The Complete Physician

In the weeks before the match we took part in a very thoughtful course centered around the idea of the "Complete Physician".  The course involved advanced clinical skills training (advanced CPR, review of emergency management, some basic ICU lectures), lectures and discussions on relevant topics (anti vaccine movement, teaching medical students, emotional resilience in medical practice).  To cap it off, we wrote reflective essays on the experiences that have shaped us in becoming physicians and how we envision ourselves moving toward completeness.  It feels super vulnerable to share my writing here on the interweb, but somehow important too.

Here's my essay:

Respect and Shame

In my third year family medicine clerkship, I saw a working mom of two whose weight and blood pressure had been steadily creeping up over the years.  When I mentioned it, she began weeping.  She felt deep shame for not being able to lose weight.  At the time I empathized with her about how hard it is to lose weight and focused on brainstorming small changes in diet and activity that she might be able to stick with.  But the more I reflect on this encounter, the more layers of complexity that I am able to appreciate, beyond just how hard it is to find time to exercise!  There is the belief that obesity is a moral failing and a mark of sloth and laziness, nothing if not disgusting and shameful, reinforced again and again in potshots taken at obese patients in med school lectures and behind their backs on the wards, and in every facet of media.  Most of the time these messages are so well integrated into the background noise that I don’t even notice them.  With effort, I am trying to notice and to think about how I can do it differently, celebrating “health at any size” and respecting my patients, even when they are out of earshot.  

There is also the issue of shame in general.  Shame does not galvanize us to change.  It paralyzes us, full of ugly thoughts about ourselves.  How could this patient start to change when she already felt that she had failed?  I have felt the hot wave of shame wash over me so many times in my life: every mistake on rounds, every time I lose my temper with my children.  As I go build my practice, I do not want to contribute to shaming my patients.  This seems a particular betrayal when patients offer themselves to us with so much vulnerability and trust, literally undressing in front of us and telling us secrets about their bodies and their lives that they tell no one else.  I want to use that intimacy to help them grow and heal, appreciating the complexity that governs their actions (and mistakes) in the world, not judging them for their shortcomings.  Likewise I am trying to cultivate a respect and generosity for myself, so that thoughts of inadequacy do not get in the way of me growing into a more capable physician.

Patient Autonomy

Parenting my children is one of the most powerful influences on my development as a human being and as a clinician.  I will spare you the details the baptism by fire that parenting my particularly wild child has been, but I will reflect for a moment on both children’s birth stories.

My best friend was the midwife for the birth of my first son at home, one year before I came to medical school.  At the time, everything seemed to go so smoothly from my perspective.  Not a cookie cutter delivery, with my pregnancy approaching 42 weeks, ending in an off and on labor that lasted for 5 days, capped by a full day spent hanging around at 8 cm thanks to an asynclitic presentation, but he came out safe and sound and then I ate the most incredible enchiladas known to man.  No big deal, right?  Looking back with better trained eyes, I see that there were many places where my care could have taken a very different turn, with much more intervention.  But my midwife believed in my ability, in the normalcy of birth, and also understood that I favored a less is more approach.  While it felt like I just cruised along and did it by myself, in reality she was busy “actively managing” my delivery without me really noticing.  She is a role model for me in supporting patients to do the work of giving birth, or getting healthy or parenting their kids or whatever the task at hand is, offering expertise and intervention when necessary, but letting the glory fall to the patient.

Fast forward 4 years to the birth of my second son, which involved different midwives and a transfer to DHMC (eek!).  Being cared for by the very same residents and attendings that I had rotated with with an unnerving experience.  And my skin crawls when I think about the comments I’ve heard about homebirth during my training, and imagine what they had to say about me at the nurses station.  My labor was not too complicated (a little pitocin and we were good to go) but I sure felt like I had stepped onto a train that was clearly not conducted by me.  Despite being a strong advocate of homebirth from the start (indeed, I was born at home) the experience of a hospital birth really helped me to clarify what is so stunning about homebirth.  It is not the soft lighting or familiarity of own’s own home, though that is lovely.  It is the fact that the whole care team is completely centered around the patient and driven fundamentally by the belief that the patient gets to decide what happens to her, that she is in charge of her own body.  This is what I wrote about it at the time:

“What matters most to me is this: Being treated with respect and reverence.  Having providers that are not blinded by protocol and are open to doing things many different ways, whatever way is working for mom and baby.  A real appreciation that intervention may cause harm.  Being able to trust that when intervention is used, it is done so wisely, out of necessity.  Being the most important player in my own care, not some bystander that comes along for the ride.”

