Transcription of David Loxterkamp for the show Doctors with Heart #127
Dr. Lisa: It’s always a pleasure to sit across a microphone from a fellow physician and especially a fellow physician who has had a hand in my own professional education. Today, I’m speaking with Dr. David Loxterkamp, who is a family physician residing in Belfast with his wife and two children. Dr. Loxterkamp’s expertise is in addiction medicine, and group visits narrative medicine, and practice transformation. He’s a founding member of the Seaport Community Health Center, and in 2012 was named Best of the Best in Medical Practice and Physician in Waldo County, Maine.
David’s most recent book, What Matters in Medicine is an exploration of the patient-doctor relationship and what really needs to come out of that relationship to insure wellness in a person’ health and in our healthcare system. Thanks for coming in and talking with us today, Dr. Loxterkamp.
Dr. Loxterkamp: It’s great to be here. Thank you Lisa.
Dr. Lisa: I remember first reading something you had written although I know you’ve been writing a long time but the first thing I read of yours was from A Measure of My Days: The Journal of a Country Doctor which was written back in, I believe, 1992.
Dr. Loxterkamp: The writing began in 1992 and it was published ’97.
Dr. Lisa: At this time, I was in my own medical training and I thought, “Wow, a doctor who writes. Somebody like me. I can relate to this guy.” Not only that but you also are a doctor with a strong Catholic faith, and you’re also a runner. There are a lot of things that you and I related, a lot of levels that I related to you on.
This is one of these levels. This is from A Measure of My Days. “I cannot dispense happiness any more than a parent can hand it down but I give to my patients a replenished heart and ears that will listen. I can hold up their fears, and doubts, and dispirited dreams as we strive toward that mutual goal, happiness. This does not deny medical science and its death-defying feats, but physicians realize that the hardest work begins when the cure is evasive and ‘the plan’ is our only defense – plans fabricated countless times over countless days by doctors and patients who infuse a diagnosis with different meanings in order to disperse the unknown and light the trail to their recovery; plans to create order; plans to sustain hope.”
When I was reading this book, this was something that I could really relate to because I think being a physician is so much more complex than many people realize.
Dr. Loxterkamp: Yes. It’s being a different kind of person, I think, to every patient that walks in the room. Some are looking for advice and some are looking for paternalism, some need encouragement, some are there just to argue with you, and to question the value of your work; that is medicine. Within a few minutes, try to figure out why the person has come to you today with this question or this problem. It’s always the most interesting issue.
The ability to adjust your expectations to those or the patients in the course of a very brief time is, I think, what defines the maturing position, the person was able to discard one’s agenda in favor of something more important on the patient’s mind.
Dr. Lisa: Which is a difficult thing to do because as we’re trained early on in medical school, we’re supposed to be eliciting the right answers to the right questions so we can create the right plan, we can come up with the right diagnosis. Many of us going in, we want to do it right. We’re perfectionist, and work a little bit competitive in our minds, I think. We want to do the right thing but the right thing doesn’t always end up being what we thought it was.
Dr. Loxterkamp: Yeah, that’s right. I certainly wanted to be an expert when I left medical school and residency. I wanted to have all the right answers, and I wanted to make sure that I wasn’t seeming – I don’t know – phony to my patients or to my colleagues maybe even more importantly, but the word that comes to mind, I think, best for me now is notion of helpfulness, not patients that or this which I stepped away from but helpfulness. How can I be helpful to this patient today?
The truth is, most of the answers that are important lie within the patient. If we can just elicit those answers, if we can just bring out and support those answers to their own questions, I think we make more headway for them. I do like certain things in medicine. I do like procedures, and I do like the occasion to be the medical detective but even more importantly, I really enjoy conversation and spending time with people who are interested in learning something about themselves, and maybe adjusting to change their life.
Dr. Lisa: Some of the things that you’re interested in are things that have come over time. Your interest in addiction medicine is something that you didn’t start out with necessarily.
Dr. Loxterkamp: That’s right, yeah. Living in a community and practicing in that community over time, I think, draws you to the problems of the community. It was probably ten years ago now that I first began to realize how much addiction was shaping a part of my community that I didn’t even know was there. Probably – I don’t know – over nine years ago, I was called to see a patient in the emergency department and he was daughter of longstanding patients of mine. I came to see her, and she was wrenching and quite sick, and had been so for two or three days.
I soon realized that she was withdrawing from heroine, actually by her own admission. Something I had no concept of and her parents who had asked me to come see her had no awareness of or explanation for it. This was a very, very bright young woman going to college, the first in her family to go to college. That drew me in because she was only a few years older than my daughter. I knew nothing about this. I thought if I can’t or my colleagues can’t respond to a problem like this, who will be there for my daughter if she gets into trouble? or my son as he could get in with the wrong crowd and make some bad choices?
