Friday Reflection 16: The Evolution of a Stable Practice

LS is an 86-year-old woman coming to see her physician for a regularly scheduled visit. She is feeling well and is just “checking in.” She began seeing her doctor in July 1997 when her previous doctor, one in a long line of residents, graduated. She was 61 at the time and asked one of the clinic coordinators for a “grown up doctor.” When she first met her new doctor, she was disappointed; he did not look much older than her last one.

Twenty-five years later, she tells medical students, “I hope to die before my doctor retires.”

My mother loved museums, particularly the Metropolitan Museum of Art. When I was a kid, sprinkled between visiting the dinosaurs at the American Museum of Natural History and mummies at the Brooklyn Museum, were frequent visits to the Met. We had an unspoken agreement that I would tolerate something she wanted to see if we also visited the “Arms and Armor” rooms. Over the years, she managed to pass on her infatuation, and I’ve wandered the Met’s halls hundreds of times.

My relationship with the Metropolitan has evolved. While it is still me visiting the same building, little else is the same. The Met’s collection has changed — new acquisitions, focus, and expansions and I have also changed. I have studied art in courses, travels and books. Art and artifacts that once went unnoticed, now hold my attention, and pieces that once captivated me now seem trivial.[i] My company for museum visits has evolved as well. Adolescence brought visits with friends. Later my mother rejoined me, now having to listen to me espouse on what I was learning in college.[ii] Later I got to relive my youth, taking my own children who, oddly, never very much cared for Arms and Armor. Now visits are mostly with my wife.

Similar to the evolution of my relationship with the Met over 50 years has been the evolution of my medical practice over 25. Though consisting of one doctor, one setting and a fairly stable group of patients, my practice in 1997 would be unrecognizable today.

I am an anomaly in medicine these days, having cared for the same panel of patients for decades.[iii] This continuity was not planned. If I am feeling self-important, I attribute it to an admirable dedication to my patients. When I’m being more honest, I admit that my endurance stems from a lack of energy and ambition.[iv]

So, let’s start at the beginning, the of days of arms and armor. The most remarkable thing about the beginning of a practice is how difficult it is. I entered practice after residency training that I still consider exceptional. I had done a “primary care track” in the residency under the tutelage of incredible mentors. These were people who taught what it meant to specialize in general internal medicine. During my “chief year” after residency, I got even more experience doing a general medicine clinic session each week, moonlighting in the urgent care of a multispecialty practice, and preparing teaching sessions for the residents. I could not have been more confident in my preparation for independent practice.

From the first day I realized that I did not know enough. Decisions I made with certainty during training were so much more difficult now that I was, ultimately, responsible for them. In addition, every patient was a new patient; some doubted my qualifications while others sought my opinion only because things had not quite worked out with their previous physician or, often, physicians.

At the end of each day, I would visit my colleague in the office next door to ask him the questions I’d accumulated over the day. I remain indebted to him for his patience, good humor and encouragement.[v]

So much has changed since those first years. The most obvious difference is that the patients became familiar. Outside of pleasantries at the start and end of visits, the core of appointments are spent assessing the patient’s health. There is no longer a need to collect social and family histories, as important issues have been learned and recorded and the rest forgotten. Gone too is the need to work to form a therapeutic alliance; that work was done in earlier visits. Rare are visits during which the patient hesitates to reveal the full story—only to pose his real concern when my hand is on the door to leave.

There is also little effort spent trying to gauge the reliability of a history. I’ve learned how to read each person. Is this someone whose every concern needs to be carefully considered, or is this horrifying story routine for this patient, an appeal for reassurance?

Patients who were once challenging tend to become less so with time. My patients and I have learned what to expect from one another; we recognize each other’s strengths and failings. Patients who once intimidated me no longer do. I have become more confident, hard to rattle, while the intimidators have less reason to don their protective deportment. Often, they have also become old and frail.

While this evolution to familiarity has made practice easier and more efficient, the passage of time has even eased the burden of the new patient visit. Almost every new patient has an established connection. A friend, a family member or a colleague referred them to me. They enter the relationship with some level of trust in my qualifications and a willingness to open up.

As relationships with individual patients changed, so did my relationship with my “patient population.” I became familiar with the culture of my patients. This might suggest stereotyping and profiling but let’s just call it cultural competency. Where I trained, my clinic was filled with elderly Russian, Jewish immigrants – refugees really. With practice and the guidance of some gifted interpreters, I learned the intricacies of taking a medical history in this population. Whereas some people express their anxieties as headaches or (like my family) abdominal pain, my residency patients manifested theirs as chest pain. After four years, and dozens of encounters, I was a pro. I could tell when to worry and when to reassure. After moving 1000 miles west, to an entirely new population, I had to relearn the chest pain history – critically important to the life of an internist (and his patients).

