• Many Maps, One Aim: Charting a Course to Family Medicine

    July 31, 2019 12:26 pm Scott Wilson Kansas City, Mo. – Your training is at your back, your purpose under your feet, your career in family medicine a clear shot to the horizon.

    But that horizon stretches in all directions. Which way do you go? Also -- wait a minute -- how did you even get here?

    Embracing that uncertainty and turning it into fuel for the journey ahead were common threads stitching together a colorful hour of stories told from the main stage to launch the 2019 National Conference of Family Medicine Residents and Medical Students, held here July 25-27.

    The theme was "Exploring More," and Anita Ravi, M.D., M.P.H., M.S.H.P. -- a memorable panelist at the 2018 National Conference storytelling event -- set the tone with a drawing. More precisely, the morning's host projected one of the sharp, simple illustrations she's known for onto the room's three screens, explaining that it was doubt that had led her to this image.

    "I found that, often, I was trying to borrow someone else's map to figure out where I was supposed to go," she told the audience. "In medicine, you can feel isolated -- you have your north, but you may not know how to get there.

    "When I realized I needed to stop borrowing maps and build my own map, I drew this."

    Her exploration, like some described by other speakers, would lead to a founding and the start of another journey. Ravi, who said she'd gone into medicine because she wanted to "find a cure for gender-based violence," started the PurpLE (Purpose: Listen and Engage) Clinic at the Institute for Family Health in New York, N.Y., in 2015, and served as its medical director until this year.

    "Five years ago, I had never really heard about human trafficking in a health context," she said. "But I happened to be at a medical conference, and I heard about this intersection and it ignited my passion."

    The five physicians Ravi introduced presented their own map moments -- individual discoveries of the unexpected directions family medicine would lead them in.

    Story Highlights

    Lighting a Beacon

    The email's subject line was "gender," and its first sentence was stark: "If you're reading this, I need help immediately, ASAP."

    Colleagues had warned Izzy Lowell, M.D., M.B.A., that the patient panel for the transgender-care clinic she wanted to start would be too light. Messages like the one Lowell read during her story, however, confirm that QMed, in Decatur, Ga., is in the right place at the right time.

    As she recently told AAFP News, the facility, which focuses on providing hormone therapy, now has more than 800 patients.

    Lowell had begun her talk with a story about a different patient, along with what would become a chorus among the morning's speakers.

    "I'm a family doctor, but most of what I do now I didn't learn anything about during my training," she said. "But it's because of that training that I can do it."

    Lowell described a day in clinic, a long one. The kind that ends with a last patient who shows up late and reminds you that you're irritable and hungry.

    When the man arrived, though, he apologized and explained that he'd left to see her five hours earlier, at 6 a.m. He'd driven from Tennessee to Atlanta because he'd heard that Lowell saw transgender patients.

    "At first, I felt honored," Lowell said. "He'd come all that way just to see me, a family doctor. Then I felt angry. This young trans man had to take a whole day off work and spend 10 hours in the car for what should be a routine doctor's visit. 'This is ridiculous,' I thought."

    To provide better access to health care for some of the nation's 1.4 million transgender adults -- many of whom report having been discriminated against in medical settings -- Lowell started virtually from scratch.

    "I didn't actually know anything about transgender medicine," she told the audience. "My only training to that point had been an elective I'd created as a resident. So I set out to educate myself. I attended conferences, contacted experts, read all that I could find. I wanted to know: What does it really mean to be transgender? What is it like?"

    One of her friends, she said, offered a vivid answer.

    "She said, 'Think back to one of your happiest memories from childhood. It was in a highly gendered space. Maybe prom, being a cheerleader, playing on a football team. Now imagine that memory never happened, because you were perceived to be the opposite gender of what you are, and you weren't allowed to participate. They don't believe us. It's not that I think I'm a woman or decided to become one. I am a woman.'"

    Lowell went on: "Every day my patients put on disguises to go to work and pretend to be someone they're not, for fear of being fired or harassed or worse. Some people feel so isolated and depressed that it seems like suicide is the only option. Forty-one percent of transgender people have attempted suicide.

    "We can change that. It's well known that affirming care and hormone therapy dramatically decrease suicide rates and improve people's lives. Simply asking, 'What are your pronouns?' communicates that you are an ally and can be the first step in rebuilding trust."

    Lowell described her efforts, which include telemedicine consultations and pop-up clinics throughout the South to prescribe testosterone in person. She also was candid about the limits of those efforts. With no medical license in Louisiana, where that desperate email was sent from, Lowell could not provide relief to the 18-year-old transgender woman who had written it.

    "Maybe one of you will be able to help her, as a regular patient in a primary care clinic," Lowell told the audience.