I needed to learn about this, and over really the last five or six years, we’ve developed a program in our practice to help people with addiction to narcotics, narcotic abuse. It’s been a fascinating journey. First, believing all that came out in the medical literature about addiction, and its treatment basically with substituting one drug, Buprenorphine, for another. That is whatever the patient was, their drug of choice was whether it would be methadone, or heroine, or prescription painkillers.
What I learned over time was how people change and why, and of what help I can be in that process. We’ve gone from one-on-one doctor-patient care and prescribing Subaxone really indefinitely to now, hosting groups and letting these individuals teach each other and me about what is most helpful for them in their recovery. It’s been fascinating, and you develop very close relationships with these people because you see them weekly and really hear about the intimate moments in their life and the struggles they’re going through. Really, the enormous challenges they’ve had to overcome to get to this point.
The other thing you realize is that since virtually all of them have children, that if you don’t help this generation, another generation is lost. It’s an enormous challenge. It draws me out of my comfort zone and working with people in a way where I am not the expert. I’m certainly not the expert on all of the legal issues they’ve gotten themselves into, and the shame they deal with, in early life experiences that are so different from mine. It’s been a huge learning experience.
I think what probably I have to give them more than anything else is an adult presence. An adult who believes in them. An adult who imagines a future for them. An adult who cares about the outcome of their struggle, maybe more so and probably in many cases much more so than their parents or the adults that they’ve had in their life up to that point.
Dr. Lisa: This sort of work is requiring something different than what being traditional medical practice requires of us these days. A lot of what we do these days has something called metrics associated with it. It’s about getting patients in, and seeing them in a timely way, having quality, meeting quality goals like every woman over 40 gets a mammogram and things like that. Sometimes these two things can be in contrast and in conflict. You wrote about this in the BMJ which used to be the British Medical Journal, this idea of humanism and the agent metrics.
Dr. Loxterkamp: That’s right. I really have no quibble with metrics. It’s just the choice of what we choose to measure. I think we’ve stopped the agenda, that is the medical association has set an agenda that can be quite different from what practicing physicians need in their office every day.
The other thing about metrics is that when you’re focused on one thing, it takes your eye off another. Sometimes, when you come in to a room with a patient, say, a diabetic, and you have in many cases, six, or seven or eight metrics to meet on that patient that day, you almost forget to ask what’s going on in their life or why are they there, and what’s troubling them. You have your agenda, they have theirs, and again, I come back to that. Our job is really to be helpful to them.
I think the opportunity for conversation, the opportunity to explore the sources of their unhappiness, these special moments which is many, many times why they’re there that day can be trampled under by our urge, by our strong performance desire to meet these metrics that have been laid out for us by others. I think metrics are important, and I think the challenge for primary care physicians is to take the lead in choosing what are the most important things to observe ourselves, observe in our patients overtime, rather than rely upon maybe the agenda of an urban medical center and their research topics or their research grant goals.
What we think is important, how can we measure that? One of the things that I think is very important is face time. How much time do we spend looking at a patient and listening to them? I think that makes a huge difference in outcomes, a huge difference in cost savings, and it’s really not been measured.
Another really important thing is to measure the power of relationships. I tried to explore that in my book, and what I discovered was there’s really not very much evidence for or against the power of relationships and moving people to a more healthy place in their lives. I really think that’s an important topic for primary care to take up. How does establishing a sense that you care about a person, that you want to listen to their concerns, that you really want to get to know them, and that you want to be with them over time help whatever struggles they’re going through?
How does that change outcomes, and in what way can we develop these relationships better to achieve those outcomes? Maybe in the next ten years as I slow down from the busy pace of medical practice, I’ll make contributions in those areas of research into primary care and what is most important not just to the doctors who care for the patients but the patients themselves.
Dr. Lisa: I’m fascinated by your practice, at least in part because one colleague that you worked with is one that I helped educate at Maine Medical Center, Dr. Megan Britton. Another colleague is one that I went through medical school and residency with, Dr. Carol Kim.
Your practice seems to have the ability to work together well enough to make fairly big and interesting decisions. You’re talking about changing the way that you see patients so that you maybe see patients for six hours a day but then you do administrative work for the remaining hours of the day so you get today’s work done today. That’s something that you actually need to have a lot of buying in for. How do you keep everybody in your practice sort of roughly on the same page so you can move forward?
Dr. Loxterkamp: Some days, it happens more easily than others but I think a couple of things. I’m not sure I’m the best leader for this practice but what I’ve been able to do is choose, I think, the right people which is the big head start in trying to get a practice to function as a team. First of all, I made an effort to find the right people and be choosy about that. I think that’s been a big help for our practice.
