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DiscussionReflections

Caring for the Tribe: From Addiction to Zen

David Loxterkamp
The Annals of Family Medicine November 2017, 15 (6) 578-580; DOI: https://doi.org/10.1370/afm.2151
David Loxterkamp
Seaport Community Health Center, Belfast, Maine
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  • For correspondence: david.loxterkamp@gmail.com
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  • Author response to Dr. Topolski and Dr. Vinson
    David A Loxterkamp
    Published on: 30 November 2017
  • Old Paths Retread
    Stefan A. Topolski
    Published on: 27 November 2017
  • Thanks!
    Daniel C Vinson
    Published on: 16 November 2017
  • Published on: (30 November 2017)
    Page navigation anchor for Author response to Dr. Topolski and Dr. Vinson
    Author response to Dr. Topolski and Dr. Vinson
    • David A Loxterkamp, Physician

    I want to thank Dr. Topolski and Dr. Vinson for their response to my essay. Several others have sent personal e-mails expressing their concern for the future of the profession and the shifting environment in which we practice.

    As Dr. Topolski indicated, we have spoken over the years about our divergent paths, and the sources of our frustration and joy in family medicine. He grew up in my adopted Maine county, a...

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    I want to thank Dr. Topolski and Dr. Vinson for their response to my essay. Several others have sent personal e-mails expressing their concern for the future of the profession and the shifting environment in which we practice.

    As Dr. Topolski indicated, we have spoken over the years about our divergent paths, and the sources of our frustration and joy in family medicine. He grew up in my adopted Maine county, and I knew his father well.

    I understand his essential criticism to be that I-- and other so-called "thought leaders"-- should have seen trouble coming. "Idealists submitting to work for pragmatists" will inevitably lead to the loss of professional autonomy, whereby community health is cast "to the whims of misguided governmental commissars." An ebbing tide strands all boats. Independent practices like Dr. Topolski's cannot escape the web of "self-interested payers and their over confident regulators."

    I take issue with two key points. Dr. Topolski states that the ideal practice of medicine "has only and repeatedly been found in the independent and community-based practice which [Dr. Loxterkamp] has left behind." I was in private practice for 30 years and grew up in the household of a solo GP. It is a life ideally suited to the workaholic. My family sacrificed as much as I did. Mistakes were borne silently, and more often assuaged with alcohol than collegial support. And my dad died at age 49, smoking 2 packs a day, leaving his family financially solvent but leaderless.

    In my new practice at a community health center, I have, for the first time, worked closely with physical therapists, pharmacists, and psychologists, and benefitted from the indispensable role of care managers in meeting the broader needs of my patients. CHCs have their problems (as I have cataloged) but solve others, too.

    We are not enemies, those of us who work differently, who find ourselves employed by hospital networks, community health centers, or Direct Primary Care practices. We are family doctors all-- deeply committed to the well-being of our patients and focused on relationship-centered care. I do not believe it is possible to return to our "historic roots." That ship has sailed; the myth is a mirage. Rather than look back, we must decide on the best way forward, together. That is why I am still working, and writing, and seeking counsel and support from my friends in the profession.

    Competing interests: None declared

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    Competing Interests: None declared.
  • Published on: (27 November 2017)
    Page navigation anchor for Old Paths Retread
    Old Paths Retread
    • Stefan A. Topolski, Country Doctor

    What is the path forward when every path leads backwards away from the physician and patient? The progressive proletarianization of physicians continues as predicated thirty years ago[1] when this writer's teaching attendings thought it quaint and absurd. Now, however, physicians who could once claim highest income by working independently now pursue employment for income maximization.[2] Contrary to our discipline's...

