Due to changes in Fair Housing Act laws, clinicians are experiencing a significant increase in requests from patients for medical documentation to keep emotional support animals with them in “no-pets policy” rental housing. On a college campus, this leads to far more than just two-legged mammals inhabiting dorm rooms. There has been an animal explosion on our University campus with over seventy animals of various types approved as an “ESA” in the residence halls and unknown dozens more who live with their owners off campus yet still frequent campus. Only a small minority of these animals are actually trained and certified as service animals with the right to accompany their owner on public transportation to any public place, including classrooms and eating establishments. The rest are approved only for housing purposes, yet they are regularly showing up in airplane cabins and grocery stores, dressed in little jackets that are easily purchased along with “certification letters” for big prices on the internet. ESAs have become part of the campus and community landscape.
As a relatively outdoorsy, green and tolerant northwest University campus, the presence of animals on our campus has yet to seem like a big deal, but as the animal numbers inevitably increase due to 25% of the college student population nationwide currently eligible for an animal due to a mental health diagnosis, it is becoming a big deal as individuals insist on exercising their civil rights along with their dogs.
And it isn’t always dogs. There are cats, along with the occasional pocketed rat, hamster, guinea pig, flying squirrel, and ferret not to mention emotional support pot bellied pigs, tarantulas, and various types of birds. And at least one snake.
Yes, a snake.
As a physician farmer concerned with stewardship of the patients I treat and the land and animals I care for, I’m emotionally caught and ethically bound in this treatment trend. The law compels clinicians to provide the requested documentation to avoid potential law suits alleging discrimination, yet I’m also concerned for the rights of the animals themselves. I’ve loved, owned and cared for animals most of my sixty two years and certainly missed my pets during the thirteen years I was in college, medical school, residency and doing inner city work (my tropical fish and goldfish notwithstanding). I neither had the time, the money, the space nor the inclination to keep an animal on a schedule and in an environment that I myself could barely tolerate, as stressed as I was. That is not stopping the distressed college student of today from demanding they be able to keep their animals with them in their stress-mess.
As a clinician, I’d much prefer writing fewer pharmaceutical prescriptions and help individuals find non-medicinal ways to address their distress. I’d like to see my patients develop coping skills to deal with the trouble that comes their way without falling apart, and the resilience to pick themselves up when they have been knocked down and feel broken. I’d like to see them develop the inner strength that comes with maturity and experience and knowing that “this too will pass.” I’d like individuals to see themselves as part of a diverse community and not a lone ranger of one, understanding that their actions have a ripple effect on those living, working, eating, riding and studying around them. Perhaps corporate work places, schools and universities should host a collaborative animal center with rotating dogs and cats from the local animal shelter, so those who wish to may have time with animals on their breaks without impacting others who aren’t animal fans, or with potentially life threatening animal dander allergies.
So I find myself reluctantly writing a prescription for a living breathing creature perceived by the law as a “treatment” rather than a profound responsibility that owners must take on for the lifetime of the animal. With great gravity, I always let my patients know an animal is not disposable like a bottle of pills (or a human therapist) when no longer needed and must have a lifelong commitment from its owner beyond a particular time of high personal stress.
Pardon me now while I go take care of my dogs, my cats, by birds, and my horses and yes, my goldfish. They are my joy to support for decades and for as long as they need me.
An open letter to the American Board of Family Medicine (ABFM):
Yesterday I chose to sit for my sixth (and I hope final) Family Practice Board ten year Maintenance of Certification (MOC) examination, having now practiced as a Board Certified Family Physician for the past 34 years and intending to work a few more years. I want to share my experience taking this examination your organization prepares, promotes, and uses at high cost to determine which physicians meet the standards of Family Medicine, as stated on your website:
Family medicine is the medical specialty that provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system, and every disease entity. When you or a family member needs health care or medical treatment, you want a highly qualified doctor dedicated to providing outstanding care. When you choose a doctor who is board-certified, you can be confident he or she meets nationally recognized standards for education, knowledge, experience, and skills to provide high quality care in a specific medical specialty.
After my experience today, I am deeply disappointed in your vision of what a “highly qualified” Board Certified Family Physician needs to demonstrate on a MOC examination in order to meet “nationally recognized standards”.
