When my husband and I stopped watching television a few months after we were married, we often didn’t notice what had changed until we’d compare notes with friends. “I miss my old hobby,” a neighbor might complain, “but I just don’t have the time.” And yet we’d see his head just above the back of the couch, silhouetted against his big screen TV for hours. Not only did we regain our time, we also noticed our perceptions switching. My sense of self and comfort with my body improved greatly when I wasn’t bombarded by perfectly coiffed and manicured, impossibly slender beauties. And once we weren’t being told what to want, we started wanting a much simpler life.
I’ve been in my solo practice for over two years now, and the process has been very similar. A convenient side effect of designing my practice for uninsured patients is that I don’t have to deal with insurance companies, so can manage my billing and time however I see fit. Now that I’ve stepped away from the usual medical system, my perception is shifting.
Sometimes I compare notes with friends, and I hear about meaningful use (such an ironic term), efficiency bonuses, and productivity. From my patients, I hear about practices that only allow you to discuss one issue per visit or where phone calls with your provider are not allowed. But the most interesting perspective is from students. Students are flies on the walls of many medical practices, not only observing but evaluating, trying to sort out how they want to practice someday. Because I’m that feared beast, an attending, I know I won’t directly hear their honest thoughts about my practice, but their surprised questions and comments are telling:
“You take the time to get to know your patients,” I hear a lot. “And they really seem to trust you!”
“I noticed you almost never scold or lecture your patients,” one of them said. “And even when you do, it seems almost tongue-in-cheek, but they are the most compliant I’ve ever seen. Why is that?”
“You keep asking the patients ‘Is there anything else,’ just like they taught us at school,” commented another. “I’d never seen anyone actually do it.”
“Why don’t other offices use technology the way you do?” asked one. “They have computers but the computers make things worse, not better.”
“You really know your patients. I mean, you know your patients well enough to figure out what’s *really* the matter, even if it’s their marriage or their mother-in-law.”
But the most disturbing comment I hear quite often? “You seem relaxed and happy, like you enjoy what you’re doing …”
And from these students, I’m deriving a picture of the sorts of role models our current system is providing to those contemplating primary care: Doctors who are stressed and overwhelmed, trying to work faster while still convincing their patients to do what they ought, trapped with backwards technology that resists change, unable to develop the trusting long-term relationships that make what we do truly meaningful.
The students seem genuinely surprised that I am happy and that I enjoy my work. No wonder so many want to avoid the drudgery of primary care! And no wonder so many primary care physicians and nurse practitioners are burned out and looking for an escape. The majority of us went into medicine with the intention of “helping people.” The current system is causing an internal war. Help people or keep up with productivity quotas? Care about the person in front of me or care about making the office manager/ACO/insurer happy? The problem is even more acute in safety net practices where providers are facing the greatest stress. When these providers burn out, they leave gaping holes for vulnerable patients.
Perhaps the answer to a primary care shortage isn’t to try to squeeze even more out of harried PCPs. Perhaps it’s time to try the opposite: Give doctors and nurse practitioners space to practice with their ideals intact. It takes a long time to make a doctor; we need to protect such a valuable resource. In the short term, creating an environment where the remaining doctors and nurse practitioners thrive seems counterproductive. Isn’t there a shortage? Shouldn’t they work more, see more, do more? But destroying those who remain and discouraging others from entering the field just leaves us with a bigger problem in a few years.
Robin Dickinson is a family physician who practices in an ideal micropractice model.