What’s Up, Doc?
What’s Up, Doc?
Real, Live Family Practitioners
By Alfie Kohn
Dr. Manuel Lowenhaupt strides into the examining room and sticks out his hand. “Nice to meet you. I think I know the rest of your family.” Nineteen-year-old Brenda Wilkins (a pseudonym, as are all patients’ names in this article) gives a perfunctory greeting and launches into her complaints: back pain, a bad cough, gum discomfort, and cramps in her leg. He nods sympathetically. “You feel like shit,” he says.
She laughs, relieved. Dr. Lowenhaupt gives her a thermometer and suggests that she tell him what her temperature is. “Our job today is to figure out whether this is a virus or a bacteria,” he announces while she slides the thermometer under her tongue. Then he discusses the possible side effects of the medication he thinks he might prescribe. “All drugs are poisons,” he says. “It’s just a question of whether you want to get rid of that cough enough to risk becoming constipated and a little sick to your stomach.”
In less than five minutes, this 29-year-old graduate of Harvard Medical School has distinguished himself from most of his colleagues. He knows the patient’s family and something of her home environment. He puts her at ease and gives her something to do that makes her feel like an active participant in the session. He lets her in on what’s going on. And — is it possible? — he is skeptical about medication.
Toward the end of medical school, most students are starting to think about zeroing in on parts of the body or parts of the population, about becoming neurosurgeons or dermatologists or pediatric oncologists. But Manuel Lowenhaupt and three of his friends made a different choice. They decided to buck the trend toward specialization and become family physicians. Last summer they got together, fresh out of residency, and opened up a practice in Melrose.
“The ugliest building in Melrose,” to be precise. That’s how one his colleagues, Clara Simeone, puts it. The black glass does make the structure seem a little forbidding. It’s sandwiched between an internal medicine practitioner on one side and a surgeon on the other. But inside, the waiting room is welcoming, comfortable. Today patient number one, a toddler clutching his Spiderman book, sits next to patient number two, an elderly woman. Both are accompanied by middle-aged relatives. Welcome to family medicine.
Greta McKenna, a very sunburned woman of 49, is complaining to Dr. Simeone. “Kids are kids,” she says, sounding defeated. “Nothing changes.” She wears designer jeans and flip-flops that display her painted toenails and her varicose veins. Because of her alarmingly high blood pressure, Dr. Simeone, who delivered two of her grandchildren, has been trying to get Mrs. McKenna to come in for a physical for almost six months now. She has been stalling because she’s strapped for cash and also because she dreads doctors. Dr. Simeone tries to put her at ease about both. Taking a medical history, she intersperses the clinical questions (“Have you ever had diabetes?”) with comforting small talk (“How ’bout your son that’s moving? Is he gone yet?”)
They are sitting in Dr. Simeone’s office, where the same kind of blend is reflected in her bookshelf. There’s the Compendium of Drug Therapy and Clinical Scalar Electrocardiography — right next to The Healing Heart, Caring, and What Do Women Want? They move to the examining room where Mrs. McKenna’s blood pressure is taken. She looks wide-eyed at the doctor: Well? It’s 172 over 90. “There’s nothing like the threat of a complete physical exam to ruin your blood pressure,” Dr. Simeone laughs. She has a high-pitched rapid laugh, but it’s clear she doesn’t like the numbers.
The blood test is next. Asked if she is ready, Mrs. McKenna nods a bit too vigorously. The doctor sees this and says lightly, “You can faint anytime you want.” Then she diverts and supports her patient simultaneously: “You’ve done your good deed for the year now,” she tells her, sticking in the needle. “You made me very happy coming in for the exam.” And it’s true.