    "Transgender care is on the edge of medicine now, but it should and will become primary care. You will see transgender patients in your practice, no matter what you do. Even if you know nothing about hormone therapy or trans medicine, you can tell them, 'Don't worry. I can help you. We'll figure this out together.'"

    A Dream, a Nightmare, a True Self

    Aaron George, D.O., dreamed of being a family doctor in the tradition of his Uncle Dennis, a stalwart healer in a tight-knit community.

    Aaron George, D.O., says he doubted he could become a family physician until he rediscovered his nonmedical passions: "Being true to things I loved helped me to excel through medical school when I went back."

    George said his uncle was larger than life, with a jet-black mustache, a massive model train set and a repertoire of magic tricks he performed for patients in his Pennsylvania coal-mining hometown -- tricks he was slowly teaching his nephew. But he died at 51.

    "I remember being 11 years old and going to his viewing on a cold, dark night," George said. "I looked down the street and saw hundreds of people lined up to pay their respects. I knew at that moment I wanted to be a family physician. It just made sense."

    Flash-forward to the rigorous training, the usual setting aside of nonmedical passions and pursuits.

    "I worked three jobs in health care one summer," George said. "Seven days a week, all summer long, morning and night, I was working. No time for exercise, no time for music. Movies were totally out. Doctors work harder than everybody else, right?"

    Then, just as his senior year had started, on the eve of a test, George had an unwelcome awakening.

    "It was the middle of the night, and I was in the middle of my street outside my apartment. I looked down, and I was wearing just boxers, and I had blood everywhere," he said. "I looked around and saw that my apartment window was shattered, and my bedsheet was hanging out from the window."

    George had sleepwalked through his bedroom window.

    Diagnosed with rapid eye movement sleep behavior disorder, he endured several surgeries and retreated to his family home, dreading sleep and doubting his future.

    "I told my mom, 'I guess I'll never be the family physician I thought I'd be,'" George said.

    In fact, he would go on to be the director of medical education and assistant program director for the Meritus Family Medicine Residency Program in Hagerstown, Md.

    But getting there, he said, meant navigating a path back to who he really was. The movies and the music he'd abandoned to get ahead. The weightlifting and exercise he thought he didn't have time for anymore. The things, he said, "that made me me."

    "Being true to things I loved helped me to excel through medical school when I went back," George said. "My anxiety dissipated because I was true to me. And today, my patients love that I share myself with them.

    "When you're trying to become the physician you think someone else wants to be, never lose sight of who you are, what you love, why you wake up in the morning. Your patients will love you for it. Being a family physician is not about denying yourself. It's about finding yourself and sharing that with your community so you can improve the lives of your patients."

    A Second Generation

    "My father sat in this audience," said Kameron Matthews, M.D., J.D. "I wanted to work in family medicine from the first day I was standing across the street from someone yelling, 'Hey, Dr. Matthews,' to my dad. I wanted to be him.

    "I am a very proud second-generation family doc, living in D.C. right now," she added.

    Unlike her dad, though, Matthews controls a $14 billion federal budget line at the Veterans Health Administration.

    As she explained her duties at the VHA, she asked the audience whether there were veterans among them. Healthy applause answered her.

    "I run Community Care, which is basically when veterans need care outside the VA, my program runs the national contracts purchasing that care," she said.

    "How did I get here? Trust me, it wasn't anything I learned in medical school or residency."

    Matthews' odyssey included a detour through law school motivated by the desire to offer higher-quality care.

    "As a third-year student," she said, "I was so frustrated with the fact that I was seeing patients back-to-back-to-back, but we were putting on Band-Aids with prescriptions. We are trained to discuss prevention and education and make sure that patients understand their own well-being. In my mind, though, I saw a larger set of societal issues -- what we now call social determinants of health."  

    She continued: "How can I, as a family physician, figure out how to help a larger community of patients? My third year, I left and went to law school. Fast forward, my first position out of residency: correctional doc in Cook County, Ill."

    It was a big, challenging setting, and Matthews said she remains committed to it.

    "I will go back to corrections (after the VA)," she said. "Prisoners are the only population we can legally discriminate against: Deny them housing, education and jobs because they've served their time. It's a population we've forgotten.

    "Every time I saw a patient, I was also thinking of it on a larger scale," she added. And so her time in Illinois culminated in building health policy there -- setting the stage for a move east. She wanted to be closer to family as well as to the center of nonpartisan policymaking.

    "Veteran health care is not in any way a partisan issue," she said. "Whatever the party, we want to support people who have defended our liberties. Ultimately, we agree that we need to get improved resources to the VA and make sure veterans have access to care.

