Monday: 6:45 pm
The phone rings. Caller ID: J.
“Hey… are you on your way home?”
“Yeah. Just a few minutes out.”
“Late day at work? Everything ok?”
“I’m fine.”
“Ok… I guess I’ll see you when you get here.”
After going through pre-med, med school, residency and attending life with me, J knows the tell-tale warning: “I’m fine” almost never means I’m fine.
As I came through the door, I could smell hints of what to come for dinner and gave a sigh of relief. The last thing I wanted to do was think of what to cook up or where to go for dinner. I had actually been prepared to spoon some cottage cheese in my mouth and call it a day.
J came over and helped me shrug off my work bag and coat.
“You want to talk about it?”
“Nope.”
What more is there to say?
After complaining in real life and on the blog ad nauseum about my job, what value do I add in regurgitating and word vomiting all of it out again?
What right do I have to spread the emotional burden of the 17 people I saw that day to my husband, family and friends?
I had hoped taking my first vacation without my work computer in over a year would pull me back from the edge of burnout. Spending time reconnecting with my sister and old friends didn’t refresh my spirits enough to make me look forward to returning to work. 10 days into restocking my Joy Fund on Instagram wasn’t quite enough time.
The first day back at work still sucked just as much as the last day prior to vacation.
I kept returning to the patient encounters that derailed me, mulling them over in my mind again and again.
It started off with an apologetic look from my nurse, a familiar warning to brace myself for impact.
“Dr. M, I’m sorry… I just spent 10 minutes on the phone with P and she is VERY upset that you had me call her instead of you calling her personally. She demanded to talk to you as soon as possible.”
“What is the issue?” I asked, as I pulled up P’s chart.
“She’s the patient you had given an antibiotic eye drop to and now she’s saying she’s going blind. She wants to know why you would prescribe something that would cause this and why you didn’t tell her it could happen.”
“If she’s losing vision that quickly she needs to go the ER or eye doctor for further evaluation.”
“That’s what I told her several times, but she stated it was your problem that you needed to fix and she refused to go anywhere else.”
What to do?
I glanced at my schedule for the day – already 30 minutes behind, 3 patients waiting to be seen and a listed concern of possible blood clot. I didn’t have time for this.
“You documented that you advised her to seek care elsewhere and she declined?”
“Yes, it’s in the chart.”
“Ok.. she’s just going to have to wait until after I see my patients. If it’s a true emergency, she’ll go to the ER,” turning to head into the next room.
“Wait.. I’m so sorry, but there’s another patient who also demanded to speak with you personally. He was upset we didn’t call him about his daughter’s care and called mom instead.”
“So he just wants to complain? There isn’t a medical question he needs me to answer?”
The nurse nodded her head.
“Then he’s going to have to wait too.”
5:30 pm
I plopped down into my squeaky office chair, wrapped my plaid shawl around my shoulders in an effort to regroup before the next foray: the getting yelled at by 2 unhappy patients experience.
Call #1: P and her eye concerns
“Hello?”
“Hi, this is Dr. M…”
“DO YOU KNOW HOW LONG I’VE BEEN WAITING? It’s been TWO hours.”
“I apologize but I had scheduled patients to see. I’m here on the phone with you now though. So what are your concerns today?”
“Well, of course your incompetent nurse didn’t tell you what happened. You know, she really shouldn’t be providing any medical advice and she’s the worst at customer service…”
“I spoke with my nurse and she told me what she understood from you, but I’d like to hear it from you yourself.”
“Well I’m going blind and it’s the antibiotic drops that you gave me.”
“Can you tell me what you mean by going blind?”
“Well, it feels like there’s something in my eye and it’s blurring my vision.”
“So you haven’t lost your vision?”
“Well, no, but I still can’t see. If you had told me this was going to happen, I would never have started the drops.”
