Do you remember your first day on the job after successfully completing your family practice residency program? Although you may have been excited to be a “real” doctor, you were likely to have been nervous as well. How many times during that first week as an attending physician did your mind seem to short circuit? Confidence does seem to improve over time, but at what point in your career would you really consider yourself an expert in family medicine?
With each passing day, we, as family doctors, shape our unique styles and talents, which eventually attract patients through our doors. We are driven to provide compassionate, patient-centered, and evidence-based care designed to improve the lives of the families who seek our professional services. Family doctors must know a tremendous amount about diseases, disorders, and preventive care that affect all individuals, members of all religions, and people of both sexes, whether healthy or chronically ill. As family medicine specialists, we can care for > 90% of the patients who consult us, and we expeditiously direct care to other specialists when necessary.
Yet, at what point in our careers do we actually become experts in family medicine? Does simply becoming board certified make us experts?
Expertise in medicine is acquired through years of contact with patients who trust our guidance. Although we have many drugs for treating both acute illnesses and chronic diseases, our track record for curing disorders such as diabetes, hypertension, and coronary artery disease is dismal. Let someone walk through the doors with chlamydia urethritis, and we can work miracles. But does that warrant claiming that we have expertise in treating sexually transmitted diseases (STDs)? More important than whatever drug is prescribed to cure a patient's STD is the approach we must employ to discuss the social and individual implications of STDs with that patient. This discussion takes considerable time and skill, for which physicians receive little or no compensation.
Expertise, or the lack thereof, may be illustrated by two consecutive cases that I managed during a single afternoon in my office. My first patient was Ron, a 54-year-old man whom I had diagnosed as having stage 2 pancreatic cancer 24 months ago. Since then, I have worked with Ron's entire family and his oncologist to successfully eliminate this aggressive tumor from his body.
Ron was initially informed that cancer is a chronic disorder similar to diabetes. There would likely be some difficult health issues in the coming months, none of which were insurmountable. My goal was to cure him, not defeat him. Through the use of an experimental drug protocol, Ron's tumor had entirely disappeared over the course of 18 months.
Two months before this visit, my wife and I were guests at the wedding of one of Ron's two daughters. We were even honored with a seat at the head table. The highlight of the wedding came as the scores of attendees watched Ron's weakened body cling for support to his daughter during their special dance. There was no sobbing, only tears of pride and of accomplishment. Although he had lost > 80 lb in 2 years and was barely able to eat or drink at the wedding, Ron was having the time of his life!
Now at the office for what would be his final visit, Ron ignored the nauseating agony of his metastatic disease to ask me one simple and selfless question: “Hey Doc, how are you feeling today?” My own heart was breaking, for I knew that Ron was in the midst of life's curtain call. Yet, no one in the room that day appeared to be at all distraught.
“Ron, you look awful,” I growled. “Look at your hair. When was the last time someone combed it? Has your wife been watching Dr. Oz reruns instead of feeding you? Here, allow me to freshen you up a bit.”
Because I have no need to carry personal grooming supplies in my pants pockets, I asked my entire staff to join me in Ron's exam room, with his family. We now had five brushes with which to work and were able to collectively spike all 17 of Ron's remaining white hair strands within 60 seconds.
“There you go, Ron,” I quipped. “I hope the wind doesn't blow when you leave, because I won't have time for a re-do today!”
Ron began to laugh, as did every-one else in the room. Photos were taken with his wife and daughters. “Dad, look over here. Smile!” Snap.
As Ron's wife wheeled him out of the room, he grabbed my hand, stopping the processional near the front door. Pulling me weakly toward his face, and in a tone loud enough for just me to hear, Ron said, “Doctor, I love you.”
Experts understand that, although there may be nothing pharmacological to offer a patient, we may still provide that patient with comfort, compassion, and dignity. I promised Ron years ago that I would never give up on him, and I had kept my promise. He came to the office looking like a living corpse, but he left by blessing his doctor and my staff. Ron had just hours to live, and he wanted his team of experts to know how much he and his entire family appreciated our efforts. He had survived nearly 12 months longer than I had projected.
After 29 years as a practicing physician, I had yet to consider myself an expert clinician … until Carmen was placed in the same exam room that Ron had just vacated. Carmen was inconsolable as she held hands with her husband, Luis. Carmen, whom I have known for 8 years, has type 2 diabetes. She never cries.
“Doctor, I am so upset at what has happened to my brother-in-law,” she said. Carmen continued as her fist repeatedly pounded against her chest, “Three months ago, he was losing weight and had severe back pain. He went to see his family doctor, who did not examine him but did order some lab tests and X-rays. When we went back to the doctor for the results, the doctor said, ‘You have prostate cancer. You are 67 years old. There is nothing I can do for you, so just go home and die!’ So, that's what my brother-in-law did. No one helped him. He was in such agony, and he couldn't eat. His wife didn't know what to do. She cried every day. How can a doctor say something like this to another person? I don't even know the name of the doctor he went to, because he never told anyone. He just came in the room, and then he left.”
I was silenced by her sadness and felt embarrassed for my profession. There is always something one can do for a dying soul. Even strangers who come upon the scene of a fatal accident and know nothing about medicine or spirituality will hold the hand of the fatally injured person so he or she will not die alone.
For those in our profession who have lost the true sense of compassionate care, I doubt they will ever become an expert clinician. In fact, I would argue against admitting them into our exclusive medical society until their attitude toward human dignity improves. Eventually, doctors will be humbled by their daily experiences and will understand that patients seek their opinion not so much because they are experts at managing diseases, but because they demonstrate expertise in human compassion. Expert physicians nurture their skills by caring for patients who challenge them daily in their practice of the art of medicine.
Expert clinicians should remind their terminally ill patients that death is the penalty we all pay for the privilege of life.
