Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, November 28, 2006

Family (Practice) Matters More Than You Think

There you go again, Sid.

Although you start your post oh-so-sweetly (about how much you admire FPs and the work we do) you then go off on a whole diatribe about how it "used to be." It's harder than you realize for the casual reader to keep your initial disclaimer in mind as you give example after example about all the FP screw-ups you've witnessed or stepped in to clean up. (And by the way, why include the last one, about a fucked up liver resection you referred to another surgeon? No FPs involved there that I could see.)

What's especially disingenuous is that most of your examples are of FPs "fresh out of training." Isn't it about time that we recognize explicitly that the acquisition of knowledge, skills and experience -- "training" -- is an ongoing process? An FP (or a surgeon, for that matter) is not magically more skilled on July 1st when they start practice than they were on June 30th of their last day of residency. I think there should be some kind of official acknowledgement that people in their first 5 years of practice, say, deserve some slack -- in the form of explicit (but not condescending) backup from the other docs in the community. I'm not saying restrict their practice or don't hold them responsible; just offer some support instead of griping about them behind their backs.

While we're on the subject of training: your recent discussion of how surgical training inculcates respect for one's limits was an eye-opener for me. Since I only saw it from the outside, I admit my perceptions were incomplete. So how dare you go criticizing my training on the basis of what you think you're seeing! What you call "having to be in charge of everything" translates to being castigated by the surgeons both for sending patients who turned out not to have surgical problems as well as for not sending them soon enough (as in your example of bowel obstruction.) My training has served me quite well, thank you, even if you don't quite understand its relationship to what I do.

You're right in that the gatekeeper concept was flawed from the git-go, especially when full-risk contracting was included. "Referrals" quickly became a joke as the malpractice advisors immediately declared that patient request should be sufficient grounds for granting one. But the one thing it did help address was something I still see all too frequently: I send someone to you to repair his hernia. You send him to the cardiologist for his blood pressure, who sends him to the orthopod for his carpal tunnel syndrome, who sends him to the pulmonologist for his asthma, who sends him to the urologist for his nocturia, who sends him to the endocrinologist when the nocturia turns out to be from his diabetes. And you're all getting paid at the considerably higher "consultant" rates than just the "evaluation and management" (E/M) levels I do. The patient goes along with it because, "Dr. Schwab/Jones/Smith/Wesson said I needed to go see that doctor." Who am I, poor little schlub, to go disagreeing with the great Dr. Schwab, to whom I sent him in the first place?

As for the sin of over-reaching: just because *you* have never made such an error, I know for a fact that it cannot be said of every surgeon. Nor of every medical specialist. On the other hand, especially with the recent changes in medicine (including the worsening malpractice climate) I think FPs are not only less likely to over-reach, tragically I think they are also less likely to practice to the fullest of their true capabilities, for example referring things like Irritable Bowel more readily because the GIs and surgeons have browbeaten us with tales of misdiagnosed ulcerative colitis.

Practicing to the fullest of your abilities while remaining aware of your limits is a much finer line than I believe you have drawn. In fact, you have demonstrated this yourself -- not once, but twice -- in your post: your surgical prof glowered at you for turning over your surgical ICU patients to intensivists, which you felt was over-reaching, but the patient you sent to the liver specialist (who, I believe your words were "fucked it up royally") would, in retrospect, might very well have done better if you had done the procedure (well within your capability) yourself.

As I listen to you bemoaning the sorry state of new FPs and modern residency training, and even your pondering whether your younger surgical colleagues' skills are diminished in response to the rising use of laparascopic techniques, I get a sense that your remarks could all end with something like, "What's the matter with kids these days?" or words to that effect. Allow me to point out that yours (ours?) is not the first generation to believe that their particular skill set constituted the zenith of their profession, and all those youngsters coming up are never going to be as good (or, as I've heard said about Family Practice, "will cease to exist altogether.")

If you're honest, can't you imagine (or perhaps remember overhearing) your old fogey surgical mentors complaining about you and your peers? "Remember when 'Residency' meant just that. You can't get adequate training unless you actually live at the hospital full time. How do these young guys think the can learn anything when they have homes and wives and kids (Gd forbid!) to worry about? Surgery will never be the same." Well, Sid, you guys seem to have turned out all right, and I daresay -- one way or another -- future generations of FPs and surgeons and specialists will find ways to muddle through, relating to one another, their patients and the practice of medicine in ways we can't even imagine -- and probably wouldn't approve of if we could.

To quote that great philosopher William Joel:
Well the good old days weren't always good,
and tomorrow ain't as bad as it seems.
Keep the faith.


At Tue Nov 28, 05:24:00 PM, Blogger Sid Schwab said...

Thanks for reading, and for your, er, comments. I hardly know where to begin, so I won't. Other than to say I meant what I said, and not what you said I meant. Including the "there was a time" part. The "perfect storm" part. The not having been given a sense of limits part. And whereas it may indeed be better now, in terms of FP training, I've also stated (in other posts and/or comments) that I think it's getting worse for surgical training. And finally: It seems obvious to me why I included the questioned vignettes.

It was Professor Joel who also said:

What's the matter with the crowd I'm seeing?
Don't you know that they're out of touch?
Should I try to be a straight 'A' student?
If you are then you think too much.

In that spirit, I shall continue to read your blog, and hope you will come back to mine.

At Tue Nov 28, 05:32:00 PM, Blogger Sid Schwab said...

Oh, and this: of course my examples were (mostly) of people fresh out of training. That was the point. When I came out of training, I knew my limits; these people didn't. Why is that, I wondered? My very point. Given that, as you said, training never ends, it would seem most important that limits be inculcated by the time the "formal" training foists its spawn upon the world. Some docs of all flavors never learn. Which, it would seem, would make it even more incumbent upon training programs to try. OK. I said I wouldn't start. Guess I don't know my limits.

At Tue Nov 28, 06:36:00 PM, Blogger #1 Dinosaur said...

My point is that your experience with new FPs is far from exhaustive. I believe I had a better sense of my limits fresh out of training than some of those you cited; also, plenty of surgeons coming out of training were not as astute as you about what they still didn't know. Still, I suppose it's only natural that the doofuses (doofi) stick in our memories more than those FPs who referred appropriately from the moment they hung out their shingle.

And I love your blog, Sid. Getting all pissy at you is half the fun. Seriously, you are one of the "good guys."

At Wed Nov 29, 02:46:00 AM, Blogger Sara said...

Thanks for this post, again.


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