02 February 2012

"The Last Family Doctor": Notes to Paul E. Stepansky's Excellent Book

Paul E Stepansky's memoir of his "father's medicine" is a beautiful book that has really helped me think through the implications of the specialization of medicine. As I was reading it, I took fairly extensive notes from the work. These may well interest regular readers. Where appropriate, I provide a bit of context. My comments below are in bold italics.

A justification for treating knowledge in the humanities seriously when it takes medicine as its object

"We have grown too disenchanted with our doctors and our doctoring to ignore the story of my father's medicine. I write about my father a loving son, yes, but also because his remarkable life and career provide a different kind of window into our current medical malaise. For my father's medicine was medicine as a calling, not medicine as commerce, however tempered by a caring sensibility and hemmed in by professional ethics the latter may be." (pp. xi-xii).

One of the implications of the specialization of medicine - this comment matters to me greatly because I think that people often forget or treat cynically the rather more noble desire to be as good as possible in as much as possible.

"I want to share with readers what we have gained but also what we have lost in the death of the postwar GP who cared for individuals and their families from birth to death." (p. xiii)


"Yet in writing about my father's medicine I am also writing about the medicine practiced by an entire generation of gifted generalists, many with battlefield experience, who came of age at the same time." (p. xiv)

The opening sentence:-

"My father's medicine was strong. Literally strong. His legendary red medicine - a mixture of paregoric (camphorated tincture of opium), belladonna (a highly toxic perennial shrub that contains atropine, a chemical that relaxes muscles), and phenobarbital (a barbiturate with sedative effects)..." (p. 3)

And from what world of professionalism did this strong medicine emerge?

"To this day, I don't know how my father learned to make the red medicine. He knew things that other doctors couldn't possible know - at least in my child's mind's eye and in the child that lives within me still. He became a licensed Pharmacist's Apprentice in 1939 and, after the interruption of the war years, completed his training at the nation's oldest pharmacy college, Philadelphia College of Pharmacy and Science, in 1947. He retained his pharmacy license throughout his medical career, formulating and dispensing all manner of medication to the patients of his rural general practice in Trappe, Pennsylvania." (p. 4-5)

Stepansky's father was a musician, a very good one. Leading to this on-point observation:-

"One marvels at the cachet accorded musical prowess in the early 1930s at a South Philadelphia junior high school laden with the children of working-class immigrants, many of them Jews from Eastern Europe." (p. 13) 

Why does this musical talent matter?

"What are we to make of all this violin playing, and in what sense is it foundational to my father's medicine? I think my father - quiet, deferential, very much under the thumb of a loving but stern and demanding father - found his voice through his instrument."  (p. 14)

Stepansky's father's wartime service mattered enormously in his professional development. It also mattered enormously in his emotional development:-

"A few years before his death in November, 2008, my father told me that one of his jobs was burying the severed limbs of American soldiers. So my father, among other things, held down exhausted, depleted, wounded GIs for anesthesia-less suturing, assisted with frontline battlefield surgery, much of which involved amputation, and went outside to bury severed arms and legs after the day's work. One can only wonder at the impact of such things on the constitution of a gentle and soft-spoken 22-year-old pharmacy student whose passion, before and after the war, was the violin, and who carried Tolstoy's War and Peace in his backpack throughout his European tour." (p. 22)

How did tragic experiences like these - any many others - define his practice and his music?

"Bach-like rhythmicity defined my father's work life. His doctoring schedule, like his Bach, expressed humanity through its disciplined cadences. His hours were long and hard because medicine was not only a professional but also a calling, and he cared deeply for his patients." (p. 33)


"The same hands that shaped and molded complex harmonies put stethoscope to chest and listened to heart sounds. He was not a cardiologist, but he loved cardiology, and like other gifted generalists of his era, he made and read his own electrocardiographs (EKGs). On a Sunday afternoon, he might play Bach, listen to  a recording of Nathan Milstein playing Bach, and then, lying on the living room floor centered between his two loudspeakers, list to recordings of heart sounds." (p. 34)

It was a career that might not have been:-

"It is the fall of 1947, and he is desperate to gain admission to Jefferson Medical College. But it is 1947: medical school, much less patrician Jefferson, is a very long shot for any Jew, much less the Romanian-born son of Ukrainian peasants. It is only after World War II, that state legislatures, prodded by the Anti-Defamation League of B'nai Brith, the American Jewish Committee, the American Jewish Congress, and President Harry Truman's Commission on Higher Education, begin to take effective action against religious and racial discrimination in medical school admissions. In 1947, all five of Philadelphia's medical schools maintain strict quotas on the percentage of Jews in their entering classes." (p. 36-37). 