As I put my nose to the grindstone of residency, I wonder how I will keep my eyes open to the question of patient autonomy.  Will I just charge ahead with the algorithms that I have memorized, or will I be able to see and adapt to the unique person in front of me?  Will I take the time to counsel my patients about risk, instead of just prescribing a particular intervention?  Will I ask them what they actually want?

Choosing Family Medicine

I am going into family medicine in part because I think it is a specialty that really values knowing patients well and will help me to develop the patient centeredness, with a focus on respect and autonomy, and the deep relationships that I think are so important.  But my motivation in choosing family medicine is about more than my own enjoyment and what I think I can gain from training in this particular field; it is about social justice and societal need.

In third year, I was asked again and again: “What do you like?”  I could answer that question easily.  I loved inpatient medicine which is so interesting, with so much depth and acuity.  I loved outpatient too, the pace, the ability to form relationships over time, being the first contact for undifferentiated patients.  I liked variety more than one narrow specialty.  I’d rather talk to my patients than do things to them.

It wasn’t until the dust of third year settled and I had some time to reflect that I noticed what questions hadn’t been asked:  “Where are you needed?” and “How can you best serve your community?”  I do not think anyone should be forced into a specialty that they do not enjoy, but the need for primary care docs and the huge inequalities in medical care are undeniable.  If students are not given an opportunity to think about these issues in the context of specialty choice, if no one asks them to think about what patients and communities need in addition to what the student enjoys, how can we hope to meet that need?  We need some help to see the larger context that we fit into.

After deciding on primary care, I struggled over internal medicine vs. family medicine.  I ultimately felt that the breadth of family medicine would put me in a better position to meet the needs of an underserved community.  Need an ultrasound, a joint injection, a biopsy, a visit for yourself and your kids at the same time?  No problem!  Again, it was less a question of what I like (although I do like procedures and variety) but rather a question of societal need.

Another factor for me in residency choice that surprised me was prestige.  I don’t think of myself as someone who is swayed by prestige.  I take pride in being from a working class family.  My mom never went to college and my dad worked two jobs throughout my childhood.  But it sure felt like I was giving something up when I chose family medicine.   At first it was difficult for me to name my hesitation.  I wasn’t sure why FM looked so unsexy, why I was clinging to the ivory tower, what made the idea of training in internal medicine at some Ivy League program so appealing.  But I have clearly been subject to the influence of training at an elite academic medical center, which is driven by specialties and pitches itself as the pinnacle of care.  I have come to associate certain specialities and training at certain institutions with super smartness, high achievement, garnering respect and reverence everywhere you go.  To step away from that, to give up an imagined prestigious career to train in a community program and take care of poor people’s everyday complaints, requires letting go of some measure of prestige and social status.  I have had to be honest with myself about this rather embarrassing desire of mine to be any Ivy League superstar.  But I hope that seeing this for what it is (the siren’s song of prestige) will help me in letting that go.  Because ultimately, my most dearly held values do not put my own glorious career over taking great care of patients who need it most.  When I think about what is most important to me, service overshadows status.  

Seeing Clearly

One of the abilities that I think distinguishes an expert from a novice is the ability to see what is in front of you.  I remember that it took months of living abroad before I could reliably distinguish tea house from corner store from pharmacy.  With a different language and script, different architecture and unfamiliar products, I had to work hard to appreciate what I was looking at.  My husband is a gifted observer.  After a movie, I look forward to him explaining to me what we just saw.  It amazes me that he can see so much: the unusual long shot, the jump cut in this scene, the absence of music in that scene, the blue lighting, the allegory in the plotline.   It is like we are watching completely different things.

This applies to clinical medicine too.  Being able to recognize the physical findings, to hear the script in the story is key to diagnosis.  I remember the first time that I actually noticed that the patient I was interviewing was pausing for breath after every few words: an important clinical sign that I had certainly seen before but never really noticed.  It is this ability to see and hear more clearly, with finer granulation, that I strive to cultivate in my career.  Not just in my direct observations of the patient but also in my ability to appreciate the interpersonal interactions, the systems of care, the larger social and global forces at play.  My values are pretty clear (service, respect, autonomy, excellent clinical skills, joy, taking time to play with my kids), but I think my work is to look more closely at how my actions align with those values in everyday clinical practice.

This is my vision of myself as a complete physician: looking closely at my practice and probing for the deeper meaning and significance.  Getting better and better at actually seeing what is in front of me, and as I see the implications of my actions more clearly, taking steps to align my practice with my values to provide the best care possible.