“P… I remember the discussion happening this way – it was likely a viral infection, and you were only to fill the prescription if your eyes got worse because sometimes the drops can cause irritation to an already inflamed eye. You do remember this, yes?”
“Well.. you didn’t stress that part very much. Anyway, I have a floater now.”
“Antibiotic eye drops don’t cause floaters. If you have concerns about that, then I would encourage you to see an eye doctor because they have specialized equipment and training to look at that further.”
“Fine. I guess I don’t understand why you would prescribe something that you can’t provide follow up care for. BYE.”
5:50 pm
Call #2: Upset dad
No answer. Left voicemail. Frustration extended to tomorrow.
I looked at the 7 charts I still had to close, 20 more labs to address and 30 documents left to read through.
“Well,” I said to myself, “This day has already gone to shit.. might as well try to do some damage control so it doesn’t spill into tomorrow.”
6:30 pm
As I walked out of the office building, I realized I hadn’t done my Joy Fund challenge yet. What made me happy today??
Leaving work.
How about that to force some positivity in my life?
It’s not you, it’s me…
Fortunately I have an amazing husband who plied me with dinner, tea and a candlelit bubble bath to finally get me to vent. He took a deep breath and said,
You spend your whole day thinking of the right thing to say, to help solve people’s problems that don’t exist.
Maybe primary care isn’t right for you.
I’ve always said I’m a true believer in primary care.
I believe the prevention of chronic diseases related to poor nutrition choices, lack of exercise and poor sleep quality is SO important.
But I’m finding the actual practice of primary care is not the best way to achieve this goal of prevention.
I have become someone people can blame for not finding the solutions to their first world problems.
I instead have become a punching bag for people who choose not to take charge of their own health and their own lives.
I have become an overpaid customer service representative and my job no longer necessitates the use of my medical knowledge that I trained so long and hard for.
I love medicine – the puzzle of it all, the thrill of getting to the right diagnosis, the fact that my skill set can actually help people.
But what I’m doing now is no longer medicine.
Perhaps it’s time to break up with my primary care medicine experiment.
Perhaps coming up to my edge of burnout is what I need to push me forward.
Time to put up or shut up.
***
Photo: My amazing sister D scaling the Ho Chi Minh Trail, La Jolla, San Diego.
have you thought about lifestyle medicine? that allows you to really focus in on nutrition, exercise, etc. And the people who come see you are actually motivated for lifestyle changes. Rather than looking for easy fixes to chronic disease of bad life choices.
I have looked into lifestyle medicine – I’m not sure about getting board certified in it though as I don’t know how I would be able to incorporate that into my day to day practice. I do try to incorporate nutrition, exercise, sleep, etc at my physicals, but of course, people just bring a laundry list of other concerns they want to discuss that day and we run out of time. I haven’t really been able to find any success stories of physicians practicing exclusive lifestyle medicine, but I may not be looking at the right places.
M, though I am an endocrinologist, I feel your pain, as I deal with the same sorts of issues. Where I work, PCPs are dropping like flies, moving on to Urgent Care, Hospitalist Medicine, Float Pool, or leaving for other organizations that promise to create a more hospitable practice environment.
What do these moves have in common? With the exception of the last one, they are all shift-work with little to no responsibility for chronic followup.
Another possibility is transferring to a concierge practice. Though many docs find the concept distasteful, I’ve heard from some PCPs that this model is much more sustainable for them.
Since starting at my current job 3 years ago, I’ve taken on new patients from probably 3-4 different primary care offices in the area that just closed up shop and left. Within my own practice, 2 docs have left in that same amount of time. In the Portland area, naturopaths and chiropractors are more than happy to fill that void which has been really interesting to say the least.
I am one of those docs that concierge medicine just doesn’t sit well with me and how I envisioned my type of practice to be. However, I’m starting to really bunker down and research about direct primary care. I’m still not sure if I have the gumption to take on that risk and practice that type of model, but if it means I can practice the type of medicine I envisioned myself practicing, I might have to do it out of necessity before I sell my soul to something else.
