All medical students and residents, those with any sense of introspection anyway, wonder if we (they) should be on the front lines. We wonder if we should be meeting, examining, trying to diagnose and treat families and children when we know that an experienced clinician just around the corner or in the next room could see the patient, perform the procedure faster and with more panache than our feeble skills will allow.
I remember being a senior resident in the NICU dreading the OB board. The 24 week twins, the 26 week prolonged ruptured membranes. I did not sleep and I had a lot of diarrhea worrying about those babies getting born at night when no attending was in house. What would I want for my own child? I remember the newborn with the congenital heart defect that I was so worried about I carried down a flight of stairs without an elevator ride or an incubator to get him to the NICU, impulsive, naive, terrified and maybe a wee bit justified that the well baby nursery was not the right place for such an infant. And of course there were the newborns that I intubated with more difficulty than an experienced neonatologist. Was that unethical or part of my training? I wanted to be more confident, but realistically I could not shake the feeling that if it were my baby I would want the attending not the resident putting a breathing tube in the lungs.
Fast forward to the last six years of pediatric practice in an outpatient clinic where there are no immediate life threatening emergencies. Yet I am the attending. I am the one trusting my patients, many of the them poor some with complex medical histories to a mix of transitory people: the nurse practitioner in training, the medical student, the family practice, dental or pediatric resident. Granted I see the patient after the trainees, sometimes 45 minutes after, while a toddler cries with inexperienced hands and a mother rolls her head and sighs at yet another obstacle to the care of her child. I wonder if I am doing right by my patients. I think about my jam packed schedule due to other commitments that take me away from direct patient care. I think about my son with seizures, autism, global delay and know whole heartedly that I would never bring him to a university primary care clinic to be seen by residents and medical students with a cycle time of 2 hours for a well visit.
So I flee to the private medical office, that offers maybe more in salary, reputation, and autonomy but inferior medical, dental, and retirement benefits. I no longer take Medicaid, no poor or lower working class children. No kids that were mirror images of myself and my family growing up in the rust belt. I cannot afford to as a matter of livelihood, business expense.
I imagine that I will find a better way. I will take a student or a pediatric resident in my personal office and show them how patient care is about relationships not diagnoses knowing full well that as a 20 something student I saw pathology not people. Maybe they will be more mature than I was. Maybe they will not need to have a child with a disability to see the holes in health care that I see. Maybe they will give up that potentially lucrative fellowship for primary care or at the very least see that a single payer system for all equals social justice. Or maybe they will see that a very tired, and burned out teacher sold out to private practice because the fight was too big, too distant to matter anyway.
There are two separate systems of health care in this country that break down along class lines with poor children and their mothers often receiving less personal medical experiences. Because I am no longer serving such families, it would be hypocritical for me to advise the deep pockets of free standing children’s hospitals that can with their money and influence improve the plight of such folks. I am leaving a hospital that incentivized research, education, and administration with titles and promotions. Pushed physicians to secure grants as a way of measuring their worth and “punished” them by having them work extra hours doing direct patient care if they were not fully funded. I am leaving a hospital that believed the medical home consists of the walls of a clinic open ridiculous hours where clinical guidelines and algorithms are followed and patients are plugged into one of those instead of having access to a regular provider. A clinic where those regular primary care providers were treated as if their skill can be matched my a researcher who staffs the clinic a half day a week. A hospital that diminishes experienced clinicians who prefer direct patient care because they can find no meaningful metric to assess their value.
So I’ll bury my head in the sand as a suburban doctor and find a way to volunteer as a mother and humanitarian at the local food bank, food store or church. I will bill the 99213 or 99214 for the earache, worried well, or rash and discuss vaccines and other anticipatory guidance with families that by the very nature of their education and economic status need me very little with few exceptions. I’ll finally have continuity without bureaucracy. I’ll go home to my own family a little earlier and a little less emotionally drained.
Have I sold out? What do you think?
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