“When people find out you’re going into family medicine, they say, ‘But you’re smart! You don’t need to do that!’ You definitely have to go against the stream to be a family doctor in Boston, that’s for sure.” Dr. Simeone seems uncharacteristically annoyed about this as she walks down Main Street to get her lunchtime salad. Still, she chose family practice within weeks of entering medical school. “Most specialists are more interested in diseases than people. I have several patients with the same complaints, but to me they’re completely different. Mrs. C______ is very compliant and takes her pills, but her husband runs her life. Another woman wouldn’t take medication. Reasoning didn’t work; nothing worked. It turned out her sister had warned her about fluid pills. It’s the people who are interesting and how they respond to their problem and how you get them to respond to their problem. I like them all ages, both sexes, and with different kinds of problems. I think it’s great fun to go from a young woman to an older man to a newborn.”
Family medicine, a phoenix that rose from the ashes of general practice (see sidebar), is far less specialized than other kinds of medicine, but it can be defined by the principles it embraces, not only the characteristics it avoids. There is, to begin with, a concern with the family system as a way of better understanding the individual patient. “I’d hesitate to say that internal medicine specialists don’t think about families at all,” says Dr. Simeone. “It’s just maybe a more consistent feature, a deliberate focus of family practice.” The way she sees it, a doctor can do a lot more for you if she not only has been your doctor for years but has treated your children and your parents, too. The medical and psychological context of the family means she doesn’t have to start from scratch.
Second, family practitioners are less likely to treat you as “that hepatitis case in room 320.” You are not a disease, but a person. This implies not only an understanding of how the different parts of your body interact, but also the behavioral and social aspects of your life. “People tend to want to separate out their physical problems and their emotional problems,” Dr. Simeone sighs. A family physician is trained to understand the relationship between the two — and, also, to allow patients to just talk. Dr. Simeone cites a middle-aged woman whose husband “drives her crazy. She’s much more comfortable dredging up some physical symptom and talking about that. She comes in every couple of months or so about some minor problem and spends time talking about what’s really going on.
“I have a lot of patients like her,” she adds. “When she can’t think up a physical complaint for herself, she’ll bring her husband in. Others will bring their children in.” This is fairly common for family doctors, who are cheaper than psychiatrists and devoid of stigma. If a patient seems more than they can handle — in this respect as in any other — they will make a referral to a specialist.
Dr. Lowenhaupt leans casually on the reception desk and recalls an 18-year-old patient he’d seen a few hours ago. “She allegedly came in for asthma, but she really wanted to talk about contraception and about the stress she’d been under. The main thing I offered her this morning was a chance to talk. It’s a real can of worms you open, asking ‘So how are things?’ It’s more than just asking the questions. It’s knowing what to do when you’ve opened the can. And you can’t do one patient every five minutes.”
Family physicians have had some training in psychiatry, of course, as well as in internal medicine, pediatrics, obstetrics, and surgery. But their practice is not just a mixture of these: It’s an attitude toward medicine and toward patients. Dr. Lowenhaupt contrasts his own field with the other specialties he had considered while in medical school. Neurology, he found, seemed to consist of expensive, painful tests that provided the intellectual pleasure of diagnosing rare, incurable diseases. Surgery, at least, “made someone better,” but he found that “the big problems that my patients were coming in with were being ignored.” Similarly, orthopedists “check the hip and don’t notice congestive heart failure.” He repeats an old saw that says orthopedists are “strong as an ox and twice as smart.”
“They drive the nicest cars, though,” he muses.
“Do you know what day of the week it is?” Dr. Lowenhaupt asks gently. Mrs. Gillcrist, her gnarled hands folded in her lap, frowns and says she should know. How about the month? The year? The President of the United States?
She can’t answer these questions anymore, and she doesn’t know why. The forgetfulness — and, with it, the depression – came overnight, according to her niece. The niece, wearing a smart pantsuit with a prominent crucifix on the lapel, is shaking her head at this display of senility, her lips tightly pressed together.
“How long has it been since you worked?” asks Dr. Lowenhaupt.
“About three years.”
The niece is dismayed and yet strangely triumphant. “No. It’s been years and years, Aunt Mary. You’re 83 years old!” She looks at the doctor to see what his reaction is to all of this. He sits on a stool, authoritative and calm, patient without being patronizing. “You know, she called me up and asked me for my phone number,” says the niece.