    "As a clinical leader, I am addressing veterans' care. There's no way I could have done that without being a family doc. Without a doubt, family medicine is the best prep for any sort of career in policy. Health care occurs in the family, in the home, outside of the hospital and the clinic. When we understand that -- understand the social determinants -- we can make policy."

    Reconsidering a Delusion

    "In medical school I got stuck with a resident I was pretty sure had lost his mind," began Allison Edwards, M.D.

    This third-year was, she said, "if not fully burned out, crispy and on his way there." He complained all day about the demands of computer charting, the miserable system of checking boxes.

    "Then I, in my infinite young wisdom, told him, 'You're going to have to get used to it. This is how it is,'" Edwards said.

    "He hadn't looked at me all day, but now he made eye contact and said, 'No, this is not how it is,' and he laid out his vision of the future. He would open his own clinic, take no insurance, get rid of checkboxes.

    "I felt sorry for him. On top of being crazy, he was delusional."

    Edwards mimed the resident's mania, throwing up her hands in Muppet fashion and widening her eyes. The audience laughed.

    "Five or six years later, seeing patients in clinic as a resident, I was complaining about the computer and the checkboxes," she said. "I realized I was turning into the crazy resident.

    "Fearing for my future, I used my superb stalking skills to find him online. He was out there in the wide world doing exactly what he told me he was going to do, which by this time had a name: direct primary care. I asked to shadow him."

    The "delusional" former resident was now running a handsome, modern clinic with a lab and a pharmacy. His frustration, she said, "had been converted into a passion for what he was doing."

    This is how Edwards came to found Kansas City Direct Primary Care.

    "I serve people in their most vulnerable moments and in their most victorious moments," she said. "And because I work only for my patients, I don't work for corporations or insurers. I work to take apart the opaque networks that make ours the most expensive health care in the world.

    "This is why I love family medicine," she said. "We have a unit of people in the name: family. It's not one specialty. It's not linear, not prescriptive. There's a huge expanse you can fill in with what you think matters. Embrace your future, because it's limitless. And be open to the effect a crazy resident will have on you."

    From Radiology to a Spark to the Super Bowl

    Ashwin Rao, M.D., was sure he wanted to specialize in radiology -- until he got to his family medicine rotation.

    "There was a spark, and it was the one I'd been looking for all along," he told the audience, recalling a change of heart on the eve of his fourth year of medical school.

    But another surprise was ahead: a rotation through a sports medicine clinic while he was a family medicine resident in Seattle.

    "What I saw was something unique," Rao said. "I saw patients with a sense of commitment and a strong drive to get better. These patients were more motivated than any I'd seen so far. That was compelling to me."

    Rao stayed in Seattle and is now both a family physician and the program director for the University of Washington's sports medicine fellowship. He's also part of the medical team for the Seattle Seahawks.

    What the roles have in common, he said, is hope -- the focus of his story.

    "Hope is central to any patient interaction and any delivery of meaningful care," he said. "Going back to childhood, I wanted to help those in need. It's easy to get lost in the rigamarole of the system, but if you latch on to the concept of hope, you can get back to that feeling."

    For some of Rao's patients, hope might come from autologous growth-factor injections or ultrasound-guided procedures or selective peripheral nerve hydrodissection -- aspects of his practice that recall his original high-tech ambitions. But in the case he recounted to illustrate his point, a family touch would remain crucial.

    A few years ago, Rao met with a college football player who had been hospitalized for an acute illness at the wrong time: just before the NFL combine, where talent and hope come together (under the scrutiny of team physicians).

    "He'd missed that opportunity," Rao said of the young man, whom he called "Darren." Discharged from the hospital, he'd gone from team to team for evaluations that continued to show that a grueling NFL career was perhaps too great a risk.

    "Eight days before the draft, he's in my office, distraught," Rao said. "Just like me, he had worked hard to find his way and was still trying and still hoping. I looked at all his labs and tests, and I saw that no one had sorted out whether his condition was career- or life-threatening.

    "I told him, 'I can't promise you medical clearance, but I promise to take the steps.' And over several days of tests, I found that his condition was resolvable. So I wrote a letter to the entire NFL saying that Darren was capable of participating."

    The man was drafted by the Seahawks and went on to play for the 2014 Super Bowl-winning team.

    And Rao was there with the team -- wondering, he said, "How the heck did my journey to family medicine get me here?"

    Family medicine had gotten Darren there, too, Rao added. The player found his physician as the clock ticked down to victory, and told him, "Remember where we were two years ago? Look at where we are now."

    "It was family medicine that provided me the skills and the drive to be prepared for that moment," Rao said. "I wanted to deliver hope, and that allowed Darren to proceed in that career. I encourage you to seek hope in your care, to seek delivering hope to your patients.

    "Look at where you are."

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