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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