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Perspectives on Process, People, Politics, and Presence J Am Board Fam Med: first published as 10.3122/jabfm.2012.06.120093 on 7 November 2012. Downloaded from REFLECTIONS IN FAMILY MEDICINE How I Think: Perspectives on Process, People, Politics, and Presence William B. Ventres, MD, MA The author, a seasoned midcareer family physician, summarizes his personal practice philosophy as it relates to encounters with patients. By focusing on 3 aspects of care—process issues, people issues, and political issues—he explores the unique characteristics of his clinical decision-making process. He concludes by noting that it is through examination of the question “How do I think in the work I do?” that family physicians can best bring their signature presences to their encounters with patients and their families. (J Am Board Fam Med 2012;25:930–936.) Keywords: Culture, Family Medicine, Medical Education, Narrative, Philosophy, Primary Care Over the past several years, 2 books have been rotations, all narrowly circumscribed by patients’ published entitled How Doctors Think. One, by Har- ages or sex, location of care, and organ system vard hematologist–oncologist Jerome Groopman, subspecialty. I experienced the requisite continuity covers how medical subspecialists see and respond clinic experience and rotations in behavioral and to their professional responsibilities.1 The other, by community medicine as add-ons to the “real” work the medical humanities scholar Kathryn Montgom- of clinical medicine. copyright. ery, is an ethnographic review of hospital-based After I had finished my residency, it took me clinical decision-making by academic general inter- approximately another 5 years to figure out what it nists.2 Reading these books inspired me to consider meant to be a family physician. Two books that I how I think as a seasoned family physician. encountered, Ian McWhinney’s Introduction to My current thinking clearly reflects my history. Family Medicine and Gayle Stephens’ The Intellec- I trained in the mid-1980s at a residency program tual Basis of Family Medicine, opened my eyes to how that was heavy on management of both in-hospital I might conceptualize my work.3,4 Then, in 1992, and ambulatory conditions but light on the process my colleague John Frey and I had the opportunity http://www.jabfm.org/ of clinical care. My schooling took place in block to gather a series of oral histories from many founders of the family medicine movement. I am deeply indebted to these people for their influence This article was externally peer reviewed. 5 Submitted 3 April 2012; revised 5 July 2012; accepted 9 on my practice style. I am also grateful to the July 2012. people who were my patients during that time, From the Master’s Program in Public Health, School of Medicine, University of El Salvador, San Salvador, El Sal- both for their help in my professional formation vador; and the Department of Family Medicine, Oregon and for their patience. on 30 September 2021 by guest. Protected Health and Sciences University, Portland, OR. I subsequently gained additional insight from Funding: Funding was received from the Fulbright Pro- gram of the US Department of State, Bureau of Educational several other writings. In his Textbook of Family and Cultural Affairs. Medicine, John Saultz proposed several factors to Conflict of interest: none declared. Disclaimer: Neither the Fulbright Program nor the US consider when approaching patient care, including Department of State had any role in the preparation, review, access, continuity, comprehensiveness, coordina- or approval of the article. The views expressed in this article 6 are those of the authors and do not reflect those of the U.S. tion, and context. Other scholars have examined Department of State, the Institute of International Educa- what family physicians actually do in practice—the tion, or the Fulbright Program. Corresponding author: William B. Ventres, MD, MA, Pro- proverbial “black box”—by focusing on issues grama de Maestría en Salud Pu´blica, Universidad de El ranging from the content of outpatient visits to the Salvador Facultad de Medicina, Edificio “La Rotonda,” 2nd o Piso, Final Calle Arce y 25 Avenida Sur, San Salvador, El cognitive strategies that family physicians use to Salvador (E-mail: [email protected]). manage those visits.7,8 More recently, the study of 930 JABFM November–December 2012 Vol. 25 No. 6 http://www.jabfm.org J Am Board Fam Med: first published as 10.3122/jabfm.2012.06.120093 on 7 November 2012. Downloaded from complex systems—the science of investigating and the lessons of past mistakes, and attending to cur- describing both how the relationships between a rent realities (such as community patterns of dis- system’s parts influence its overall behavior and ease and the unique characteristics of each patient), how the system in turn interacts with its environ- I balance the possibility that I might be wrong ment—has been used to elucidate the varied con- against the probability that I will be right. When a siderations family physicians must consider when hypothesis needs revision, I expand the range of my attending to their patients.9,10 The British practi- thinking, step by step and visit by visit. This model tioners Iona Heath and John Launer astutely re- works well for the kinds of undifferentiated prob- viewed the roles of family physicians as witnesses to lems with which many if not most patients present the human experience and cocreators of personal to every type of generalist practitioner. 