“I am ashamed of the callous, avoidant goodbyes that have been made in my name, and I regret the distress caused by this widely accepted standard. The determined patients will figure it out anyway, and the less-resourceful ones are left confused, hurt, and more likely to avoid important medical care.”

Karen Dong is a family physician.

She shares her story and discusses her KevinMD article, “The missing doctors’ goodbyes.”

Did you enjoy today’s episode?

Rate and review the show so more audiences can find The Podcast by KevinMD.

Subscribe on your favorite podcast app to get notified when a new episode comes out.

Reflect and earn 1.0 AMA PRA Category 1 CME for this episode.

Also available in Category 1 CME bundles.

Powered by CMEfy – a seamless way for busy clinician learners to discover Internet Point-of-Care Learning opportunities that reward AMA PRA Category 1 Credit(s)™. Learn more at about.cmefy.com/cme-info

Do you know someone who might enjoy this episode? Share this episode with anyone who wants to hear health care stories filled with information, insight, and inspiration.

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.

Today on the show we have Karen Dong. She is a family physician. She wrote the KevinMD article “The missing doctors’ goodbyes.” Karen, welcome to the show.

Karen Dong: Hi, Kevin. Thanks so much for having me on. I’m excited to be on.

Kevin Pho: We’re getting to the article in a little bit, but first off, can you share your story and journey to where you are today?

Karen Dong: So I haven’t brought this up yet, but I’m also Canadian. I grew up in Calgary, Alberta, in western Canada, and I did my undergrad there. While I was in undergrad, my dean actually mentioned to me, he said, “You know what’s a great med school? University of Hawaii.” That’s where I went to med school. My 22-year-old self was like, “Yes, that is an excellent plan.” And so I was lucky enough to get in, and I decided I wanted to do primary care there. I ended up doing my residency and finishing my training over here in New Jersey, where we had some family on the East Coast. So I’ve been international and bicoastal and more. Now I’m in New Jersey, in the greater Philadelphia area, doing primary care and some obesity medicine, which is super exciting, and I have a pretty busy family medicine practice.

Kevin Pho: All right. So we always hear about the challenges of primary care in the United States. I’m a primary care physician myself. Tell me about some of the challenges and rewards that you experience on a daily basis.

Karen Dong: There have been so many. Just coming from Canada, there were so many mundane surprises. I remember in med school I had to go to an urgent care for some reason I don’t even recall, and the lady goes, “Your co-pay is XYZ.” And I was like, “It’s a co-pay?” Then she explained it to me, and I went, “So my insurance is paying you, and then now I have to pay you some more?” And she was like, “Yes. What don’t you understand about this?”

So I think those are some of the mundane things we probably don’t question but probably should question more. Not that an individual person has that much influence on that system, but there are just so many things that I think any family doctor can bring up off the top of their head about why the incentives are warped and why they aren’t working well.

Being on the East Coast, we are in a physician-saturated area, so I think there are lots of questions in terms of overuse or inappropriate use of health care, especially, and I have to compare it to Canada, but in general. I think about the psychology of what I’m telling people, and I really try to make things accessible. I think that’s a difficult thing, even if you’re a very experienced clinician or you’re a charismatic person: to tell people why you shouldn’t do something, why you shouldn’t look, why you shouldn’t go digging. So I try to explain to people that we don’t like to go on fishing expeditions, but I think it’s very tough for people to just accept that and be comfortable with it.

Kevin Pho: So let’s transition into the KevinMD article that you wrote. It’s titled “The missing doctors’ goodbyes.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Karen Dong: Yeah. So I was in private practice for a couple of years after I graduated residency. It was a pretty traditional, broad-spectrum practice. We rounded at the hospitals, we did some nursing home rounds, normal outpatient care, and lots of procedures. It was a long-established practice, and I had some great relationships with patients. I decided to leave to get more academic and career development opportunities than were available in a little private practice.

After I left, a certain number of patients decided to hunt me down, and it just struck me how bizarre that whole process was. I’ve since talked to lots of people who said that these restrictive covenants and non-compete, I mean, non-solicitation clauses, are variably defensible legally, but they have a chilling effect. We self-censor. So I’ve had lots of patients who have since joined my new practice who tell me, “My old doctor disappeared on me,” and they were looking for them. When they say that, I’m like, “Oh, I’m that doctor to a bunch of people.” I’ve had some people who, even two years on, have found me eventually. As an educated, internet-savvy person, I’m like, “Just Google it. It’s not a big deal.” But for some people, that is an insurmountable barrier, or they just don’t feel comfortable doing that.

