Doctoring in the Here and Now

I used to be a stickler for time. One of my first blog posts was about how it felt to go to work without my wristwatch.

I also used to be very particular about knowing the purpose of each visit, partly to help me manage my time, and partly to help me feel prepared and in control of the visit.

I often questioned why my colleagues’ patients would sometimes end up in my schedule for issues that seemed to me safe to wait until the patient’s own provider was available.

Over the last five years I have relaxed about these peeves of mine. I have become more accepting of the fact that patients don’t think in terms of how many minutes they have assigned to them as well as the fact that many patients can’t or choose not to tell the front desk staff why they want to see me on a given day.

Thinking about the way I used to be, I was more efficient than my employer expected me to be, but I don’t believe I quite lived up to my full potential as a healer. There were already then systems in place that made sure the housekeeping aspects of health care weren’t missed for very long if I were to digress in the visit – we had our chronic disease registries and recall systems for pap smears, mammograms and immunizations.

Lately, I have come to think more and more about the physician’s duty to ease suffering. So much of modern medicine is about population and disease management, and there are so many pressures on our time and attention that physicians seem to have little left to offer patients who are suffering, physically or emotionally.

But the systems to manage the measurable aspects of medicine are there, backed up by even more computer power, and we physicians may just need to step back from the numbers long enough in every encounter with each fellow human being to allow us to be open and see our patients as individuals. We need to listen actively to hear their unique agendas. We have teams behind us now to help manage the housekeeping details; we have health coaches and case managers and more nurses than we used to. But since only we have the title “Doctor”, we need to have our senses open to those things only we get to hear.

My wife, reflecting on her years delivering primary health care, always says: “I never had just a Diabetes visit. There was always something else.”

The sad truth is that the health of a nation is more dependent on public health, socioeconomics and the prevailing attitude among the majority of the population. The quality of medical care matters very little. For example, a healthy diet together with an active lifestyle is at least as good a weapon against heart disease as all the cholesterol pills and interventional cardiology that money can buy. It doesn’t take a medical degree to change the attitude of a nation, and trying to do it on a case-by-case basis with each patient at $7 a minute is not effective population management – not that I don’t try every single day.

So, what is the role of the physician in today’s health care system? I believe we are the ones who can best help patients make sense of their symptoms and also understand what the health care system can and cannot do for them.

With common human experiences given names that make them seem like diseases, and with our nation’s increasing confusion about even common ailments and preventive measures in spite of the glut of information out there, physicians can bring wisdom and empathy to a system that provides neither. Since we are closer to the mysteries of birth, disease and death than most people, we need to be there for our patients to turn to when the angst of life afflicts them.

I believe the new systems we have all been required to put in place to meet all the public mandates are actually blessings in disguise. If we are wise, we can meet our quality and productivity metrics through the use of the technology at our disposal and at the same time rediscover and cultivate the ancient art of doctoring. Because the phones at my clinic as well as every other doctor’s office keep ringing, not with patients asking to have diabetes follow-ups, but with patients who have a new concern, a new fear, or the courage – just today, or they will lose their momentum – to finally tell someone their deepest fear.

Pausing, as I do every time before knocking on the exam room door, I clear my mind and I am ready:

“Hi, I am D—. What can I do for you today?”

8 Responses to “Doctoring in the Here and Now”

  1. 1 Christina May 7, 2013 at 12:35 am

    If I haven’t told you before, let me tell you now: I LOVE your blog! Please write more and more often.

    I am an alternative medicine practitioner (Chinese medicine and homeopathy) and I frequently hear from new patients, and old, the problems they have communicating with the MDs and other allopathic practitioners in their lives. That would not happen if more had your deep intention.

    I believe, of course, that we practitioners of true complete systems of alternative healing modalities have something real, deep, vast and wide to offer people seeking health care. But that said, frequently I am sure that we are sought out, at least initially, because so many people do not feel “heard” by allopathic practitioners. That’s such a travesty! Often we are sought out after people have been trying for years and years to be heard… finally they give up and seek elsewhere and by that time often it’s too late for us or even for allopathy to aid the patients. Heartbreaking, really.

    I do disagree that the new systems, rules, and regs will aid in the rediscovery of the true healing relationship by the allopathic community, at least the majority of the allopathic community. I believe those new systems will be even more of a deterrent to the human to human contact than what already exists. But I am very willing to be proved wrong.

    I would like to take a moment to recommend a couple of resources to explore more along the lines that you write in this post.

