Sunday, September 2, 2012

How I Practice Medicine

     When I meet a patient, sick or not, for the first time, I am presented with an immediate option:  Am I willing to travel the long, dark path with him, to his interior, or will I stay on the surface?
     Sometimes you meet a stranger under the same circumstances--seated next to you on an airplane, or train, or a long bus ride, or at a party or reunion, a hospital appointment, a cruise ship, a bar.  It's a bit different when it happens this way, since there are natural boundaries to the meeting--the trip or party will end, and a lid is placed over the contents of all that has been said.  Still, the choice is the same:  Will you listen, and encourage the person to take you on a trip to his deepest self, or not?
     "I had cancer," the stranger may bait you, for we are always reaching out to one in another in these ways.  You can answer, "Yeah, my aunt had cancer too--hey, do you know if the next stop is Catahoochie?"  or, very differently:  "Wow, that's a big deal--what happened?"  How you respond  depends on many factors, but mainly on whether you're interested in people and how they unveil themselves, and whether you like involvement, or not.
     Doctors are supposed to like involvement with people, and many of us do.  We ask additional questions, and we're thinking about what the answers mean about your symptoms and what they say about your personhood.  But there are also jokes in the medical profession about patients who will not let us go, who prolong office visits with their urgent need to talk--who, when the session seems to be over and the doctor has his hand on the doorknob to exit--say, "Oh, by the way, I'm having chest pain"--thereby forcing him back into the room and into engagement.  We're under pressure to see all the patients who come into the office, and we can't spend hours with each one.
     Except that we can, in Family Practice, over a period of years, even decades.  When I see a patient for the first time, I like to make room for a dialogue to begin, Chapter One, so to speak.  I spend an hour or more, gathering information from the story of his or her life, the genesis of the current symptoms, and diagnostic tests that might provide a series of clues as to the nature of the problems--the small problem of the illness, and the bigger problem of that person's task in life.
     Most doctors are trained to do this.  We're taught how to ask questions, but no one can teach us how to be interested--and maybe that's where, finally, doctors fail.  Our interest in people and the profession is dampened by a constant feeling of personal imperilment.  Are we going to get in trouble for doing our jobs?  Being overloaded with bureaucratic necessities doesn't help.  We have been taught in medical training to choose tests and procedures carefully, but when frightened by the prospect of a malpractice lawsuit for missing rare conditions we spend much more money than really makes sense.   And the current habit--exercised by insurance companies, government authorities, and patients--of questioning every move we make, and every test we do--as though they happen to be the authorities, not us, in the practice of healthcare--creates a level of distress, even paranoia, that makes it impossible to think, and unlikely that we'll be inclined to engage the patient.
     I like hearing patients' stories, and I rely on the details to lead me to a diagnosis.  I also like information, believing that it will illuminate the territory through which the patient is wandering, feeling ill.  So I order tests, partly to prevent problems down the road--ER visits, hospitalizations, cardiac arrests, late-stage cancer, and so on.  I discover a lot more than could be uncovered in quick visits or the false economy of "urgent care."  I can't ignore my patients' family enmeshments, extramarital affairs, overuse of harmful substances, STD exposure, unhealthy diets, sluggish dispositions, sadness, history of childhood abuse, or subtle physical symptoms.  Addressing all of these makes for excellent healthcare--but it takes time, and costs money.
     It is interesting, then, that the big question in the healthcare debate these days is how to get family doctors to do exactly what it is I already do--exactly what has gotten me into trouble with the federal government, and what impels insurance companies to audit me incessantly.  How can we get family doctors to spend more time with patients, ferret out their problems, do more tests, and prevent costly problems in the future?--is the recent appeal.
     "Primary Care's Role is Crucial in Cutting Costs," the medical journal articles have been shouting, month after month.  Then, why am I under investigation?  
     Into the foreground have recently appeared many proposals for giving family doctors incentives to add diagnostic equipment to their offices, spend time counseling patients about alcohol and drug use, and get involved in the patients' personal and family dynamics as a way of offsetting depression, anxiety and sleep disorders that open the gateway to physical maladies.  Family doctors are being encouraged to provide treatment in their offices, thereby circumventing referrals to specialists, or resorting to hospitalization.
     But I have always had diagnostic equipment in my office--it helps me to determine what's wrong with people, and it keeps them from doctor-hopping.  I have devoted long, fruitful sessions to conversations with my patients, saving untold expense.  Family doctors are the key to cheaper and better healthcare in this country.  If we aren't threatened by insurance companies and handcuffed by government agencies, we can do our jobs the way we were trained, and keep the country from hemorrhaging healthcare dollars.


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