Seven years ago, I officially became a doctor. After years of hard work, sacrifice and insecurity, I finished my residency and passed my board certification exam in internal medicine. I was a fourth generation internist in my family and was so eager to begin my career in a new city with my fiancé. My first job out of residency seemed perfect. I had a set outpatient schedule, administrative support, and great salary and benefits. I was ready to hit the ground running, managing chronic disease and promoting preventive health. What I did not realize was that the next two years at this practice would be some of the most gut-wrenching and difficult in my career, making me regret my decision to enter medicine more than once.
Going from a resident to an attending physician is a difficult transition for any doctor. You no longer have a safety net — you are it. In addition, you are learning how to manage your time, code and bill appropriately and wrestle with insurance companies. For me, the greatest struggle was my patient population. Over 50 percent of patients that walked through my door were on one or more controlled substances, mainly opioids. As an internist, I had some experience prescribing these medications to my patients in the hospital but rarely had to manage chronic pain in the outpatient setting. I had trained in New York City where specialists were abundant, and pain management doctors were largely involved. Same went for psychiatric conditions. Most patients on stimulant medication for ADHD or chronic benzodiazepine therapy for anxiety were managed by their psychiatrists.
Moving to an underserved region of a Midwestern metropolis was wildly different for two reasons. First was the culture. Most of the older primary care doctors were the main prescribers of these controlled substances for their patients. The second was that the vast majority of my patients were on Medicaid, and the few pain management doctors and psychiatrists in the area did not accept this insurance. Only a small percentage of those patients truly needed to be on controlled substances, but years of using (and abusing) these medications had left them dependent.
I was trying to build up my practice, so I struggled with wanting to take care of these patients myself and wanting to refer them out to another primary care provider. I battled with trying to determine who truly needed controlled substances and who should be weaned. I had many difficult conversations in my office, some which resulted in patients getting belligerent and storming out. I received calls from other doctors regarding doctor shopping. I received calls from pharmacies regarding tampered scripts. I became familiar with controlled-substance agreements and routine urine drug testing. I had to teach myself how to taper patients off these medications and screen them for side effects. My patient satisfaction scores suffered because I was not adequately feeding the controlled substance dependence of these patients. Worst of all, I received hate mail and threats of physical harm.
I felt betrayed by my profession as this was not what I had spent years studying for. I felt betrayed by the older primary care doctors who automatically refilled opioid prescriptions because they were too busy or indifferent. I felt betrayed by my age because I was often told I was “too young” or “too inexperienced” when I questioned patients on the necessity of these medications. I was even asked on several occasions what the point of a primary care doctor was if not to prescribe hydrocodone or Xanax.
My husband and I ended up moving to a different state, so I left that practice. I have had several jobs since that first one, and the opioid crisis has followed me through them all. However, I have gotten older, wiser and more resilient. I have also learned how to be sensitive to the needs of patients dependent on controlled substances while knowing my limits and what I am willing to manage. I have learned how not to be bullied, and for the most part, have a patient panel that understands what I will manage and what I will outsource to other specialists. I have accepted that I cannot make every patient happy and I am OK with that. I have shared my experience with other primary care doctors of my generation and have discovered that I am not alone in my sentiments. Even as the federal government and state medical boards implement programs for the opioid crisis and restrictions on prescribing controlled substances, this problem is far from being resolved. I am just one physician doing my part and doing my best.
Shaily Shah is an internal medicine physician.
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