A Change Will Do You Good

I want to express my heartfelt gratitude to Johanna Shapiro, Howard Stein, and Gayle Stephens for reading my essays so carefully, and for sharpening their message in cogent replies.

Johanna wondered if I might consider it sacrilegious to thank God for me. I would check with God first. But she is right in assuming that I see the work of an Other in all of medicine, especially in the doctor-patient relationship, where "redemption and salvation" are in ample supply for all who enter it in good faith.

It is a true honor to leave Howard speechless. He has been talking about the doctor-patient since I began medical school, and there is no greater witness and authority on the subject. I agree that my words are meant for more than the rural physician; what strikes me as vitally important requires only a patient and doctor in need of each other, no matter the setting (or specialty, for that matter).

Gayle has also been present in my life since medical school. It is through his encouragement that I dared to write, and through his friendship that I could begin to accept my imperfections. Of the four essays, he chose to comment on "The Dream of Home Ownership," and the loss of control in our practices. If financial capitulation should translate into moral surrender, it would be an act of mercy to pull the plug on primary care. But I think that end is unlikely. Through my involvement with the National Demonstration Project and the Maine Patient-Centered Medical Home Pilot, I have found colleagues who believe as I do, and are willing to invest their time and energy in the reinvigoration of family medicine. But I agree with Gayle on two accounts: we need to "make the ideals real again," and we need to mobilize around serving the best interests of our profession (and not the industry).

Lastly, I owe a debt to Jean Annotucci and Gordon Moore, who helped me understand the difference between SIMPd and IMP. The former is an organization of concierge practices; the latter is concerned with practice transformation. Ideal Medical Practices, in fact, have adopted many of the technologies and techniques of the Patient Centered Medical Home, but emphasize a lowered overhead that allows the doctor to spend more time with patients. Concierge or Ideal, Corporate or Community-run, we have too much in common to be enemies.

Medicine and society are rapidly changing, and we are in the midst of a "revolution" more powerful than the one that delivered Family Medicine from the ashes of General Practice. Lest it not perish, we must keep alive those beliefs that are shared by idealistic residents and seasoned practitioners, and by my father (a GP) and my daughter (who may become one):

Health is not a commodity. Aging is not an illness. Quality is more than metrics. Community is locus of healing, not the hospital Doing all we can is not necessarily doing all we should. The essence of our work is conversation, friendship, and hope.

In praise of conversation,

David Loxterkamp

Competing interests:   None declared

Having just read his wonderful set of essays in the May/June issue of Annals of Family Medicine, I must say thank God for David Loxterkamp, and hope that as a “cradle Catholic” he does not find that sacrilegious. These essays remind us (even those of us who are not family doctors!) with poignancy, authenticity, and compassion what being a family doctor is all about. In “A Change Will Do You Good,” Loxterkamp asks provocatively, what need for family doctors when “midlevel providers and the internet” can accomplish pretty much the same thing? Of course his intention is not to undermine family medicine, but to revivify it, to persuade, to motivate(1) the specialty, much like a recalcitrant patient, into have the courage to reclaim its heart and soul back from managed care, boutique practice, and hospital employers. To drive home his point, Loxterkamp focuses on the process of facilitating and birthing change in patients as a metaphor for all the intangible but essential ways the family physician works with her patients to ward off despair and inspire hope in them both.

As Loxterkamp knows, the doctor-patient relationship is “both gold mine and land mine.” In the case example he provides, he chooses not to tell a satisfying but simplistic restitution story: patient with unstable angina and worried wife meets compassionate doc in the ER, receives a talking-to, and changes his lifestyle for the better. Instead, at the end of the essay, not much has changed for his trucker patient. Or has it? This patient has found a physician ready to recognize that change is a process of fits and starts, not a discrete event; that in the words of a later essay on care for an aging population (“The Old Duffers’ Club”), it requires “slow medicine,” (2) “faithfulness to the end,” patience and kindness; that it is a shared and uncertain journey. Loxterkamp is wise enough to know that the moral authority of the physician derives less from her expert knowledge (though this is obviously an essential foundation of doctoring) than from her emotional connection, commitment, and caring. He is also wise enough to realize that, to use theological terminology, the redemption and salvation that may be found in the patient-doctor relationship belong not only to the patient, but to the doctor as well.

This is the focus of Loxterkamp’s third essay, “Eulogy to My Vocation,” in which he takes stock of what matters to physicians as they draw near the end of their doctoring lives; and indeed near the end of life entirely. He movingly acknowledges that, as a physician, his neat youthful ideas of service and calling often seem scattered “like pieces of a jigsaw puzzle.” His honesty resonates. Who among us has not felt the inescapable chaos of living real life, in contrast to our early dreams and ideals? Yet Loxterkamp uses this meditation not to despair, but as an opportunity to allow new meaning to emerge, and one suspects they are surprisingly like the “old” meanings that inspired him in the first place, albeit tempered with greater humility and tolerance to absorb the “sorrows, longings, and imperfections” that are an inevitable part of human existence. Despite doubt and disillusionment, Loxterkamp still insists that, in medicine, “one is chosen,” “one is vowed,” the passive voice making clear that something larger acts upon the individual to provide the meaning and purpose we all seek. Further, echoing John Sassall, the general practitioner described in A Fortunate Man (3), Loxterkamp notes that authentic, satisfying meaning in doctoring becomes less about the “big” dramatic moments, the thrilling saves in the ER, and more about “small” things – connections, shared conversations. Like Rachel Remen (4) , in his interactions with patients, increasingly he realizes that the secret of living well is not always in having all the answers but in pursuing unanswerable questions in good company.

As a post-script, I can’t help but cherish Dr. Loxterkamp’s wide- ranging literacy, as he draws unselfconsciously on Kafka, Clarence Darrow, Anais Nin, Michael Balint, Dickens, Capra’s It’s a Wonderful Life, and the theologian, educator, and civil rights leader Howard Thurman to express his insights. This is a doctor who knows that healing, again in the words of Rachel Naomi Remen (4), cannot be contained within biomedicine alone; and that physicians must be conversant with the languages of storytelling, of poetry, and yes of love to speak with conviction and heart about their profession.

1. Miller W, Rollnick S. Motivational Interviewing: Preparing People for Change. New York, NY: Guilford Press; 2002

2. McCullough D. My Mother, Your Mother: Embracing Slow Medicine, the Compassionate Approach to Caring for Your Aging Loved Ones. New York, NY: HarperCollins Publishers; 2008.

3. Berger J. A fortunate man: the story of a country doctor. New York: Vintage, 1997.

4. Remen RN. Kitchen table wisdom. New York: Riverhead Books, 1996.

Competing interests:   None declared