As a medical student educated at the University of Washington during the early years of a newly organized family medicine specialty in the late seventies, I was inspired by the physicians who were our teachers and mentors in the art and science of caring not just for the individual, but their family system as well. I then had the privilege of family practice residency training at one of the most progressive health maintenance organizations in the country (Group Health Cooperative in Seattle) where my teachers were not only excellent family physicians who were deeply involved with training residents, but actively involved in caring for their own patients as well. In addition, one of my best teachers at Group Health was a full time non-physician behavioral health specialist who taught us how to understand a patient’s experience of their illness and how an excellent family doc makes a difference in a patient’s sense of well-being.
As a result of those role models in my training and education, I have devoted my four decade career to family medicine in a variety of primary care roles — as a physician with a full spectrum practice in the inner city, as a director of a family planning clinic as well as a community health center for indigent and homeless patients, as an occupational health clinician for industry, as a community inpatient behavioral health and “detox” doctor for our local hospital, as a forensic examiner for hundreds of child sexual abuse evaluations, as a college health physician, and as an administrator. I have had the privilege to work with an immense variety of patients in diverse clinical settings, and only family medicine specialty training could have prepared me for that.
I believe in my specialty and the incredible versatility it offers to the physicians who choose it and to the patients who benefit from care by clinicians who are trained to work with the whole person, not just one aspect of their health. I believe in those who practice a “womb to tomb” approach in providing continuity of care for an individual throughout their life cycle. I believe in the opportunities within my specialty for some clinicians to concentrate only on certain aspects of patient care (geriatric care, palliative/hospice care, emergency medicine, hospitalist care, adolescent medicine, sports medicine, addiction care, behavioral health, etc)
I no longer believe, based on the contents of the MOC examination, the American Board of Family Medicine is living up to its commitment to its paying physician constituents. Board Certification is no longer an “option” for us but an economic necessity for our ongoing professional employment, credentialing and privileging.
First, I knew my preparation for this exam would need to be more rigorous than for previous exams as my current practice exclusively manages patients’ behavioral health issues given the current lack of psychiatric consultant availability or affordability. As family physicians often do, we must step up and become the specialist our patients need when no other specialist is available. I no longer see the full spectrum of life cycle medical issues so the many hours of review I did for the exam was necessary, extensive and time-consuming, even though I will not ever practice full spectrum family medicine again.
Second, the experience of taking the examination at a regional “testing center” goes beyond standard airport security humiliation: having my eye glasses inspected in case they contained a camera, my wedding ring looked at, my pockets turned inside out, my sleeves pulled up, my ankles and socks uncovered, being “wanded” for metal hidden on my body, my wrist watch locked up with my purse and cell phone — this happened not just once but after every break, even to go to the bathroom.
Third, the exam itself in no way measured the diversity of skills required of an excellent family physician. Over three hundred multiple choice questions each providing a few data and clinical points about a particular patient and based on that limited information, the test taker is asked to choose the “best” evidence-based treatment option or “most likely” diagnosis. Absent are the nuances of patient demeanor in the exam room or how they respond on history-taking, the subtleties of a hands-on physical assessment. No information was provided about whether this particular patient has a family involved in their care, or what finances they have to afford the “best” treatment option when insurance won’t cover, or their willingness to comply with what is recommended. A phone app could easily answer these exam questions with a search that takes less than twenty seconds yet our cell phones were taken away and locked up. Your test content implies a family physician has to know all the details, the numbers, and the drug interactions committed to memory without the benefit of the technology tools we, along with many of our patients, use every day.
An excellent family physician can easily look up the “guidelines” and the “evidence based treatment” for a medical diagnosis, but beyond that must know how best to work with a particular patient given all the variables in their life impacting their health and well being.
Less than 5% of the exam questions dealt with any behavioral health issues when mental health concerns can be more than 50% of the issues brought to us in any given appointment. There was minimal mention about the dynamics of family support, or insurance/financial stressors or relationship conflicts, or the many social justice issues impacting patient health. There were no questions involving LGBTQ patients. There were few questions about the impact of the current epidemic of substance abuse and addiction contributing to our patients’ premature deaths. There was nothing that dealt with how to encourage and inspire patient compliance with our recommendations. There were no questions dealing with ethical decision making, or how to keep the computer screen from coming between the clinician and the patient, or how to maintain humanity in medical practice.
Fourth, I left that examination feeling very discouraged that the (all younger) family physicians who sat with me in that testing center are facing future years of this kind of superficial yet onerous assessment of their skills. They are likely reluctant to “rock the boat” in questioning how our specialty has devolved to this but I am not. I want to see this improve within my professional lifetime.
