The green dots on the schedule screen in my primary care office light up in rapid succession. All of my patients are arriving.
“Don’t look too hard at the board, it will just stress you more about the busy schedule,” I think to myself. Still, I note that one patient arrived early and will be waiting for a long time before he sees me. And one mom brought her newborn baby. I don’t want them to sit too long in the waiting room, particularly when we are trying to socially distance patients during Covid-19.
Another patient’s transportation home is likely to arrive before she has a chance to go to the lab. Since half of our clinic visits are telemedicine, who knows when she will come back?
The session started late. My first patient wasn’t ready for me until well after the assigned time for her physical exam, a visit that always takes longer than the allotted time because patients often come in with a multitude of concerns. Since it is even harder to get an appointment for a physical during the pandemic, I try to address all of my patients’ questions rather than making them reschedule.
I gradually fall further behind. Everyone wants to share their story. Patients have been waiting for months during the pandemic for a 20-minute in-person appointment. And all the issues and concerns that built up during the months our primary care office had canceled all non-urgent appointments come flooding out.
My patients share news of new jobs, losing jobs due to pandemic furloughs, children growing and the difficulty of remote learning, new grandchildren, and sad reality of loved ones passing from Covid-19. They have been isolated and alone for long pandemic months. But today they are out and about, talking with their doctor in person!
Hungry for social interaction, they linger more than they did in the past. They inquire about my safety during the pandemic. I have missed seeing them and am worried about them; I want to hear about them, too. But connecting to our shared humanity slows down my clinical work.
Despite my careful pre-planning for the session, surprises pop up. The pandemic is making people feel more anxious and depressed, so we take the time to refer some to behavioral health. For patients who are out of work and struggling financially, we connect them with our community health worker. Some have used the Family and Medical Leave Act to care for loved ones with Covid-19, so we fill out paperwork. Pre-pandemic referrals to specialists have expired, so new ones are placed.
So many clicks of the mouse as I navigate through the electronic medical record; so many ticks of the clock as I run past each allotment of time per appointment.
I try to use each moment to the fullest, maximizing my efficiency — the e-word health care providers dread. The patient is changing back into their clothes — I am charting. The computer is warming up — I am establishing rapport and gathering the patient’s history. A letter is printing — I am reviewing with the patient how to take a new medication. I feel like the Looney Toons’ Road Runner. Meep meep.
During the day, I get a text from my at-home daughter who is doing remote schooling. Later, my daughter at college calls me via FaceTime. Both times my mind flashes to the worst-case scenario. I can’t help it — I worry: Is my daughter at home having trouble with our internet? Is my daughter at college calling because she has been exposed to or tested positive for Covid-19? So I text back or answer the call, just in case.
As I pass exam rooms where my patients wait, I peek in through my smudged face shield, flash my biggest smile under my mask, and cheerfully say my mantra, “I’ll be right with you. Thank you for waiting.” They reply compassionately, “You’re busy today, doc!” “Always,” I respond.
“You don’t even know,” I think.
A medical assistant asks me, “How much longer until you get to room 13?” This question means that a patient is frustrated with waiting. “Five minutes,” I chirp calmly. Inside I’m am tense and anxious, working hard to avoid losing it.
I have felt emotionally depleted during the pandemic. The work of the initial surge took so much out of me. My mask suffocates me. My face shield makes my head hurt. I am perpetually moving, constantly talking, always hand sanitizing, plowing forward. The adrenaline coursing through my veins leaves me breathless and my heart races. It feels like aerobic exercise, but without the endorphin high.
I make my way through the session. I sneak a glance at how many green dots remain, and compare them to the time. I quickly calculate how late I’ll be for the in-person work meeting scheduled for soon after the session is supposed to end.
After seeing my final patient of the morning, I can relax, not to mention pee, eat, and drink. In the privacy of my tiny office, it feels so good to take off my face shield and mask. But the race isn’t over. Now I need to complete my notes, order labs, and manage paperwork, as well as answer my messages. During the pandemic, patients ask their questions with new urgency. Everything is top priority. Clinicians like me are working more on our “off time” to meet these needs. This increased responsiveness comes at a cost to our well-being.