Another is the commitment we’ve all made to what we call, what has been called for the last 22 years now, that there is a morning meeting. 23 years ago, my then only partner, Tim Hughes and I went out and recruited Mary Beth Leone, a social worker, licensed clinical social worker, to come be in our practice one day a week because we saw the absolute need for behavioral health in our practice, and because we wanted her to help us work better as a team.
The way I knew to do that was to host a conversation every Thursday morning for an hour, what we call a “check-in”, where I learned about what was going on in the personal life and sometimes, the clinical life of my colleagues. I think physicians for a long time have been very good at parallel play. That is working exam room to exam room right next to others with lots going on in their personal lives, and maybe some troubling medical issues that they’re facing or mistakes that they’ve made, or concerns that they have about certain patients.
We gave voice every Thursday morning and have for 22 years, as I’ve said, to those kinds of questions and conversations from 8:00 to 9:00 every Thursday morning. Building that kind of trust and that kind of concern for one another, I think, also goes a long way to creating a team environment.
I think, lastly, people who have come to work for us have, some more reluctantly than others but have, all bought in to this notion that change is important. That we can’t do things the same way we’ve always done them, and that we need to try new things because maybe the old ways are not as effective or not as good as we thought they would be or because new challenges are confronting us, not just our patients at our practice but primary care more generally.
I think they’ve all bought in fairly freely to the notion of joining, in 2006, the National Demonstration Project. We were one of 36 practices in the country to look at practice transformation and see how we could promote it in our own practice. In 2010, to join the Maine Patient-Centered Medical Home Pilot. Right now, so many things are going on and it’s really such an exciting time. Very soon, we’re going to have a psychiatrist be consultant in our office which is really unusual but in many ways, absolutely necessary for the kinds of people we take care of.
We become a federally-qualified health center to expand our reach to the people of Waldo County and make more patients available for the kinds of sliding scales and other financial supports that an FQIC can bring. Even more importantly for me now is this notion of colocation which is the idea of bringing the essential ingredient of a primary care practice together. Certainly, integrative behavioral health is a big part of that, but also pharmacy, and lab, and imaging, and physical therapy, and dietary education.
All these things are absolutely important not just to have in the same place which is maybe kind of the mole mentality of medicine but actually working as a team, talking about the same page and at the same time about what we might really benefit from or how we can help them move forward in their lives. I think my job has always been to bring the right people together in the right circumstance.
That is in a place where we can have real conversation and make joint decisions together and also to push them to take tiny risks and sometimes major risks out of their comfort zone, trying new things with the hope, with the possibility that this could actually make their life better, and even more importantly, further the mission that we all agree upon which is taking care of patients where they are.
Dr. Lisa: Dr. Loxterkamp, how can people find out about the books that you have written? A Measure of My Days: A Journal of a Country Doctor and What Matters in Medicine: Lessons from a Life in Primary Care.
Dr. Loxterkamp: Probably the easiest way is to drive to Belfast and go to my wife’s bookstore where these are prominently displayed. I think another easier way probably for most people would be to go to my website. I have a website in part to introduce my newest book but also to collect all the things that I’ve been writing about really the last 20 years.
Writing has always been a way for me to collect my thoughts and to push away all of the ambiguity and uncertainty that a family and a family practice can bring to one’s life and organize it a little bit better. It’s been a recreation for me. It’s really been a part and parcel with my work that one really can’t … I can’t perform well at one without the other.
On this website DavidLoxterkamp.com or WhatMattersInMedicine.com, both entries will bring you to the same site. I highlight the book. I highlight some of the articles that I’ve written over the last 20 years, and I talk a little bit about where I’ll be speaking or getting involved the next.
Dr. Lisa: Your wife Lindsay’s bookstore is Left Bank Books?
Dr. Loxterkamp: Exactly.
Dr. Lisa: People who happen to be up in the Belfast area, and I recommend that they go actually because it’s a really unique community and offers quite a lot beyond just the books and the good family medicine, and they can stop in at your wife’s bookstore.
Dr. Loxterkamp: Absolutely. Now, to further the advertisement by saying dogs are always welcome.
Dr. Lisa: Very good. I do thank you for taking the time write about your experiences as a family doctor and also, for helping educate me when I was a resident at the Maine Medical Center, for driving all the way down from Seaport to come participate to my education professionally, and for being so thoughtful as a family physician in a time of great transition.
We’ve been speaking with Dr. David Loxterkamp, author, father, runner, writer. Thanks for coming in today.
Dr. Loxterkamp: Thank you very much, Lisa.