Sunday, October 28, 2012

Guest Post: Telling family medicine's stories

Richard Young, MD is a family physician educator and director of research at the John Peter Smith Hospital Family Medicine Residency in Fort Worth, Texas. He is the author of American HealthScare, a critically acclaimed book about the excesses of the current U.S. health system and potential primary care-based reforms. Dr. Young also regularly posts on his blog of the same name.


I think one of the underlying reasons Family Medicine continues to be under-supported in the U.S. is the very nature of storytelling, and the media's preference for telling stories over reporting facts.

The ologists have it easy. Their stories go something like this: A mother has a child who isn't doing very well both at home and at school (protagonist). She goes from one doctor to another, and they tell her there is nothing physically wrong with the child and one even tells her that bad parenting is to blame (antagonist and conflict). She refuses to take no for an answer, and she scours the Internet and finds an ologist at a major medical center who thinks he has the answer. They travel to see this medical fairy godmother, he waves his magic wand (a complete battery of tests), and the boy is saved and becomes normal again (resolution). Nightly news and magazine shows (60 minutes, Dateline) love these stories.

Here is family medicine's story. A patient comes to the family physician with a list of physical symptoms. The physician listens to the patient (in itself therapeutic), orders a few basic lab tests that are normal, and essentially asks the patient to be patient -- the symptoms don't raise any red flags for a serious underlying disease and will probably resolve on their own. A month later the patient feels better. BORING. There's no action and no conflict.

Other medical nonsense is magnified on shows like Private Practice and Grey's Anatomy -- when the characters aren't banging each other and actually taking care of patients -- in dialogue where they scream at each other lines such as, "You have to let her go!", then "I will not let my patient die. I swore an oath to do everything in my power for my patients and I will not give up!" And so on.

Therefore, the story of family medicine isn't what it does as much as what it doesn't do. Our quality care is best understood as a counterpoint to ologist excess. This is why Shannon Brownlee's book Overtreated and the recent video about the harms of overtreatment are a step in the right direction to get the American people to understand the tremendous cost, waste, and harms caused by an over-ologized physician workforce, and an American medical culture that is locked into the overall ologist philosophy of what is standard of care.

Some colleagues and I have collected some great stories of how family physicians deliver better care at a lower cost. The power of some of the stories we heard had their greatest impact when set against the ologist alternative. For example, a patient was taking 13 pills and seeing 5 different doctors multiple times per year and still feeling sick. Then a family physician took over all her care and got her down to 8 pills and 4 visits per year, and the patient felt better.

Patients and storytellers want certainty, but family physicians are the masters of managing uncertainty. Americans want action and immediate answers, but family physicians are the masters of patience, judgment, and prudence. Let's face it, family medicine is just un-American.

That's why our healthcare system is so costly and inefficient and why our children will have worse lives than their parents. The task is enormous, but the culture of America must change to right the listing ship. Americans need to develop a different understanding of what a healthcare system should even provide in the first place.