Intended for healthcare professionals

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 desperation. Their fears and insecurities must be met with authority, knowledge, and action. But their humanity requires something more: a handshake, a funny story, our undivided attention—and all that this implies: a doctor who will champion and remain faithful to their cause. This is what distinguishes primary care physicians from consultants. We are not merely underachieving specialists; let’s not be judged on specialists’ terms, but on ours.

    Serious efforts are now being made to test and prove the clinical efficacy of the therapeutic alliance, and I applaud them. But the true value of human relationship eludes description. Like fish in water, doctors and patients are largely oblivious to what gives us breath. The descriptors of relationship centred care are embedded in long, twisting narratives that often bend back to include the narrators themselves. Here, rivers have something to teach about relationships.

    The river

    My first extended canoe trip was on the Allagash Wilderness Waterway, near Maine’s Canadian border, in the summer of 2007. Before that, I had little connection to rivers except to cross or skirt them, or admire their proud pedigree: the Kennebec, the Cobbosseecontee, the Penobscot, the St Croix.

    With my son and two of his friends, their fathers, and the guide and his family, we took a week to paddle 100 miles from Eagle Lake to the town of St Francis at Maine’s northern tip. We quickly came to grasp the purpose for which we rose and rested each day: to paddle, only this; to move with the river towards our destiny.

    A river is not simply a conduit or a sewer system, or something to be bridged, harnessed for hydroelectric power, diverted for the unquenchable thirst of agribusiness, or—in a word—engineered. It can also wash us and feed us, paint in perfect pastels, and transport us in a moving monastery where the mind empties and the soul is replenished. Our forerunners on this waterway, the Abnaki Indians and French trappers, made the river their source of commerce and communication, much as we rely on the internet and interstate highways today. It was their livelihood and drew them together in common industry and condensed geography.

    There are seasons to a river. It flows fast and wide and wild in its vernal youth, then settles to a steady stride by mid-July, and finally bares its rocky bars as summer nights take on an autumn chill. Largely unshackled, the Allagash varies its pace from windswept lakes to white water rapids to full bodied streams. But mostly it moves in an unhurried meander, carrying all who come to it on its tireless shoulders.

    Rivers also have a destructive force, a fury and anger that can wash away our constructions and drown the weak and heedless. Though we had an uneventful journey, we minded the submerged rocks, the sweepers (low outstretched branches), and the headwinds on Chamberlain Lake that would have blown us backwards. And there was Chase Rapids, which in the spring has class 2+ whitewater—we were thankful to portage our cargo and hire a guide. Chip Cochrane, who grew up on the river and guided solo at the age of 17, was a surgeon in command of his operating field. His skill lay in reading each undulation of the rapids while making spot calculations of current speed, wind direction, and the maturing ability of his fledgling crew so as to guide us through safely.

    As we ended our week 100 miles downstream and hauled out the canoes, it was bittersweet to watch the Allagash wend on without us. Our river run was a metaphor for human relationships. Rivers move us, often regardless of or contrary to our will. They hold a mythic place in our imagination and unsettle us when we see trash and oil slicks where merganser ducks and canvas canoes should be. This is why a burning river, like the Cuyahoga in 1969, could stir the US Congress to pass the Clean Water Act of 1972 and create the Environmental Protection Agency. Rivers are threatened by the pace and pressure of civilisation and need conservationists and naturalists to protect them.

    Some rivers have purpose. They carry barges or spawn salmon or create kilowatts or supply municipal reservoirs. They pull their weight. But to make demands on a river is to miss its intrinsic value. Rivers carry us, past and future. They soak watersheds and fertilise deltas. They grow the pines that harbour eagles and moose. They are ever moving, changing, cleansing, bearing, and through their tributaries they become deeper and wider as they approach their self-immolation in the sea. Those who navigate them are not of the river; it is larger and more lasting than they. But once they have experienced the river, they are forever absorbed.


    Less than a year into practice, I was called to the home of a 45 year old Christian Scientist. His wife had telephoned, saying he was “too sick to see the doctor.” Three months earlier, after recovering from a viral illness, he became progressively short of breath, anorexic, and oedematous. Before long he was a prisoner in his bed. Though he gazed at me with wasted, fearful eyes, I had to bargain with him to enter the hospital, where the echocardiogram exposed a frayed heart valve. Then we gambled his life on furosemide and salt restriction while searching for insurance coverage through the narrow window of open enrolment. Three months later, surgery gave him new life.