As I multitask — shoving down lunch, managing the post-session chores — I reflect on the session. Did I provide excellent care to my patients today? Did I miss anything? Did I rush and confuse someone? Are they complaining to friends or family right now that their doctor did not listen to them?
I feel like I am in a perpetual race. Every work day I show up to the starting gate, wishing for this day’s race to be different. A leisurely stroll, perhaps, where I could gaze at the scenery, pace myself to be in sync with each patient, take time for my bodily needs, not keep anyone waiting, and not disappoint anyone.
In the race of the primary care session, there is no finish line, there are no medals, and there are certainly no T-shirts for the first 500 entrants. The evidence concurs: Health care providers are burned out, spend too much time on administrative tasks, and work too much — and that was before the pandemic. Covid-19 has made it worse.
I worry about my mental and emotional health, and that of my colleagues.
Still, primary care providers show up every day, hoping something systemic will shift to make that day different.
Pamela Adelstein works as a family physician at the Codman Square Health Center in Dorchester, Mass.
I almost feel like I could have written this essay myself, as it sounds so so so similar to my experience as a family physician.
About the only difference from this description and my own was the description of at least having a tiny private office in which to escape a bit. In my case, and in the case of so many colleagues, the traditional office has now been replaced with a cubicle, surrounded by noisy coworkers including other physicians, nurse practitioners, physician assistants, nurses, medical assistants, etc. Lot’s of chatter and noise to distract one’s attention and make it difficult to focus. HIPAA mandated privacy is a joke when your hearing impaired colleague can be heard talking loudly on the phone to their patient from across the room. When you are in the cubicle, nobody, and I mean nobody, seems able to respect boundaries either. If I’m in the middle of reading a patient report, or trying to complete notes, etc., and some back office administrative person has some bureaucratic task that they wish for me to address, there is no closed office door to hinder them. With a cubicle, they just walk right up and shove their item in your face and demand you address it right now. Usually, this means I have to log out of the patient chart I’m in the middle of, and log into the chart of whatever patient their task involves in order to give them the answer they want. Then, once they are out of my face, I can think “Okay now, what was it I working on again prior to that interruption?” If I’m lucky enough to remember, I can then log back into the original chart and try to review whatever it was I was working on previously and hopefully finish that task before the next administrative person forces themselves upon me with their bureaucratic task. This dynamic happens literally a hundred or more times a day.
Ultimately, the only time I can really get any of my own bureaucratic work done (finishing patient notes, filling out FMLA forms, reviewing and signing home-health orders, etc.) is after hours when the clinic is closed and the only people in the building are me and the cleaning crew. Not at all unusual to be stuck in my cubicle until 10 or 11 pm. Then rush home, woof down a cold supper lovingly prepared by my spouse several hours earlier, and go to bed to try and get a few hours of sleep before being back in my cubicle again at 8am.
Try to address any of the above issues to the clinic administrative leadership, and basically just get a bunch of platitudes and non-answers. Try to exert some control on your own, such as suggesting to the admin person shoving their task in your face in the middle of the day that they can perhaps drop their form in your in-box and you’ll address it later, and they immediately get offended/annoyed and complain to the aforementioned clinic admin leadership who then have a meeting with you to put you in your place.
This is just a small slice of the crap-show that practicing primary care medicine has increasingly become as the system has been taken over by corporate and government bureaucrats.
I went to medical school to be a physician, so that I could help my patients. Now however, physicians, particularly in primary care specialties, have mostly been demoted to “Providers” who spend the majority of their time staring at computer screens clicking away on boxes in inefficient electronic medical records systems, systems not actually designed to enhance patient care, but rather to satisfy the myriad of meaningless bureaucratic dictates put forth by politicians, and corporate and government bureaucratic overlords.
