The Reflective Practitioner

I was recently asked to write the Forward to a book on practice transformation. The authors invited me to “speak to what is needed to reinvigorate primary care from the perspective of the reflective practitioner, and how what we have written addresses that and what more you would suggest needs to be done.” I had not really heard or considered the term “reflective practitioner” since my sabbatical of twenty years ago, and its memory excited me.

In 1984, I moved to Belfast, Maine. My only connection to the East Coast was my wife’s upbringing in suburban D.C. As we contemplated our move from Chicago, I bargained for “anywhere rural,” just as she negotiated for “anywhere East.” Almost immediately after my arrival, I established a partnership with Tim Hughes, a family doctor with amazingly similar needs and interests. But five years of caring for the old and infirm, poor and marginalized, pregnant and critically ill, house-bound and incarcerated took their toll. We both craved the opportunity for renewal. While I “held the fort,” Tim spent a year in Costa Rico helping to establish a new family medicine residency program; the following year I left on my adventure.

It was during that time when men with AIDS were returning to Waldo County, often to reconcile with their families, always to die. HIV was unknown during my training, and in the first years of practice it was only barely understood and inadequately treated. As I looked around for fellowship sites, San Franciso- the epicenter of the epidemic- seemed a logical location. I was accepted into the Family Medicine Fellowship Program at San Francisco General Hospital, then directed by Dr. Peter Sommers. It was during his seminars that we read Donald Schon’s ground-breaking work, “The Reflective Practitioner.” I felt then, and believe now, that this professor of Urban Studies and Education at M.I.T. was describing the way a good family physician practices and where family medicine is now leading a transformation in primary care.

In his book, Schon was critical of what he saw as the dominant pattern of professional thinking, something he called Technical Rationality. In this mindset, practice is a problem-solving activity undertaken by professionals who decide how to name and treat problems and what to do with contradictory data. When these data that do not conform to the canon of fixable problems, it behooves experts to discard them. And where people are the source of that discordant data, they are labeled as outliers, malingerers, and neurotics.

Schon acknowledged that emergencies and routines (e.g. procedures or exams), in fact, require a methodical approach. But he was more interested in what happened before the treatment began- how professionals went about “setting” or framing the problem. Not uncommonly, treatments don’t work, or they lead to unexpected consequences. How easily do we acknowledge failure; how often does discordant data get ignored or explained away? He described something he called “reflection-in-action” as the ability to adjust to surprise, frustration, or harm, and to make corrections in understanding or technique in time to make a difference.

For the family doctor, our work always begins by “setting” or framing the problem. For whom is the complaint a problem? Why? Is it urgent, or can it be constrained by standard criteria? Is it amenable to our knowledge and skills? Has treatment failed because of our misdiagnosis, the need for more time, or an incomplete grasp of the setting?

A reflective practitioner must welcome surprise. His rewards come not from reaching a certain level of comfort in treating familiar problems successfully, but from a sense of discovery in the strangeness, instability, uncertainty, and value conflicts that surround the difficult problem at hand. Rather than working safely within pre-existing categories, the reflective physician joins the patient in a shared, intuitive, and largely creative process. Such a process is otherwise know as a therapeutic relationship, where the doctor is invested in the quality of human lives- his own and the patient’s.

According to Schon, the reflective practitioner “gives up the rewards of unquestioned authority, the freedom to practice without challenge to his competence, the comfort of relative invulnerability, the gratifications of deference. The new satisfactions open to him are largely those of discovery- about the meanings of his advice to clients, about his knowledge-in-practice, and about himself.” (p.299)

Recently a patient’s wife sent me this e-mail [identifying details have been changed]:

“I guess I just want you to know this. Tony is happier than he has ever been. He is not depressed. I hesitate to tip the balance with my all concerns. He seems accepting of his health limitations and life.

Yet, he sleeps 12 hours at night and naps a few hours each day. He never feels rested. His heart doctor seems unable to help us. Provigil didn’t work. Tony said no to stimulants. He’d rather sleep. The sleepiness is apparently from his heart attack. I have also seen a huge loss of “vitality” in every aspect of his life... his hip fracture and inactivity only compounded the problem. Lastly, I’m suspicious that he may have had another heart attack while on vacation. He was very sweaty and had trouble breathing, and then the symptoms passed. He slept more on vacation than ever before.

When I ask about second opinions, Tony is not interested. If he knew how concerned I really was, it might send him into a depression. So I’m only going to push gently. I am limited by what I can say in front of his doctors. I wanted to tell you so that you would have the whole picture, at least according to me.”

Tony’s wife closed the e-mail, “love, Evangeline.” And as you can see, it was a love letter to Tony, one she could not deliver in person. What is the problem? Is it organic? Is it fixable? Does it involve their difference in age, a long-standing barrier to communication, her unresolved grief, or Tony’s denial? Before embarking on additional tests or second opinions, what it is needed is a doctor with time and the desire to offer Tony and his wife conversation, friendship, and hope.

