The demise of the primary care role model

It was just like every other email I had gotten in the past.  A young student at a local university was interested in primary care, and wanted to shadow me for a month between his second and third years.  I responded swiftly.  I was delighted to bolster the interest in my specialty.  Over the years I had helped train students, residents, nurses, and nurse practitioners.  By exposing them to the office, hospital, nursing home, and hospice and palliative care, I felt I gave them a window into a nontraditional view of internal medicine.

He showed up on a Friday for clinic.  His excitement was palpable.  He jumped out of his seat, and trailed behind me from room to room.  But something was off that afternoon.  The patients were elderly and difficult.  Their problems were amorphous and complex.  I could see the fatigue and consternation after each visit, though he said little.

This is not how a student glamorizes the specialty when daydreaming about their future.  Eventually those that learn from me, however, realize this is a small part of the job.  They also experience the thrill of the diagnostic process, the humility of human interaction, and the privilege of becoming a part of your patients lives.

The student’s gaze seemed especially trained on me when I was being distracted: the cell phone call from a nursing home in the middle of a visit, or the unending overhead pages pulling me away from what I was doing.  Time and again, though, his eyes glazed over most when I was typing on the computer.  The strain of meaningful use had altered my most intimate interactions.  As my patients were bemoaning their newest symptoms, I was busy clicking, making sure to print the after visit summary and patient education.

Meaningful use has been the tipping point, the beginning of the avalanche.  I was able to keep it together before.  Now, I have become a befuddled, frazzled, ball of stress instead of cool and in control. And this student saw right through me.

It’s not that I don’t enjoy teaching.  I encourage any who want to spend some time in my office.  But the number of emails has decreased dramatically.

And like this student, those who do show up once, often decline to return again.

Jordan Grumet is an internal medicine physician and founder, CrisisMD.  He blogs at In My Humble Opinion.

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  • Nick Davis

    Last week, for the first time in my career, I recommended to an enthusiastic student that he NOT become a primary care physician. (please see above succinct and eloquent essay). My heart is still aching.

    • Anthony D

      For a medical doctor to say that. It must be a good time to seek other areas instead of other specialties besides medicine!

      • buzzkillerjsmith

        You got it.

    • buzzkillerjsmith

      The question is whom to help. If you want to help society, encourage primary care. If you want to help the student, do what you did. In any case the student will make his or her own decision and your input is unlikely to be decisive.

      I precept med students too. I try to talk about the pts we’re seeing, not the practice environment, but they know. They see it.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        I’m beginning to wonder if society can be helped by a multitude of “befuddled, frazzled, bal[s] of stress”….
        If you can’t shake off the things that render you ineffective and miserable, I don’t know that there is any point in just increasing the ranks.

        • buzzkillerjsmith

          Pretty much.

    • Guest

      I find myself telling more and more students to not go to medical school. It’s disheartening, but I can’t imagine a more painful pursuit for such little reward. Residency absolutely ruined me. No one should ever be treated so poorly.

      Private practice is deplorable. Patients are viewed as cash cows. I’ve had surgeons tell me “don’t waste too much time or energy on this one – she’s medicaid.”

      Really, medicine in the US is nearing rock bottom. Maybe we are already there?

  • Anthony D

    Doctors don’t like ObamaCare. Why?

    1. More patients, same # of doctors

    2. Doctors are overworked as it is, and they would be worked like slaves after Obamacare

    3. Socialist Medicine means that doctors are not free to make their own wages

    4. It puts the government in between the 1 on 1 relationship between the doctor and patient

    5. It raises taxes on doctors

    6. It raises taxes on medical equipment

    7. It will regulate what doctors can and cant recommend

    8. It makes the government more important than the doctor

    9. The government would be in charge of your treatment

    10. The government can decide how you are treated

    11. Death Panels

  • Anthony D

    Doctors don’t like Obamacare. Why?

    1. More patients, same # of doctors

    2. Doctors are overworked as it is, and they would be worked like slaves after Obamacare

    3. Socialist Medicine means that doctors are not free to make their own wages

    4. It puts the government in between the 1 on 1 relationship between the doctor and patient

    5. It raises taxes on doctors

    6. It raises taxes on medical equipment

    7. It will regulate what doctors can and cant recommend

    8. It makes the government more important than the doctor

    9. The government would be in charge of your treatment

    10. The government can decide how you are treated

    11. Death Panels

  • Anthony D

    A large percentage of doctors will find that they will be unable to survive financially…so many have huge loans to repay from their time in school, and with the 6-digit cost of malpractice insurance thrown in, they won’t be able to pay their bills, let alone make an income…it’s simply an extension of what’s going on now with the way medicare/medicaid programs limit what they can
    charge, making it necessary for them to depend on other patients’ ability to pay and the insurance they carry…which in turn becomes problematic because ObamaCare or any national healthcare program will severely limit those insurance payments, making it then necessary to charge even more to the patients who pay on their own…and there won’t be many, if any, of those anymore…in short, or severe doctor shortage in this country today will become even more of a problem, and a lot of
    the treatment now available simply won’t be available from truly
    qualified personnel anymore, and thus will become rationed, and of course that will make it even more difficult for doctors…Because they’ll be stretched so thin…

    In effect, what ObamaCare does is create a situation in which there will be many fewer highly qualified physicians and a tremendous amount of your medical care will be administered/prescribed by minimally trained/educate/experienced people making, for all intents and
    purposes, minimum wage…think of it this way…when you go to have something fixed on your car, you want someone working on it who has a bit more idea about your car than where to put the gas in.

  • jpsoule@hotmail.com

    As a solo internist I have opted to fore go EMR, meaningful use, accepting any Medicaid, new Medicare patients, any HMOs, but see my medicare patients without accepting assignment. (Medicare patients pay in cash and then medicare reimburses them 80% of my charge.) Things are slow, income is down, but I can practice my own way.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Hang in there… Things are bound to get better because practices like yours will become a very sought after luxury for many.
      By the way, if things are uncomfortably slow, you may want to let people know what you’re doing, and why… A nice website should help a lot when folks start looking for a physician, and with a little patience you can build it yourself for pennies, or have an enthusiastic young family member do it (don’t go spending thousands of dollars on some rip-off get-rich-quickly company specializing in websites for “medical practices”).

      • jpsoule@hotmail.com

        If you are willing to drive a Ford instead of a Mercedes and live in an average neighborhood instead of the country club, you can still be your own boss in primary care. Your kids wont go to Harvard, but they will get a proper education and work ethic they can be proud of.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          I love it! Best of luck!

          • jpsoule@hotmail.com

            Thank you MGA.
            The point is that nothing in life is free.
            You work hard to become ANY professional, be proud of that.
            One’s success or failure in life really boils down to your mind, your work and your guts.

            It ‘don’t matter’ what race/sex/religion you are.

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