All sorts of folks who aren’t physicians have all these ideas and answers to the problem of physician “burnout”, but frankly that word is offensive. It implies that the source of the dysfunction is with the physician. He/she is “burnt out” like a faulty light bulb. Yep, we need to unscrew that “burnt out provider” and replace him/her with a new one. Don’t bother to address the systemic mess that is causing all these bulbs to burn out. Just label folks as burnt out and suggest they meditate or some other horse crap to help them achieve wellness. Meanwhile, keep cranking up the speed on the hamster wheel you’ve shoved them into and tell them they need to run faster.
I know I’m ranting here, but honestly, I’m barely scratching the surface.
Sadly, I feel pretty confident that things will overall get a lot worse before they ever get better systemically.
There are real world reasons so many doctors are “burnt out”, but nobody in charge wants to truly acknowledge and address those reasons. Instead, they just slap on a burnout label, and crank up the assembly line medicine machine to keep the gravy train of profits rolling in to their coffers.
So many doctors are dropping out of mainstream primary care medicine for a reason. The rapidly growing Direct Primary Care (DPC) movement is just one avenue many are taking, but as DPC threatens the status quo, there are many forces in government and the corporate world who wish to co-opt it and/or destroy it.
Anyway, I’m sure some smug person, who has never actually practiced medicine, will probably chime in here and tell my how wrong I am, tell me how all these problems are due to my own lack of vision or efficiency or whatever, tell me how it can all be solved by just implementing their solutions, etc. Believe it or not, I’ve heard it all before. I’m not some outlier here. The experiences of Dr. Adelstein and myself are typical. They are the same experiences of thousands upon thousands of our colleagues across the country. I’m certainly open to hearing from experts in practice management, etc. Unfortunately, the solutions they shove down our throats, all of which look great in theory (such as the idea that cubicles are the way to go…yipee!), oftentimes just make things worse. I’m not arrogant enough to think I’m always the smartest person in the room, but guess what. As a physician, I’m probably also not always the stupidest person in the room. I can’t even begin to count the number of times that I’ve been treated like the stupidest person however.
Wanna know who is arrogant? Look to all the folks who have deemed themselves most qualified to run our healthcare system and have been running it (into the ground) for the past several decades. It mostly ain’t physicians. How many politicians dictating various healthcare laws and regulations are practicing physicians? How many Government bureaucrats in the world of health care administration enforcing these mandates are practicing physicians? How many Insurance company executives are practicing physicians? How many hospital CEOs are practicing physicians? The answer to these questions isn’t “zero”, but it’s pretty damn close to zero. No, physicians are largely not the ones who have created this mess, nor are they the ones continuing to create more mess. Instead they are the ones who are becoming increasingly “burnt out” to the point of ever increasing rates of suicide and other mental and physical health issues. All of which ultimately have an adverse effect on the care they try to provide to their patients in this very very very broken and dysfunction health care system.
And just to be clear, I’m writing from my personal perspective as a physician, but that should not be misinterpreted. I have nothing but the utmost of respect for all the non-physician folks, who also struggle with these issues in our broken system. If you are a nurse, or medical assistant, or nurse practitioner, or physician assistant, or nurse’s aid, or physical therapist, or radiology technician, social worker, or whatever other occupation in the healthcare world, and you show up every day to work hard on the behalf of patients, my hat is off to you. Thank you for all you do. I mean that sincerely. Thank God for you all!
We all, all of us, healthcare workers of all stripes, patients, ancillary staff, our families, etc….we ALL deserve better!
While I sincerely appreciate all the personable effort and input by this clearly caring Doctor, I do dare to suggest some adaptations. Get a nurse to take a pre-exam (notes, grievances, referrals, vitals, etc). Tell the patient that you care but that patient is one of many you need to help today. Get your staff to schedule problem-patients (and full physicals) at the end of the day – so you might not run behind right away. Have your patients wait in their cars, call them in (for a short or no wait to the exam room). Etc etc. Your office / clinic might need such well-orchestrated efficient management (it’s what I did for many years).
Great ideas – we aren’t able to implement them at this time due to staffing shortages. Also in the often chaotic environment of an FQHC, such momentum is hard to sustain
Thank you. A well written accurate description of a day in primary care. I’m asking myself how long this is sustainable. There has to be a better way.
Thank you for your hard work. You are keeping people alive and hopeful.
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