“Hi, Doctor Kamajian! I finally got health insurance that I can use to come to see you with my son.”
I looked at the chart and realized it had been three years since I had seen her very familiar face. So, before the exam, we chatted and got reacquainted. It is remarkable what family doctors remember about their patients. This is not an unusual conversation.
Patient: I have a new job. I took three years off to take care of my son.
Dr. Kamajian: So you aren’t working at the pet store anymore?
Patient: Oh no, I left that after he was born. You know my grandmother died … she loved sharing her music with you.
Dr. Kamajian: How many years ago was that … three already?
And so the conversation goes. We talked about her mom, her grandparents, her great-grandparents and her two older children. I have been the doctor for all six generations.
“You know,” she says, “My son is only five, but he is writing poetry too, just like my great-grandmother.”
I excuse myself and walk out of the room and come back with an autographed book of poems written by her great-grandmother (who was born in 1890). Her great-grandmother’s message to me on the inside flap of her book of poems simply read, “To the doctor who keeps my hands and mind still able to write poems.”
My patient looks at the book of poems and tears up. “You know I was only four when she died. I can still remember how she looked and her voice. I wish I had gotten to know her better. I knew she wrote but have never seen any of her poems. What can you tell me about my great-grandmother and great-grandfather?” So, I tell her a story her great-grandmother had told me about attending live theater in London before World War II. I can still remember her great-grandmother saying: “Anyone could afford live theater even during the depression. London has changed so much.” Her great-grandmother had died in 1994. She would have been shocked at the London of today we both commented. I gave her the book of poetry, and she said, “When I come back the next time I will bring all of my children. Please tell us stories about both of my great-grandparents.” Oh, the stories I could tell, but that would be breaking the doctor-patient relationship, even this many years later.
My patient asked, “What story can you tell me about my grandparents?” I told her the story of how after he retired, her grandfather finally took oil painting classes and said to me, “I wish I had never been a businessman. I was a success, but I always wanted to be an artist.” The last years of his life he painted like a madman, trying to put on canvas all that he had wanted to express his entire life. I asked her if she has any of his artwork? She said, “No, my aunt and cousins tossed everything after he died. The house was full of paintings, and no one wanted them.” I told her I would bring one of his paintings of a storm at sea from my home and give it to her when she comes in next time.
Over 10 minutes had passed before I started taking her medical history and doing a physical exam. I helped her with her current issues, and we went to the reception area together. There she introduced me to her husband and five-year-old son. The other children were at their first day of school.
And so it goes in an osteopathic family physician’s office. With time, you become part of the community’s memory. You know the families. Sometimes better than even they remember. You have heard the dreams and the fears. You have taken the time to look into their eyes and listen to their voices and know like your mother knew when she looked at you when things were different — when things were not right. You have helped when people were sick of course, but you have also helped when they were down and out financially, and emotionally. You have comforted the dying and heard their last thoughts and prayers and their last fears and seen their last moment of joy.
Who are we that we have been so blessed? We are the lucky ones that got into medical school. So many of our classmates applied and never got into medical school. Now and again, I run into them. Read about them in my college alumni book. Hear about their lives. Many have earned more and have not had the sleepless nights, the stress, and the losses that an osteopathic family doctor experiences. None have had a young person walk into their office and heard the question, “Tell me more about my great-grandparents. We have had the opportunity to practice the art of medicine.
I see this beautiful profession from the long view of 40 years. I listen to my students. I watch their heads buried in the EMR, rarely if ever looking up at the person who is talking to them. I see how they are rewarded by the prompts of the EMR and by the managers who manage everything. I hear the anger of physicians and know the ever-increasing significance of burn out. I know what happens when we all become employees and are told we have 15 minutes not only to see the patient but do the electronic charting or you have to finish the charts at home. I know what it feels like to have been converted from family physician to clerk typist.
Students tell me, “I won’t be shamed into feeling bad that I don’t know anything about the patient other than why they came to see the doctor. I will not be shamed into feeling bad about not knowing what the patient looks like. I won’t be shamed into feeling like I am missing something by letting a hospitalist see the patient. Continuity of care means only being able to access the EMR and read what was done. I won’t be shamed when I never take a call on nights or weekends and sign out to a telemedicine corporation and the nurses at the clinic in the pharmacy down the street.”
It is a shame however that they are missing so much. Will this model improve the health of the patient? Will this improve the health of the doctors? Will this improve the family life of the physicians? Will this decrease burn out?
The science is in. Burnout rates are dramatically higher with this model. What is the doctor missing that all of these changes were supposed to improve? The doctor is losing the doctor-patient relationship and has replaced it with the doctor-computer and doctor-corporation relationships. I do not think that 40 years from now my younger collogues will be sharing poems and paintings and family stories when a patient walks into the room. Unless we all see what is valuable before it is lost. If we do not, we will then find ourselves like this patient’s grandfather, at the end of our lives trying to do art when we have missed our forty-year opportunity to do the art of medicine.
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