Family Matters

Don't get me wrong: I admire family practice docs. I recognize what a tough and undervalued job they have; and the ones I know do it well. It's just that it was not always the case, either in terms of my admiration or their job performance. There was a time, of course, when all doctors were generalists. We can long for those days, or not; they drove their Model Ts to the farmhouse, passed out potions, delivered a baby or two, cut off a dead toe, comforted the dying. I might like to have a Model T to drive on special occasions. But for regular use, I'm glad I have a nice radio, air conditioning, and traction control. Thanks, but no thanks. The concept applies generally.

Years ago, family docs expected to assist in surgery for the patients they referred. Internists, who early on made up the bulk of my referring docs, hadn't the slightest desire to do so; was it because they didn't care as much about their patients? Did their patients, for some reason, not need the comfort obtained from knowing ol' Doc'd be there? Self-selection by patients, or self-delusion by doctors? I have an opinion. Whatever the answer, I can say without equivocation that having the family doc assist in surgery was an enormous pain in the ass. It began with scheduling, and got inexorably worse. The doc could only be there at such a date and such a time, usually first thing in the morning. Since I had certain reserved times in the operating rooms, and since I usually had people scheduled well in advance, signing up the FP patients meant making lots of calls to rearrange my other patients, along with a bunch of calls to the doc's office to make sure he/she knew the final arrangements. Ordinarily, such calls weren't necessary, because I had my own assistant; highly skilled, totally familiar with how I liked to do things, there from start to finish. People who really understand surgery (or people who've read my book) know how excellent it is to have an experienced team working together in surgery. People who spent a few weeks rotating through surgery during training do not understand surgery. If they did, and if they really cared about their "whole patient," they'd INSIST that the surgeon to whom they sent their beloved patient use his best and most experienced team when cutting on them. They'd know without being told that the best team decidedly did NOT include them. But we're talking about knowing limits, and about knowing what you DON'T know...

So after rearranging my list several times, and making calls and followup calls to the doc's office, invariably that doc would show up late. Regular readers of this blog know how I feel about lateness. (For a short operation, their lateness sometimes allowed me the pleasure of finishing before they showed up.) If they made it into the OR in time for the incision, they'd arm themselves with the cautery pencil and start buzzing the tiny skin bleeders as soon as my knife moved on. Drove me crazy: those things stop bleeding; cooking them probably adds to scarring, and I'd have to stand there while they got off on their workmanship. They also loved to tie knots. Slowly. Deliberately. Feeling surgical.

None of this is particularly critical: I'd get the operation done just fine, if a little less quickly, and with a little less of the pleasure one gets from an operation done rhythmically and artfully. If being annoying assistants in the OR was the only problem, I might not be writing this.

It's puzzling. How much familiarity with a thing is necessary to know how unfamiliar one is? Where's the dividing line between understanding and kidding oneself? What's the responsibility of a training program to make the delineation clear? What I do know is that seven years elapsed between getting my MD and finishing my surgical training; and that during that time I'd gone from knowing nothing to knowing a hell of a lot. And a lot of what I knew was that I didn't know everything. For example, when I first went into practice my partner asked me if I wanted to do vascular surgery. I told him I didn't think I'd had enough experience in it. (I trained right at the time of transition: earlier, all vascular surgery was done by general surgeons. In my time, vascular fellowships were appearing, and at my institution, which included one of the premier vascular departments in the country, general surgery residents were doing fewer vascular cases, as fellow were doing more.) My partner offered to observe and mentor me until I was more confident. To me, that seemed like a deception to a patient: I've always believed if I were to operate on people, I should be able truthfully to tell them I thought I could do it as well as anyone. I knew how to do those operations; yet I would not have and did not feel right passing myself off as a vascular surgeon. I knew enough to know that ability to sew a graft was only a small part of vascular surgery. And were a complication to occur, I don't know how I'd live with myself. So how is it that family practice docs were coming to town, right out of training, and asking to do (click warning: gross, NC 17) hernia repairs, C-sections, and tubal ligations? Tracheostomies! What did it say about them, and about their training? Since, as I eventually learned, these are good people, I think it says their training sucked. They learned from teachers with an inflated sense of the primacy of primary care, and a deflated sense of what's involved in surgery. They were told that the more they did themselves for their patients the better it is, and to the extent that they referred to specialists, they were letting their patients down -- subjecting them to narrowly focused monomaniacs who didn't care. Whereas my training was characterized by the constant reminder of how little I knew, by the public out-hanging of every error big or small, theirs must have been the opposite: the paltry time you spent on a surgical rotation, doing OB, is enough to have given you everything you need to know. (Again: this was a while back, when the holy grail, the salvation of American healthcare, was the gatekeeper.) A few examples may serve to explain why I felt that way: (most of these refer to incidents in my community but not in my clinic, I hasten to add.)

