What’s a typical day of a primary care doctor like?

It’s common knowledge that fewer medical students are entering primary care and that patients are having a hard time finding a primary care doctor. Part of the reason is that insurance companies place little value on much of the work that primary care doctors do.

Even though physicians’ complaints are seen in the medical and lay media, it is rare to see descriptions of a primary care physician’s “typical day” in either.

Of course, there is no such thing as a “typical” day. Each day is different. But the administrative demands and coordination of the human drama are matters with which all doctors are familiar.

After 35 years of practice, I limit what I do. I no longer do pediatrics and do very little office surgery and gynecology. I no longer see patients in the hospital or in the nursing home but I do try to keep in touch by phone. Many patients have been with me since I started practice which makes for easier communication with them and easier insight into their medical and psychosocial problems.

Let me choose a “typical” Monday in October. At home, before going to the office I typed up a case report on a complicated patient that I was referring to a specialist. Arriving at the office at about quarter to eight, I looked over the laboratory, X-Ray, and CAT scan reports collected in my fax machine over night, deciding on which needed immediate attention and which I could attend to during the day. I filled out and faxed back four fax requests from pharmacies for refills.

I saw my first patient about 9:00 am, a woman who I had started on medication for shingles a week ago. She was recovering nicely.

Next, I responded to a fax report which showed a seriously low potassium level on a patient whom I saw last week. On large doses of diuretic for leg swelling which had not yet responded, he took it upon himself to double the dose. I called on his cell phone to put him on potassium pills. He was in Florida and because he is on a state program that doesn’t cover his medications in Florida he wanted just enough pills that he could afford till he returns home. I asked him to call me back with a phone number of a pharmacy there and I phoned in a prescription. I will re-check his potassium levels when he returns.

Sipping my coffee, I filled out two physical exam forms for a young couple planning to adopt. I leave a message on their answering machine to confirm that lab reports and chest X-Rays are normal but we still need a urine sample.

A few seconds after hanging up, I got a call from an 80 year old widow in the hospital. She had gone there right after her son had died over the weekend and was hospitalized with worsening of angina. The next day she was having a test to see if the stents in her coronary arteries were still open. I did my best to comfort her and filled out four more faxes from pharmacies for refills I gave to my nurse to fax back.

My next patient was a “walk-in,” without an appointment. An elderly widow in her eighties, she was very upset because the drugs for hypertension which used to cost her six dollars a month now cost over a hundred dollars. She was mad at the local pharmacist. I told her that it wasn’t his fault she is on a brand name drug and her insurance company will only pay for generics. I received a fax form from her mail order pharmacy and filled it out explaining that she needs the brand name medication because the generic didn’t control her blood pressure and gave her a headache. My nurse faxed the form back.

After my walk-in patient had calmed down and left, I saw a woman with diabetes. She was having minor hand surgery, and she just needed a letter from me okaying her for the procedure. I did a quick exam, wrote a short note to her doctor and gave it to her.

Next I received a phone call from a son whose mother is in her eighties, in a nursing home. She was recovering from knee surgery but the nurses there told her that her oxygen levels were low, and that her chest X-Ray showed “a little fluid and possibility of pneumonia.” I called the lung specialist who had seen her in the hospital for this problem and then I called her son back to fill him in. I also called the patient back at the nursing home to let her know I was on top of the situation. I also called the nursing home trying to speak with the doctor there. He wasn’t there so I left a message on his answering machine recommending follow-up with the lung doctor.

The next patient was an elderly widow in her eighties for follow-up of respiratory infection. She was getting better but a rash she had had for several week was not getting better with treatment. I called a dermatologist and made an appointment for her.

I then answered a call from the sister of the patient who had died over the weekend. She was crying and I tried to comfort her.

A man in seventies whom I had seen for a respiratory infection the week before called wanting to know, since he was still “coughing a little,” if should see him or just phone in more cough medicine. I phoned the cough medicine.

I then received a call from a woman asking for a tranquilizer. The pharmacist told me that he needed a hand-written script because she only uses the brand name. The pharmacist insisted on a hand-written prescription which I wrote and gave to my nurse to fax.

Next was a woman in her sixties complaining of neck pain. She had seen another doctor but was not getting better. In the course of my examination she broke down telling me that her husband needed a bone marrow transplant and that her insurance wouldn’t pay for it until “he got sicker.” After a normal exam, we both agreed that perhaps stress was the cause of her neck pain. I prescribed a tranquilizer and planned to see her in one week.

A patient with uncomplicated sinusitis followed. I phoned in an antibiotic.

Next, a woman in her eighties came in for a follow up of pneumonia.

After her I saw a woman for a sore throat, but she spent most of the visit talking about her husband’s concerns over erectile dysfunction.