This throws him for a bit; he struggles to stifle his amusement. “She called you and asked for your phone number? That’s pretty, uh…” Instead of finishing the sentence, he rolls up Mrs. Gillcrist’s sleeve to take some blood. Her arm is a mass of bruises. After a minute, he says cheerfully, “Your blood is the right color.”
She looks up at him. “Well, I tried to live a good life,” she replies seriously.
Dr. Lowenhaupt is concerned because she is forgetting to eat, because she lives on the second floor, because she has congestive heart failure, and because she may be randomly taking medication that happens to be lying around her apartment. But this is only her first visit. First he has to make sure she can take medication on schedule, so he prescribes a mild diuretic for her swollen leg. He ponders the possibility of getting a visiting nurse for her and, in the meantime, suggests Meals on Wheels. (“I wish I had someone to bring meals to me,” he smiles.) He tells the niece to go through the apartment and look for stray medication. And he arranges to visit the house to check out the situation himself.
Within three minutes the two women are on their way home and 19-month-old Stephen, his mother and grandmother have replaced them. You can tell right away that something is wrong here. Stephen is crying, fussing, hitting; even when he’s calm, he seems strangely unresponsive. The problem is described as “failure to thrive,” and Dr. Lowenhaupt’s goal is to “get him sleeping in one place for one week in a row. His father is who-knows-where and the mother’s been going through some heavy changes,” he explains. Indeed, the mother, who is all of 19, is pregnant again and paying very little attention to Stephen right now.
There is a tiny koala bear perched strategically on Dr. Lowenhaupt’s stethoscope, and he calls attention to it now, hoping it will amuse the squalling child. It does not. He asks the mother whether Stephen would prefer a Garfield plastic stick-on toy or a Snoopy. “He’s not particular,” she replies. He disappears and brings a stick-on for her instead.
The two doctors are a study in contrasts. Simeone is 41, a product of Dorchester who talks about “wicked bad headaches.” She has a gap between her front teeth, thick glasses, and a reputation for thoroughness. Her family had no money and she wound up spending ten years teaching Spanish and French at Mass. Bay Community College before switching to medicine. “By the time I got really good at teaching, I decided I didn’t want to be doing it for the rest of my life,” she says.
Lowenhaupt has a deep voice, and, at six-foot-three, a commanding presence. He wears a huge M.I.T. ring and has taped two acupuncture charts to his office wall. (“I’m fifty percent Chinese,” he explains.) As a child he read textbooks for fun; at 15, his parents wanted to know what kind of doctoral program he’d eventually enter. His colleagues describe him as the “motivating force” of the office, as “fussy,” as having an “encyclopedic mind.” He’s the one who got this practice up and running, designed the office, and set up the computer, his pride and joy. He has far more patients than the other three doctors, largely because he went on a self-promotional binge as a resident, seeing twice the usual number of clinic patients and then sending out 1200 announcements when he started his practice. “I planned all this for years,” he says proudly.
Faced with a stranger who needed medical attention, some doctors would respond instinctively. Clara Simeone is one of those. Other doctors would hold back, thinking about malpractice and other possible complications. Manuel Lowenhaupt is the sort who would consider these issues and then go ahead and help anyway.
The office is a strange amalgam of the personalities of the four doctors, and a visitor feels like he is in the presence of, well, a family. Besides Lowenhaupt and Simeone, there is Beatrix Thomas, 38, a chunky woman with bright orange hair, and Ken Kopec, 29, who seems much younger than Lowenhaupt, although actually he graduated from M.I.T. a year earlier. Dr. Kopec loves to rock in the huge judge’s chair that dominates his small office. He also likes to needle Dr. Simeone until she says, laughing, “Shut up, Ken!”
