Bruce Bushwick, M.D.: Doctoring the Family

Bruce Bushwick, M.D.

“We are all related. We all come from the same mother. We are all part of the same family. This has been scientifically validated. So, we need to treat each other the same,” said Dr. Bruce Bushwick, as we sat down together on a quiet Saturday afternoon to discuss his practice of family medicine.

You see, it turns out that we inherit a specific component of our DNA, our genetic code, the map of life, only from our mothers. The DNA in her mitochondria, the cell's energy source is passed on to all of her children. By analysis of these small bits of DNA (making up 37 genes) from different populations around the world, the “most recent common ancestor” from whom all living humans have descended walked the earth between 150,000 and 200,000 years ago.  (Of course, there were people before then, but their lineages came to dead ends, as did many others along the way till now.)

So everyone currently alive today, everyone, all 7.7 billion of us, carries loops of DNA passed down from that one very-tired woman. 

The loop of mtDNA

Family Medicine. The term certainly has warm connotations. Even as the nature of what a “family” is has changed radically in recent decades. Even as the nature of the practice of medicine has changed as well. Dr. Bushwick is the Chairman of the Department of Family Medicine at the York Hospital, and I wondered if he could help me understand where things have gone.   

He was raised in the Washington D.C. area and went to the University of Michigan for his undergraduate degree in general studies. In high school, he was a county champion gymnast in the “all around” category. In college, he soon dropped his athletic career and focused on “all around” academics instead. He had an “aptitude in science and math”  (where have we heard that before?) and, by his first semester, decided on a career in medicine. However, he carefully took a wide variety of non-science courses to broaden his view of life. 

University of Maryland Medical School Campus

While a medical student at the University of Maryland he did an Infectious Disease rotation at York with Drs. Manzella and McConville. He said that there was a feeling of family amongst the physicians; things were “very collegial.” Since Dr. Bushwick likes “the big picture” and a “holistic” approach (in addition to knowing “how things work”) he decided to go into the relatively new (since 1969) “specialty” of Family Medicine. The experience in York as a student drew him back for a residency, and he has stayed here since.

After a few years in private practice with two other physicians, taking care of pregnant women, delivering their babies, treating infants and children, seeing teens, adults, and the elderly and dying, and doing simple orthopedics and minor surgeries in the office, and following his patients in the hospital he left for a teaching position. 

Over the years the nature of that ideal comprehensive way of practicing medicine from birth to death in the context of the family has changed. Few doctors can take care of people throughout the entire life cycle now, and hospital care has been taken over by hospitalists.

But, while the role of the family physician has become somewhat restricted (e.g., the obstetrician handles most pregnancies and deliveries, the orthopedist sees fractures, and the geriatrician often takes care of the dying, etc.) the essential nature of what they do, and how they do it, has not.  

Dr. Bushwick said that the “pillars” of his practice remain “comprehensiveness, coordination of care, continuity, and access.” This is framed by the all-important “biopsychosocial” understanding of the patient in the context of their family and the broad community. Accountability, and having a sustained partnership with patients, are essential as chronic conditions are managed differently than acute illnesses. The focus is always on the person with the disease, not the disease. The person, not the disease. 

One Schematic of the Biopsychosocial Model

He is especially passionate about teaching. He recalled that in his residency training he was sometimes observed through a two-way mirror as he took a history and examined a patient. A social scientist watched, recorded, and analyzed the encounters. Did he listen with interest? Did he interrupt the patient? Did he gently touch the patient? Did he say affirming things? Did he position his body properly? Did he fidget, or remain too stiff? 

(My mind slowly wandered as Dr. Bushwick ticked off these studied observations. I drifted off and pictured the young Jane Goodall crouching down in her khaki shorts scribbling on a small notepad as she watched Flo taking care of poor Flint, trying her best to get him to become independent. I’d better refocus...)  