    Out of gratitude he began to see me at the office. And I saw him for the next two decades—through his spiritual crisis, marital affair, intentional overdose, hospitalisation for obsessive-compulsive disorder, second and third valve replacements, divorce, remarriage, treatment for alcoholism, and separation once again. He “fired” me not long ago, but when I refused to rebuke or forget him, he soon returned.

    I cannot prove that my intimate knowledge of and liking for the man yielded any clinical benefit. I never cracked his chest, managed a ventilator, or sorted out the complex imbalances of his brain. But are these the things that constitute real medicine? My patient received earlier treatment, more consistent care, personal advocacy, and the steady voice of an ally who believed in him when he himself had lost hope. His life goes on—this is a fact—and we built a friendship on the reasons that some choose to stay alive.

    It might be said that I buoyed him at his low point, helped him through rocky times—saw around a bend in the river that he, for one dark moment, could not. Together we let the river carry us, knowing it was stronger and swifter than our solitary effort to swim ashore.

    I am reminded that the life of Robert Frost, the great American poet, was racked with grief and self-doubt. He buried three of his children: two in infancy and one from suicide. His wife preceded him in death. Through all of this, he wrote some of the most beautiful, serene, and widely read poetry of the 20th century. He once said: “In three words I can sum up everything I’ve learned about life: it goes on.”

    Life goes on

    We can learn the value of human relationships as readily in general practice as we can on the Allagash. It requires only time and attention.

    The curriculum emphasises the common good, nature’s severe beauty and vengeance, and the irreversible stream of human events. With maturing intuition, we learn to read the river’s course and react to it. We gradually shed our presumptions and preoccupations in order to fully experience the flow around us. On the river, too, it is still possible to imagine those who came before us—the Penobscot brave, Bangor lumberjack, Maine guide; the naturalists and outdoor sports enthusiasts; and anyone who has ever appreciated or found hope in a river. Life goes on.

    A patient sits nervously before the doctor, hiding an old embarrassment, a new growth, or some deep unsettled sadness. His secret is not something easily elicited by a checklist of questions or revealed in a digital image or metabolic panel. It is doubtful that this patient, with only vague yet insistent complaints, could ever be cured by a procedure or meet study criteria. Circumstances alone make it unlikely that his real needs will match my expertise or that the bill I send him will find a permanent address.

    The doctor, arriving late and already anticipating her next three moves, could deflect the ambiguity of his averted eyes and nervous hands by writing a prescription and moving to the next room, where a strep test has already turned positive. Or she could gamble her balancing act on five unscripted minutes that could open a can of worms.

    At that moment of indecision, why would a patient risk self-disclosure or the doctor relinquish the safety of higher ground? Their choice often reflects a mutual leaning towards relationship: trust that here one’s true self can safely emerge; reassurance that their galloping fears will be calmed through the clinician’s touch, words, and familiar surroundings; companionship that ends the exile of illness and offers a promise of deliverance to some recognisable shore; some sign that there is shelter here, and restorative good will. And mindfulness of what matters most. Why do we live? What is our sacrifice for? When is there more to cherish than the time stretched between us?

    The investment of these moments, whose consequence ripples in ever widening arcs, matters as much as any lifesaving heroics. These are the moments that make life worth saving. They unveil the worth of a living thing, an intrinsic value that can never be priced or marketed or proved beyond the affirmation of a handshake or nod of thanks. We cannot justify the comfort a river offers us. But it runs for all. Like the doctor-patient relationship, its presence matters. It matters for all the reasons we ignore, take for granted, exploit, and desperately clutch when our chins slip below the waterline of sanity. There is good will and fidelity between humans and their encountered world. We trust that these feelings will nourish us, and by their endurance carry our hopes for life unending.


    Cite this as: BMJ 2008;337:a2575


    • Contributors: DL is sole contributor.

    • Competing interests: None declared.

    • Provenance and peer review: Not commissioned, not externally peer reviewed.

    • Patient consent obtained.