Tag Archives: art of medicine

A Modern Country Doc–playing the game

Tom Bibey

The insurance companies love to play doctor. Take my noncompliant diabetic patient with a hemoglobin A1C that does not meet goal. (We explained this in an earlier blog post.) The first order of business, since I wish to stay in practice, is to send him to an endocrinologist. If possible, one should bolster the case by the choice of one from a medical center. A year later, the patient will still have the same numbers, unless he comes to Jesus and decides to change his life. The cost of the endocrinologist changed nothing but increased the bill to insurance, and my risk as a target for the blame is dramatically lowered due to the referral.

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

Here Dr. B is referring to our effort to meet certain treatment goals with patients. Some insurance companies reimburse physicians with extra money if a certain percentage of their patients reach the recommended goals. This is called Pay for Performance and sometimes referred to as P4P.

A large randomized controlled trial on diabetes–ACCORD— helped to outline the goals management of  patients with Type 2 diabetics. Here is an easy explanation.

The challenge is to motivate patients to change their behavior, often easier said than done. In earlier posts we’ve talked about Motivational Interviewing techniques to help patient weigh the pros and cons of continuing to do what they do. As you spend time in clinic, you’ll see different attempts to help patients quit smoking, lose weight, start exercising, be compliant with their medications. It is no easy task. However, I don’t want to leave you with a downer. When you do assist someone in making a behavior change, there is nothing like it—it can make your whole day or week for that matter.

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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

Home Visit

As a medical student in North Carolina, Dr. Fleg did a home visit with his preceptor and received a gift for his heart.

 The Sisters

–Written in Love

by Anthony Fleg

My watch said it was time to go,

But my heart spoke otherwise,

Fortunately, I listened to the latter

And went with Dr. Stuart to see

The Sisters

Miss Minnie and Miss Viola

Hailing from Georgia,

With ten scores of wisdom between them,

They spoke first, without words

Perfuming the room as we entered.

They began to tell of their aches and pains,

Joking about whether Dr. Stuart or I would be their “catch” for the day

When asked about the key to their longevity,

Viola answered, “God has been good to us,”

While their relative with them offered, “It is because they were good to their momma.”

Which caused me to pause,

Trying to shut off that medicalized, left-brain-oriented way of hearing that afflicts many of us in medicine,

They spoke not on the recipe for reaching the holy feat of triple digits,

But instead on the way to appreciate each and every day whole-ly,

as something holy,

They teach that the goal is not to reach an old age

But instead is about how to be on your way there

They remind us that the goal is not to avoid death

But to fully embrace life

I am thankful,

I am refreshed,

Dr. Stuart and I leave smiling with our minds and hearts

If someone asks me why I am late

I’ll simply say, “My teachers had something I needed to hear.”

(used with permission and published in The Country Doctor Revisited, KSU, 2010)

Many patients have lots to teach us, especially older patients, who know their bodies and themselves pretty well. One of my favorite elderly patients, a retired farmer, cannot do much on the farm now that he’s reached 90, but he takes great pride in growing tomatoes. He’s given me many pointers and improved my green thumb. Despite the pressure of seeing lots of patients, Dr. Fleg reminds us that we need to take the time to listen and connect with patients on topics beyond their health and diseases. These kinds of connections nourish us and are the rewards that come from taking care of people. If we don’t take time to bask in these, we will get burned out and cynical. What are some of the treasures you’ve heard and witnessed on your rural rotation? What wisdom will you carry with you for a while? Urban patients have many treasures to share as well. Urban or rural, have you seen interactions between your teacher and a patient that remind you of Dr. Fleg’s. Sometimes you are working with teachers who are burned out. What opportunities to interact with patients have they missed?

Welcome to Elma

–Mitchell L. Cohen

Dr. Cohen, who practiced family medicine for five years in rural Washington, describes a typical day’s roster of patients to the third year medical student spending the month with him:

First on the schedule is a forty year old log truck driver coming in to get his physical for his license. I never knew how many log truck drivers were in this county until I started working here. Here’s a thirty two year old female with chest pain that’s probably either her asthma, anxiety, or both. She smokes way too much tobacco and marijuana. Then there’s a depressed patient with fairly newly diagnosed diabetes, high blood pressure, and elevated cholesterol. It’s so frustrating. He just doesn’t seem to care, but I know a lot of this is the depression. The next guy you’ve got to meet. He is eighty nine and coming in to talk about his gout. He’s a retired veterinarian and tells some pretty amazing stories. Just ask him about serving in Italy in World War II. A tough case of ADHD in a kid in foster care is next. We’ll do a skin biopsy on the next guy. His dad is one of my patients in the nursing home. Really sad; rapidly advancing dementia.  He’s having a tough time watching his father go through so much. 

Then it’s lunch time. Do you like Mexican food? Good. For lunch we’ll walk on over to this great Mexican place on the next block. The owners and most of the employees come here for their medical care too. I highly recommend the spinach enchilada.

In the afternoon we’ll start with a pregnant patient of mine. I delivered her last baby. I also take care of her parents and grandparents. We have quite a few third and fourth generation families in the practice. My partner holds the record for a five generation family, but then the great-great grandparent died and it went back to four generations. This guy here always comes in to get his ear wax cleaned out. Ahh, fascinating stuff there! Here’s a guy in his mid-forties with low back pain and, and, oh by the way, he’s seventy pounds overweight, smokes, and uses walking to his mailbox as his form of exercise. These visits are painful for both of us. Anyway, dispersed among all of those there are a few well child visits, other pregnancy appointments, some of these might be Spanish speakers. How’s your Spanish? I spent two years of my CME time learning Spanish. I am passable, unless it gets complicated, then I use a phone translator—but as you’ll learn, the visit fee hardly pays the cost. Then of course, more high blood pressure and diabetes, and the rest we’ll figure out when we take a look on the other side of the door.  Looks like about twenty-two patients total—pretty typical day.

Remember, you’re here to learn about rural medicine. Get to know the patients. Let them tell you about their families and what they do for a living. You’ll see that so much of what they tell you relates to their medical illnesses in ways that you haven’t ever considered. This is one of the intangible benefits of family medicine and it is best brought out in rural areas. It doesn’t appear in any proficiency scores or quality measures, but the continuity of care we provide for generations of families allows us to tailor modern medicine to fit their needs. This is the art of medicine. 

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

Today we talk about the value of evidence-based medicine, knowing the best practice for your patient’s disease and situation. Research and science have their place in caring, but so does the art. Dr. Cohen describes the art as letting the patients tell you about their families, what they do for a living and about their lives and then comes the art—you adjust the science to make it work for them and their unique situations.  I am thinking of one of my new diabetic patients. If I want to get quality credit for my diabetes management I need to have the BP well controlled, the Hemoglobin A1C under 8, the LDL under 100, and the patient needs to take an ACE/ARB (like lisinopril) and aspirin. If I addressed all that with him during our first visit he would have been drinking out of a fire-hose—not fun for anyone. So little by little we examine the various issues and negotiate what he can and cannot do.

What has surprised you about the patients you have encountered on your rotation? Where have art and science intersected? How has your teacher/preceptor’s knowledge of the patient over a number of years informed the diagnosis and treatment?