Primary care: the variety and the intimacy of the problems I see [PODCAST]

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“Fifteen minutes for a checkup or urgent problem, thirty minutes for a physical. In the tiny gasps of time in between: Refilling scripts, checking labs, and signing medical supply orders and insurance authorization requests. Maybe lunch. Maybe a chance to get to the restroom if I am lucky. Clicking, always clicking away on my EMR, hoping to finish my notes. Maybe typing notes while holding on a phone call (why do patients call with a question about a medicine, but they leave the vial upstairs and have to retrieve it while you wait?), while trying to cram a few bites of lunch, while wondering if I will get out of there in time to get the blasted Valentine’s napkins before picking up the kids from their after-school program.

I take a deep breath.”

Melissa Schiffman is an internal medicine physician. She shares her story and discusses her KevinMD article, “Primary care: I love the variety and the intimacy of the problems that are placed before me.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Melissa Schiffman. She is an internal medicine physician, and she wrote the KevinMD article “Primary care: I love the variety and the intimacy of the problems that are placed before me.” That’s a story from the book Becoming Doctors 25 Years Later: 25 Physicians Sharing Their Journey From Medical Student to Retirement. Melissa, welcome to the show.

Melissa Schiffman: Hi, thank you for having me.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Melissa Schiffman: So today, I am a primary care internist outside of Philadelphia. I see mostly geriatric patients. I did my training at Emory University in Atlanta, and then at the University of Pennsylvania for residency.

Kevin Pho: Wonderful. And I’m an internal medicine primary care physician myself, so I’m certainly looking forward to speaking about the virtues of primary care. Now, in your practice, you said that you see primarily geriatric patients. So tell me what some of the challenges and rewards of your practice are.

Melissa Schiffman: So I’m relatively new to this field, and to be honest, I chose this job mostly for work-life balance, which is important, but I’ve really come to enjoy the geriatric patients. I think one of the challenges is just that so many people come to our practice and say they feel like they weren’t listened to, that they were not taken seriously after being a certain age. I think there is a lot of age discrimination, and it really is a joy and a pleasure to develop relationships with these patients and to see their value and the value of the lives that they’re living.

Kevin Pho: So give us a sense of the types of patients that you see. What do they come to see you with? Give us a case study of some typical patients that you would see on a typical day.

Melissa Schiffman: So I mean, it could be anything, and that’s what is so fun about primary care. It could be a little thing; it could be a big thing. A lot of times, we do get a lot of patients that are new to Medicare and may not have had a physician for years or had any health insurance for years. So it’s not uncommon that a new patient visit turns out to be a pretty dire diagnosis or something that’s been ignored, which is always really gratifying, to be able to help patients that have been waiting for so many years to get their heart condition treated or their emphysema under control.

Or it could just be the little day-to-day: “I’m stressed,” “I’m lonely,” “I have a cold.” So many of the conditions of geriatrics are embarrassing for patients to talk about, the incontinence, the memory issues, and I think it’s so important for them to have a safe space to feel heard and to be able to connect with someone about those challenges.

Kevin Pho: Give us a sense of the clinician access when it comes to geriatric care in your area. Is there a shortage, and/or how difficult is it for a geriatric patient to see primary care?

Melissa Schiffman: I think there’s a shortage. It’s pretty incredible that we’re in Philadelphia, which has such a wealth of medical services, but it’s very difficult to find a primary care practice that is taking new patients. A lot of our local practices, the local independent practices, have closed. I think a lot of physicians have retired over the COVID year, so we do have a lot of patients that come to us saying that their doctor that they had a long relationship with is no longer practicing, and they’ve had a hard time finding someone.

Kevin Pho: Are you seeing new physicians or newly graduated residents go into your field?

Melissa Schiffman: I think it’s a challenge. I love primary care, but I think there also are so many unfortunate downsides to the logistics of primary care these days that I do think there are not enough providers going into it. I am learning, in recent years, to work more with nurse practitioners and other team members to help extend our care, and I think that is going to be really important going forward.

Kevin Pho: All right, let’s talk about the KevinMD article that you wrote. It’s titled “Primary care: I love the variety and the intimacy of the problems that are placed before me,” and that’s from the book Becoming Doctors 25 Years Later: 25 Physicians Sharing the Journey From Medical Student to Retirement. So for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Melissa Schiffman: So 25-plus years ago, I was published in the original anthology, Becoming Doctors, where medical students all over the country submitted stories and essays and artwork about being a medical student. I submitted a very whimsical story about a cadaver in anatomy lab that turned out to be a vampire.

When I was invited to write a 25-year update, I was not going to write about vampires anymore, but I was inspired to think about corpse pose in yoga, and just that moment of the day where you’re kind of getting your energy together, getting ready to face your day and all of the things you need to do, whether it’s in the clinic, with your family. I really just wanted to provide a slice of life of what goes on in someone’s mind as they’re getting ready for their day.