A) Fresh out of training, a young FP asks for tubal ligation privileges, and is denied by the OB department. She goes to the hospital board, threatening suit. Over the resignation of the OB chairman, she's given privileges. At the independent surgery center, which grants privileges based on the hospital's, she does her first procedure, assisted by her slightly more experienced partner. Pathology report from the right tube: "normal appendix." A general surgeon handles the subsequent admission for sepsis, from which the patient recovers without sequellae.

B) I'm referred a patient with a hernia, repaired by his young family doc. The doc assists as I repair it, finding the original operation was one I thought universally abandoned because of its well-known high recurrence rate. I didn't hide my surprise. "Well, that's what Joe taught me," he said. Joe was his senior partner, an older guy grandfathered into pretty broad surgical privileges, having learned most of what he knew from HIS senior partner, long since retired. Joe usually managed to get general surgeons, to whom he referred those cases he didn't do, whorishly to help on his own operations. I wasn't on his list.

C) Another young study of Joe hacks into the femoral artery during a hernia repair. (Trust me, that's pretty damn hard to do.) He does have the sense to hold a finger on it while awaiting the arrival of a surgeon.

D) Called to see a man hospitalized with a bowel obstruction, I find a FP had admitted and cared for him without consult for several days. The dead bowel I removed wasn't enough to leave him nutritionally affected, and he did fine after several more days. Consultation on admission would, I'm certain, have led to a quick operation with no dead bowel, and many days fewer in the hospital.

E) I run into one of my old mentors at a meeting; he's a trauma guru, and a strong advocate for surgeons managing ICU patients. In training, I did manage those patients, with their ventilators, cardiotonic drugs, their multi-organ failures. In practice, I thankfully dealt with such critically ill people far less frequently. Intensivists, I tell Don, are much better at it than I'd become. "Don't give up your role," he says, strenuously. "You don't understand what it's like in the real world," I tell him. "I'm not as good at it anymore." He glowers.

F) While I'm serving on the board of my ever-expanding clinic, in the midst of the gate-keeper frenzy, a family doc presents a form he's planning to send along with his patients to every specialist, requiring specific enumeration of reasons for every test, every procedure proposed. He'll not authorize anything without its return and personal review. After some possibly ill-chosen words, I resign from the board.

G) Having saved a woman who'd showed up in the ER with a perforated stomach due to cancer, requiring emergency gastrectomy (and washing her belly with distilled water to kill any cancer cells that were spread by the perforation), I ordered tests after she recovered which showed a solitary metastasis in the left lobe of her liver. Liver resectionally, the left lobe is more or less a piece of cake; but I hadn't been doing elective liver surgery because it just didn't come up much. Despite her strong desire to stick with me, and despite knowing how to do the operation, I referred the patient to a more experienced liver-surgeon (who fucked it up royally, I must say.)

It wasn't fair: taking young docs right out of too-brief training and immediately telling them they must be in charge of everything. Even if they knew at some level they weren't ready, they really weren't in a position to say no. And I think, because of their training, many didn't think they weren't ready. Until they found out, the hard way. At the time, I could fathom neither the training that sent them into the world so misinformed, nor the system that demanded it of them; nor especially the fact that many seemed not to have the warning mechanisms built in to have kept them above water.

Other realities settled in: for one thing, as reimbursement for surgery steadily declined, and as the assisting fees did likewise, it became clear to most family docs that it simply wasn't cost-effective for them to be out of their offices. I guess their patients' need for knowing ol' doc was there disappeared at just the right time. Meanwhile, pre-paid healthcare, with its extraordinary pressure on primary docs and its placing them in direct conflict with their patients, came to be seen as a false profit. (Good one!) So family docs began, perhaps first of necessity, but eventually as a matter of reality-testing, to realize they could with impunity leave specialty care to specialists. Most are even giving up OB, if sadly.