A career not open to many:-

"In 1947, the American Medical Association, in its wisdom, continued to deny membership to qualified black physicians whose local chapters were racially restricted. This meant that the AMA of 1947 had not a single black member from the District of Columbia or the entire south. Only in 1950 did a single African American physician serve in the AMA's House of Delegates. Jefferson hardly bucked the tide; indeed, it was part of it. Immigrant Jews at least had a chance." (p. 37)

His training at Jefferson, his background in pharmacy, his music, and his military service:

"My father's medicine was a holistic medicine that treated sick and suffering people, not diseased and dysfunctional organs. He was destined to be, and to remain, a generalist." (p. 47)

And more importantly:

"Like the great generalists of the late nineteenth century, he rejected the sensibility of a narrow specialism that concentrated on one or another body part or body system at the expense of the suffering person. To doctor was not to treat the illness but to care for the person - indeed, not the person, but a person in all the singularity of that person's life circumstances." (pp. 47-48)

In what world was a generalist necessary?

"Rural practice in the 1950s means house calls, plenty of them." (p. 55)

And the demography of that world?

"Many older couples - couples with names like Gromis, Walker, and Knisell - are initially able to drive to [his] office. As age and infirmity make the husband's drive more and more difficult, my father adds them to the list of regular house calls. Sometimes the families he sees at home are related and there are tensions among them. In such cases, he graciously accepts the role of mediator, conciliator, and relational problem-solver; his house calls straddle the boundaries of medicine, psychiatry, and case work." (p. 57)

He therefore remarks later of his career to a course for Jefferson Medical Students:-

"In addition to medicine, pediatrics and obstetrics, I found psychiatry important to understand and apply practically. Good EENT concepts and treatments as well as knowledge of allergy and dermatology, I learned, were vital to successful general practice." (p. 61)

His medicine meant being informed in a great deal of modern science too. He said:-

"To me this means relating the effects of the body systems one upon the other in health and disease through knowledge of the basic science - i.e. biochemistry and physiology - through some understanding of the social and environmental stresses on the patient and finally through insight into the psychological influences of personality structure as it affects health and disease." (pp. 63-64)

There was a tacit dimension to this medical practice:-

"Any caring physician who looks at a lesion or listens to a description of a symptom but sees and hears the anxious and confused person who contains the lesion or offers up the symptom is drawing on tacit knowledge. And any caring physician whose gaze goes beyond the lesion, the reported symptom, and the containing or offering person to the patient's relational world, to the family members who, variously, bolster up (or add further insult to) his or her lesion-burdened self - that physician's clinical gaze, we may say, is informed by a tacit knowledge that is deeper and multidimensional." (p. 64)

Stepansky's father was recognized widely for his many achievements:-

"What impresses me more about my father than these institutional accouterments, unusual as they are for a generalist, is the relentless drive to know more so that he can do more for rural patients who need more." (p. 68).

His generalism extended to surgery too:-

"But my father's medicine was not the medicine of a GP surgeon. He was no more inclined to surgery than to cardiology, infectious disease, or psychiatry. at the same time as he sets fractures and throws nerve blocks, he takes and reads EKGs and teaches hypertensive medicine at Jefferson." (p. 70)

He is also something of a psychotherapist:-

"One day I strike up a conversation with a friendly young woman of about my own age. We talk comfortably about the things small-town 19 year olds talk about in 1970. After office hours, I remark to my father that I enjoyed talking to her and add that she didn't appear ill to me, not in the least. He looks up from his desk directly and tells me quietly that the girl's mother is an alcoholic and her father beats her, so she comes to the office every Saturday morning to talk to him for a while. "Does she pay you?" I ask him. "Oh, no," he replies. He doesn't charge her anything. She simply needs to talk to him. She likes to tell him that someday she will pay him, he adds, and always smiles and nods. They both know full well that money will never be involved in their relationship, that he, his nurses, and his office provide him with what the British child psychiatrist Donald Winnicott termed a "holding environment," not a billable service. She is of the community, he  serves the community, it is a perfectly natural thing that she should come to him in this manner, Saturday after Saturday, month after month, probably year after year." (p. 75)

And such support mattered significantly:-

"Contemporary psychiatrists  who disparage the therapeutic value of support probably don't know how to provide it. My father's support was critical to his doctoring because it derived from an understanding of the individual that was familial and familiar." (p. 77)

Such a holistic medicine determined the structure of his practice and dispositions:-

"His was an open-ended commitment to Hippocratic medicine as a mandate to help people in those ways in which they needed help, which mean allowing them to use the physician in those ways in which they needed to use him." (p. 86)

His father's medicine was:-

"...a medicine of living and dying. That is, his commitment to his patients embraced living well and dying well - dying with dignity and grace and with as much comfort as he could provide." (p. 98)

Such awareness made this medicine a family medicine too:-

"Now, a half century later, medical educators have belatedly recognized that medical students should be trained to deal with the process of dying, so  the medical school curriculum has come to include courses in palliative care." (p. 99)

And now for a dose of realism about a specialization:

"It is revealing of contemporary medicine that students and resident need to be taught that their physicianly obligations extend to elderly patients who become ill, suffer, and die - that with such patients, so to speak, the doctoring is in the dying. So we end up with yet another subspecialty, to which a knowledge base and "well-defined competencies" can be imputed. For my father and other rural generalists of his time, coming to grips with the death of patients was not a medico-educational project but an integral part of lived experience. Of course his doctoring meant being present for his dying patients and lending weight to their experience; this was the only kind of physician he knew how to be." (p. 100)

And further depressing realism:-

"Family doctors and primary internists can no longer afford - in any sense of the term - to be available in the manner of caring generalists of my father's generation. To an extent, this is because medicine itself has become commerce, however tempered by a caring sensibility and hemmed in by professional ethics. Commerce of necessity reins in the human offerings that can be legitimized (and reimbursed) as medical." (p. 104)

This was medicine of a specific time and place.

"Throughout the 1960s and into the 70s, especially in smaller communities, there were no CT scans or PET scans or MRIs to order; no multidisciplinary pain clinics to refer patients to; no laparoscopic or laser-assisted or computer-guided or micro surgery. Transplant surgery was in its infancy, with the first kidney transplant in 1963 and the first heart transplant in 1967. Cancer treatment was, by current standards, primitive. Understanding of the human immune system, including the cellular nature of acquired immunity, was more primitive still." (p. 113)

The work of professionalism required by the generalist was large but also in some sense noble:-

"When the American Academy of General Practice was established in 1947, it was predicated on the belief that general practice was sui generis, unique unto itself, and that, unlike the specialties, it would be defined by the individual GP's commitment to continuing education rather than completion of a time-limited residency program. This definition fell back on the assumption that GPs wanted to be GPs and were motivated to read journals, take courses, attend conferences, in all, to "keep up to date." With respect to the content of postgraduate training, the Academy provided the generalist with great latitude in pursing specialist skills according to personal interests and aptitudes. Doctors such as my father were permitted, indeed encouraged, to work to the limit of their licenses by acquiring post-internship "specialty" knowledge and procedural expertise and then utilizing it in their own practices." (p. 116)

What in part explains the decline of these generalists? Where did they go? And why?

"With biotechnology comes risk; with risk comes the need for specialized expertise; and with such expertise comes the need for clinical guidelines and regulations to codify expertise by stipulating who does what and who gets reimbursed (and insured) for doing it. Physicians coming out of medical school no longer have the opportunity to become broad-based, decision-making generalists over time. Motivation - or its absence - has little to do with it. The current system does not encourage, and makes it well-nigh impossible for, medical school graduates to achieve what I will term a generalist level of multi-specialty competence. Quite the opposite. Newly minted physicians must choose at the outset one or another delimited area of the medical "field" in which they will acquire the residency-based competence to make treatment decisions, devise medication regimens, interpret test results, and implement a set of procedures." (p. 120)

We used to call this deprofessionalization or alienation:-

"The structure of residency training and reimbursement not only straitjackets physicians who aspire to become total-body healers; it also robs them of the perquisite that facilitated this transformation in generalists of my father's generation: time." (p. 121)

And further evidence:

"Today, physician time is a precious commodity, regulated, rationed, and closely monitored in the interest of productivity. My father and the postwar generalists of his generation retained the privilege of being inefficient." (p. 122)

One might think that family medicine or general practitioners would have been able to resist this transformation:-

"But truly comprehensive care, it would seem is no longer within the purview of any single physician, however driven to broaden his or her knowledge base and acquire new instrumental skills. Our corporatized system of multispecialist care, which revolves around science, technology, and research dollars as they are deployed in academic medical centers, often reduced comprehensive single-physician care to little more than continuing medical interest in patients over the course of their lifetimes. Given this reality, family medicine educators, who seek the identity of specialists in a society of specialists, increasingly arrogate to family medicine the specialist role of gatekeeper to the healthcare system. This role is not only different from, but opposed to, the kind of comprehensive care provided by generalists of my father's generation." (p. 130)

Some final thoughts - especially about drugs

"There are too many medications for too many conditions, and, as a society, we are well medicated and no doubt overmedicated. It is no longer possible for a single physician to have at his or her fingertips a working knowledge of commercially available drugs for the majority of acute and chronic conditions, much less a secure grasp of risks and benefits of complicated mutidrug regimens." (p. 137)


"Insurers not only determine which medications within a family of medications are covered but, increasingly, impose on physicians a prescribing schedule according to which coverage will be provided. Typically, in what is referred to as "step" therapy, more expensive, proprietary medications are allowed only after less expensive, generic medications have been tried and found wanting." (p. 138)

One last impression of the differences between his father's medicine and ours?

"The red medicine, like my father, bridged the science and art of medicine. It was the best, the absolute best." (p. 139)