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    What is the path forward when every path leads backwards away from the physician and patient? The progressive proletarianization of physicians continues as predicated thirty years ago[1] when this writer's teaching attendings thought it quaint and absurd. Now, however, physicians who could once claim highest income by working independently now pursue employment for income maximization.[2] Contrary to our discipline's thought leaders, idealist values of compassion, service and sacrifice do not appear to be the central drivers/attractors for the practice decisions of physicians. Independent physician community practice which the Searsport author exemplified - and the ancient origins of family practice originally posited as the future of health and wellness - appear to be a profession disappearing. As Dr. Loxterkamp states, those who do not sell out to corporate (including governmental) practice become extinct.

    What has now been tried anew which has not been tried before? This author visited Dr. Loxterkamp years ago on the verge of this experiment in his "new model" of partnering community practice with a Community Health Center bureaucracy. The valid goals were presumably enhanced reimbursement, possibly broader leadership, and hopefully a sustainable future. The trade-offs and prior histories of such experiments were shared and, truthfully, there have been no unanticipated consequences. Dr. Loxterkamp's experience remains the common experience of idealists submitting to work for pragmatists. Surrendering professional autonomy and community health to the whims of misguided governmental commisars who are convinced of their superior knowledge and leverage their economic power leads to very predictable outcomes.[3]

    In this present analysis, Dr. Loxterkamp concludes by describing wonderful examples of where physicians still do find joy in healing practice. These practices of joyful medicine continue to occur where the relationship of healer with patient comes first and, by extension, the relationships among health care team members also spring from this healing well. What may be perceived as lacking from our thought leader's opinion piece are the following - 1) the reasons for failure of rural CHC retention are many, common, understandable and predictable [4,5], and the lack of explication or certainty in this regard poses the question of whether our author's present employment limits his ability to openly share his findings in an academic journal. 2) the ability to accomplish these wonderful examples of healers' healing practices demands the power which today's said physicians have already surrendered to the bureacracies whom they now supplicate for the needed changes which run counter to the misguided core drivers/attractors of corporate medicine.

    This vision of our leading and committed rural physician in Belfast, Maine appears to call us to an ideal practice of medicine which has only and repeatedly been found in the independent and community-based practice which he has left behind. Those of us who continue in the joy of rural community practice on the fringes of the complex sea of healthcare see our economic niches shrinking by the month and year to the whims of self-interested payors and their over confident regulators. When the authentic practice of our healing tribe returns to our historic roots, will any of us be able to afford the sacrifice? And will any healer be appreciated for the sacrifices we make?

    1. McKinlay JB, Arches J. Towards the proletarianization of physicians. International Journal of Health Services: Planning, Administration, Evaluation. 1985;15(2):161-95.
    2. Roemer M. Proletarianization of physicians or organization of health services? International Journal of Health Services: Planning, Administration, Evaluation. 1986;16(3):469-71.
    3. Singleton T, Miller P. The Physician Employment Trend: What You Need to Know. Family Practice Management. 2015;22(4):11-5.
    4. Cutchin MP, Norton JC, Quan MM, Bolt D, Hughes S, Lindeman B. To Stay or Not to Stay: Issues in Rural Primary Care Physician Retention in Eastern Kentucky. The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association. 1994;10(4):273-8.
    5. Lee DM, Nichols T. Physician Recruitment and Retention in Rural and Underserved Areas. International Journal of Health Care Quality Assurance. 2014;27(7):642-52.

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (16 November 2017)
    Page navigation anchor for Thanks!
    Thanks!
    • Daniel C Vinson, physician

    David, many thanks for your thoughtful reflections on what ails us as physicians and how we can regain what we've lost. May we all heed.

    Thanks
    Dan Vinson

    Competing interests: None declared

    Competing Interests: None declared.
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The Annals of Family Medicine: 15 (6)
The Annals of Family Medicine
Vol. 15, Issue 6
November/December 2017
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Caring for the Tribe: From Addiction to Zen
David Loxterkamp
The Annals of Family Medicine Nov 2017, 15 (6) 578-580; DOI: 10.1370/afm.2151

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Caring for the Tribe: From Addiction to Zen
David Loxterkamp
The Annals of Family Medicine Nov 2017, 15 (6) 578-580; DOI: 10.1370/afm.2151
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Subjects

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