They frequently stop into each other’s offices to chat about medical matters, to consult with one another. They may be generalists, but each has a favorite specialty that can be useful to the others. Today Dr. Lowenhaupt pops into Dr. Simeone’s office to brag about a rare injury he has witnessed. “I saw a real live central retinal venous thrombosis today,” he tells her. “Blood and thunder. It was a classic.”
“You rat!” she says. “I’ve never seen one of those.” And he describes this blood clot near the inner eyeball.
The same informality is present at their Thursday noon staff meetings, which are held in a tiny room. On the bulletin board are the menus from nearby restaurants and a quotation that has been cut out from the newspaper. It says: “Where everybody is in charge, nobody is in charge.”
The excitement this week is the arrival of a new IVAC (electronic thermometer). “We like toys,” someone explains. For Lowenhaupt it is the office computer; for Simeone it’s the snazzy new electrocardiogram machine.
In short, it is obvious they are new to all this. Sometimes they answer the phones themselves, and they take turns vacuuming at the end of the day. And because they are still building their practices, three of the four of them also moonlight at those shopping mall clinics and at psychiatric hospitals. They yearn for the day when they will not have to do this. In the office’s first month, last July, they had just under 500 patients collectively. Respectable, to be sure, but a full patient load would be nearly this large for each one of them.
Their patients are primarily white, lower income women, and a lot of them followed the doctors from their residency days. Some are in nursing homes or confined to their own homes. And, by golly, family doctors make house calls.
Dr. Lowenhaupt takes an old-fashioned black medical bag and gets into an enormous land cruiser waiting for him in the parking lot. It’s an outsized memento from his college days when he would spend Christmas vacation doing rescue work in the White Mountains. Right now it’s almost dinnertime and he’s on his way to visit 87-year-old Mrs. Ross. “I like to save house calls for the end of the day because they always run over,” he says. “I guess that’s because I enjoy them.” He has a special feeling for Mrs. Ross because she was his first home patient. “Ninety percent of what I do with her is reassurance: ‘You’re not going to die today.'”
Mrs. Ross is dwarfed by her blue comfy chair. Dozens of knickknacks and photographs surround her in the small living room. Her hair looks as though someone with a sense of humor set down a large white brillo pad on her head. But Mrs. Ross is sharp as a tack and will settle for nothing less than first-class medical care. Dr. Lowenhaupt routinely asks all his patients, “Any questions? Anything I can help with?” — and this woman takes him up on the offer with gusto. She has prepared a list of complaints and questions, and when he answers one, she is already preparing to ask the next.
“I think I should have some blood taken,” she will say. Or: “You want to take my pulse?” This is in case he should forget. He examines her eye and says, “Good!” Immediately she prompts him: “The other one?” When it’s time to take her blood pressure, he wraps the cuff around her skinny arm and tells her to “think nice relaxing thoughts.” Clearly she does nothing of the kind. She is afraid it will be dangerously high, and she is afraid it won’t be.
Mrs. Ross consults her list and describes some warning signs of cancer she heard on a television health program. She thinks some of them probably apply to her. Dr. Lowenhaupt takes a deep breath and says the program is “more for people who don’t have a doctor looking after them.
“You’re doing very, very well. But accept that you’re doing well and don’t worry quite so much.”
“I dwell on myself, yes,” she admits, “but I know how I feel.”
“Well, you’ve got to leave some worrying for the rest of us,” he says lightly.
Dr. Simeone does some worrying for her patients, too. She has no more office patients this afternoon, so she does one of her callbacks before taking off for the hospital. The woman at the other end of the phone had come in with vaginal irritation and Dr. Simeone had not reached for the prescription pad. Instead, she gave her a recipe that works for diaper rash: Maalox and corn starch whipped together. The woman was dubious. “A lot of people almost feel you’re not taking them seriously if you don’t give them something in a bottle from a store,” the doctor remarks.
She identifies herself now and asks how things are going. After listening for a moment, she smiles broadly. “I told you!” she says. “You thought I was crazy, didn’t you? But it worked, didn’t it?”