Kevin Pho: One of the common themes on this podcast, on my blog, of course, is clinician burnout, and I’m sure that everyone here is familiar with the numbers, of almost 50 percent of physicians saying that they are burned out. Now, tell me about some of the rewards of your profession. I always want to take a more positive slant when it comes to primary care. Tell me about some of the rewards of primary care. What drives you, and what brings you to work every day?

Melissa Schiffman: I really think the best thing is the stories of the patients, and writing this story reminded me of that. I used to write creatively as a college student and medical student, and I think one of the things that drew me to primary care was the access to patient stories and the layers of getting to know them through the years. I think it really is such a rewarding relationship on both sides.

I’ll tell my patients just something off the top of my head, “Oh, you know, my son’s learning to ride a bike,” and they’ll come back six months later and say, “Hey, did your son learn to ride the bike?” I think it really is just a privilege to be a part of their mental space, and I certainly have many patients that are just an important part of my mental head space as well.

Kevin Pho: One of the things that you mentioned earlier about why you went into the field was work-life balance. So talk more about that.

Melissa Schiffman: It’s a challenge for all of us. There’s never enough time in the day, and even parents who don’t work outside the home don’t have enough time in the day. Plus, you’re adding a whole other job to that. I think it’s definitely doable and rewarding, but you’re going to do things a little differently than a parent who does not have another job outside of the home.

Kevin Pho: So talk about some of those challenges that you’re describing, and how did you overcome them?

Melissa Schiffman: First of all, I think if you’re fortunate to have a partner, pick a good one who’s going to partner with you. I’m fortunate to have a husband who is very involved with the day-to-day workings of the family. I think it’s important to have whatever supports you need, whether it’s, in my case, before- or after-school care, whether it’s a cleaning service, whether it’s just saying you’re not going to be able to do everything.

Think about what’s important to you. I think a lot of times, we get wrapped up in doing things because we think we need to do them, making the perfect cupcakes for school or attending every single event. I think it’s really important to soul-search and think, what’s important to you and your family? Don’t worry about who’s judging you, and do the things that are going to be meaningful, and don’t do the things that aren’t meaningful to you.

Kevin Pho: One of the things that I also think contributes to the success of primary care, and its rewards, is the practice itself: whether it’s properly supported, whether administration is on the side of the physician. So talk about your practice, about how it has contributed to your joy of primary care.

Melissa Schiffman: It’s interesting, because I actually had changed practices between writing the story and the time it was published. So the new practice I’m in definitely has more supports, as far as nurse backup, as far as structure for things like answering phone calls and refilling medicines and things like that.

I think one thing: As primary care doctors, we’re often kind of like the final dumping grounds of stuff no one else wants to do. So, “I can’t get in touch with my eye doctor. Can you fill my glaucoma drops?” “Can you write my return-to-work note for the shoulder surgery I had?” And you want to help. I think most of us go into this because we care about our patients and we want to help them, but it’s just not sustainable to do everything for everyone else.

So it’s important to be able to ask for help where you have it. And I really wish, as a system as a whole, there was more of an integrated way for all of us to work together as a team, instead of the specialists kind of pushing and pulling with the primary care: “No, you do this.” “No, you do this.”

Kevin Pho: We’re talking to Melissa Schiffman. She is an internal medicine physician, and she wrote the KevinMD article “Primary care: I love the variety and the intimacy of the problems that are placed before me.” Melissa, if you were talking hypothetically to a group of medical students, and you wanted to tell them about primary care and why they should go into it, what would you tell them?

Melissa Schiffman: I just think, again, it’s about the patients. It’s about the longitudinality of it, getting to know people over time. At this point, I’ve been in clinical practice for over 20 years, and I have patients that I’ve known for most of that time. Many of them have followed me to my new practice, and there really just is such a special bond and relationship and ability to help people.

It’s very different if you go to an urgent care and get an antibiotic for your bladder infection, as opposed to coming to a physician that you’ve known for five or 10 years and can really just catch up on so many things in that visit. So I really believe that it’s important and an essential part of our medical system.

Kevin Pho: If you were to do this journey all over again, is there anything that you would do differently?

Melissa Schiffman: I think it’s just important to take time to reflect and think about where you are and what you want. Writing the story gave me a chance to step back and see where things were. I don’t know that I would have done things differently, but I think it’s easy to get caught up in the day-to-day. So take time to think about why you’re doing it, to appreciate the rewards of the career you’ve chosen.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Melissa Schiffman: My take-home message is: Breathe. Take a pause, enjoy where you are, and really feel good about the benefits you have for patients’ lives. I think what we do as primary care physicians is so important. So give yourself a pat on the back, and enjoy it also.

Kevin Pho: Thank you so much for sharing your time and insight, and thanks again for being on the show.

Melissa Schiffman: Thank you very much.

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