In my last article, I alluded to how medical care is changing at near warp speed, as the volume of new knowledge keeps doubling every few years or less. There’s a load of good treatment and care, as well as improved outcomes that comes from that. At the same time, there are some downsides to the changes in medical care that I believe should be resisted when possible. One downside is that the default drift of our medical care is to become steadily less personalized, less relational.
Consider the family doctor of past decades who would often help deliver the children, see them when they were sick, watch them as they grew up, do home visits when needed, and be present when death came. They knew the families well and could administer care in very reassuring and intimate ways. Of course, they often averaged only a few patients a day, had a low overhead, needed only minimal, if any, staff and had an exponentially smaller amount of medical facts to digest. That is not in the least to diminish them; they were often brilliant, sacrificial, intensely devoted persons administering the most effective treatments of their time in a deeply personal manner. But going back to that kind of practice with today’s medical realities and costs is probably not practical.
Continuing forward to my three decades of medical care, the depersonalization of medical care has continued apace. I have watched the trend rather regretfully and most patients have been the poorer for it. So, what are the driving forces for this depersonalization of care? In my opinion there are several: One is the smothering blanket of bureaucratic requirements that sucks more and more time away from the patient-doctor interaction. Another force is the fragmentation of care. Patients receive care from so many different doctors, walk-in clinics, specialists and non-physician providers that no one care-provider is likely to really know the patient in the way a physician of bygone decades would have.
Another driver toward depersonalization is the huge financial overhead that pushes a typical practice to see more patients, shrinking down a typical visit to a few pressured minutes. Add to that the loss of physician/patient control of medical care brought about by the insurance-driven model of medical care. With insurance typically collecting and then distributing the money in this system, they increasingly assume the power to decide what gets done, what the payment will be, who you can see (and that might change year to year) and what diagnostic and treatment options will be withheld.
In spite of all this, I love what I do. But, at the same time, these forces, and probably many I haven’t mentioned, have threatened to sap away much of the blessing of providing personal, relational medical care. My intent isn’t to be negative, but only to point out some of these forces with the hope of battling to preserve personal medical care.
Of course, no one is obligated to follow my suggestions. But as a participant in medical care over three decades, my hope would be that many would:
- Promote the right of patients and their physicians to direct medical care, not insurance companies and government agencies.
- Consider joining one of the cost-sharing ministries to cover your major costs and then budgeting for your own basic primary care, perhaps through a direct primary care arrangement with your doctor, so that the financial power stays in your hands.
- If possible, consistently see your own physician for your standard medical care so that you stay connected and a level of personal relationship develops that enhances your medical care.
- Support policies that reduce bureaucratic burdens that suck away the time and attention of your physicians from actual personal care.
This is a topic that is close to my heart, but impossible to cover in the scope of a brief article. Still, maybe this can stimulate a little of your own thoughts and ideas; maybe in some small ways we can, together, battle to keep the human touch, the focused personal connection of medical care. Personally, I hope so.
Andrew Smith, MD is board-certified in Family Medicine. He has recently relocated his practice to 2217 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835
Wow he’s really struggling coming up that hill.” I was watching my eighty-something father-in-law labor up the hill to our house. In context, you need to realize that, “Grandpa” is normally one of the most vigorous elderly guys you’ll ever see. He generally comes blasting out of his room in the morning like a man on a mission. After breakfast he may head down the hill to the barn and chop some wood, spray the poison ivy, or any number of other projects. Even much younger folks are usually huffing and puffing after making their way back up the hill to our house. But Grandpa was pretty used to it and usually took it in stride.
That’s why it seemed odd that he actually looked old as he slowly made his way up the hill, pausing a couple times along the way. When he got in the house he quickly eased into a chair and looked spent. On asking him if he was alright he responded, “I don’t know; I guess I’m just getting old. Getting up that hill is really getting tough. My thighs and shoulders are sore as can be. I can barely get moving in the morning.” I’d noticed he certainly wasn’t rocketing out of his room of late.
