Rod Dreher

Rod Dreher

Family medicine: Small is beautiful?

I e-mailed a physician friend and medical school professor today to tell him about Dr. Tim Lindsey, and the incredible personal care he’s giving to my cancer-stricken sister, who recently became his patient. I recalled for my friend a conversation I’d had with Tim in the hospital last week, in which Tim said he loved being a small-town doctor because he got to treat the whole patient — the heart and the soul, not just the body. He explained to me that he knew his patients’ families, he knew where they came from, he had a context in which to understand their disease. That’s something he doesn’t know if he’d be able to have if he practiced in a big city, he said — but it’s so vital to the kind of healing he does.
This is actually an insight key to Traditional Chinese Medicine. For TCM practitioners, disease is never something confined merely to the body. It has a relationship with the mind, and with the context in which the patient lives. That is to say, TCM recognizes that you cannot easily separate the biological organism from the context in which it lives — an insight that has a number of implications for understanding how to heal the whole person, not just the affected parts of the body.
In Western medicine, if our understanding of “healing” is limited to “eliminating the symptoms of disease,” then we won’t necessarily pay attention to these other factors. But a more holistic view of healing, one that includes “eliminating the symptoms of disease,” but also treating other factors arising from sickness, requires it. For example, Dr. Lindsey has taken an active interest in helping Ruthie’s children deal with their mother’s illness, not only, I think, because it’s the compassionate thing to do, but also because it’s part of the way he’s helping to heal Ruthie. He knows she cannot fight this cancer as well as she should if she is stressed over her children, so that’s part of the treatment. Or so it seems to me. Ruthie’s husband Mike was telling me that he can’t believe how much time Dr. Lindsey takes to listen to them — this, as opposed to rushing in, hearing a list of symptoms, writing out a prescription and going off to the next patient.
Dr. Abraham Verghese, the physician friend to whom I wrote earlier today about Dr. Lindsey, is deeply concerned about the technological mindset among American doctors today, and how our physicians have lost the human touch. Here he writes about the importance of the exam ritual, in part because it “conveys to the patient that we are with them on the journey, we will not abandon them.” Elsewhere, Dr. Jerome Groopman has written about how American doctors have lost the ability to see their patients as human beings, with a narrative and a context — and that an overdependence on technology can lead to misdiagnosis, and even a break in the sacred bond between a doctor and his patient. Groopman:

But only recently has medical care been recast in our society as if it took place in a factory, with doctors and nurses as shift workers, laboring on an assembly line of the ill. The new people in charge, many with degrees in management economics, believe that care should be configured as a commodity, its contents reduced to equations, all of its dimensions measured and priced, all patient choices formulated as retail purchases. The experience of illness is being stripped of its symbolism and meaning, emptied of feeling and conflict. The new era rightly embraces science but wrongly relinquishes the soul.
In his book Carrying the Heart, Dr. Frank González-Crussi, a professor of pathology at Northwestern University, has made a sharp departure from medicine as a cold world of clinical facts and figures. Rather, he asks us to return to a view of the body not as a machine but as a wondrous work of creation, where both the corporeal and the spiritual coexist.

I wonder if there is actually a profound philosophical point in Tim’s view that he doubts he could give his patients the kind of care they need if he didn’t practice in a small town — a rich information environment that cannot be reduced to data points. Is it perhaps the case that family medicine can most effectively be practiced in a “small is beautiful” environment? That is, to be a real healer, not just a technologist of medicine, you need to practice in a social context that embeds you in the community from which your patients come?
What would E.F. Schumacher’s “small is beautiful” ethic look like applied to the field of family medicine? How would family medicine (as distinct from specialized medicine) look different if Schumacher’s economic and moral insights about the human cost of abstraction and technologization were appropriated in a serious way by general practitioners?

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posted February 23, 2010 at 3:49 pm

These issues are very significant when it comes to childbirth. I am very, very glad that all the technology exists to save babies and birthing mothers who need it. But for most women birth is uncomplicated, and can be done with the assistance of a skilled midwife and without signifcant or any medical interventions. I don’t think most American women believe that, though.

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Nancy Hyton

posted February 23, 2010 at 3:58 pm

I am an acupuncturist practicing in Asheville, NC. Physical conditions can cause emotional symptoms and vice-versa! It is impossible for the body and the spirit to be separate, they simply could not exist without each other. Nancy @

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posted February 23, 2010 at 4:40 pm

Abraham Verghese is an amazingly gifted writer. His book “My Own Country” is considered a classic up there with “And the Band Played On” telling the story of the early AIDS crisis. The “Tennis Player” is one of the best books about addiction I’ve ever read.
Have you read his newest book?