The patient after her complained of pain over the right eye and along the side of her head. My exam was normal and I considered migraine, but she wanted to see a neurologist because years ago she had had a concussion. I made the appointment for her.

The patient seen next was a follow up for a skin infection of the scalp.

After that a woman called and I phoned in her tranquilizer..

The daughter of the woman who was hospitalized with worsening of her angina called crying and upset because she just found out that her mom needed bypass surgery. I tried to comfort her.

Sipping another cup of coffee, I phoned in a cholesterol report to patient who had had a stroke.

My most difficult challenge of the day was not medical but an administrative problem. A patient I had taken care of for years had recently gone on state aid had been getting his medical care at a community health clinic. His complaint was sore throat and chills. I told him it was a viral infection and that an antibiotic was not needed and to take Tylenol for fever and muscle pains.

He mentioned that he also had some weakness and tingling in his right arm for several months. My exam confirmed the weakness. The specialist I wanted to see him didn’t see state aid patients and his office referred me back to the clinic.

The patient told me that the clinic dropped him because he made $14,000 a year which was above the limit for coverage. I called the clinic’s main number and was referred to the financial office, whose receptionist told me that the patient had it all wrong. Apparently he was supposed to save his bills and once they reached $1,000 a process called “spend down” was supposed to go into effect. Then the clinic was supposed to pay for his care.

I told him to save him to save his bills. I got him an appointment to see a neurologist at the clinic but it wasn’t until February 2010. I ordered an MRI of his neck to rule out nerve compression. The hospital will do the tests even though he is on state aid. I will see him in one week and when I get the report I will speak to the neurologist.

These are the various services I provided. I left the office at 4:30 pm. Much of the time that I spent with my patients was administrative. It was time-consuming and tiring. Most primary care doctors, have similar “typical” days. Some are much busier and see a wider range of diseases and patients. Some still make hospital and nursing home rounds as I once did. Some have weekend hours and night time hours. Their practice styles depend on their skills and their financial goals and their ages.

Most primary care doctors provide services similar to those I described. The time and energy consumed represents a dimension of health care that goes beyond technical competence. Insurers do not acknowledge the value of these services and rarely compensate primary care doctors for them. As a result, many of them cannot afford to take time off to rejuvenate their spirits. Others have suffered physical and psychological and marital problems trying to deal with the stresses and dissatisfaction of a career in primary care.

Is it any wonder that so few students are choosing primary care?

Most medical students recoil from primary care. Add to that the 11 years it takes to produce a primary care doctor, and one wonders how society’s need for primary care services will be fulfilled.

Edward J. Volpintesta is an internal medicine physician who writes in The Yale Journal for Humanities in Medicine.

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  • Sarah G

    Dr. Volpintesta: It was very, very kind of you to spend time with the people who needed comforting. Thank you for choosing compassion over ‘the bottom line’.

  • stargirl65

    I noted that you did a lot of phone work and coordination of care. It would have been nice if you pointed out which of your care was compensated for (office visits) and which was not (everything else). This would illustrate how much of your work was “free”. It is not just all the administrative work, it is that none of that is compensated for. Even a salaried physician has levels of care to meet, and all the “free care” takes time would go against their bottom line. There has to be a way to document all the uncompensated care so we can get paid for it.

    It is nice to choose compassion over the bottom line. Compassion won’t pay the bills though and when you close your doors, then there will no longer be anyone there to provide the service.

  • http://www.twitter.com/iamLeila Leila

    Very good article for a future doctor! Very insightful.

  • jsmith

    It will be interesting to see what happens to primary care (interesting in the way it is interesting to see a landslide or a tsunami). Clairvoyance is not my field, but my best guess is that we docs are going to hand it off to nurse practitioners and physician assistants. They will take it, because it will represent an increase in money and prestige for them. A few family docs will be left, but they’ll gradually retire and the specialty will be pretty much wrapped up. The hardcores that survive will go cash- only and make a good living at that. Internal medicine will consist of hospitalists and subspecialists. Americans will get used to this set-up in time.

  • Mary Schwartz

    I enjoyed this article (granddaughter, daughter and aunt of primary care doctors) and appreciate the compassion shown. However, I do think there were several cases and problems that do not require an 11 year trained primary care specialist. I know that patients want to see YOU but going forward we must wean these patients (tactfully and responsibly) from taking the doctor’s time to taking the time of a PA or the like. Like school teachers, primary care doctors deserve whopping heaps of $$ but they can help on their side by delegating non-essential doctor care to others whom they supervise. What do your other readers and doctors think? Sincerely Molly

  • jsmith

    Molly, I have been a family doc for 20 years I agree that most of what I see I should not see. A NP or PA under my supervision should see the pts instead. Someone else should fool around with the computer and the paperwork and so on. Unfortunately, hiring these folks costs money, money that the American people do not intend to give us PCPs. So we do have to do the scut work instead. Med students are justifiably aghast and turn tail.
    Here’s related problem, under-discussed. In every job I have ever had, my supervisory duties have been in addition to clinical dutes, not in lieu of them. So, for example, now I consult on all my NPs difficult (for her) cases, but have a full case load myself. More work, no more money.
    Could this change? Yes. Will it change? I doubt it.

