An heir of general practice



Of what is past, or passing, or to come.

William Butler Yeats, “Sailing to Byzantium”

For the past 3 decades, no physician-writer has articulated what is important, meaningful, and impactful in our work as family doctors as well and beautifully as Dr David Loxterkamp. He is a member of that generation of American family physicians so wonderfully described by writer John McPhee as the “Heirs of general practice.”1

Over the years, Dr Loxterkamp’s essays have served as signposts on his personal journey as a family physician in the small town of Belfast, Me, as well as for the journey of family medicine as a discipline.

In “Hearing voices—how should doctors respond to their calling?”2 written during the fug of managed care in the United States in the 1990s, Dr Loxterkamp sets the following scene for his essay’s reflections:

Typical damn day. I am running behind, swilling lukewarm coffee, and whittling away at the tower of charts and messages the nurse has stacked on my desk. I peep around the corner to survey the crowded waiting room, and I recognize every dependable name and complaint on the morning roster.2

As his workday draws to a close he asks, “What do they expect of me? Who do they think I am?”2 It is a workday and questions most family physicians recognize. But he realizes that while “we are called upon, it often seems, for unreasonable things at unsuitable times,” they are “times we often later judge to be the finest hours of our days.” This is the heart of our “vocation”—our calling, as Dr Loxterkamp so skillfully argues.2

In “Doctor’s work: eulogy for my vocation,”3 he writes with unusual honesty and candor about finding himself mid-career with a sense of a loss of that personal calling so well described in the earlier essay. How to move forward in the face of such a loss?

As often happens, it was a patient of mine who brought the issue into focus and showed me the potential that lay in each encounter. We long for connection—doctor and patient alike—and for the skill and compassion to express it without judgement or self-denial. There is no higher calling.3

In similar unflinching fashion, Dr Loxterkamp’s “No country for old men: on mentoring in medicine” describes his final days in clinical practice and the transition to retirement.4

When I entered family practice in the 1980s my concept of “the work of medicine” was exactly like my father’s. The science of medicine had advanced well beyond sulfa, penicillin, and the Salk vaccine, but I too worked generally alone, on intuition and the fumes of exhaustion, and for my patients’ gratitude and the community’s respect. We felt as though we could handle almost all problems that came our way, and we accepted them as our own.

Then came the electronic medical record; patient centered care; population health; hospital consolidation; physician employment; expanding roles for nurses, physician assistants, and pharmacists; healthcare teams; the social determinants of health; robotic surgery; and genomic medicine. Our work has gotten better—and easier—but it would be completely unrecognizable to my father’s generation. And it’s quickly drifting beyond my reach.

Medicine is no country for old men.4

He later makes the compelling case about the importance of older physicians being mentors to those at the beginning of their careers “for medicine to retain its ethical foundation and dedication to service.”4

Dr Loxterkamp gave the 2019 Ian McWhinney Lecture, presented on September 18 at Western University in London, Ont, and published in this month’s edition of Canadian Family Physician (page 869).5 Readers will find the same kind of deep thoughtfulness, candor, compassion, and wisdom, as Dr Loxterkamp contemplates the future of the family physician.5

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