Recently I received a hospital discharge summary on a patient who was hospitalized for coronary stent thrombosis. The stent was placed three years ago after his first heart attack. The summary concluded with a warning:

“This patient has undergone coronary stent implantation. In order to lower the patient’s long-term risk of abrupt stent thrombosis, we strongly urge the patient and/or his/her treating clinicians to avoid stopping or interrupting the patient’s aspirin or clopidogrel without first discussing this with your cardiologist.”

The problem with this warning- like so many others promulgated by experts- is that it doesn’t give the primary care physician or his patient the information they need to make the right choice under the circumstances.

It might have been worded differently: current guidelines call for dual antiplatelet therapy (DAT) with clopidogrel and aspirin for at least a year following stent placement. It might have reported that the evidence is strongest in the first 6 months following stent placement, or that discontinuation of clopidogrel after 6 months does not predict the occurrence of late stent thrombosis. It could have added that 32 patients (the so-called Number Needed to Treat) must be treated with DAT before stent thrombosis is prevented in just one, or that the majority of patients with stent thrombosis are already taking DAT, or that the risk of hemorrhage is 4 times higher than for aspirin alone and the risk of vascular surgical complications is triple.

Primary care physicians are perfectly capable of reading guidelines and coping with their complexity. Indeed, it is the family doctor who must frame them in a broader context, one that includes side effects, competing health issues, compliance, and the patient’s life goals.

As primary care moves in the direction of practice transformation, we need to resist coercive enforcement of best practices, recommend processes, and digital measurements of quality. Jerome Groopman makes the case for caution in a recent essay. Not only does evidence evolve, he argues, but best practices are steeped in bias. “Overconfidence bias” results when experts (including Groopman, he admits) “become intoxicated with their past success and fail to be sufficiently self-critical.” (p.13) “Focusing illusion” results when predictions based on one small change are extended to an entire condition. “Confirmation bias” is similar to Schon’s description of Technical Rationality, where experts ignore or dismiss data that does not fit their categories or expectations. He concludes that “the care of patients is complex, and choices about treatments involve different grade-offs. That the uncertainties can be erased by mandates from experts is a misconceived panacea, a ‘focusing illusion.” (p.15)

With the promise of practice transformation, our challenge is to create institutional environments where the reflective practitioner is welcomed and supported. Almost 30 years ago, Schon provided the necessary vision:

“A reflective institution must place a high priority on flexible procedures, differentiated responses, qualitative appreciation of complex processes, and decentralized responsibility for judgment and action. In contrast to the normal bureaucratic emphasis on technical rationality, a reflective institution must make a place for attention to conflicting values and purposes.” (p.338)

I am not certain that my practice is a good example of this. It takes time. It distracts from the work at hand. It leads to inconsistent results in extractable measurements of quality. It is hard work that holds us to a higher bar. But it is the natural outcome of caring for patients through long and committed relationships, and of remaining curious about the causes of illness and the definition of health. There are others who can apply protocols more consistently, automatically, and routinely than a family doctor- including computers and technicians. This is not where our skills are needed. Rather, it seems to me, our role lies in uncovering the unique elements contained in the patient’s chief complaint- at this moment in time and for reasons yet unknown- and in helping him overcome the impediments to health that he desires.

Becoming a reflective practitioner- once we have felt and recognized it- can be the source of our greatest joy and good as primary care physicians. The challenge before us was anticipated in Donald Schon’s closing words:

“The extent of our capacity for reciprocal reflection-in-action can be discovered only through an action science which seeks to make what some of us do on rare occasions into a dominant pattern of practice.” (p.354)

David Loxterkamp
Seaport Family Practice

The Reflective Practitioner: How Professionals Think in Action.
Donald A. Schon
Basic Books, New York. 1983

Health Care: Who Knows “Best”?
Jerome Groopman
The New York Review of Books, February 11, 2010/Vol LVII, Number 2, p12-15.

Doing it all

Larry Bauer recently e-mailed me with a question, “Does anyone in your practice deliver babies?” He was contacted by a journalist who wanted to talk with a rural FP who “does it all.”

No, not currently, but the question got me thinking about who, anymore, does it all. At one time, I thought I did: I delivered about 20 babies a year, enough to stay modestly proficient, but relied upon an OB/GYN to do my C-sections and bail me out when the circumstances required. I also admitted and rounded on our hospitalized patients, had ICU privileges, made home visits, and visited the nursing homes. Here, too, I must qualify: I shared hospital duties with three colleagues, so that my patients- those admitted during my off-weeks- never thought that I did it all. I only did it all part of the time. The rest of the time I chaired hospital committees, attended wakes, led Hospice family meetings, got elected to the school board and parish council, and sang with the community choir. I was doing it all except staying home with my young family.

My father, a GP from Iowa, did a better job of doing it all. He, delivered babies, yes, but also administered anesthesia, performed appendectomies, removed tonsils, repaired hernias, and took his own call. Always. Doing it all may have did him in, as he died of a heart attack at age 49. He also drank too much as a means of coping with work stress; when he drank, he argued with my mom as a means of coping with domestic stress. My father’s generation would question whether the FP who delivers babies but fails to cast fractures or perform surgery is really doing it all.

