A commentary in the New England Journal of Medicine titled “Beyond Evidence-Based Medicine” received much well-deserved criticism for not only mischaracterizing EBM, but advocating for a novel approach, “interpersonal medicine,” that was explicitly codified in the recognition of the U.S. specialty of family practice nearly 50 years ago. Here’s what the authors wrote about this practice of medicine that is, apparently, new to them but well-known to the rest of us:
Interpersonal medicine would recognize clinicians’ influence on patients and informal caregivers and the relationships among them. It would be anchored in longitudinal, multidirectional communication; broach social and behavioral factors; require coordination of the care team; and, constantly evaluate and iterate its own approach.
After reading these sentences via a tweet from Dr. Eric Topol, I quickly added my perspective on interpersonal medicine, which, judged by the volume of likes and retweets, was greeted enthusiastically by other primary care clinicians and their allies:
It was one of the few times in recent memory that other physicians were eager to jump on the #FMRevolution bandwagon, as geriatricians, general internists, and general pediatricians tweeted that their generalist fields provide interpersonal medicine too. I agree. But I draw the line there. No matter how excellent one’s beside manner, a subspecialist whose job description revolves around treating a specific a body part, organ system, or disease state, or intermittent contacts during specific periods of illness (e.g., emergency medicine, hospitalists) is not using the generalist approach described by longtime Annals of Family Medicine editor Kurt Stange in a 2009 editorial:
A generalist approach involves working on the parts while paying attention to the whole; being connected by sustaining relationships; having a broad base of knowledge while being grounded in specific information; scanning and prioritizing, then focusing on what is most meaningful; moving back and forth between the universal and the particular. The generalist approach is rooted in recognizing connection to person, community, and cosmos.
The skills of generalist physicians — and family physicians in particular — have long been devalued by our health system’s mechanisms of measuring and paying for clinical work in discrete tasks, rather than for caring for the whole person. The movement toward “paying for performance” has not helped. As Dr. Dhruv Khullar and colleagues observed in a recent JAMA Viewpoint, “because these programs are disconnected from the needs of patients and physicians within organizations, they often result in erroneous metrics, gaming of the system, and unidirectional assessments that emphasize meeting thresholds over open dialogue.”
In other words, never mind that I carefully reviewed with my 65-year-old patient of the past 5 years with a recent blood pressure of 145/92 the pros and cons of intensifying his medication regimen, the limitations of the evidence, and his personal values and preferences; 140/90 is my practice’s non-negotiable cutoff for poor quality. This is hardly surprising, since quality management has rarely accounted for what makes a difference to patients in primary care – particularly, as Dr. Justin Mutter and colleagues suggested in “Core Principles to Improve Primary Care Quality Management,” prioritizing therapeutic relationships over time. Reflecting on changes in the role of the personal physician since the dawn of the specialty, a group of senior leaders in academic family medicine has observed:
We have watched our patients age with us. They beg us not to retire. For our patients, we are caregivers, healers, advisors, friends, and navigators through a complex system. Our patients are admirable human beings who taught us our craft, offering clinical challenges and providing us with the gratification that makes practicing medicine worthwhile. A principal challenge for the present and future … is to be able to establish and maintain the long-term trusting relationships that have characterized family doctors and our role in health systems and society.
In a similar ode to continuity of care, Dr. Adam Cifu, a general internist who has cared for the same patient panel for more than 20 years, wrote in JAMA Internal Medicine: “In our own practices and in our roles engineering health care systems, we should prioritize the maintenance of these relationships. We are losing much more than easy clinic days as we foresake long-term physician-patient relationships.” This assertion not merely anecdotal, but supported by evidence: a recent analysis of Medicare data by Dr. Andrew Bazemore and others at the Robert Graham Center found that higher primary care physician continuity is associated with lower costs and hospitalizations. At the same time, one of my colleagues notes that insurers are paying five times as much for patients to have a video or telephone visit with a “teladoc” than with their family physician.
Enough with interpersonal medicine! EBM is not the problem, and it never has been. Rather, the patient experience in the U.S. will not improve without first recognizing that family physicians and other generalists have expertise in whole person care, grounded in long-term therapeutic relationships. Then, policymakers must create conditions that support providing generalist care from the continuum of medical training through clinical practice.
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