I am a Family Physician. What does it feel like, in the decade of the patient, and why you should care – Part 3 of 3

This is part 3 of 3 of “I am a Family Physician”. Click here to access parts 1 and 2.

What it feels like to be one (a family doctor)

The first secretary of the American Academy of Family Physicians said his contribution was to:

give prestige and dignity to the general practitioners. They had been discriminated against for years, and were considered nobodies among medical organizations.

There’s an undercurrent in our history of wanting respect, which manifests today as a kind of underdog feeling.

(and maybe it’s a little ironic that within medicine, a profession that commands such respect in society, there are feelings of disempowerment – we have a lot in common with our patients)

Artist Regina Holliday (@ReginaHolliday) captured this so well in my first Walking Gallery jacket, maybe more than she realizes (she tends to do that), when she created a piece called “Shoot the Moon.” . Regina wrote in her blog post about the jacket

No great change is possible without the chance of great failure. 

In medicine, this is the kind of choice that people like me made when we chose family medicine. We made it willingly.

Meeting another family physician in a room of doctors or any room is like finding another American in Europe. 

Meeting a member of the community who learns that I am a family doctor almost always gets a genuine smile.

We are conditioned to have unlimited curiosity because we can’t limit the depth of our interest in any topic or person.

We study the art and the science (and we hang out with artists :)).

We know as doctors that when we talk people listen. We know as family doctors that when we listen, people talk, and we love that. A lot.

We’re all necessary – every specialty, every clinician

I have the interesting (and quite awesome actually) niche experience of training as a family physician in (a) a multi specialty medical group (b) in a non-profit integrated care delivery system that was (c) created and is governed by patients as a health care cooperative

What I know good health care to be means that:

  • I reject any notion that sub or other specialists are a problem or at cross purposes with myself, other primary care physicians, or our patients
  • I see family physicians as integrators and collaborators across all the specialties, our patients, families, community, society
  • I don’t see family physicians as the exclusive bearers of the social movement or mission driven flag in medicine
The last point is reflected really well in an email dialogue I had with Mark Smith, MD, Director of the Medstar Institute for Innovation, about his choice of emergency medicine as a specialty ( born in 1979,  younger than family medicine ):
The question that I got (from my advisor in medical school who was an internist) when I decided to do a residency in emergency medicine (1977-1980) was. “why don’t you do an internal medicine residency?  You can always work in an ER.”  There was strongly conveyed sense of the illegitimacy the the specialty. I wound up sitting for the 2nd or 3rd offering of the boards (and have now recertified 3 times (q 10 years)).

Here I want to say that I’ve recognized in this review that family medicine is unique; its values are not exclusive. I’ll expound on it more below, but first:

Good news about technology and the decade of the patient

I came across these quotes, across the generations of doctors, that express a kind of defiance, mixed with fear, about the role of the physician in the era of an enabled patient.

It may be that computers will soon diagnose better than doctors. But the facts fed to computers will still have to be the result of intimate, individual recognition of the patient. (From A Fortunate Man, 1965)

Family physicians will become more in demand and more clearly a center point of an efficiently operating health care system, says Robert Graham, MD….he discounts predictions that patients of the future will become their own doctors with little diagnostic computers (Robert Graham, MD, Executive VP of AAFP, 1997)

 In 2013, I can put their fears to rest, thanks to the exploration of colleagues like Susannah Fox ( @susannahfox ) – (see: The relationship with Health Professionals in the era of social media | Ted Eytan, MD ) and  the work of Edelman and the Health Barometer (see: Edelman Health Barometer 2011 – Doctor most credible source of health information | Ted Eytan, MD), and just being alive in health care.

The decade of the patient is only going to make you, compassionate, caring, curious, doctor, even more important in people’s lives. All you have to do is keep listening.

Why you should care

I’m not writing these posts so that people care about the story of family medicine over any other specialty. Instead, I hope people care about the stories of all physicians as much as physicians care about the stories of their patients and their families. I would like people to care that the calling of every physician and specialist is genuine and meaningful.

One of the lost opportunities I see so often when people work with doctors is that they stop at, “What do you do?” instead of continuing on to “Why do you do it?”  

Try that latter question with any physician, regardless of specialty. You’ll (a) probably get more than 3 blog posts of narrative (b) be very impressed (c) find out you have a lot in common.

