I entered the room to see a face that I recognized. As soon as I looked at my chart, I immediately knew this patient. I saved their life last year. I know this because the patient told me so.
The teachers and mentors that I was privileged to learn from and train with 25 years ago emphasized the essential principle of osteopathic medicine — we make physical contact with our patients. Some of this is in the form of manual medicine skills to help balance the musculoskeletal, respiratory, lymphatic and digestive systems, and some of this contact is in the form of a thorough, focused physical exam. Some of the contact occurs with a needle.
I saved this patient’s life because when he complained of a “cold,” I took the time to visually look at the symmetry of his face and noticed a mass in his neck. When I queried the patient about this mass the patient said that they had been to their primary care physician a few weeks before and nothing had been said about it. Nodding my head in a gesture of understanding, I continued with a standard survey of the patient’s eyes, ears, nose and pharynx. I then moved to their neck and palpated the quail-egg sized mass that was creating the distorted symmetry that I had observed.
This same patient now sat before me having survived the lymphoma that I identified and asked me if they could have their ears flushed out.
As an urgent-care physician, removing cerumen impactions is sort of a bread-and-butter procedure. I informed the patient that we would be glad help. The patient then informed me that they had been to their primary care doctor earlier in the day. When confronted with the patient’s request for help with impacted ear wax, the primary care physician told the patient to go to the urgent care.
I shook my head “metaphorically” (so as not to convey to the patient my dismay with his primary care physician’s referral), but before I could continue my exam the patient then asked me, “Doctor, can you give me my allergy shots?”
When I was in Iraq, medicine was liberating. We did what needed to be done to care for patients. The U.S. military has an equivalent of civilian EHR disasters known as Armed Forces Health Longitudinal Technology Application (AHLTA). But we didn’t serve AHLTA in Iraq. We served our patients. Now, as a civilian, I serve a disastrous EHR but without the rank and freedom that I had 8,000 miles from here to just get things done.
I asked the patient about their primary care doctor, and the patient explained that they had tried one but, because of advanced age and frailty, the patient and their spouse could not get across the parking lot and to the upper floors of the building to see the physician. So, they changed physicians. They changed to a physician who couldn’t irrigate ears and who also said that they would not help the patient with their allergy shots.
Allergy shots are not a terribly complex thing to administer. Yes, there can be reactions, but these can be mitigated with some simple drugs and anticipation. So when confronted by an elderly patient who had received such shots for years without complications and who was now suffering from latent effects of not having had those shots for several weeks, I felt compelled to move on the issue.
I got nowhere.
I queried my corporate managers, and I was told that we don’t do allergy shots in the urgent care.
We do a lot of things in the urgent care. We are also the dumping ground for every physician’s front office that decides their own patients are too inconvenient for them to work in; for overworked ER staff who send us “healthy-looking” people who have actual ER problems; for walk-ins too tired of trying to get through “Press 1. Press 4. Press 6” to get into their own physician; and for those who conflate “emergency” with “urgent” thinking that they will wait 6 fewer hours to get their dyspnea treated by coming to us instead of the ER. We even contribute to the estimated 47 million unnecessary antibiotic prescriptions handed out every year in the USA.
But for eosinophil-congested, histamine-laden, runny-nose patients well into their third quarter-century of life, cane-dependent and stamina-sapped to the point that they cannot cross a parking lot, we do not do allergy shots.
I can save lives in Iraq.
Here, I work in a system where I cannot give relief to a gentle, cancer-surviving old person when their own physician won’t.
As a medical documentarian, I have interviewed many experts on the topic of burnout. I admit that I am in that category. I have blamed administrators, overzealous colleagues, the creators (obviously not practicing physicians) of god-awful EHRs and feckless politicians who play politics with an imploding ACA.
But the problem is me.
The problem is any physician who forgets that they are licensed to practice medicine. Most of the other trappings of contemporary American “health” care are just “pretty ornaments” that only serve to make care more expensive and prevent us from meeting patient needs. Only direct caregivers work in the Haitian hospital where I volunteer and yet, efficient, low-cost, good (not international-departure-lounge fancy) care is delivered.
I once treated a gunshot wound on a roadside in Iraq in Teva sandals, Army physical fitness shorts and the T-shirt of my undergraduate college. I cared for my patient without needing a single MBA.
I am the one with the license. I am the one with the NPI number. The only individuals absolutely necessary for most successful medicine encounters to occur, including allergy shots, are a patient and their physician.
This weekend, the timer on my life as an emotionally-thrashed and burned-out minion of the system started counting down. I’m making some changes. They include getting back to actually doing medicine, taking a vacation, not clicking boxes and — giving allergy shots.
Todd Fredricks is a family physician.
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