Jane Goodall in Tanzania 

Such feedback about (our primate) behavior helps immeasurably, he noted, but modeling those we want to emulate, modeling by way of the famous mirror neurons (that help us understand other people), is another way to develop the skills and traits of the accomplished family physicians. These skills include effective communication, appropriate empathy, proper engagement, and careful listening. 

Andre Lijoi, M.D.

Dr. Bushwick and his friend and colleague Dr. Andre Lijoi  (a passionate proponent of finding the patient's narrative) both mentor and mentee as they watch each other. They share what they have learned from their patients. Lifelong learning is the rule.   

But since there are few 24/7 physicians with inpatient and outpatient practices, continuity of care has suffered. Urgent care tries to fill the gap, but the absence of a familiar and trusted face when patients are frightened adds to their anxiety and their suffering. The hospitalist has likely never seen the patient before and doesn’t know the family dynamics. 

And there are time constraints in the office; for example, the 20-minute visit may not leave room for the well-known “doorknob moment.”  The critical moment when the patient suddenly “remembers” that “there is one more thing.” And it turns out, then, that this is really the most critical. 

(Dr. Lijoi suggests asking the patient up-front to try to focus on the most important issue. But patients may have trouble expressing that because, according to Michael Polanyi, “we know more than we can tell.”  Our deep-seated fears may block what we “know” from bubbling up to conscious awareness. We may need time for this to happen.)

Dr. Bushwick took courses at the Georgetown Kennedy Institute of Ethics and has chaired

Kennedy Institue of Ethics at Georgetown

the hospital’s bioethics committee for the over 25 years as they try to understand “high-stakes situations” at the beginning and end of life. While “Do no harm” is medicine’s first rule, he tries to incorporate the Aristotle’s “virtue ethics” of character and excellence into his thinking. 

He then quoted another heavyweight he admires, Emmanual Kant (1724-1804): ”Act In a way that you always treat humanity, whether in your own person or in the person of any other, never simply as a means, but always at the same time as an end.”

Two Types of Ethics

Aiming to lighten the discussion just a bit, I ask, “How are the young residents doing today?”

“They are wonderful, idealistic, engaging, and great to work with. Their hearts are in the right place. They want to improve the world and are very much into social justice. They are a generational transition that is positive. I love this generation,” he happily replied.

Dr. Bushwick takes time to be active outside of medicine. For example, he has had leadership roles at the York Jewish Community Center (where he is currently president). He is still quite athletic as he swam, in full wetsuit, the 4.4 miles across the choppy Chesapeake Bay not once, but twice (a “very tough” meditative experience), and he rode a bike from Jerusalem to the Red Sea, including a grueling, punishing, 20-km steady climb up the Dead Sea rift. And, in his spare time, he serves as the only physician on an advisory committee to the Pennsylvania Supreme Court dealing with issues involving the vulnerable elderly. (I am exhausted just thinking of doing all this while he is married and helping to raise three daughters.) 

The Twin Chesapeake Bay Bridges

As an educator, his goal is to “help people develop their natural skills to better serve humanity.” As a physician, his goal is to offer “quality, timely, thorough, and compassionate care.” As a citizen, he feels that we, as a country, need to decide whether healthcare is a basic human right (he thinks it is) or a commodity.

Reflecting on the current healthcare climate, Dr. Bushwick objects to patients being called “consumers” and doctors being called “providers.”  He objects to the reimagining of the doctor-patient relationship as nothing more than a simple commercial transaction. He knows in his heart that it is very much more than that, and hopes, by his efforts, to help protect the sanctity of this most human and intimate of relationships.

I finally asked Dr. Bushwick if he is optimistic about the future. “Yes,” he quickly said, “the evidence is that our world is getting better and better in terms of the human condition.”

I wonder whether our ancient common mother would look kindly upon her family and agree...

Watercolor by Anita Cherry ~1983

Anita Cherry

P.S. 1/4/20: Recent mitochondrial DNA data suggest that the earliest humans, and the single mother of us all,  may have populated southern rather than eastern Africa 200,000 years ago. (Read more about this here.)