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posted February 23, 2010 at 4:42 pm

Tennis Partner, not Tennis Player.
How did you become acquainted with him?

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posted February 23, 2010 at 6:21 pm

The solution is easy enough. Physicians just have to decide to spend more time listening to their patients. But in general, that ain’t gonna happen because physicians value the income more than the doctor-patient relationship.
And about that relationship being “sacred”. I don’t know about that when the most personal doctor-patient relationship should probably be psychiatry. And that specialty has devolved in a 45 minute diagnostic intake followed by 15 minute “med-checks” to fiddle with drug combos. Not a whole lot of sacred there.

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posted February 23, 2010 at 7:05 pm

May I point out (again) that many of the behaviors you think are lacking in western medicine are routinely practiced by NURSES? I don’t know why nurses are invisible in your perception of medicine. I bet your sister noticed them during her hospitalization. In fact, I bet they were present ten times as much as the doctor was, and contributed a lot more to the strengths and weaknesses of ‘western medicine.’
I wish all the best for your sister and her family.

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posted February 23, 2010 at 7:22 pm

In the town we live in the local clinic has about 35 doctors, so it’s super easy to hardly ever see the same one twice. However, a couple of years ago, I happened to get a particular doctor a couple of times and took a liking to him. As it happens he has made a point of specializing in family medicine kind of the old fashioned way in the middle of this large practice. Pretty much whatever you need, he will do it. So he recently delivered my last baby. A few weeks later he did my husband’s vasectomy. He saw my 5 year old today for a tummy ache and will see the baby Thursday for her shots. If we ever need an appointment and scheduling says he’s booked, he’s told us to just have them send a message back to his nurses and they work us in. I’ve never had a real family doctor before and honestly, it’s been a little weird for me at times. I have 5 kids, but this is the first time I’ve had any ongoing contact with the Dr. who went through childbirth with me which felt almost uncomfortably intimate. And there have been times I have really wanted to skip some follow up that I was supposed to do, but didn’t because I knew I would be seeing the Dr. sooner or later and he would remember and ask about it. Part of it is having such a large family means I go to the doctor obnoxiously often, but having a real relationship with a family doctor has become a surprisingly important part of life. I feel like he genuinely looks out for us and oddly enough, we take a bit better care of ourselves because there’s a bit of accountability inherent in the relationship.

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posted February 23, 2010 at 7:51 pm

We recently lost a wonderful family doctor. She knew the whole family. She saw all of us regularly. She knew what was normal for us an what was not. She knew how to listen and to then give advice that would persuade us to follow it.
The hospital that owned the practice closed it and all (or virtually all) of its family practices in order to put money into yest another heart center in our city. Worse, the closed some of the practices, moved families to the remaining ones, and then closed the remaining ones.
We went through three pediatricians before finding one that was good. We now how an adult doctor for us, but it’s not the same. The doctor won’t talk. You can learn a lot from a patient just by chatting. You miss a lot by swooping in and swooping out.
One thing we need to do in health care reform is to pay doctors for talking to patients. Yeah, that will happen.

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Kim Boone Dreher Lozano

posted February 23, 2010 at 8:11 pm

Rod…..I agree with your “diagnosis” of some of the ills of medicine, and would like to piggy-back on those emotions with the same reference to education. We get so caught up in numbers, test scores, and all types of data, that we often forget that the child we see in the morning may not have had breakfast, may just have seen Dad hit Mom, or may have needs and pains that we can’t even imagine. I recall a former student that had been reprimanded by another teacher constantly for not completing his homework. The students in his class were to go on a field trip one Saturday, but they had to pay for the trip and provide transportation to the school on a Saturday morning. He had neither, so I provided both. When I went to his home to pick him up, the conditions were deplorable. There wasn’t even running water in the home. I learned that part of his responsibility each evening when he returned from a day of elementary school, was to take old milk jugs down the road to a faucet in the community and fill up the jugs, then to carry them back to the house. He did this every evening, making several long trips, sometimes until dark. While we (educators) were concerned about him spending an hour or more each evening doing more academic work, he was worried about survival. Just as doctors and nurses need (and many do it so well) to take into account the WHOLE being, physical, emotional, and spiritual, educators also need to be cognizant of the WHOLE child. Ruthie is one who always does that, and it is only one of the millions of things I love about her. Anyway, you made me think, you made me reflect, and maybe you made me be a little better teacher (and person) today……thanks and love, Aunt Ka

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posted February 23, 2010 at 8:44 pm

I’m not a fan of doctors generally, but didn’t you say your sister was going to a local family doctor before her switch?
[Note from Rod: She was going to a family doctor in another town. I’m not saying that all small-town family doctors are the same. I’m saying that Tim Lindsey is extraordinary, and he finds the conditions under which he practices contribute to helping him be an effective healer. — RD]

