The Country Doctor

The image of the “country” doctor, the “old school” doctor, the Marcus Welby if you will, persists in the minds of practitioners and as a modern myth in the minds of learners.  Did doctors really see patients in their homes?  Did they really have that much availability?  Did the patients respect the doctor as much as it sounds like they did?

Well… yes… and not that long ago.  A colleague of mine was completing a house call in Nanton this week on a palliative consult and I still do house calls in the city here.

That intense doctor-patient relationship, with its foundation in relational continuity, no longer seems evident in our fractured urban environment.  Residents in some programs are bounced from half day at one site to a full day at another site. New physicians in practice have a half day in this clinic, then 3 clinics at the refugee center but then the regular hospitalist shift derails that from time to time.  Some travelling warriors reside in the city but work three days at one rural community and two at another because of the scope they can practice there. … the only continuity that seems to exist is with the chart, the disease, and now the EMR. 

Is this really a doctor patient relationship?  Are significant relationships built and left in brief appointments?  What about making the extra bit of effort where the linkage might be better called a covenant?  Does anyone wake up and think to check in with the parents of the sick child from the night before on their day off?

Suneel Dhand is an internal medicine physician and author of three books.  He has summarized some thoughts about individualized care, or what may now be known as “precision medicine”.  I continue to believe that the bastion of generalism and relational continuity is in the communities outside of our large cities and that maybe the cities are catching up to rural docs in applying “precision medicine”.

“Every doctor, patient, and family yearns for more direct and individualized care. The ironic thing here is that many of the administrative and technological requirements that have pulled doctors (and nurses for that matter) away from their patients, have been enforced by regulators and administrators who themselves would love an “old school” physician for them and their families. So where did it all go wrong? We can save that debate for another time, but let’s focus on those universal traits that all patients and families seem to desire:

1. The doctor who sits down with them. The old school physician pulls up a chair (when in a hospital), sits face-to-face with their patient, maintains eye contact and asks open-ended questions. They allow the patient and family a chance to speak, directing them when necessary towards the questions. Just good old fashioned talking. At the end of the encounter, they are given a chance to ask any questions. The doctor isn’t distracted by a computer, tablet or smartphone. Writing down notes on a piece of paper if necessary looks for more attentive to the patient.

2. A doctor who is not rushed. In the health care system we work in, this is a tough one. There are certain techniques that can be utilized to make the most out of our ever-shrinking time slots. But the second the doctor gives the palpable impression that they are in a hurry to move on, this is something that’s remembered as the “doctor being in a real rush.”

3. The doctor thinks carefully through the problem. The old school physician is the one who would visibly be a thoughtful problem solver. They would think thoroughly through the problem at hand and utilize their breadth of knowledge to come up with a diagnosis, and then take the time to explain it to you.

4. The doctor has solid clinical skills. Physical examination (along with history taking) has become a lost art. It’s now too much of a quick protocol driven, box-ticking exercise. And this is something that is noticed by our patients too. The old school physician has the diagnosis in mind right after talking to and examining their patient. Before ordering a battery of tests or having a shotgun-type approach to investigations.

5. The doctor knows you. This is perhaps one of the biggest changes over the last few decades. Your old family physician would know you (and likely your family) very well. They didn’t rely on computers (more about that below). You felt a personal connection to them and knew they were rooting for you. Nowadays, little things we can do include reading and recapping on the medical chart before we walk into that room to make sure we know as much as possible about the human being in front of us.

6. The doctor was free and independent. This may be more difficult to recreate with the way the health care system is going, but back in the day doctors were their own boss and not at the whim of health care administrators and overly burdensome regulation. Back then, it was more about the doctor and the patient in its purest form, as it should be. There wasn’t a small army of a dozen administrators for every physician! Likewise, this was reflected in how their doctor acted and behaved, free to be the true advocate for their patient.

7. The doctor wasn’t glued to their computer screen. I’m saving this for last, because health care information technology and cumbersome electronic medical records — in their current suboptimal state — now represent one of the biggest barriers between the doctor and patient. With studies now suggesting that doctors (and nurses) spend an absolute minimal part of their day, as little as 10 percent, in direct patient care — everyone at the frontlines, but most of all our patients, lose out. As does productivity. Until better and faster IT solutions are created, the world of health care IT has reduced patients’ stories to reams of garbled data, tick boxes, and random incomprehensible lists. Whatever physicians and nurses can do to push for less time with their screen, and more with patients, will benefit everyone. The old school physician wasn’t bogged down by information technology, yet still delivered excellent, competent care to their happy patients.

The above are just seven ways in which the old school physician operated. All parties involved would be happier if we pushed for modern doctors to keep these traits. Yes, even administrators. Do you know why? Because as well as it just being good medical care, imagine the healthcare cost savings that would result if doctors and nurses are able to go back to actually focusing more on our patients. Reduced need for repetitive, unnecessary testing, higher patient satisfaction, shorter lengths of stay, keeping people at home instead of in the hospital, and also higher productivity and efficiency.

Old school is good. For this debate at least, the answer lies in looking backwards and regaining the lost art of good medicine.”