An obsolete physician.

An Obsolete Profession. 

 Being a physician of almost any type requires the ability and the interest to listen and to talk to one's patients and to communicate like two adults talking to each other. This applies particularly in general practice. For about half of my career I was an academic trying to teach young men and women how to be family physicians or general practitioners, I use the two terms interchangeably. The term 'family physician' was introduced in the sixties to try to put general practice into a 'specialist' category, quite the opposite to what was really needed. What the well-intentioned founders of family medicine were aspiring to was a physician who was a specialist in everything, a super-doc of impossible breadth. The impossibility of the task became all too apparent fairly early on, as evidenced by the early necessity of providing 'certificates of special competence' in ever expanding areas. This is what gave rise to specialization in the first place. One of the most important requirements of general practice is the ability to elicit the relevant information, sometimes highly personal and /or embarrassing and sometimes not obviously related to health to make a diagnosis. People come into medicine with varying gifts. Long before they have any clinical knowledge I have seen students interact with patients with skill and alacrity. The conversation was enjoyed by both patient and student. Others are not so fortunate and do not easily establish rapport with patients. Of course a sound basis in clinical medicine is extremely important but equally important is knowing when to refer and to whom. (Not always as simple as one might think). Almost as important is the ability to live with ambiguity and uncertainty which every generalist has to do. In the 'olden days', the medical history and physical examination were the keystones to finding out just what was wrong with the patient. When I was a teacher of Family Medicine I used to tell my students that when they had taken a history if they didn't have a differential diagnosis (list of possible diagnoses) in their own mind of what ailed the patient, or at least in what system the disease originated, they better go back to square one and re-take the history. Rather glibly in retrospect, I would say ' listen, let the patient give you the diagnosis.' Most of those sophisticated tests that people tend to be subjected to today did not yet exist. The physician relied upon his eyes and ears and sense of touch to make a diagnosis. Because the science of medicine was so primitive, the art of medicine determined the exceptional physician from the merely competent. Conan Doyle, himself a physician, modeled Sherlock Holmes on one of his mentors, Joseph Bell, and I have had the privilege of being taught by such an individual myself. Such individuals were well aware of their exceptional skills and were as susceptible as any stage magician to displaying their magic. All of them emphasized painstakingly collecting the data and observing the evidence to come to the correct conclusion. In fact, I found them to be more akin to Columbo than to Holmes (who had his brilliant judgement clouded on occasion by his cocaine addiction). I sometimes suspect that his close association with Dr. Watson might have had ulterior motives. Then along came ultrasound, CT scans and MRIs and all of the miraculous technology that made clinical skills as irrelevant as gas lighting - no, as candle lighting. Overnight, a lifetime of clinical skills were replaced by a cookbook of algorithms.
   In the final medical examination in those distant days the candidate had to show he knew how to take a history and do a physical examination. Alone with the patient for up to 45 minutes, the candidate emerged from behind the curtain and presented his history and physical findings in detail to the examiner, as well a list of possible diagnoses. "My" patient was an affable older woman in a public ward bed and in the course of taking her history I asked her if she had any idea of what was wrong with her. To my surprise (and delight) she said "Yes, of course, but I am not supposed to tell you." she added mischievously, with a grin. She went on to tell me the diagnosis. "And when you examine me you'll find my liver and spleen just a little bit enlarged." I did! They were! That conversation certainly paid off! In all cases an appropriate history had to be taken before it was appropriate to move on to the physical examination. Physical examinations were divided into complete or regional. Massive textbooks were dedicated to clinical signs and symptoms and to have a new clinical test named after you was an assurance of immortality. The 'complete' physical examination involved a detailed organized examination of every system, cardiac, pulmonary, neurologic, gastro-intestinal, musculoskeletal, all of which were systematically documented. Every orifice was explored and omission of a rectal examination was almost negligence. Now such a complete examination is regarded as unnecessary and most physicians don't know how to competently do one anyway. I remember when as a young physician, a respected specialist in Internal Medicine said to me: "It's time to throw away the stethoscope. It's an obsolete instrument." It wasn't true then and it isn't true now but it reflects an attitude that continues to exist and indeed, to grow.. That is why GP/FM is dying and would already be dead if it wasn't the cheapest way the political hacks can pretend to provide what they have promised.
   I enjoyed my 55 years in medicine but if I was starting again I would be somewhere else in the medical establishment where I'd have a life outside of medicine.