I had a eureka moment recently. It came after what was probably the ten thousandth time a patient responded to my brightly warm greeting, “How are you today?” with a curmudgeonly, “I’m getting older. How do you think I am!”
Aha, I thought, now I see. So what if it took 22 years of practice to reach enlightenment. Wisdom was now within my grasp this fine Tuesday morning. But the understanding gained in that moment provided me scant comfort. It actually heightened my angst, obliterated endorphins, and caused my catechol levels to surge.
What is the knowledge I had abruptly acquired, you may ask. It is this. I suddenly understood what makes the practice of general internal medicine and family medicine so ultimately frustrating, and why our fields are more daunting than all other areas of medicine. If you are already among the cognoscenti, forgive my wonder and awe and check out a different post. If you to are perplexed, however, read on.
Our job, as adult primary care practitioners, is to help people grow old, become more infirm, progressively less abled, and then to die. What kind of profession sets these goals for itself?
Think about it. The measure of our competence and skill is whether we succeed in getting our patients to experience more joint pains, more tiredness, and more bladder and bowel difficulties, and to become more dependent on their children. The physicians who are failures in this field of practice are those whose patients do not become more infirm, whose patients do not grow older and sicker.
I recommend we call this the GIMFA Paradox: general internists and family physicians succeed when we cause our patients to suffer, and fail when our patients avoid suffering. GIMFA, of course, stands for General Internal Medicine/FAmily medicine.
Let’s look now at other fields of medical practice and see whether they are characterized by a GIMFA-like Paradox. Pediatricians? These doctors aim to help young persons become healthy and happy adults. No paradox here. Surgeons? Their aim is to cut out diseases and make people healthier. Radiologists? They live in a world of darkness, but they aim to shine light on illness so patients can be made better.
You get the point. I could review every other field of medical practice to see what makes its physicians successful. In each case, it is to help make patients feel healthier and happier. In every field besides GIMFA, the doctor-patient relationship is characterized by a good faith effort on the part of the doctor to cure or ameliorate disease. For GIMFA docs, our relationships with patients are marked by our earnest attempts to make them feel ultimately downright lousy and enable them to acquire chronic diseases. The more chronic illness they acquire, the better we have done, and hopefully their infirmities will continue for the 20 years or so. We aim to bring about the ultimate non-sequitur: successful aging.
So many things fell into place at my eureka moment. As soon as I understood the GIMFA Paradox, I immediately comprehended why so many primary care docs seem a little down in the mouth. Our mission in life is to cause suffering. Adding insult to injury, we are surrounded by colleagues whose mission is the opposite. No wonder, I thought. It is all so clear now.
But my breakthrough that day did not end when I grasped the GIMFA Paradox. As the day wore on, my internal monitors were continuing to send sporadic signals of satisfaction to my brain. I found fulfilling moments sprinkled throughout the day as I helped my patients grow old.
It must have been around 3:00 that afternoon that I stumbled across the Corollary to the GIMFA Paradox. The GIMFA Corollary says, in essence, that those doctors who chose to enter the GIMFA arena must find their professional satisfaction in helping patients grow old gracefully. This, I realized, was truly a high calling. It requires an incredible combination of skill and finesse to help patients and their families travel successfully down the road of aging.
Yes, our mission is to help people grow old with all that that implies. But our mission is also to help these same people maintain expansive, yet reasonable, horizons on their journey forward.
Hmmm, I thought. The Corollary to the GIMFA Paradox explains a lot I truly do love about practicing general internal medicine, despite the fact that the successful outcome of every patient interaction is, eventually, death. Other medical specialties contribute to the human journey, but in a more compartmentalized way. Surgeons remove the thorns from the voyager’s foot. Psychiatrists help the traveler pick which road to follow. Radiologists help see what is around the curves. But adult primary care docs are the ultimate guides. We are the ones people check in with periodically to see whether their journey has merit, if it can continue, an dhow they can navigate the increasingly narrow and rocky road to the hilltop. What an amazing and rewarding responsibility.
So, the GIMFA Paradox isn’t so terrible. We GIMFA docs just need to keep a firm grip on the Corollary. Our careers can be just as meaningful, just as satisfying as those of our colleagues, if we simply open ourselves to the magic.
(October 2003)