Given that he was eighty, there were concerns that maybe age had finally caught up with him. Or maybe he had some hidden cancer, or late-onset rheumatologic disease, or any number of other problems. With how he felt, it wasn’t hard to get him to come in for a check-up. Most of the tests came back pretty unremarkable, but an old, simple blood test, the sedimentation rate, was very high. It’s a non-specific test, but together with his other symptoms and the normalcy of most of the rest of his tests, it pointed to a diagnosis we see a couple times a year: polymyalgia rheumatica (PMR). The clincher would be how he responded to a low dose course of oral steroids. They tend to work like magic with PMR and that can help confirm the diagnosis. Sure enough, a week or so after starting the steroids, we had the old “young” Grandpa back, motoring up the hill like it was nothing.
PMR is an uncommon, but occasional, illness involving the rapid onset of soreness in the large muscles of the thigh and shoulders with a sense of weakness and fatigue. Sufferers are almost always over age 50 and more than twice as many women as men get it. The cause is not known and is thought to possibly be autoimmune. As noted, steroids work wonders for PMR and are slowly tapered over many months. The entire course of PMR averages about three years. It’s one of those diagnoses you don’t want to miss since it’s so debilitating to have, but so very treatable.
Interestingly, about 15% of people with PMR also have a condition called giant cell arteritis (GCA), which has also been called temporal arteritis. GCA involves inflammation of arteries, most commonly the temporal artery up on the head. GCA causes a substantial temporal headache, and if untreated (with higher dose steroids), can even cause sudden blindness. Grandpa actually had some temporal pain that came and went. In the end we had him get a temporal artery biopsy (which happily was normal) so as to not miss this potentially blinding malady.
Unlike almost 50% of individuals with PMR, Grandpa did not experience a relapse. Several years later, he’s still going strong. The only minor glitch – I hear him all too enthusiastically recommending prednisone to any of his older friends with aches and pains: “I’m telling you, get your doctor to put you on some prednisone – it fixed me right up in no time.” But it’s a small price to pay to have him back as a young Grandpa.
Andrew Smith, MD is board-certified in Family Medicine and practices at 2217 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835
This has been a crazy, but mostly enjoyable week. We moved our medical office about a half mile closer to the mountains on Rt. 321. It’s exciting to see a band of workers busily laboring to turn a beautiful but empty shell of a building into a humming place ready to provide medical care. When everything is first pulled out of a few dozen cabinets, drawers and cupboards, brought to the new place and strewn around, it looks like a bomb went off. It seems impossible that that much stuff was stowed away in the old medical office. It’s a bit overwhelming. But slowly, with everyone doing their part, some semblance of order and organization is restored. Monday morning, we were (mostly) ready to roll.
It makes me think of how medicine as a whole is constantly moving, and the pace just seems to be constantly accelerating. Some of the movement is exciting and helpful, while some of it is distracting, burdensome and counter-productive. The part that’s exciting is the explosion of medical knowledge: new treatments, better surgical approaches, more accurate understanding of the causes and prevention of disease. Every time I start to get a migraine and reach for the medicine that stops it in its tracks and lets me keep working without the rather horrific pain I used to experience, I’m thankful for the advances of modern medicine, and that I didn’t live with migraines fifty or a hundred years ago.
At the same time, not every new discovery is better than what came before it. New treatments sometimes come with new complications and almost always come at significant cost. And realistically, trying to keep up with the steady doubling of medical knowledge is no easy task for any physician. Happily, there are lots of online resources that can get you the information you need in a heartbeat. Gone are the days of my bookshelves of medical texts that are already becoming outdated when they come to print, or the files of articles on recent studies that I used to keep. Now a few clicks can get me where I need to go to find the latest studies and information on a given disease or treatment.
But as I make what I expect will be my final physical office move, I must confess to some major concerns about where medicine is moving. Although much of this movement would apply to all branches of medicine, I’m mostly referring to primary care medicine – the front line, “blue collar” medicine done by family physicians, pediatricians, and general internists. These are the first line of medical contact, often aided by physician assistants and nurse practitioners, who sort through someone’s symptoms and seek to arrive at a diagnosis and treatment plan. It is estimated that 80% of the time a primary care doctor will completely handle whatever problem comes to them, and the other 20% or so, they will access an appropriate specialist.