Thanks again to all the people who expressed curiosity about what this is, the people who came before me, and American Board of Family Medicine and the American Board of Medical Specialties who are with us today.

I am a Family Physician. Where did we come from (and why should you care)? – Part 2 of 3

McWhinney IR. Family Medicine in Perspective. New England Journal of Medicine. 1975;293(4):176–181.

This is part 2 of a 3 part series. Click here to access all the parts. In part 1 I talked about what I am. Here’s what I found out about where I came from,.

Conceived in the 20th Century as a new specialist, with a different view of “knowledge”

The problem of the primary care shortage didn’t happen recently; during World War II, medical students were given military exemptions by the U.S. Government if they pursued specialty training. Problem was, there was no residency in general practice. The GI Bill exacerbated what became an increasing fragmentation of medical practice through its incentives.

Further, medical knowledge was conceptualized as a “lump,” ever increasing, needing to be broken up into smaller bits, and managed by an increasingly narrow physician pool. 

The creators of this new specialist thought differently. They believed that knowledge of a person, their environment, and the application of medical knowledge to their situation was the most vital type of knowledge and called the lump theory a fallacy:

One tends to think of poor physicians as badly informed physicians. But everyone has encountered superbly informed physicians, who can quote all the latest references, but are woefully lacking in clinical judgment, and also excellent clinicians who in their dealings with people are incredibly naive. (McWhinney, 1975)

They didn’t want to handoff an organ system from one doctor to another, and they didn’t want to take over or diminish the role of sub-specialists either.

he will be a specialist by inclusion – in contrast to the classical clinical specialist who specializes by excluding. His aim is to broaden his concern, to widen his skill; he seeks to accept responsibility; not merely to pass it along. He utilizes specialists, rather than surrendering to them. (Wilson, 1969)

A social movement, less because of new technology, more in response to it

The kind of commitment I am speaking of implies rhat the physician will “stay with” a person whatever his problem may be, and he will do so because his commitment is to people more than to a body of knowledge or a branch of technology.

The times that ultimately spawned family medicine, the late 1960’s, influenced a generation of physicians who wanted to mirror the social change happening around them. 

There are … deeper reforms … which have motivated significant subsets of family physicians. I labeled these agrarianism, utopianism, humanism, consumerism, and feminism. (Stephens, 1979) 

Clearly we have been on the side of change in American life. We have identified ourselves with certain minorities and minority positions. We have been counter to the dominant forces in society. (Stephens, 1979)

Interestingly, while the counterculture-ness of the specialty was apparent, the point was made that the formation of family medicine may have taken the heat off of a medical profession that was becoming less appreciated by the public.

We are benevolent, well-intentioned, “humble country doctors” who only want to restore some balance to medicine. We do not want to destroy anything, or take anything away from anybody; we just want a place in the sun for ourselves and our residents and students. We are not radicals who wish to turn the world upside down. (Stephens, 1979)

In that sense, this specialty was also a preservation movement for all physicians. It appears there was even discussion (maybe heated at times?) about whether generalists should create a specialty in the first place.

I thought you already were a doctor? Where recertification came from – family medicine

An interesting bit of selflessness and protection of the future is the fact that the first family medicine specialists guaranteed that they would not hold their certification within 10 years – after that time it was required that everyone complete a 3 year residency.

In addition, family medicine was the first specialty to require periodic recertification. That’s the nod to consumerism:

The commitment to continuing education and recertification by family practice was right on target for the 1960’s resurgence of consumerism. Honest labeling of the physician’s qualifications, quality control of medical care and medical education, patient education, and patient advocacy are all consumer issues.

Prior to family medicine, the other specialties would simply grandfather their own for a lifetime. This is all changed now. This is why physicians secretly or openly prepare, study, fret, and go through this process on a regular basis. Medical school is just the beginning.

To all of the above, I say, “yep, that’s me.”

To all the social issues above, I add in my career “end to homophobia.”

What I found when I joined was a profession that lagged in human rights instead of leading in it, ironically, and it’s still very much challenged today in this area. To learn more about this part of my story, my itgetsbetter video is here.

If I didn’t have family medicine as a choice when I became a doctor, medicine would be less interesting to me, and maybe not viable at all.

For me, I think the choice was a correct one to establish family medicine as a specialty, for people who wanted advanced training as physicians in care of people, family, communities, society, AND to change the profession and society itself.

Tomorrow: what it feels like, why everyone is necessary, where we fit in the decade of the patient…