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Rod Dreher

posted February 23, 2010 at 8:48 pm

Kim, your story reminds me of something Ruthie told me back in 1994, when I was living at home that winter, and helping her one night grade papers. A surprising number of her students were missing easy questions on the test, and I said something unkind about their capabilities.
“Let me tell you about that one,” she said, pointing to the kid’s name on the test in my hand. She told this heartbreaking story of deprivation (I think the kid’s mother had dropped him off one day on her parents’ doorstep, and ran away; he never saw her again). She went on and on about these kids, and the awful problems they had at home (most of them from mothers and fathers who just didn’t freaking care). In the end, Ruthie said, “You know the kinds of home lives these children have, and you realize it’s a triumph for them just to make it to school in the morning with their shoes tied. Anything else they manage to do is gravy.”

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posted February 23, 2010 at 11:06 pm

First, Rod, let me offer every good thought and prayer for Ruthie and her family right now. It’s a terrible situation, and impossible to get through without providence and grace.
As someone with a recent cancer diagnosis, I think the situation re: “big city” vs. “small town” medicine is complicated. Small-town medicine for family practice is wonderful when there’s closeness and communication, as you describe. However, there are some serious shortcomings of the small town which come into play when there’s a serious diagnosis.
For better or worse, specialists often congregate in large cities and/or around major medical centers. It’s where the diagnostic and treatment centers are, too. When someone has a rare or especially complicated situation, sometimes the “numbers,” the specialists, and the technology are necessary life-savers. Sometimes, too, doctors who are expert in rare or difficult situations (especially surgeons) *aren’t* the best “people-persons” in the world. What you need them for is their expertise, which sometimes comes at the expense of bedside manner. (Sometimes of course you get both in one person – very nice!)
Many people in small towns find that if they are to receive the best care available, they have to travel to the city (where the treatments are.) It’s daunting for me to drive 15 min one way to chemotherapy (and all the follow-ups and other visits which chemo requires.) I can’t imagine having to drive 1 1/2 or 2 hours, to come into the city. It would be nice if resources were more distributed, but sometimes they aren’t. Add to that a rare or especially complicated illness, and sometimes the city is the *only* place to be if one wants better chances.
Also, big hospitals work on an economy of scale that can be terrifying at first to a patient, but can help with survival. With some conditions, every day (or every hour) matters. When that is the case, bigger, more specialized hospitals often have the equipment, personnel, and support to deliver care in the fastest way.
I used to dream all the time of “life in the country.” Now that I have a life-threatening illness, I am personally very glad to live minutes away from my doctors and Level III hospitals. Cancer changes your perception of a LOT of things.

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posted February 24, 2010 at 1:15 am

I think physicians who practice in a holistic way do so because that is their personality or value system. There is little about medical training – both in med school or continuing education later – that orient a physician towards holistic care. Then there are all the economic issues – the expectation that a MD will make serious money and the way the system of reimbursement rewards short visits. The extraordinary array of technology available has created a generation of physicians who rely so heavily on those technologies they lack good diagnostic skills.
I admire Schumacher’s ideas very much – he is of course essentially a distributist and would then emphasize subsidiarity. I thinka Schumacher system of health care would emphasize the use of midwives and even birth at home. It would emphasize the sue of nurse practitioners and physician assistants for much primary care – certainly well care. Regional hospitals for the high tech and specialists. The problem of course is that people are very resistant to the use of midwives and nurse practitioners. And this despite the much higher satisfaction ratings that both midwives and nurse practitioners get when people do use them. Our family practice doctor brought in a nurse practitioner a few years ago to help with an expanding practice. She is now the person I always request when making an appointment as do my other family members. The difference between a visit with her and the MD is unbelieveable. She does want to get to know you and what issues are important in your life. She spends more time explaining things. And it seems that nationwide people who do use a nurse practitioner report the same thing – a more holistic approach. I think the issue is again – training. Nurses receive more training on educating the patient, providing counseling and looking at the person holistically. So they are more apt to provide that sort of approach to care than an MD.

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Rod Dreher

posted February 24, 2010 at 8:27 am

Stef: As someone with a recent cancer diagnosis, I think the situation re: “big city” vs. “small town” medicine is complicated. Small-town medicine for family practice is wonderful when there’s closeness and communication, as you describe. However, there are some serious shortcomings of the small town which come into play when there’s a serious diagnosis.
Stef, that’s why I made the distinction in my post between family medicine and specialized medicine. Dr. Lindsey sent Ruthie on to specialists in Baton Rouge after that first visit, because he knew her treatment would almost certainly require it. The context I’m talking about is everyday general practice. It’s certainly possible to get lousy, inattentive care in a small town, but Tim’s point to me, as I understood him, was that practicing medicine in the context of a small town, where there’s a much greater chance he has some personal, non-professional contact with and knowledge of his patients, helps him to be to them more than just a technician of the body.
Interestingly, Ruthie has found that her oncologist at the big Catholic hospital in Baton Rouge is also surprisingly attentive and compassionate. A friend and cancer survivor told me that that doctor had a reputation for being brusque, until he himself was diagnosed with a serious chronic disease, which changed him.