11,12 narratives, respectively. In addition, I have When clinically stumped, I resort to assessing found wisdom in family physician David Lox- problems using the differential model that I learned terkamp’s many essays describing his rural practice in medical school. (Table 1.) As I review lists of 13–15 in Maine. diagnostic categories, Up-to-Date® and clinician Although each of these works has helped me to colleagues are frequent companions, reminding me conceptualize my work, there was something miss- of possibilities beyond my immediate recollection. ing from them. They omitted some important as- Yet, as professionally rewarding as it may be to pects of how I think about patients and their pre- uncover a clinical anomaly (think of all the atten- senting concerns. In this essay, I hope to fill in tion paid to “zebras” in medical education), I do not those missing areas. ascribe to the school of diagnostic thinking whose I frame my personal practice philosophy around highest goal is to discover a “plum of pathology.”17 3 sets of issues—of process, of people, and of pol- My expertise lies elsewhere. itics—all within the context of the primary issue I Second, I use a “waterline” model for deciding face as a family physician: what to do at any given on diagnostic and therapeutic strategies (Harrison Ն copyright. time with any 1 patients who present to me with R, Scherer J, Short RR. Waterline model. Ken- Ն any 1 problems. more, WA: Leadership Institute of Seattle; 2001; unpublished data; Figure 1). Knowing that time is Process Issues often on my side in clinical practice—that many As I see it, every patient encounter encompasses concerns are self-limited and that many others will several needs: these include recognition, assess- make themselves known with time—I perform di- ment, understanding, documentation, and commu- agnostic testing only as I deem necessary at any nication. Each patient presents with a story that is given point in the process. A million dollar workup formed by his or her personal experience of illness http://www.jabfm.org/ is not my first priority. Rather, my commitment is and the context of care (including, among other to continuing care: I go deeper below the waterline factors, the setting of care, the historical and rela- (ie, expand the scope of diagnostic testing and ther- tional dimensions of care, and such concerns as healthcare policy and economics).16 At a minimum, I listen to this story and conduct an examination. Table 1. Categories of Illness from a Differential Simultaneously, I use my clinical knowledge, expe- Diagnosis Model rience, and external resources to reorganize this on 30 September 2021 by guest. Protected ϩ information into an integrated clinical case that is VINDICATE P amenable to the development of an assessment and Vascular plan. I also document and communicate this plan to Inflammatory/infectious my patient—a requisite part of any routine visit. Neoplastic Five strategies help me manage this integration. Degenerative First, I use a hypothesis model to assess presenting Intoxication/toxic problems. I work from a clinical hypothesis using a Congenital combination of quantifiable information and clini- Allergic/autoimmune cal intuition born of learned experience to deter- Traumatic Endocrine/metabolic mine a working diagnosis. Knowing what is com- Psychosomatic mon and serious and what is not, keeping in mind doi: 10.3122/jabfm.2012.06.120093 Perspectives on Process, People, Politics and Presence 931 J Am Board Fam Med: first published as 10.3122/jabfm.2012.06.120093 on 7 November 2012. Downloaded from Figure 1. Waterline Model of Diagnostic and Therapeutic Intervention (adapted from Harrison R, Scherer J, Short, RR. Waterline model. Kenmore, WA: Leadership Institute of Seattle; 2001; unpublished data). apeutic intervention) 1 step at a time and only as patients: I might recall some moment of impor- needed. tance in the visit, remind them of a key plan, or, Third, I keep in touch with the special spot in very simply, let them know they have been heard my brain that helps me to identify and address and will continue to be heard. With most health urgent and emergent needs when they arise. This concerns, especially chronic ones, the real work spot is a place to store details of conditions like begins once the visit is over.
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