If the every ten year high stakes MOC examination were a surgery, an imaging study or a new medication, it would never pass muster for the ABFM standard of “best practice” and “evidence-based”. That seems ironic for an exam that is designed specifically to measure physicians’ abilities to memorize and recall guidelines, best practices and what is recommended and what is not in certain clinical situations. Over my 30+ years of family medicine, many generally accepted and “evidence-based” medical practices have now been found to be ineffective, or at worse, harmful. So we stop doing them and stop recommending them.
Yet somehow the high stakes MOC exam survives without evidence of benefit and one could argue causes significant harm including the immense cost in money, time and aggravation. I am not advocating for ceasing MOC, but want to see ABFM move on from the once a decade exam to a more frequent open book assessment — help us physicians learn more effectively and more eagerly.
I have worked at a University for three decades and understand the style of learning that results in information “sticking” versus that which is memorized and quickly forgotten, especially when it is not used on a regular basis. As Dr. Robert Centor has cogently commented about the MOC process, there is a difference between “formative” assessment of knowledge which is an ongoing monitoring of knowledge acquisition reflecting a learner’s strengths and weaknesses versus a “summative” assessment which is the high stakes end of the semester (or decade) examination. We want our physicians to be enthusiastic ongoing learners with incentive to keep up on new medical innovation and knowledge. To encourage that we need to launch frequent mandatory open book assessments of knowledge before more and more physicians drop out of the MOC process (and their practices) altogether.
I’m asking the ABFM and its Board members to not be tone deaf to the voices of physicians who are telling you “the emperor has no clothes” when we all have tried for decades to be good Board Certified citizens pretending that all is right and well with the process we are subjected to.
I’m also asking the ABFM and its Board members to reexamine the cost and need for security measures in a strip mall testing center setting which is the equivalent of MRI scanning 10,000 patients to find the one cancer — this would never be an acceptable option on one of your exam questions. Treat us as the professionals we are.
I know why I became a family physician over thirty years ago and it wasn’t to treat patients as demographic data points whose health parameters and decisions must meet “evidence-based outcome measures” so health care entities can be fully reimbursed for the work we do with them.
And so I ask you, on behalf of family physicians who don’t speak up, and on behalf of our patients:
~with your organization leading the way, let’s put the “family” back in family medicine.
~let’s put the doctor/patient relationship back in the forefront of the care we provide for people.
~and let’s stop meaningless multiple choice high stakes MOC examinations in strip mall testing centers and look at what really matters in Maintenance of Certification of family physicians.
Experiencing the present purely is being emptied and hollow; you catch grace as a man fills his cup under a waterfall. ~Annie Dillard from Pilgrim at Tinker Creek
I am often unprepared for the rush of challenges each clinic day brings and lately far into the night.
Each call, each message, each tug on my arm, each box of kleenex handed over, each look of hopelessness — I empty continuously throughout the day to try to fill the deep well of need around me. If I’m down and dry, hollowed to the core with no more left to give, I pray for more than I could possibly deserve.
And so it pours over me, torrential and flooding, and I only have a mere cup to hold out for filling. There is far more cascading grace than I can even conceive of, far more love descending than this cup of mine could ever hold, far more hope ascending from the mist and mystery of doctoring, over and over again.
I am never left empty for long. The hollow is hallowed, filled to the brim and spilling over.
Astonishing material and revelation appear in our lives all the time. Let it be. Unto us, so much is given. We just have to be open for business. ~Anne Lamott from Help Thanks Wow: Three Essential Prayers
I have the privilege to work in a profession where astonishment and revelation awaits me behind each exam room door.
In a typical busy clinic day, I open that door 36 times, close it behind me and settle in for the ten or fifteen minutes I’m allocated per patient. I need to peel through the layers of a person quickly to find the core of truth about who they are and why they’ve come to me.
Sometimes what I’m looking for is right on the surface: in their tears, in their pain, in their fear. Most of the time, it is buried deep and I need to wade through the rashes and sore throats and coughs and headaches to find it.
Once in awhile, I can actually do something tangible to help right then and there — sew up a cut, lance an abscess, splint a fracture, restore hearing by removing a plug of wax from an ear canal.
Often I find myself giving permission to a patient to be sick — to take time to renew, rest and trust their bodies to know what is best for a time.
Sometimes, I am the coach pushing them to stop living sick — to stop hiding from life’s challenges, to stretch even when it hurts, to get out of bed even when not rested, to quit giving in to symptoms that can be overcome rather than overwhelming.
Always I’m looking for an opening to say something a patient may think about after they leave my clinic — how they can make better choices, how they can be bolder and braver in their self care, how they can intervene in their own lives to prevent illness, how every day is a thread in the larger tapestry of their lifespan.
