Analysis Christmas 2008: Professional Considerations

The headwaters of family medicine

BMJ 2008; 337 doi: (Published 09 December 2008) Cite this as: BMJ 2008;337:a2575
  1. David Loxterkamp, physician
  1. 1Seaport Family Practice, 41 Wight Street, Belfast, ME 04915, USA
  1. mclobster{at}

    The river is a metaphor for the doctor-patient relationship, says David Loxterkamp

    Most general practitioners I know are reasonably accomplished diagnosticians, skilled technicians, composed professionals, and hard workers. We do a job; it pays the bills. Our surgeries are a formidable façade for life’s free-for-all: making friends, building businesses, raising families, and growing old together. We have never thought to enforce a degree of separation between the patient and us. In the process, we have learned about human relationships and the larder of trust and gratitude our patients stock on our behalf. Their real value cannot be proved in a laboratory—how can friendship be double blinded or controlled? Yet in this setting, over the space of days or years, patients can discover why they come to see us. We learn how to help. We might even begin to recognise the source of our patients’ unhappiness, which lies behind their symptoms and beyond the reach of our diagnostic categories. We offer them recognition, as John Berger taught us in A Fortunate Man. We offer something more.


    If therapeutic relationships possess a certain unquantifiable magic, it is the magic of hope. When a patient visits the doctor, he or she hopes to be reassured that the lump is not cancer; that the pain will soon end; that a ladder leads from this despair. Hope hinges on the presence of another and the reassurance that yes, we are knowable, even in the darkest place, yet unknowable to ourselves. Patients and their families need treatment plans to assure them that “everything is being done” and that the struggle has meaning and purpose in their own terms.

    If all this could be accomplished with computerised interviews, health maintenance checklists, and evidence based guidelines, we would not need doctors. Vulnerable patients come to us in …

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