In 2009, I started a family medicine residency. This dream had been brewing since age five when I decided that I wanted to be a doctor. I followed that dream like a mouse follows cheese. Despite some obstacles in the way, I kept my eyes on the prize. I couldn’t wait to be a doctor—a PCP. I couldn’t believe that someone would call me “their” doctor. The thought thrilled me. Ten days ago, I walked out of an office, having survived the most difficult year of my life. There have been other difficult ones, but this one took the cake by a longshot.
Do you ever find yourself complaining that you always have to wait for your doctor? “They are always behind. It’s like my time isn’t valuable. Why can’t they just run on time? It’s a respect thing.”
Well, here. Let me give you a glimpse of what is going on behind closed doors in that office.
Here’s a typical primary care encounter:
The patient was scheduled for a 15-minute visit.
The first 5 to 7 minutes are spent with the medical assistant. The list of boxes to check would blow your mind. Among the things asked include tobacco, drug, alcohol, caffeine consumption, gender identity, sexual orientation, depression screening, screening for transportation issues and food insecurity, review of medications, and family history.
Now that I have 9 minutes left in my scheduled time with my patient, I can finally address the reason for the visit.
A patient who hasn’t had insurance for several years comes in with shortness of breath, persistent back pain following a back fracture during a bad car accident years ago for which she never followed up due to lack of insurance, and also chest pain with exertion.
How well do you think you would fare handling this in 9 minutes?
Now that I’ve evaluated this patient and determined that she needs further evaluation and possibly medications, the real fun begins.
I send a prescription for a prescription anti-inflammatory to help with her back pain. But the insurance doesn’t want to cover that one until you provide dates of previous trials of their “preferred” ones. And the reason why the patient can’t take that one. So, I end up sending the one they prefer this week. This changes like the weather, often without true rhyme or reason. Even if I take the time to look up the online formulary to see what the insurance prefers, this may or may not be accurate.
Perhaps I think this patient needs an MRI to further evaluate her back pain with associated neurological symptoms. Insurance will almost assuredly deny this until she completes 6-8 weeks of physical therapy. However, if I try to send her to a neurosurgeon, they will often refuse to see her without an MRI. I agree that most times, imaging is not needed right off the bat, but you get my point. I am stuck between a rock and a hard place. And the insurance company says things to the patient like “well, your doctor didn’t feel like you needed it” or “your doctor didn’t send us enough information,” thus making U.S. look like the barrier to care. Not true.
God help this patient if she needs any sort of durable medical equipment (a cane, walker, hospital bed). Several times within just the past 3 to 4 months, I had medical equipment denied because I had neglected to write one word in the office note. There are guidelines for coverage of these products, for which I had cheat sheets to follow. One patient’s hospital bed order was delayed by three weeks because instead of “requires frequent changes in position not feasible with a traditional bed,” I had written, “requires changes in position not feasible with a traditional bed.” I am not kidding.
I could go on forever about the ridiculousness that primary care has become. In a 7-hour day, I saw anywhere from 18 to 25 patients. And I panicked every single time I saw my schedule and saw that I had 3 or 4 patients waiting. It is damn near impossible to provide good and comprehensive care in the time allowed. It is much easier, when you are crunched for time, to just prescribe a pill rather than taking the extra time to explain why a pill may not be the best answer.
About 18 months ago, I saw myself fading. No longer the doctor who was excited to go to work. No longer that idealistic physician who felt able to change the world. I started having panic attacks on the way to work, anticipating the onslaught of messages and results to deal with amidst my schedule of patients. Dreading the pile of paperwork that would be waiting for me on my desk. I started feeling guilty that I couldn’t be fully present for my patients and felt that they deserved someone better; someone who wanted to be there.
I wanted out. But I had signed a contract for $50K of state loan repayment (not affiliated with my company but through our state department of health). I reached out to them about repaying the loan with my own money, so I could pursue different work. Suddenly, that $50K had morphed into $150K (thanks to penalties, accumulated interest, etc.). I was completely trapped. I somehow had to survive another year.
For six months, I seriously considered taking my own life. I could not bear the thought of feeling like I was drowning every single day at work. In medical culture, the solutions for burnout include things like yoga, meditation, “resilience training” and becoming “more efficient” so you can leave work on time and enjoy more time at home. I wanted to throat punch people every time they suggested that I try deep breathing or watching funny movies.
I am finished being quiet about this. Doctors commit suicide at twice the rate of the general public. And it is because medicine has become an assembly line where patients are not the priority. Rather, our focus is on checking boxes so we can meet the metrics determined to be important by Medicare/Medicaid. This system is broken at so many levels, so far above the reaches of individual organizations. I don’t blame either of the organizations that I worked for. I blame our system.
So, please, do me a favor. The next time you are angry about having to wait an hour for your doctor, or are mad that your CT scan wasn’t approved, give your doctor a bit of grace. Chances are, he or she may be in their office, shedding a tear, frustrated by the exact same thing.
Lauren Roth is a family physician.
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