So, what are the major threats to good, satisfying primary medical care? Many answers could be given, but I see four major threats that end up producing the depersonalization of medical care. By depersonalization in medical care, I mean that the idea of one human being trying to engage and help another achieve relief of symptoms and maximal health in the midst of a personal one-on-one human encounter, is being lost. In its place is often a fast-paced, distracted, non-empathetic, and all-too-short visit.
While some efficiency is a good thing, medical care is best delivered when a personal human connection is made. The iconic family doctor of Norman Rockwell paintings and stories of family physicians who personally knew their patients over decades seem quaint and unattainable in today’s medical and social climate. That may be true, but if we recognize what is driving us toward an impersonal medical care we may be able to slow, or even reverse, the drift in that direction. Next article I want to lay out the four factors that seem to be driving us toward an impersonal, unsatisfying medical care. Maybe we can get medicine moving in a more positive direction, at least on a local level here in the Maryville area.
Andrew Smith, MD is board-certified in Family Medicine and practices at 2217 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835
“Goldilocks was hungry. She tasted the porridge from the first bowl. ‘This porridge is too hot!’ she exclaimed. So, she tasted the porridge from the second bowl. ‘This porridge is too cold,’ she said. So, she tasted the last bowl of porridge. ‘Ahhh, this porridge is just right,’ she said happily and she ate it all up.”
The story of Goldilocks and the three bears fits the story of our relationship with the vital mineral, iron. We don’t want to have too little, but we actually don’t want to have too much either; we want to have just the right amount.
Iron is an essential element for blood production. About 70 percent of our body’s iron is found in red blood cells as part of hemoglobin, which carries oxygen to the body, and in muscle cells, as myoglobin, which accepts, stores, transports and releases oxygen. About 6 percent of body iron is part of certain proteins which are essential for respiration, energy metabolism, and nerve function. Iron also is needed for proper immune function.
Where do we get iron in our diet? A wide variety of foods contain iron. Red meat is a rich source of iron, and iron in animal products is absorbed better than iron from plant products. Nevertheless, foods such as spinach, fortified breakfast cereals and even dark chocolate have substantial amounts of iron. However, individuals vary a great deal in how well they absorb the food in their diet.
If iron consumption and absorption is chronically low, iron stores become depleted. In the typical American diet, iron depletion from poor dietary intake alone is uncommon. Most often, having low iron results from losing iron by blood loss. In women who are still menstruating, blood loss from their monthly cycle is the most common cause of iron deficiency. In non-menstruating women and in men, iron deficiency usually points to unrecognized persistent microscopic blood loss from the gastrointestinal (GI) tract. Thus, a colonoscopy and upper endoscopy are usually carried out to search for a GI source of blood loss such as a colon polyp or cancer, or a bleeding ulcer. There are numerous other causes of low iron, but the point is that, in addition to taking iron supplements, the reason for the iron deficiency must be thoroughly sought after.
What’s wrong with not having enough iron in our bodies? When iron is depleted over time, it begins to cause reduced red blood cell production and eventually results in a low red blood count, called iron deficiency anemia. Other symptoms such as fatigue, shortness of breath with exertion, restless legs, paleness, headache, racing heart, and a desire to chew on ice (oddly enough) can accompany the low iron state.
So, should everyone take an iron supplement just to play it safe? No, indeed; in a healthy non-menstruating adult an iron supplement can cause iron overload, which has its own toxicity. Likewise, children getting ahold of excessive amounts of iron-containing vitamins is a common cause of poisoning.
Besides taking too much iron in the form of supplements, there are also built-in genetic abnormalities which cause some adults to hold on to too much iron, even with a normal diet. The best known of these hereditary conditions is called hemochromatosis. It affects over 1 million Americans. Iron overload from these causes can damage the liver, pancreas, joints and heart, and can even be fatal if left untreated. Hemochromatosis is one of the few conditions that can benefit from an updated version of the old practice of blood-letting.
So, if you have symptoms that make you wonder if you have too little, or even too much, iron, get it checked out. Iron is vital, but like Goldilocks, we want the amount to be just right.
Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835