I can't say if I was right about what they were told then in training, or if it's different now. I can say that most family practice doctors now have practices mainly in their offices, and that I think it's a good thing. I don't think their surgical patients are any worse off for their doctors' absence from the OR. And whereas I think it's true that the referring docs with whom I worked -- if for no other reason than being in a contained group with frequent interaction -- eventually came to trust me with their patients without having to throw up roadblocks, it's also the case that I came to understand what an important and difficult job family docs have. They're the central clearing house, the entryway, the providers of continuity; and they still have pressure to do as much as possible themselves. They need all the love they can get.

Postscript: It's not as if I think surgeons don't make errors. I have. They do. But I can honestly say I've never made one because I over-reached; never because I failed to recognize when I was in over my head. Such errors ought, in my mind, never occur. Inculcating the sense of limits, giving doctors and nurses the intuition and knowledge to know what they don't know, and when they don't know it, is the single most important mission of training, as I see it. Nor am I absolutely certain it can be taught. I think it can, and I know for sure doctors (and nurses) who don't have those mechanisms ought not be in the business. Maybe there's a way to pre-test for it... And based on experience, I can say it's surgical training that comes at all close to the mark, with the medical specialties not far behind. For a while there, family practice was decidedly (bringing) up the rear. I'm guessing not all readers will agree.

Testing the Limits

If surgery training, with its brutality, inculcates a saving sense of limitations, of knowing when you're about to get in over your head, family practice training does the opposite. That's what I thought a few years ago, and the reason I thought so was that at the time, it was true. Things have changed, and so has my opinion. But there was a period in my practice when I believed the worse thing you could do was choose as your doctor a family practitioner. And that was AFTER I'd happily and with no subsequent regrets chosen as my doctor -- and that of my wife and son -- a family practitioner.

It was a perfect storm: the confluence of the concept of the "gatekeeper," and the idea that specialists were overvalued, and the shift in emphasis of medical schools toward cranking out more primary care doctors. A darker view would be that it was the fruition of the belief by all the various healthcare payors that the more you pit doctors against one another, the easier it is to get them to work harder for less money. But I digress.

During my training, the only contact I'd had with family practice docs was at the county hospital, which provided them a residency program. It was only in the emergency department that we intersected: they had no role nor spent any time on the surgical service, which seemed fine. Why would they need to? In the ED, as interns we were the same: grab the next chart and deal with the problem at hand, among those of the countless souls waiting for help. Sore throat, vomiting, belly-ache, discharges and drips. See and sort. We were all pretty much interchangeable at that level, but I noticed all the male FPs had beards, and liked to spend too much time (given the seemingly self-fertilizing piles of charts waiting) convincing drunks they should stop drinking. Surgeons -- by decree -- were clean-shaven, and we tended to focus on turning the crank as fast as possible. After internship, my dealings with medical types were entirely with practitioners of the fields involved in internal medicine. Family practice folk were, I must have assumed, office docs.

Before arriving in my current location, I spent five years in a small clinic in Oregon. Adjacent to my office was that of the family practice doc who became my friend and my doc. He was about my age, but because of the shorter length of his training and having escaped military service (unlike me) he'd been in practice for several years. He had broad knowledge of adult and pediatric medicine, giving excellent and devoted care to his patients, and referring to specialists when any sort of procedure or complex hospitalization was required. So did his three compatriots. It so happened that the hospital had rules prohibiting FPs from doing any operations, and even from admitting to the ICU/CCU. I'd understood they were adopted not without acrimony; but my clinic-mates never expressed a desire to be doing more than they were. They liked to assist on the operations I did on their patients; that was about it.

I joined a much larger clinic when I moved. Initially, we were a FP-free zone. Unlike the smaller clinic in Oregon, this clinic had figured out that multi-specialty groups couldn't survive forever without a broad primary care base, for the simple reason that docs who weren't in a clinic preferred to refer patients to specialists who were also not so aligned. In the years prior to my arrival, and for the first few after, the expansion of primary care had been in the form of general internists, pediatricians, and OB/GYNs. But family practice had developed momentum in the public arena: caring for the "whole patient" had a certain logic to it. Why leave your kidneys here, your heart there, and your gallbladder god-knows-where? Those specialists: all they care about is a few organs and a lot of dollars. So our leaders told us that in addition to having opened walk-in clinics, extended hours to seven days a week, emphasizing access, we needed to hire family doctors, because that's what the demographic studies were saying. It was controversial.

