As I enter the patient exam room, the first question is no longer “When can I get my COVID-19 vaccine?” but rather, “Are you leaving? My old doctor left. You are my fifth doctor in three years. What is happening?”
Nowadays, I spend more time educating patients about the visible cracks our medical system flaunts. They were present before the pandemic and will remain as it ends. In my health care system, no one can get a real person on the phone to schedule an appointment in under 30 minutes. Patients have instead become savvy, finding me via social media, messaging me for an appointment or refill through this back door channel.
We remain inundated with 25-plus patient messages daily through the electronic medical record messaging options — with no time to respond as we see patients — never chilling at our desk reading and responding to emails. There is no credit or pay for our administrative burden or enough qualified people to help us weed through it. People drop off random forms routinely and expect them to be completed without an appointment.
Regularly, a patient will pop in with a form, ask someone to find me, and have me stop seeing a patient to sign something: “But it should only take her a second.”
I am expected to be a robot.
I hop on my work treadmill at 7 a.m. and am supposed to see patients every 20 minutes back-to-back, with the occasional 20-minute hop-off break to look at my inbox or take a sip of water. Yet these breaks rarely happen because nothing is truly automated in health care. I constantly adjust throughout my day to the human nuances of a late patient, a suicidal one, or a “Just one more thing while I have you, doc” patient for whom time constraints need to be reconfigured. Imagine the strain — knowing the conveyor belt of patients still is moving, and people are waiting. If you feel rushed out of an appointment, empathize with how I feel, knowing I cannot provide the best care because of the metrics our leaders create and the impossible schedule constraints we are forced to accept.
Rest assured, primary care physicians are the most resilient of the physician groups. This is our life. We signed up for this. We are good at multitasking and love the variety and these daily challenges. At the right pace- I thrive in this and honestly love what I do. But as every fine factory worker attests, there comes a point when even the best of the best lag behind or dangerously fall off when the treadmill or belt is turned on too fast.
Burnout is not to be blamed on the health care professional. No amount of yoga or organic, plant-based smoothies in the mornings will fix this. Health care administrators like to talk about the wellness plans that they offer. I do not need a therapist to point out that the health care system is grossly flawed. I use a therapist to help me discern if I should stay in a career that does not acknowledge or support me as a passionate, highly functional family physician.
Cherished patients: do not think for a minute we do not speak up or offer solutions.
We wish to regain control of our schedules and put in breaks where we can manage our flow and efficiency and stay “on time,” but we are often met with hostility every step of the way. We are continually understaffed and do not have enough medical assistants to room you promptly. I sit ready for you while you sometimes wait in the lobby until an overworked, underpaid team member can get to you.
There are so many more forms and tablets and questionnaires to fill out. Has it improved your care? Our leaders do not understand or place a high priority on what we do as primary care physicians — they demand it is done faster at the highest possible charge to you.
Patients have increasingly begun to complain about charges, split billing, and how much things cost. I have noticed it, too, when I see my bills. Ironically, most people do not understand their medical bills or how health care providers are paid.
To oversimplify: most in primary care in a hospital-based organization use the national RVU (relative value unit) compensation model designed to standardize physician fees, assigning an RVU to the work done determined by codes billed and procedures performed. For example, a simple office visit for a sinus infection is worth just under 1 point, while a visit to manage diabetes, high blood pressure, and your recent heart attack yields 1.5 points. I get paid directly on these points (approximately $50 per point). Whether you are a new physician or an experienced one, you all get the same number of points per service. If you are a no-show for an appointment, I make no points. If you do not come in for a visit and want something done over the phone, we resist- because this is extra unbillable work, meaning no RVU points.
I cannot exist if I do not see patients as scheduled visits in the office or now virtually. More succinctly, the goal of corporate medicine is to be able to bill the insurance and be reimbursed. If we do not bill and generate codes, the RVUs cannot be counted, and we do not get paid.
Ponder this: for most of us in the primary care world, a portion of our RVU salary is also attached to your quality outcomes and satisfaction surveys.
Yep. In this pandemic, our measured metric in 2020 was colonoscopy and mammogram screening. If a certain percentage of patients in the 50+ range did not have both screens per screening protocol (when no one was doing colonoscopies or mammograms), we did not meet metrics.
Let’s be real. I lost 5 percent of my salary. Another 5 percent at my current job is impacted if you are upset about the parking ramp or my care and you drop my “popularity” ratings below a certain threshold. Crazy? No kidding.
While I wholeheartedly believe I should influence behaviors and cheerlead my patients to be successful, I do not follow you home. And sometimes, what is in your best interest is not always agreed upon. I do not prescribe unnecessary opioids to drug seekers. Yet these patient surveys are always completed before they leave the lot.
With the rise in TV shows and documentaries glamorizing health care: Have you ever wondered why you never see one about primary care? We are stereotypically not glitzy or steamy enough. And each day is so different that it would be impossible to capture clinic without making the viewers dizzy to understand the chaos we actively manage.
How are we so different? Ideally, you identify most with your primary care team. This should be your medical home, your point of care. We can take care of most things for most people outside of trauma, emergencies, surgery, or an acute illness needing hospitalization. In a picture-perfect relationship, you and I have known each other now for years. I know your health history without needing to read your chart. I know your dog’s name and remember your grandchild attending school at my alma mater. I honestly care and will answer your messages. Our visits are like a quick coffee with an old friend. We are a team and partners in the life journey. We are in it for the long haul and have a mutually satisfying long-term relationship.
Unfortunately, I was born too late to reminisce about the good ol’ days of medicine my now-retired colleagues recall fondly. I fear my teenage kids will steer clear of medicine growing up in a household where I dominate too many dinner conversations, sharing my frustrations about the business side of this job that keeps changing. I want to be part of the solution and feel I am successfully managing a huge panel of patients well. But it is seemingly never good enough.
The idealistic undertones of medical school and training always focused on medicine’s heart and the patient-physician relationship’s sanctity. This represents the core and foundation of my professional persona.
I am not sad I went into medicine, but I am deeply disturbed every time I am asked if I will stick around. Nobody wants this job. But everybody needs us.
Katie Klingberg is a family physician.