    The first is a book: God’s Hotel, by Victoria Sweet, MD

    The second a talk:
    A Doctor’s Touch, by, Abraham Verghese

    Thanks again for this post.

  2. 2 acountrydoctorwrites May 7, 2013 at 1:25 am

    Thanks for your comment
    I am familiar with Dr. Verghese’s work. I’ve been meaning to write about his “Stanford 25”, bringing back old fashioned bedside clinical diagnosis.
    I am not at all saying all the changes in medicine are good, but I think there is a new momentum building as a reaction to all of them….and all we have is the “here and now”.
    BTW, my wife, mentioned in the post and a former allopath, is now a Bach practitioner, animal Reiki practitioner and a student of homeopathy.

  3. 3 Stacie May 7, 2013 at 2:55 am

    I have enjoyed reading many of your blog posts but wanted to ask — If you could go back to your days of medical school, would you still choose again to work as a family physician in a small town? I am starting medical school in the fall. I initially started in this direction with the intent of becoming a small town family doctor, after living and working in small communities in West Virginia and overseas. But the more I learn about medicine, the more I wonder if the kind of practice I would hope to have will even be feasible in a couple more years. Is everyone going to start going to CVS and Wal-Mart for primary care and/or be seen by nurse practitioners? Will I be able to find a good rural health center or hospital or will many have closed down by then? I do well in school and could probably enter any specialty I’d like. I don’t want to be over-idealistic and pursue a dream that will be nothing like I imagined. And I don’t want to waste years of training. At the same time, I went into medicine because good healthcare is so central to communities and peoples well-being, and I saw primary care as the most direct way to make an impact. Fortunately, I still have several years to decide, but it is a tough decision not knowing what medicine will be like by the time I finish.

    • 4 acountrydoctorwrites May 8, 2013 at 12:19 am

      I would choose primary care all over again. It is where my passion is. In this country, the economic outlook for Federally Qualified Health Centers is still good. We get preferred rates from Medicare and Medicaid.

      As a rural FP, I know I make a difference in people’s lives. I see things that never end up in urban or suburban primary care doctors’ offices. I feel I contribute to my community by not only delivering care but also by helping people understand medical issues, evaluate claims by drug companies, etc.

      Rural and FQHC salaries are generally better than urban jobs, and if you want to take on leadership or mentoring/teaching roles, there are plenty of opportunities. If you get tired of working for a big organization, you might start a micropractice all on your own.

      I have no regrets.

      • 5 Christina May 8, 2013 at 12:40 am

        “Micropractice”? Why “micro”? How do you think it would be different from an old-fashioned single practitioner practice?

        And I’d love to know where your wife is studying homeopathy? May her studies be fruitful and fulfilling. Did you know that Will Taylor, MD, long a practitioner in your (broad) neck of the woods, is teaching online homeopathy classes? I recommend him very highly!

      • 6 acountrydoctorwrites May 8, 2013 at 2:24 am

        Micropractice is the modern word for minimal staff/overhead practice…
        Will and I shared patients way back; he the homeopath and I the allopath.

      • 7 Stacie May 8, 2013 at 2:59 am

        Thanks, that is really wonderful to hear! 🙂 It reminds me of why I loved living and working in a rural area, and I’m glad to hear that the outlook right now is good. I had nearly jumped the boat, but that gives me a lot to think about.

        I always wondered about the cost and hassle of starting a practice, but I remember one doctor I visited in West Virginia who had his office set up in a prefabricated trailer along the side of the main highway. I bet that was actually very feasible for him, once he had worked a few years, to purchase a pre-built medical practice with exam rooms and a waiting room and office spaces and start seeing patients. It probably just takes a little creativity to minimize cost.

        When I see a report like this one (, where only 28% of family medicine doctors say they would choose the same specialty again if they had the chance, it is a little worrisome. But of course not all are working in rural areas, and the community makes a huge difference. Also, someone who is dissatisfied with their job is probably more likely to take an optional survey to voice their complaint than someone who is happy and content in family medicine.

        Anyway, thanks again. I will keep all this in mind. I have a feeling that I have just been listening to the wrong people.

  4. 8 Christina May 8, 2013 at 2:28 am

    Will is great! He and I share a Teacher (Misha Norland) and therefore a lineage. Will’s own teaching is brilliant, he has captured the style of his Teacher and gone on to make it his own. I cannot recommend him highly enough.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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