And so each jump, which I think is going to be more and more common, because new medical graduates don’t necessarily expect to stay in the same practice for long, and I believe most people will switch jobs in the first five years they’re practicing, those transitions of care will be more and more common. It’s almost sad when I notice patients who tell me, “Oh, this is just the way it is. I haven’t had a stable doctor in X number of years.” That’s too bad. I wish I had a chance to say, “I’m not leaving because of a certain reason,” and give people the choice to decide if they want to see me. Some want to drive too far, miles further down the street, and some people do.

It’s just funny, because people have told me, “Oh, we heard you moved to the West Coast,” or, “We heard you had a medical issue.” People fill in the blanks in such funny ways. It’s like extended medical telephone for what people think happened to you.

Kevin Pho: So how exactly did you make that transition? For those patients or physicians who aren’t familiar with how physicians transition from one practice to another, go into detail in terms of what exactly happened with you. Did you suddenly leave? Did you tell patients you were going to leave? Was there a letter sent out to all the patients? What were some of the details of that transition?

Karen Dong: I had a fairly low-key transition. I had a great relationship with everybody at the office and the practice owner, and so I verbally told people that I was leaving, that I was staying in the area, but that I couldn’t share any more because of business, kind of anti-competitive or pro-competitive, practices. I don’t know which category to put that in. Nonetheless, I did that for maybe four months, which I think is kind of as much as you can reasonably do. I wanted to respect the people who were still there, and I didn’t want to give off the impression that I was trying to threaten their business, even though that’s probably not how people thought of it.

Not that many people came with me. It was a very established practice, and people had been there a lot longer than me. I’ve since filled up my panel completely again. But it’s not about me in particular. I don’t feel hurt that people chose or didn’t choose to continue to see me. But I think that confusion really undermines what we try to tell people about how we care about them, how we care about clear communication and transparency. And then you’re in the middle of some sort of treatment, or perhaps someone’s made some admission to you that they’ve never told anyone, and they’re not entirely comfortable with what’s happening, and then you kind of up and leave. To some extent, that’s life, of course, but I think we should probably have a more thoughtful professional stance, or professional standards, about what that’s supposed to look like.

Kevin Pho: From a primary care perspective, I see internal medicine and family practice physicians transfer practices all the time, certainly in my area. But from your perspective, what are the reasons why there is so much transition between practices?

Karen Dong: Geez, I think that’s such a mix. Like I said, there’s less of an expectation that you’re going to be in a stable practice for a long time, so I think people come out with an awareness of what the opportunities are. With the internet, and with people scattering in all directions after medical training, even more than in the past, I would guess, though I don’t know that for sure, I think people are aware of their opportunities. I think people are looking for flexibility, for lifestyle options.

Not many of my co-residents or the people that I trained with do broad-spectrum traditional family care, and the ones who do are in rural practice. So even my private practice before is becoming more unusual. I don’t do hospital rounds; I just do outpatient care now. So I think you lose some of your, I don’t want to say skills, but some of the breadth of what you can do or what you’re willing to do. But the trade-off is a better lifestyle. I have call coverage with this big pool of physicians now. I can take vacations without kind of abandoning my patients, even though they still complain when I do go away for a week.

And people know what’s out there. There are a lot of people heading toward hospitalist care and urgent care. I don’t know, I wonder if people are less attracted to this idea of having an established, long-term family medicine practice. In a big health care system, you have a lot of support services, and maybe you’re one of a fraction of people here, but I think it’s still so important to have long-term relationships, to have people that you can trust.

Kevin Pho: We’re talking to Karen Dong. She’s a family physician. She wrote the KevinMD article “The missing doctors’ goodbyes.” Karen, what are some of your take-home messages that you want to leave with the KevinMD audience?

Karen Dong: I think it’s important to take ownership of the communications you have with your patients. I am concerned with every step, from the person who answers the phone when someone leaves, to take a message, to the messages that I send out, to follow-through. It really takes a village, especially when you’re in a large health care system. The circle of accountability grows and grows and grows, to the point where someone can easily say, “Ah, there’s XYZ other teams. Someone else will take care of it.” I think we have to redesign communications so that the circle of accountability becomes like a small office, where people can do multiple tasks, cover multiple things, feel ownership of communicating with people, and do right by people. I think that’s a big question for big health care systems: how we’re going to do that.

And then, just, everyone communicate honestly, and find the right person for you. It doesn’t matter if you need to jump around. I think people are uncomfortable doing that, but we’re used to that by now as health care providers. I get patients all the time, and patients who tell me what they don’t like about me, and I’m like, “All right, noted.” So I think it’s important for patients to advocate for themselves and find themselves a place that’s comfortable for them, where they’ll get good care and trust in the care that they’re getting.

Kevin Pho: Karen, thank you so much for sharing your time and insight. Thanks again for being on the show.