Transformation

By David Loxterkamp (’79 MD)

It has been almost a quarter century since I began the practice of family medicine. My duties were as broad as my father’s before me. There was something magical and heroic about it all—managing a postpartum hemorrhage, repairing a deep laceration, or finessing a patient through cardiogenic shock in the twilight hours of an ICU admission. Life was equal parts exhaustion and reward.

In my early fifties, the spinning top lost speed. I discovered that I had no close friends and that I barely knew my wife and children. When my marriage began to unravel, I joined a men’s group and got therapy. One day I read a quote by Howard Thurman, the theologian and civil rights activist, who said, “Don’t ask what the world needs. Ask what makes you come alive and go do it, because what the world needs is people who have come alive.” It struck me like a lightening bolt, and I began in earnest to recover the redemptive sense of joy.

Shortly thereafter, I applied to participate in the National Demonstration Project (NDP), a study of practice transformation sponsored by the major organizations in family medicine. Surprisingly, our practice was chosen, along with 35 others from around the country. The two-year study introduced me to amazing ideas and technologies. With encouragement, we began to incorporate them: open scheduling, patient portals, e-mail, and e-prescribing.

The most important lesson from the NDP came from the physicians themselves. They are an optimistic, self-motivated, and indefatigable lot. At one of our retreats, we talked about what mattered most in the work we do. The conversation quickly turned to relationships. We understood that information technology and systems change and payment reform were important, but only to preserve the relationships we cherished most. And we agreed that no matter how troubled the health care system, it could change by our willingness to be agents of that change. As Gandhi challenged us, “Be the change you want to see in the world.”

I began to realize the old disease categories missed much of why patients came to see me. The chronic headache, fatigue, diarrhea, chest pain, and insomnia often pointed to an underlying unhappiness, one that was never addressed. Doctors don’t voice the question, frankly, because they ignore their own unhappiness. But once you start to come alive, once you realize that the hardest change lies within, once you take responsibility for your own happiness, the thrust of our work ineluctably changes. The “heroic” physician no longer requires an ICU or delivery suite, but needs only an exam room where the patient begins to unlock a hidden sorrow, or regret, or sense of shame.

An elderly patient came to me not long ago about his diabetes. Before launching into a review of medications and recent labs, I asked him off-handedly what he had been up to. “A moose hunt with my son,” he proudly reported. “But doc,” he added, “I was no use in hauling it out of the woods.” As he looked away, tears streamed down his cheeks. Despite my efforts to clarify the source of his pain, we made no progress.I asked him if he would see me again in a week. He nodded yes.

At our next meeting there was no breakthrough, either. But I mentioned a group of men—all precisely in his predicament—who intended to meet at the office in a couple of weeks. Would he join them? Again a quick nod, so I began to recruit members for a group that was still forming in my head. Now two groups meet regularly to help older men adjust to their loneliness and loss of identity.

What is true of them is true for us; we need conversation, friendship, and a sense of connection to fill our lives. This has become the functional measure of my patients’ health, and I ask about it and foster it as directly as I promote treatment for hypertension and asthma. In response to changing needs, the practice also cares for opioid addicts, chronic pain patients, those infected with HIV, and the dying. But we gave up certain areas, too, that were once integral to my self-image: hospital rounds, obstetrics, and outpatient procedures.

I am adjusting to the change, just like my patients. I am adjusting because of them and through them, in deepening relationship. I am struggling to be the good doctor my father was, though in ways he might not have recognized. The one thing I routinely share with my patients is my own happiness, as a gift and example for their struggle toward health, connectedness, and self-respect.

Dr. Loxterkamp is the author of A Measure of My Days, chronicling a year in the life of his practice, Seaport Family Practice, in Belfast, Maine. He is working on a new book that will expand upon this essay.