Each morning I rise early to get work done before I actually arrive at work, trying to avoid feeling unprepared and inadequate to the volume of tasks heaped upon the day. I know I may be stretched beyond my capacity, challenged by the unfamiliar and stressed by obstacles thrown in my way. It is always tempting to go back to bed and hide.
Instead, I go to work as those doors need to be opened and the layers peeled away. I understand the worry, the fear and the pain because I have lived it too. I am learning how to let it be, even if it feels miserable. It is a gift perhaps I can share.
No matter what waits behind the exam room door, it will be astonishing to me.
I’m grateful to be open for business. The Doctor is In.
a calling out to the others to see if they’re there; ~Dermot Healy from A Fool’s Errand
We are here to witness the creation and abet it. We are here to notice each thing so each thing gets noticed. Together we notice not only each mountain shadow and each stone on the beach but, especially, we notice the beautiful faces and complex natures of each other. We are here to bring to consciousness the beauty and power that are around us and to praise the people who are here with us. We witness our generation and our times. We watch the weather. Otherwise, creation would be playing to an empty house.
~Annie Dillard from The Meaning of Life edited by David Friend
By the time Saturday rolls around, I am overwhelmed by the amount of “noticing” I needed to do in the course of my work that week. Each patient, and there are so many, deserves my full attention for the few minutes we are together. I start my clinical evaluation the minute I walk in the exam room and begin taking in all the complex verbal and non-verbal clues sometimes offered by another human being.
How are they calling out to me?
What someone tells me about what they are feeling may not always match what I notice: the trembling hands, the pale skin color, the deep sigh, the scars of self injury. I am their audience and a witness to their struggle; even more, I must understand it in order to best assist them. My brain must rise to the occasion of taking in another person, offering them the gift of being noticed and being there for them, just them.
This work I do is distinctly a form of praise: the patient is the universe for a few moments and I’m grateful to be watching and listening. When my patient calls out to me, may they never feel they are playing to an empty house.
Well I know now the feel of dirt under the nails, I know now the rhythm of furrowed ground under foot, I have learned the sounds to listen for in the dusk, the dawning and the noon.
I have held cornfields in the palm of my hand, I have let the swaying wheat and rye run through my fingers, I have learned when to be glad for sunlight and for sudden thaw and for rain.
I know now what weariness is when the mind stops and night is a dark blanket of peace and forgetting and the morning breaks to the same ritual and the same demands and the silence. ~Jane Tyson Clement from No One Can Stem the Tide
Soon to arrive, a wave of 15,000 young people
with such potential to grow,
their health needs entrusted to us
as if we tend them as gardeners:
most thriving and flourishing,
yet some already withering,
their roots thirsting.
As the winds of time bring
new thousands to our care,
blown in from places unknown,
I weary weep for those who may not bloom,
wondering if I will fail to water or care enough~
or is it me with thirst unceasing,
my roots drying from each new morning’s
same ritual and same demands unceasing,
as if I’ve forgotten how to be glad for this work,
being met with the silence
of my own gardeners.
The nail of each big toe was the horn of a goat. Thick as a thumb and curved, it projected down over the tip of the toe to the underside. With each step, the nail would scrape painfully against the ground and be pressed into his flesh. There was dried blood on each big toe.
It took an hour to do each big toe. The nails were too thick even for my nail cutters. They had to be chewed away little by little, then flattened out with the rasp, washed each toe, dried him off, and put his shoes and socks back on. He stood up and took a few steps, like someone who is testing the fit of a new pair of shoes. “How is it?”
“It don’t hurt,” he said, and gave me a smile that I shall keep in my safety deposit box at the bank until the day I die. I never go to the library on Wednesday afternoon without my nail clippers in my briefcase.
You just never know. ~Richard Seltzer from “Toenails” from Letters to a Young Doctor
I know for a while again the health of self-forgetfulness, looking out at the sky through a notch in the valleyside, the black woods wintry on the hills, small clouds at sunset passing across. And I know that this is one of the thresholds between Earth and Heaven, from which even I may step forth and be free. – Wendell Berry from “Sabbath Poems”
Whenever I lose perspective about what I’m trained to do
and who I am meant to serve,
when I wallow in the mud of self-importance
rather than in the health of self-forgetfulness~
I wash out a plug of wax from a deaf ear
and restore hearing
or clip someone’s crippling toenails
so they can step forth in freedom.
I’ve been given these tools for a reason
so need to use them.
You just never know.