  • http://www.familydocs.org/blogs/fp-forum Carla Kakutani MD

    I’m biased (being a proud family physician with a varied practice, including inpatient work), but the joy of longitudinal relationships and the challenge of the ever changing state of the art in primary care makes me confident that there will always be a cadre of us that can’t imagine doing anything else. We have an obligation to our patients and to our health system to fight like hell to stay in the picture. We have to change to some degree (be the leader of the medical home and learn to work in a team) in order to improve care and spread ourselves around better, but the basic satisfactions of primary care will stay the same. I have confidence we won’t disappear.

  • anonymous

    jsmith-are you using your NP appropriately? s/he should be able to generate income for you if you are busy enough with your own schedule.

  • http://everythinghealth.net Toni Brayer, MD

    Your day shows how much non-medical, uncompensated work we do. But this is why PCPs are burning out and unsatisfied and what medical student would freely choose that type of career?
    The changes in medicine demand that we start delegating other tasks and use our physician training for diagnosing and treating and teaching patients. Dealing with pharmacies, forms for adoption or generic meds and making appointments for referrals (?) should be done by medical assistants.

    The entire field of primary care is due for some office workflow re-design. It is so unsatisfying to be doing paperwork and telling a patient about their normal cholesterol level by phone. No wonder Primary Care is going the way of the dinosaur.

    At least you got done at 4:30. Most of my colleagues are never home before 7 because they are doing all of those tasks after patients are gone.

  • jsmith

    anon, Excellent point. Alas, I am salaried.

  • jo

    Yeah, primary care is ‘pretty much bullshit’ in many ways due to the amount of administrative work.

    There are a couple things you might do to be more efficient. First the calling in of prescriptions is time consuming. Do you have a nurse that can call those in for you? Also, using an electronic medical record can speed up doing refills as well. Also prescribing antibiotics over the phone for sinusitis? I would’ve done that as an office visit, same amount of time.

    Sounds like you’re ‘too nice’ making appointments for your patients etc., just have them call and make the appt themselves.

  • LynnB

    I love the free effeciency advice. Every sitaution is different, the guy is trying to show what he does. Primary care sucks everywhere, it isn’t that he is ineffecient..
    I have thought many times that I would love to have a someone with more training doing those darn prior auths , but then I (or my system) is paying even more people to help the insurance compainies save money so they can hire more people to check up on us, or rather how good our IT staff is.

    … I am an employed general internist. My medical assistant is a lovely person with a high school education , who was in the military and passed the MA certification. She makes less than an experienced grocery checker. She’ll be around until she can afford nursing school. Then I get another one who may be good or bad., I’m on salary, they don’t pay anyone to help me because I just work more hours . They don’t need anyone particularly well trained (my asst now is a jewel, but the major support of her family of 4 since her husband’s construction job is dead) because I will be there to complete their work and correct their errors, all for free.

    The doc is making the appts , or at least giving a lot of direction because
    1. The staff may not know what the problem/urgency is, especially with primary care where it can be diabetes or a brain tumor. This does waste everyones time . Ex: the receptionist scheduled a VQ scan (bad beans, good lungs) for 10 days later , not because she was evil, because she didn’t know. I can train her, but there are always new employees because we don’t pay that well.
    2. The specialist office staff feels they are above talking to “a receptionist” even though that is the specialty staff’s job title. 90% of specialist also tell them, if its important the doctor will call me. It is alo true that the receptionts or MA at the specialty office may not realize “patient is urinating blood” sounds horrid, but is likley not something that needs to be fixed today
    3. Some pulmonologists want a thin cut CT and complete PFTS before they see a patient with non-resolving infiltrates and some want to look at the plane film and order it themselves and some want to see the patients first. What is appropritae depends on the patients health and renal function. The assistant doesn’t know all of this , and it truly is my job to be sure the patient has a productive appointment.
    4. In the case of the publicly insured patient they will force patients to go through hoops so they (the specialist) don;t waste their valuable time.

    I have worked with NP’s in the past , now that we are employed we can’t afford one .Generally LOTS more work and malpractice risk for no extra compensation.

    Just one comment -my employers system , like most others uses mid levels in our most difficult areas, like walk-in appts and urgent care centers . The easy stuff, like is your pottasium back to normal? or is your BP< 130/80 or your LDL< 70 all goes to the doc.

    I

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