While relations with patients and the population as a whole changed, so did my relationship with medicine itself. More and more of it became routine. Much of my work I learned to do automatically. At this point, I can discuss prostate cancer screening, evaluate dysphagia, or work up unintentional weight loss with barely a thought. I also established my supports. How can the nurse or medical assistant help me? When should I engage a pharmacist? Who should I ask to look at this rash? With whom should I review these lupus serologies?

The patient panel itself evolves. Most patients who fail to connect with their physicians find new ones. Those who remain find their physician’s style therapeutic and efficacious. We notice this when we cover our colleagues and recognize that each physician’s practice has its own personality. In this way, a patient panel is less like a structure, slowly being built from a foundation and more like a ship of Theseus. People leave the practice for all sorts of reasons (search for a better fit, dying, moving, changing insurance) always to be replaced by someone looking for a primary care doctor.

So far, the museum/clinical practice analogy is working pretty well. Museum visits continue to evolve over the decades, remaining stimulating and enjoyable. As the practice evolves, the doctor gets better and the patients (at least those who stick around) are more satisfied. But this being 21st century medicine and not a pleasant, artful excursion, things can get a bit more complicated.

Patients are not universally impressed by the seasoned physician. A new patient referred by her friend to “my wonderful doctor” is often disappointed when I turn out to be as human and fallible as her last physician. Relationships with patients I’ve become close to can be complicated. I might demur when asked to see a friend, but I’ve never terminated care with someone because we have become personally close over the years. The patient who is now a friend might be hesitant to admit to a perceived failing—relapsed alcohol use, an extramarital affair, medication nonadherence.

The aging of my patients adds challenges as well. Most of the patients I initially took on in the 1990s were in their 50s and 60s. By some strange calculus, 25 years later, these very same patients are in their 70s and 80s. Newly discovered diagnoses tend to be worse, complications more severe, recoveries rare.

This evolution of the panel itself can raise some uncomfortable issues. When I started, new patients came from the emergency room, the inpatient general medicine service, and the “find a doctor” number listed on the medical center web page.[vi] Now, my practice is closed. I accept a few new patients a month, family members of my patients, referrals from friends or colleagues and referrals from people to whom I can’t very well say no (read dean, chairman…). Given the hoops one has to jump through to see me, my practice has evolved to cater to the more privileged and connected. Although I don’t think that the people I see actually get any better care than those seeing our residents or our newest attendings, this evolution does make me uncomfortable.

And then there is time’s effect on the doctor himself. As the patients I care for have aged, my acumen diagnosing and treating certain diseases, especially those most common in younger people, has certainly declined. I am not the doctor to see if you need the perfect birth control pill. It can also be an effort to remain vigilant with patients I have seen for decades. I have frequently diagnosed “physician-transfer–associated aortic stenosis.” In this condition, a severe aortic stenosis murmur is heard during a patient’s first visit to a new physician. This murmur was not detected by the former physician, who had long since stopped examining the patient. Staying alert, inquisitive and energetic with patients who, mostly, discuss the same concerns at every visit is not easy. Even the hypochondriac eventually dies of something.

How does it all end? I see myself spending more time at the Met (and the more convenient Art Institute of Chicago) in the coming decades. I can’t predict if I’ll keep making new discoveries or if I’ll eventually settle into revisiting a group of favorite works. From what I’ve seen from older colleagues, there comes a time when, through a combination of physician choice and patient attrition, a practice begins to shrink. I imagine I’ll always revisit my practice, even when there is nobody left in it.

An earlier version of this reflection was published here.

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[i] I remember telling my father that I really like the painter Giorgio de Chirico. He responded, “Sure, adolescent boys always like him.” One more thing that my father was right about. I don’t find him that interesting anymore.

[ii] She told me I was her favorite guide but what else would a mother say.

[iii] Doctor patient relationships that span decades are increasingly rare today. I am not sure why, but I imagine that the demands of electronic documentation, the stress created reduced visit lengths, the myriad ways that patients can access their physicians and the declining reimbursement for primary care all play a role. At the same time, our increasingly mobile society and the restrictions on physician choice imposed by payers make remaining with the same physician difficult for a patient.

[iv] These are probably the same qualities that led me to a career for which, as long as I kept succeeding in school, a path was laid out in front of me.

[v] This person remains not only a close friend but also my internist. Once, a couple of years into practice, I even asked him to verify the diagnosis of appendicitis I had made on myself. We agreed. I was in the OR by the end of the day.

[vi] My schedule used to list the source of referral for new patients. Patients who came to me through “find a doctor” number were listed as “Dr. Line,” meaning that they had called the find a doctor line. It took years for me to figure out that Dr. Line was not a physician who thought highly of me.