was limited to restless sleep on the bed or the sofa with painful, exhausting, and embarrassing trips to the bathroom.

Dr. McRay’s grandfather was enrolled in hospice and Dr. McRay agreed to become his grandfather’s physician so he could die at home. ..

The morphine and the hypoxia-induced sleep kept him unaware of the fluid that was filling his lungs. “I’m ready. Let’s go home,” were his final words. He slept and did not arouse again. His son held one hand and his daughter the other. I moved across the room and sat in a chair, watching with quiet reverence. This location provided my parents, aunt, and uncle enough space to be at his side. Perhaps the move was symbolic as well. My grandfather was dying on the couch, but he was also my patient. I needed to maintain some space, to hold on to the equinimitas I had found. Until my task was completed, I wanted and needed to protect my objectivity.

The end came quietly. Some of those present had never witnessed a death before. Startled, they looked to me for an interpretation, a diagnosis, a verdict. My solemn nod unlocked the door to their grief. Together we—his family and friends, his church and community, and me as his grandson and physician— allowed my grandfather to go home and stay home. With grace and courage, he overcame the obstacles presented by the rural location where he lived. With
hesitation and gratitude and with some sense of urgency and necessity, I overcame my uncertainty about the dual roles I was asked to play. I was honored and humbled by the privilege of helping my grandfather write the final chapter of his story. I believe he wrote it well.

Dr. McRay explores a number of important issues: ending life sustaining treatment such as dialysis, managing the dual roles—grandson and physician, the value of religion in exploring the big questions in life. In today’s world technology creates benefits and burdens. We can extend life, but those days and months are sometime more quantity than quality. Dr. McRay helped his grandfather decide to quit dialysis. Have you witnessed or been part of such discussions and decisions with patients? What did you learn? What will you take away from this essay as you help patients explore how they want to die and make decisions about resuscitation, intubation and advanced directives? How is religion and spirituality helpful to patients who have a faith?
Dr. McRay negotiates his dual role more carefully; this is explored more fully in part of this essay that is not included in the blog. What are important considerations for managing the dual roles?

Published in The Country Doctor Revisited (Kent State University Press, 2010) used with the permission of the author