Two years ago I stopped doing it all, or at least all that I was doing. I hated the hospital environment: treating by protocol, ever under the watchful eye of those who played the power rankings, often caught between the two places that I needed to be. I was “there” because I felt it was part of the total package; there because my patients needed, or least expected, me to be there; there because of the intensity of the relationships, the adrenalin of the ER and ICU, the gratitude of new mothers and exhausted hospice families, and the simple satisfaction of doing it all.

Its been hard for me to adjust to forfeiting that satisfaction, to knowing exactly who I am as a doctor, or who I am within the specialty and who family medicine is within the larger profession. It has been impossible for us to find consensus. As with any group, our greatest enemies are with factions within us.

I still take pride in doing it all, which nowadays includes caring for Medicaid patients, treating opioid addicts with Suboxone, running an elder men’s support group, teaching occasionally in a family medicine residency program, and sitting on a medical school admissions committee. I have been doing this for a quarter century in one community, and believe that geographic stability has been a boon to both my patients and me. This is what I do. But my unique contribution, my fulfillment and joy is really this: I offer my patients a relationship. I provide them conversation, friendship, and hope. I attempt to do this for every one at every ever visit, and sometimes succeed. Sometimes, even when I am unaware of that success.

This is the first in a series of weekly blogs on the life of a medical director in an evolving rural family practice. Seaport Family Practice (www.seaportfamilypractice.com) is one of 26 practices in the Maine Patient Centered Medical Home Pilot, and one of 36 practice nationwide who participated in the National Demonstration Project (2008-2008). We will be joined this summer by three young providers- two family physicians and one physician assistant. Their arrival will double our provider hours and halve the average age. I hope to continue writing, and am planning a several month sabbatical next summer. These themes and activities will occupy my thoughts and utterings, but medicine is only part of my life in Belfast, Maine. In some ways, it simply allows me to be “here,” to pay the bills and provide a very privileged entry point into my neighbors’ lives.

Thank you to those who read this blog, and who respond, but most importantly who count me as their friend. For all the times I have misused and ignored you, take consolation in finding a part of you in what I have become. In what we are becoming together.

David Loxterkamp
21 February 2010

Beginning the New Year

Caminate, no hay camino, se hay camino, se hace camino al andar.
Traveller, there is no way. The way is made by walking. 
Antonio Machado

A confession: I don't Text, Twitter, or make friends on Facebook. Not that I am opposed to any of these activities, but I have others ways to waste my time. Blogging is likely one of them.

Seventeen years ago, I blogged (or journaled) privately, with the thought that one day it might become public. It did- in 1997, as the book A Measure of My Days. It was, of course, a diary without photographs or links, and only passing reference to a small number of literary works and current events. It chronicled my life and work in Belfast, Maine- a year, as is often the case, of incredible intensity and richness. I had hoped that my ordinary life would be of sufficient interest to pay back the publishers at the University Press of New England. I turned out to be the case. "Why my life and not others?," I often asked myself. Certainly others' lives are equally deserving. The answer is straight forward: because I invested the time and energy, devoted myself to the cultivation of words, and got lucky.

A blog offers certain obvious advantages, taking advantage of current technology to recruit and link its readership, and to make obvious connections to the wider world. But it still relies on content, a content that has not been carefully edited or tested by time. Needless to say, I accept the inherent limitations and possibilities of blogging, and am ready to plunge ahead.

This entry and all subsequent posts are my attempt to make sense of (a) life in Belfast, Maine. This is the real work and likely return on one's effort- making sense. Making beauty, too, when all goes well. And making a written record, with a conscious effort to stay awake, present and accounted for, as life streams by.

Why this year, after a seventeen year leave from journaling? Because of the changes it promises to bring. This year our small practice will grow from 5 providers to 8, and nearly double the number of available hours. We have recruited two physicians and one mid-level practitioner right out of training- an almost unheard of feat in a time of critical shortages in primary care providers. This year, my potato patch will double in size, and include the keuka, a variety with unparalleled suitability to the Belfast growing season. This year, I hope to begin a part-time fellowship in geriatric medicine, and take classes in Tai Chi, and form a small writing group to support and improve my efforts. This year, I will make and cultivate new friends, without short-changing those who have given themselves to my friendship. This year, my daughter will graduate from college and my son will move into his junior year of high school, which makes the empty nest that much closer down the road.

The quote by Antonio Machado was sent to me recently by a dear and long-time friend, Mary Beth Leone, social worker in our office, facilitator for the provider support group that has met every Thursday morning in our office for the last seventeen years. Along with Cris and Tim Hughes, we marched the Camino (de Santiago de Compostella) together in 2003. So it was apt that she chose this phrase to encourage me, rudderless, as I sail into the great unknown. I once had the certainty of a professional calling, the confidence of my Catholic faith, and- as a young man beginning his family and career- a future without visible end. Time and experience has a way of pulling the rug. And this I don't regret. I accept it as part a part of life. So I am walking now, and thus writing my own future with optimism and hope, adversity and friendship, in this one place called Belfast. Please join me. I'll be back soon.