- Everyone should have a physician in the family
Over the past 35 years, I have told friends and family that everyone should have a physician in the family. I did not mean to suggest that the familial physician should provide medical care, formal or informal, to loved ones. Indeed, I have avoided such things as diagnosing or prescribing for family members. As a physician and academic–medicine educator, my recommendation (actually, more a wish) that families should have a physician member was driven by my first–hand experiences in witnessing the downside of expediency, cost containment, and high care volumes in today's healthcare. These pressures have diminished U.S. healthcare routinely, not just exceptionally. One need only consider the ongoing crisis in medical errors as one example. In spite of real progress in humanizing physicians in training and in practice, these economic pressures have only become more powerful and more limiting over those 35 years, as the unspoken rationing of care enables the continued profitability of insurers, pharma, and healthcare delivery systems.
My father enjoyed relatively good health until the last two years of his life. Even before his death as an advanced octogenarian, he did have some brushes with serious illness. He owned a successful small business that enabled him to pursue his passion, golf, several times a week, but in an era prior to sunblock lotions and SPF ratings. When I was finishing up college in another state, he was diagnosed with a 'skin cancer' on his shoulder, which was locally excised at his small–town hospital and clinic. However, his later tumor recurrence, now having invaded his local muscle tissue, came to my attention in my early years of medical school. Even before I was a physician, my connections in medical school connected him with a specialty surgeon at our tertiary–care, academic medical center. Dad was impressed by the thoroughness and engaged counseling provided by his academic surgeon. The surgeon told Dad he had a squamous cell carcinoma of the skin that required significant surgery to remove it fully. Dad bounced back from his surgery, which involved an extensive local tumor resection, and a muscle flap to allow his skin graft to grow in over the bony protuberances of his scapula. He quickly resumed his golf game around the age of 70. However, the surgery took its toll on his swing and his handicap went up, to his chagrin.
Years passed, and I became a psychiatry resident, then a faculty member at an academic medical center in another state. Over the years I would be called intermittently as the 'doctor in the family'. Extended family would bring me questions that remained obfuscated or unanswered after consulting with their own doctors. While in the youth of my physicianhood, I had some worries about liability for my advice–giving, but with experience found myself progressively less concerned. What was needed was not diagnosis and treatment recommendations, but guidance about how to navigate our fragmented health care system, what questions to ask, how to recognize a good doctor and good care, what to expect, and what not to accept.
A relative with congestive heart failure found out from me how to ask about the cause of her heart failure, her prognosis, and how to recognize a physician's dodging of her questions. When given a diagnosis of 'just getting old' from his primary care physician, a geriatric in–law with excessive daytime sleepiness needed a referral to a neurologist to address what turned out to be vascular dementia. (This leitmotif of the elderly not requiring diagnosis and treatment simply because of advanced age is one that will recur in this story. We need to talk more about ageism in medical practice.) What was a medical mystery for local doctors in a lakeside community was diagnosed by me easily, over the phone, as textbook Parkinson's disease through obtaining a secondhand history from an in–law's brother. I urged the patient and family to see a neurologist in a bigger community and raise the question of Parkinson's. (Years later, I experienced significant sorrow about failing to ask a colleague about his early movement disorder...