"Keeping up" demands more than clinical knowledge

Which disciplines or knowledge bases do you draw on most, as a family physician, and how do you maintain such broad competency?

Reply:

The thought of "keeping up" in medicine has always produced angina in the hearts of specialists and novices. The seasoned generalist, oddly, has grown accustomed to the race. How do we find equanimity when there is so much to learn, so little bandwidth to our brains?

We often find it through teaching. Medical students and residents are amazingly facile at performing clinical exams and reaching working hypotheses. Diagnosis is usually the first concern of the student; treatment preoccupies the resident. What remains to be taught is the art of medicine. Physicians are managers: We manage the patient's clinical course and our own emotional investment in its outcome.

"Keeping up" is a problem encountered along every career ladder.

Our solution relies on the old adage, "It's not what you know but who you know," where "who" always refers to the patient.

Electronic health records have made it possible to grasp -- on command -- a practice profile: demographics, health maintenance, outcome markers. It is the report card by which physicians will be compensated and recertified. The new parlance is "performance." Insurers are looking at diseases and treatment guidelines to gauge our performance. This is progress, both overdue and commendable.

With electronic connectivity, clinical information not only flows out of the doctor's office but into it. It is possible to review treatment guidelines and drug options in "real time," at the clinical bedside. Software has become sophisticated, affordable, and mobile. The Medical Letter on Drugs and Therapeutics, and electronic resources, such as ePocrates, UpToDate, MD Consult, and 5-minute Clinical Consult, are suddenly indispensable tools of the trade. We have reached the point in medicine where learning can be utilized at the point of care.

The transformations of the digital age only heighten the need for a competent history and physical examination. Without it, we are sailors without a bearing, at the mercy of Bayes' theorem and its concern for pretest probability. And yes, patients will heal themselves and die at their appointed hours. But these stubborn realities should not deter us from investing in technology for our patients.

Most physicians enjoy a patient's smile more than their desktop interface, the touch of a brawny hand more than the click of a keyboard. We are humanists. Our workspace is the doctor-patient relationship, however old-fashioned or "analog" this construction has become. We realize that every technology is but a tool with an intended purpose. That purpose is to help our patients feel better.

Thus, technology must never distance the doctor from his patient. "Keeping up" includes our energy level, our ideals, and our love of the profession. Here, then, is the advice I offer the PDA-toting practitioner as he enters the clinical encounter.

• Listen to your patients, lest they leave having satisfied your needs alone, or hang you with a question on the doorknob, "Oh, about the blood in my sputum ..."
• Determine if they are sick or not sick, that is, if the diagnosis can be nuanced or needs an immediate answer.
• Outline when the patient might expect to feel better, and what you'll do if he or she doesn't.
• Do what is needed, even if it is not your job. Kindness creates inestimable goodwill.
• Ask for help and listen to your critics.
• Adjust your schedule, expectations, authority and pride if it benefits the patient.
• Love each patient, or, if the word embarrasses, find a way to connect to her or him. Otherwise you will waste time and money generating tests, referrals and excuses to be "fired." This simply postpones the moment of truth your patient is searching for.

Sadly, we may be judged by our secretarial skill, not our compassion; penalized for time we spend, not rewarded. But all good work converges toward professional excellence. The sooner we master the technical requirements of the trade, the more fully present to our patients we will become. And the more we can help and enjoy those we are pledged to serve.

David A. Loxterkamp, MD, Family physician, Seaport Family Practice, Belfast, Maine

Reply:

At 5:30 a.m. I get a call from a nurse on the telemetry floor at the hospital for a patient with chest pain and possible stroke. At 9:30 a.m., the first of 25 patients is processed and escorted to my office for follow-up of her hypertension, diabetes and obesity. In the afternoon, the 45-year-old son of a patient in the hospital with low potassium comes in since he knows what his father is going through and just wants to "get checked out."

Later, a new patient I saw four weeks ago comes in to share her success in changing her lifestyle, eating more vegetables, increasing her exercise, decreasing her cigarette use, and losing three pounds!

These are just a few of the situations I encounter many times a day, every day. I am in private practice with one partner, my mother, Aleli Romero, MD. We continue to follow patients in the hospital when they are acutely ill and in the office for common problems and for health maintenance/prevention visits. We enjoy providing this continuum of care to help patients when they are ill and to prevent them from getting sick.

Our practice serves predominantly adult patients, although I also see children. Often, I take care of the parents and grandparents of these children as well.

As I observed my mother in her early practice years, I saw how happy she was to help so many people. When I joined her practice nine years ago, I walked into a full office schedule and a busy hospital practice. But I have quickly learned that a family medicine practice of today has changed significantly from a family medicine practice from yesterday.

In the office, the volume of patients is still high but the amount of time that can be allocated to each patient is less. This change is multifactorial. First, more paperwork and documentation are required. Often, more time is spent with the documentation than in actual face time with the patient. Secondly, the reimbursements for office visits have decreased while our overhead continues to increase. Clearly, with decreasing reimbursements and increasing expenses, it takes more patients to generate the income necessary to sustain the office. And third, many patients of today are informed, Internet-savvy and empowered to care for themselves or their family members as much as possible. These patients come in knowing what they want, where they want to go and who is going to help them.

Meanwhile, the number of hospital patients has declined, but the complexity of the cases has increased. Often, compliance issues are to blame. In other patients, disease still progresses and they experience serious conditions that require hospitalization, despite being compliant with their medications, diet and exercises.

My mother and I have been fortunate to learn from every patient and from each other. We share cases, ask challenging questions and help each other search for answers in books, journals or on the Internet. In the hospital, we keep up to date with hospital medicine through our interactions with colleagues. We learn from our subspecialist colleagues who serve as consultants for our patients, and we also learn from other family doctors, internists and pediatricians whom we encounter in the hospital setting.

My mother and I subscribe to several medical journals and take advantage of evening educational seminars. In addition, we obtain updated clinical and practice management information through the many activities of our state specialty society, Virginia Academy of Family Physicians, and the national American Academy of Family Physicians. Our academy offers face-to-face continuing medical education, mail-in CME and now, quality improvement education.

Do we have busy days? Yes. The sheer volume of patients that we see in the hospital and office combined can be overwhelming and exhausting.

However, what has not changed from years ago is the satisfaction of caring for our patients; being available for their health care needs is fulfilling and rewarding beyond words. Would my mother and I become family physicians all over again? As we appreciate the privilege of serving as family physicians and revel in the pleasure of being part of so many lives, the answer is a resounding yes.

Cynthia C. Romero, MD, Family physician, Romero Family Practice, Virginia Beach, Va., member, Commission on the Health of the Public, American Academy of Family Physicians