Patient Reflections: Saying Good-Bye to a Retiring Family Doctor

Setting

The practice was located in the eastern suburbs of a major city and the area included rural farm and coal mining communities before the city grew out to encompass it. The patients were mainly white middle class, with a mixture of those moving in to raise their families and those remaining from the small communities around the farms and coal mines. At this time there were 6 family physicians in a group practice, all doing hospital work but only one doing obstetrics. Three of the physicians, including one of the authors (BM), also had faculty positions at the largest family practice residency in the metropolitan area.

Process

This physician sent a letter to all his ongoing patients approximately 3 months before retirement, thanking them for their trust and confidence and offering help for their future medical care. A majority of patients responded with a last visit or call. In addition there were 200 notes, letters, e-mails, and general correspondence.

Analysis

We used content analysis to search for meaning in the correspondence. We did not record or analyze the multiple in-person or phone verbal responses. Using the written correspondence, an independent transcriptionist typed into one master list every word verbatim, with no identifying source. Because the correspondence was obviously positive, this constituted a selective sample consistent with qualitative research methodology.¹² Our intention here was not to simply reiterate what patients expressed to their long-term doctor but to focus on what longevity and continuity seemed to mean to patients. We made no effort to obtain any demographic information about the correspondents because that information would not add to our purpose. The University of Pittsburgh Institutional Review Board gave approval for this as an exempt study.

Both authors independently reviewed the typed comments. We separately highlighted important themes and, after multiple comparative reviews and repeat discussions, developed a single set of agreed-upon themes.

Biases of Investigators

Biases to these notes included the personal involvement of both authors and a philosophy of practice that included the balance between scientifically sound medicine and the Balint principle: the desire by the physician to be perceived positively and even loved by these people and sadness and guilt at leaving them; “that by far the most frequently used drug in general practice was the doctor himself.”¹³ Although it affected us personally we believe the analysis and interpretation were not influenced by our biases.

Theme 1: “Being There”

The concept of “being there” is a state of mind, a belief system, a sense of trust, although not literally meaning being there every moment.¹⁴ As Loxterkamp asserts, “we must return to what has been our greatest asset—the relationships that flow from practice.”¹⁴ Overall, patients believe that the physician is available and accessible when they need him. Furthermore, patients believe the physician will recognize their needs and be able and willing to help even when there is not a cure or a solution to the problem.

Patients here expressed this in their remembrances of house calls in a time of need from many years past; in the consistency of having phone calls promptly returned; and always being available for listening and discussion. It is not so much that the physician must be there at all times, but that the patient has the sense that the physician is available when necessary. Simply knowing this can result in increased quality of care in terms of how the patient views the doctor.¹⁴

Theme 2: Caring

A second and equally important idea to the level of importance of the doctor to patients has to do with the very general yet crucial concept of “caring.” Caring summarizes many aspects of the good doctor–patient relationship and is most eloquently described in Peabody's 1927 article.¹⁵ Caring or care in some form was the most common word mentioned in all of the patient communications. Patients also used other words that we interpreted as expressing a similar view, such as “gentle counsel,” “personal devotion,” “compassion,” and “loving care.” At other times, the use of these words in context informs us that the patients were not always referring to the actual medical care provided by the physician, but were often signifying an overall level of care and concern for them as a whole person or family unit.

Theme 3: Medical Expertise

We would be remiss if we did not acknowledge that many patients wanted medical wisdom. This included various components: they were pleased with the amount of knowledge they felt their doctor had, they appreciated being referred to a specialist when necessary, and they valued that the doctor explained medical issues to them in such a way that was manageable and clear.

Although there is skepticism within the medical system, particularly in academic centers, that there can be one physician who provides comprehensive care for a broad range of health care problems and remain competent and current, patients generally accept that their own family physician knows and practices a high quality of medicine.¹⁶ Similarly, we found that, although very few patients mentioned specific medical expertise, many patients noted knowledge, medical skills, and conservative approaches to medical concerns as factors they appreciated.

Theme 4: Personal Characteristics of a Family Physician

There are many characteristics that patients think are unique or at least special to their own personal physician. This may be based on a coincidental match or an active selection based on trial and error by patients. In either case there is some need for the doctor and patient to like each other and certainly more important for the patient to feel that way. Some of the attributes patients here admired in this doctor were patience, gentleness, calmness, good cheer, kindness, and reassurance. In many ways, patients in this practice expressed pleasure that this doctor respected, informed, and involved them in their own decision making. Patients in this practice recognized and appreciated both the verbal (eg, responding in an encouraging way) and the nonverbal (smiling, nodding, etc) mannerisms of this physician.

Theme 5: Multiple Roles/Anything Goes

The classic or mythical old time country doctor served many functions in the community not limited to traditional doctoring.^17,18 Patients often see it as a compliment to tell their family doctor “you are more than a doctor to me.” Often, patients feel they receive a lack of personal attention from their physician; this is related to the sense that the physician is not “giving” enough to the patient. As one British study noted, patients are looking for whole person care.⁶ Patients want physicians who know about them and their family, as well as those who deal with the “whole person” in the entire context of their life and illness, not just centering on the illness itself.⁶ This was a common theme among the patients in this practice; they consistently used such terms as friend, advisor, guide, mentor, and “helped me make the right decision even when not medical.” The word friend was used repeatedly by patients, although some physicians believe that a level of professional distance should be maintained between themselves and their patients.³ Patients in this practice felt connected and reassured by their physician precisely because he did not maintain an excessive level of professional distance and they could discuss anything with him.

Theme 6: Family

Family doctor implies not only caring for families as well as individuals but also being perceived as members of the patients’ families. Patients responded to this total care by desiring not only the whole person care mentioned previously, but by desiring care for the entire family. Patients even traveled some distance to be seen by the same physician who had treated them as a child, treated their parents, siblings, and now, perhaps, their own children. Numerous patients told stories of how the physician treated their mother and was there when she died, and who now, at the time of retirement, was treating their child. Generational care is a component of continuity of care existing within the family–doctor relationship.

Patients here repeatedly noted that the physician took care of the entire family, as well as expressing concern for the caregivers. Many wrote that they perceived the doctor as an actual member of the family.

Theme 7: Continuity

Connected to this idea of total family care is the idea of continuity of care. This remains one of the major tenets of family medicine or primary care. Having a physician that knows you and your family and has shared with you important life events, happy and tragic, is a powerful force on the doctor–patient relationship that patients recognize.¹⁹ As Mainous et al explain,²⁰ it is the interaction between the continuity of care and the experiences between the physician and patient that matter the most. Therefore, the longevity discussed here must be considered with regards to the previous discussions of characteristics expressed by the physician and the overall quality of the care. Although this may be more obvious in small rural towns where patients and physicians share many roles and activities, it is a necessary part of all family practices.¹⁷ In this practice numerous patients began their note by calling attention to the longevity of the relationship, noting that they had been a patient for more than 40 years, that 4 generations of their family were patients, or that they and the doctor had grown old together. What was also notable is how patients could recounting the exact number of years they had been a patient of this doctor. They were able to be specific because the years mattered. Additionally, what was significant about the years they remembered were details of events that had occurred to them as a patient, or to a family member who was a patient, from years ago. One woman wrote that, as she read of the retirement, she began to reminisce and recalled the very first house call this physician made to her house to see her father. As she noted later in her letter, that house call was more than 40 years ago. It is this interaction, between the bond of the relationship and the longevity of the relationship, that patients expressed over and over. Clearly this is important to patients, a quality they look for and hope to receive from their family doctor.