Precepting is a sieve that catches all the most complex pieces of the clinic day. A man with liver failure, who is somehow still alive, is present for a hospital transition of care visit with our nurse practitioner. He is dying, and while no one has yet told him this, it could be surmised from a quick glance at his chart.
The resident presents a patient with a history of opiate addiction who has a severe ankle sprain, and only the most tenuous employment. The resident wants to know if the risk of relapse is higher if we prescribe an opioid or if the patient loses their job.
Another resident would like to order a patient’s sixth CT scan of the abdomen this year for their non-specific chronic abdominal pain. The treatment here is in first taking a history of the resident’s fears, and in assessing the therapeutic value of another CT.
I am fortunate to rarely precept alone. Our clinic is large enough that I get to eavesdrop on many of the preceptors who trained me. I look up to them as mentors. I see them as The Great Family Doctors, with whom I hope to someday be held in similar esteem. What makes for a Great Family Doctor?
The Great Family Doctor can differentiate the undifferentiated patient. The prize diagnosis is not the zebra, it is the critical piece of social history that connects the “non-adherent patient” to the human in front of them with the what-is-really-going-on-“aha”-moment.
The Great Family Doctor treats the common ailments uncommonly well. There is more to treating than knowing the dosage.
The Great Family Doctor inspires trust that is stronger than medicines. Lacking this, you cannot reassure those for whom we have no medicine.
The Great Family Doctor both treats and refers with precision, communicating how much has been done and is yet to be done.
The Great Family Doctor titrates their communication with the patient, ensuring that the time spent teaching the patient what is needed to heal can be remembered.
The Great Family Doctor can take a physical with questions, and with their hands take a history. Knowing what they hear, both their ears the stethoscope.
The Great Family Doctor treats in context. The social impactors (determinants) of health are the rules that dictate a Haiku, but restrictions do not stop a doctor’s healing.
If I could only
Prescribe a medication
That you could afford
I would not know to
Review a food bank ready
Low carb diet plan
The Great Family Doctor is more an extensivist than a generalist. The human condition is enough of a unifying diagnosis.
The Great Family Doctor can pass this on to the next generation.