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Ron Pavellas

posted February 24, 2010 at 9:10 am

Yes, we in the west have metaphorically dissected the human into separate parts which are usually addressed by different ‘doctors’ who are typically not in communication with each other. I and others assert that the spiritual aspect (whether or not any given person recognizes this ‘part’ of him or herself) is near or at the root of most dis-eases.

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posted February 24, 2010 at 9:58 am

Most doctors have so much debt when they graduate from medical school that they want to go into specialties where they make a lot of money. They also prefer urban centers. My home town has had a rotating series of doctors who are there for a year, two at most, probably becuase some outfit is paying off part of their loans if they serve in an underserved rural area. Sometimes they don’t speak English well or they come from foreign countries and have a hard time relating to the locals. My mom just told me that she’s traveling three hours to see a doctor for medical care because she doesn’t trust the doctors in her town and doesn’t know them well. When I was growing up the town had a medical practice with three doctors who knew everyone in the town intimately and were from this area. I went to school with their kids. They’d taken care of me since I was a baby. One of them made a major mistake in treating me as a toddler that could well have killed me and my parents decided not to sue them because they didn’t want the reputation as the people who sued the town doctor and they knew the guy and knew he was sorry. They never let him treat me again but the two other doctors treated me regularly. That kind of bond doesn’t exist with the doctors there now.
I live in a larger town now with access to 24/7 medical care and have a regular doctor. She, like many of the doctors here, is from outside the United States, somewhere in Africa. Her partner is also from Africa. Some of the other doctors in town seem to come from India or Pakistan or China originally. I’ve wondered if there’s an incentive that makes them more likely to set up in this rural, predominantly white state, when they might have been happier in a more diverse and more cosmopolitan area. I like my doctor and she does a good job, but the nature of medicine means I don’t have a lot of time to see her at visits or build much of a relationship. She charges me close to $100 for five minutes of her time. I don’t think there’s much incentive for the old style country doctor anymore, financially or otherwise. I also used to cover the medical beat and have seen the local doctors’ files with the state medical examiner’s board, including the malpractice suits and patient complaints. That tends to make me a little more cynical. Your sister appears to have lucked out in having a doctor she knows well and trusts.

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posted February 24, 2010 at 4:54 pm

You are catching on that there almost must be a difference between small town family docs and specialists. While many specialists I know are also warm, nice people, they need a different skill set than your family doc. If you need to be able to go from asleep to in the OR operating in ten minutes, that requires a personality and skill set different from the primary care guy.

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posted February 25, 2010 at 5:41 am

The doctoring-by-the-numbers post is exactly what one of our kid’s pediatricians did. After losing our fantastic family doctor (see the post above), the second pediatrician we went through was dealing with a weight issue. She didn’t look at the fact that our kid was clearly thriving. She only looked at the numbers (and was emphatic that that was her job), and put our family through a month of needless Hell doing numerous tests (which showed that our kid was just fine) and trying to stuff more food into a screaming toddler. We switched doctors.
Patients don’t need doctors with a medical degree to do medicine-by-the-numbers. We could do that just as well and a lot more cheaply with a computer program. We need doctors who listen and exercise sound judgment.
Some of the fault is with patients. If you don’t trust your doctor, find another one. But another part of the problem is that it’s hard to get good information on doctors in advance. They generally don’t do interviews, and doctors groups fight against web sites that allow patients to comment on doctors (arguing that we aren’t qualified to evaluate our own care).
One of the leading causes for malpractice claims is bad patient relations. Patients don’t sue doctors they like. On the other hand, patients are very intolerant of bad results from doctors they don’t like. Both doctors and patients would be better off if it was easier for patients to find a compatible doctor.

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Mary Russell

posted February 25, 2010 at 7:53 am

I hope to have time to parse these issues sometime soon, but would just like to throw out there that primary care docs are actually more holistic in their approach now than was the case 20 years ago. Read the book “House of God”, about an internal medicine residency in the 70s, to get an idea of this.
Let’s also be clear: the doctors who get such high grades for personability back in the 50s and 60s are the same docs Rod chastised for being arrogant and god-like because they were dismissive of breastfeeding.

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