Monday, May 13, 2013

General Practice Pathology

This post is dedicated to an amazing clinician, MomTFH.  You are The Wind Beneath My Wings.

I get frustrated.  At the financial interests that pit private practice general pathology against subspecialty academicians.  It seems to happen a lot more these days than it did in the past.  Some cities get it.  They work in concert. Unfortunately, it is rare.

I have written here before about my brother.  He has an intractable case of Crohn's disease, one that has plagued him his whole life.  He has lost most of his small intestines and all of his colon.  He has been in a coma in the PICU.  He has received many infusion therapies.  He holds a Ph.D. in food science from Cornell, and a degree from the Culinary Institute of America.  He is crazy smart, a leading authority in his field.  He has overcome many health obstacles to get there.

He called me the other day.  "Hey Giz!  Guess what?  I got a family doc.  Not just any family doc, but the golden ticket one.  He works at Harvard, he is a liver specialist, but he loves family medicine so much that he devotes half of his practice to it.  He is incredibly hard to get into, but I got a referral and I got lucky.  I can't wait to get plugged in."

My brother has had a lot of issues with the fragmentation of medicine, as a patient.  He used to thrill in the bypass of the generalist - his insurance allowed him to go straight to the specialist.  And he has had a lot of specialists; derm, infectious disease, gastroenterologists, surgeons.  But now, in his mid to late thirties, he has come to the realization that he needs someone to tie it all together.  He is tired of that being him, the patient - he holds a lot of knowledge in his head but is not a trained physician.  "Giz, they don't talk.  I bounce from one to the other and get great individual therapy in their area of expertise, but communication is poor.  So I end up navigating the system, poorly as a non-clinican, and it is tough.  I'm tired.  I realize what I need is a good family doctor.  I am thrilled to finally have one."

I remember a letter recently on MiM, one from a med student looking for advice.  She clearly said, "family medicine is out - they get no respect."  I think this is a big fail in our current society. They don't get enough respect, but they should.  They should be seen as the glue that holds it together.  The ones that sweat and toil and advocate for their patients.  The ones that tie it all up in a neat knot, so that their dependents, their clients, their patients, can sit back and relax in the knowledge that they are getting good care and someone out there is advocating for them.

I empathize with the family docs because like them, as a general practice pathologist, I do everything.  I inspect labs.  I am the head of microbiology.  I look at GI biopsies every day, alongside breast biopsies.  I get called to the OR to triage unknown cases that end up being rare sarcomas or common cancers, but I don't know what until I get there.  The knowledge base I have built up over the last 7 years in private practice of the entire human being, of all of its tissues, is immense.  And I like to think that by studying everything, by getting to see all aspects of the patient, that I have become a great diagnostician.  Not a specialist by any means, but still.  I have heard the term, "Good at everything, great at nothing."  That sounds derogatory, although I can relate.  But I'll take it a step further.  I'm pretty good at everything.  And I am finally coming to the realization that my knowledge base, although not entirely specific except in my area of expertise, is good enough for what I do on a daily basis.

Global vision: knowing your whole patient, being a pathologist or a family doc, trumps tunnel vision in many ways.  But by saying that it feels that I am slamming subspecialists.  I am not.  We can work in concert, but we are all equally valuable to the patient.  And that's all that really matters here - the patient, I mean.  My brother, and the millions of others out there like him navigating a fragmented health care system.  Our patients deserve our respect.  Family medicine, our glue, deserves our respect.  If I am allowed one wish in my lifetime, I think it would be that family comes back around, and gains back the respect it deserves.  Like me.  A general practice pathologist.  We are all, patients and doctors, in the trenches together working for each other.  That is how it should be.


  1. It's nice to read this from a physician. I'm not yet a med student, but have always been drawn to family medicine and I know with a fair degree of certainty that it is where I want to end up when/if I am lucky enough to get in, yet I hear so many people (premeds, med students, residents) disparage family medicine.

    It is precisely because I want to be that for the patient - the one who ties it all together - that I am attracted to family medicine. It's a little bit of everything, not everything about one system.

    While I know my mind may change when I actually get into med school and approach the time when I will make that decision, hearing things praising the 'global vision' of generalists, helps cement the interest I have in making it my future.

    Thanks for this.

  2. Yay from a general internist, who still feels the tug of subspecialty practice, the lure of greater financial compensation, the appeal of a narrower focus on one disease or organ system. This made my morning!

    1. Sometimes I get angry that generalists ridiculed by specialists for lack of knowledge or needing help with tough cases but that's why they are specialist and we are generalists! One of my favorite non-judgmental specialty pathology attendings once told me he would be terrified to do what I do - triaging down in the trenches.

  3. Thanks for this! I am a family doctor in Canada & we also feel the lack of respect from many of our specialist colleagues and from society at large. Our medical system is designed such that we are the gate-keepers to the specialists (i.e. you can't really find yourself in a situation like your brother who has all these specialists on board without a family doctor) and we have to be the glue... but the respect doesn't always come with the responsibility. It's frustrating! Even well-meaning acquaintances & relatives sometimes ask me if I plan to specialize in the future - as if the career that I've been working hard at for almost 10 years is just my stepping stone to bigger and better things!

  4. I agree - practicing general medicine - be it internists, pediatricians, pathologists, or family docs, is a unique, challenging, scary endeavor worthy of respect and chock full of responsibility, as you point out. It is refreshing when the academic specialists in my field, and many do, acknowledge this, but frustrating when I feel criticized or judged for asking for help on occasion!

  5. Thank you again for this! Family physician in Canada here, where some of the provincial governments (ie. the payers in our Medicare system) have been trying to justify cutbacks/no increases to health care with comments such as "doctors get paid too much" without any recognition that the generalists are making much much much less than the subspecialists are and perhaps (in some cases) working harder than them as well.

    1. I agree, we work hard, and are not nearly as compensated as the specialists. Not complaining about my own compensation, but still. It is backwards. Reminds me of a sage professor in college that preached about the backwards compensation of preschool teachers vs. college ones. Preschool is the most important, but paid the least. It's not just us doctors, it's ubiquitous.


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