At New England Memorial Hospital, where she and the others spent countless hours during their residencies, Dr. Simeone is now an “attending” — a doctor who has a life outside the hospital, who breezes in (wearing civilian clothes) to check on private patients. The visit today is with a newborn who was not supposed to be any trouble. Unfortunately, Mrs. Aligheri, 26, went into hard labor very rapidly and developed various other complications. An obstetrician had to be called in. Dr. Simeone has had a disproportionate number of difficult obstetric cases and she is getting out of the baby delivering business. First, though, she has a mother and infant to check on.
Mrs. Aligheri is puffy from her eyelids to her toes, but she seems in good spirits. She is sitting up in bed, lost in a forest of flowers and cheese baskets and such. Dr. Simeone runs her eye down the woman’s chart and gives her a pep talk at the same time. “You are tough! You did a ton of work!” Reassured that her patient is all right, she puts on a sterile gown and walks into the incubator room to see Christopher Nunzio Aligheri. He weighs almost ten pounds and seems even larger than that because he is surrounded by premature infants. She checks him out carefully, looks at his chart, and pronounces him “wicked cute.”
Dr. Lowenhaupt, meanwhile, has a final callback of his own before calling it a day. The patient has encephalitis, and he is telling her that she sounds a whole lot better. “Dynamite!” he says to her upon hearing some good news. He is chatty and apparently undisturbed by the fact that the patient doesn’t remember having talked to him five or six times before. He listens for a minute and then says, “Very little that the doctors did for you changed anything. You healed yourself.”
Probably. But it sure doesn’t hurt to have a family doctor around, too.
Family Medicine: Why Is Boston Left Out?
Oh, it’s your right thumb that’s broken. Sorry — I’m a left thumb man.”
The jokes about specialization in medicine exaggerate only slightly. By the mid-1960’s, the old Marcus Welby-style GP was practically nowhere to be found. The money and prestige were in the specialties.
After a while, though, the pendulum had swung too far. There was an oversupply of specialists. Rural areas, in particular, desperately needed Renaissance doctors. Medical students were beginning to resist the narrow and even dehumanizing direction of their training. And the federal government decided it was time to encourage a return to primary care medicine by funding such residency programs.
In 1969, family practice became the 20th official medical specialty — an interesting irony considering its attitude about the very idea of specialization. Today, its professional association, the American Academy of Family Physicians (AAFP), boasts 56,000 members, more than any other specialty society. Even so, there is still a shortage of family doctors.
There are about 7,500 residents in 384 family residencies around the country. In Massachusetts, however, the story is very different. A mere fifty-four residents attend the state’s three programs, and one of the three — at New England Memorial Hospital in Stoneham — is closing its doors. The other two are in Fitchburg and Worcester; both are affiliated with the University of Massachusetts.
Family practice programs are generally in short supply around the northeast, but Boston is the only large city in the nation to have none at all, according to Dr. John McCahan, associate dean of Boston University’s School of Medicine. Why? “Many of the private medical schools which have large research bases were not ready to jettison the model that they had built up since the ’50’s,” he says.
The specialization and research orientation often means that medical schools don’t emphasize the caregiving aspect of medicine. An enthusiasm — some would say obsession — with technology also works to the exclusion of the values stressed in family medicine. The idea of generalism is still regarded in some circles as obsolete. It is enough of a challenge to master the explosion of information in a single specialty, some say. How can a doctor possibly stay on top of everything?
“One doesn’t keep up with information,” Dr. McCahan replies. “One keeps up with patients.” Family practitioners are not multiple specialists, nor do they try to be. But they know enough to handle 80 to 90 percent of all problems that come through the door. The rest can be referred to specialists. Moreover, if a family doctor wants to be certified, it’s necessary to be retested every six years. No other specialty has such a requirement: Once a surgeon is certified, it’s for life.
Besides resistance in the medical schools, family physicians have to cope with territoriality in the hospitals. They overlap with other specialties and these practitioners — particularly obstetricians — sometimes are unwilling to grant hospital privileges to the doctors they see as their competitors.
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