Being a relative newbie, I didn't speak up much; plus, my prior experience with family practice had been positive. Probably overly snooty, it was the general reaction that the clinic had promoted itself on the basis of specialty care and expertise, and that hiring family practice would be a downgrade. Would they be allowed to deliver babies, the OBs wanted to know. How would we survive, asked the internists? Still a work in progress, turf-wise, the family practice department was brought to life. In the long run, it's worked out great: the clinic is one of the most successful doctor-run ones in the country, still growing at a staggering rate, and thriving. When I came there were about thirty-five docs; now there are around two hundred fifty. It's gone from one main office and one satellite, to around ten satellites, all happily staffed with FPs among the internists, pedipods, and OB/GYNs. It has two MRIs, at least two CT scanners, a comprehensive lab, its own nucular medicine department, two surgical centers, fully electronic medical records, patients up the wazoo. But the family practice idea didn't start entirely well.

Let's take a moment to set the scene: this was all happening at the time of early focus on the skyrocketing costs of healthcare. (It should be obvious that there are still no really comprehensive solutions; in one guise or another, it's still just about cutting payments to doctors and hospitals.) But for a while the hot idea was that of primary care doctor as gate-keeper, with or without pre-paid care. Not only the insurers, but the companies that paid the premiums bought the concept; and it's not without a certain purity of logic. Left to their own devices, specialists will do what they do, unrestrained (certainly not by conscience, ethics, or a sense of propriety. Surely not.) Put the primary care doctor -- clearly the only one in the equation who truly has the patients' best interest at heart! -- in charge of deciding when a specialist is necessary and what procedures that specialist is authorized to do. Clean, and tidy. Economical. And if you really want to see an end to unnecessary care, give all the money to the primary care doc, pre-paid based on how many patients he/she has, and make that doc pay for the specialist care out of that stash. Perfect. My clinic, in another overly snooty bit of self-delusion, figured if anyone knew how to monitor and control costs and to deliver highly efficient care, it was us. We bought the pre-paid, gate-keeper run model, hooker, line-item, and stinker. Nor did it occur to us that if we were going to entrust that responsibility (not to mention the huge pressure and implicit conflict-of-interest) to people, they ought to have some preparation and experience in the matter. Which gets us back to the training issue.

My first clue came with the first call. Within weeks of hiring a couple of family practice doctors (fresh out of training, shiny as a new penny) I got a call from one, asking if I did pediatric hernia repairs. I did. At which hospital? At a surgery center, outpatient. Well, I'd like to refer you a baby, and I need to be there to assist. Uh, I generally don't need or use an assistant for a pedi-hernia; you're welcome to be there, but I really wouldn't want there to be a charge for an assist. Well, I think the family would feel better if I were there...

OK, not a real big deal. But my thought was, this isn't exactly good ol' Doc Jones who delivered three generations of the same family on the kitchen table. This person has been in town all of three weeks, and can't possibly have the sort of relationship with the family from which that sort of comfort derives. So it's got to be the training: you, they must be told, are the only thing standing between your patient and mayhem. No specialist (certainly no pea-brained, slash and cut, think-with-his-wallet surgeon, fergodsakes) will ever have the patient's interest at heart the way you do. Maybe I'm a little paranoid. Maybe even more then than now. But I wondered about the larger implications: if, after three weeks out of the oven, this doc believes he has the rapport, the knowledge, the TRAINING to run interference between his patient and me, what other delusions might he have? And where might it lead? I'd had five more years of training than he, and more than five years in practice. Maybe he was the most brilliant guy on the planet, or maybe those FP residencies had actually found a way to fill brains to the max with all the info in all the specialties -- as opposed to mine, which took three times the years to fill me up with only one specialty, and left me needing a little time in the world to feel competent. Was I making too much of it? It was just a request to be there, after all. But it seemed to bespeak a mindset: whereas I'd had grinding, lengthy, browbeating, comprehensive, non-stop 24/7 training that left me able to do very complex operations and evaluations but still wondering if I knew a damn thing, these guys had had a few weeks each in several specialties and were evidently told they knew everything. Was I wrong? We'll see....