I have been enjoying your blog for a couple of weeks now, it is nice to know that the struggle is real and shared.
I unfortunately had to do just what you are talking about. While I am also a “true believer” in primary care (trained as a rural family doc), I increasingly do not believe that the American patient is. I don’t think there is any longer a true market for relationship based, longitudinal care on a large scale. I recently had to move from a rural area to the city in which my wife grew up (for multiple reasons) and rather that do suburban outpatient primary care I am driving around the High Plains doing shiftwork covering low-volume EDs and critical access hospital inpatient services and filling in for the occasional primary care clinic. My life outside of medicine has improved greatly, even though my hours of actual work are largely unchanged.
Regarding direct primary care, I actually had a couple of phone interviews with a company, Paladina Health, that does direct primary care to see if it was a model I wanted to entertain (since I could be employed and avoid the risk of starting a business before knowing whether or not I wanted to commit to it). In the end, the idea of being on phone-call 24/7 was too much to bear after just getting out from the oppression of primary care’s never ending responsibility to so many stakeholders with conflicting priorities. But at least the incentives in direct primary care align for the better.
I think one of the inherently overlooked issues of modern primary care is that as a profession we have not been trained and built care models that deal with the overwhelming about of addiction, manipulative behavior, and chemical coping that we are forced to try and manage on a regular basis. True, maybe only 10-20% of your patients are those people, but they seem occupy more than 50% of your time and visits in adult primary care, and the emotional labor of caring for people with addictive and manipulative tendencies is immense.
Also, have you read “Attending: medicine, Mindfulness and humanity?” Not my book, fyi. http://www.ronaldepstein.com/attending/ Unfortunately, my take away from that was that modern primary care seems to be designed to sabotage any attempt at mindfulness and so my way around has been move to shiftwork, at least for now. I consider it a “strategic retreat” from primary care.
No, I haven’t read the book but thank you for sharing that with me! It is now on my to-read list!
You bring up a great point about the disconnect between how we as physicians vs patients see and value primary care. I went into Med-Peds for the relationships I thought I would build with patients over time, but it seems today’s society now just wants everything immediately, relationships be damned. My care is no different than some walk-in clinic at a pharmacy, except when a bad outcome happens. This happened just last week when a patient was started on an antibiotic that she had an urticarial reaction to (this was listed in her medical record in my office, mind you), then was upset when she called my clinic up to demand I put her on another antibiotic without me having any awareness of or access to the care she received and what she was treated for – of course I refused. She actually came in just to tell me she was “firing me” for treating her “like a number”. Because all I was after was her money… not that I was concerned she could be having an anaphylactic reaction that required intervention.
Every. Damn. Week. Something like this happens.
Yes, the hoops insurance companies make us go through bring us down. But it’s also people. It was the same when I worked in retail during college and the same thing now – people are just horrible sometimes. Makes a relationship based practice a hard thing to justify, as does being on call for them 24 hours a day with DPC as you pointed out.
Still not sure what I’m going to do but I haven’t ruled anything out yet. At the very least, I still have to work another year and a half to finish paying off my student loans so I’ve got some time 🙂
Thanks for reading the comment and for reading the blog the last couple of weeks! Trust me, the struggle is very widespread – everyone in primary care I’ve had real and honest conversations with admit they’re burned out. 100 PERCENT. A little terrifying, isn’t it?
I so very much feel your pain. I’m pretty new to the field, only out of residency a couple of years, but my residency almost did me in so I came out of the gate determined to not suffer as much as I did during training. I never even started in primary care after training, despite everyone telling me I’d be great at it. I just felt like all my patients were emotional parasites. They brought all these problems to me that I couldn’t solve and then got upset with me that I couldn’t solve the issue and didn’t want to artificially medicate away their terrible life circumstances. I’m so much happier in the ED, although I feel guilty watching the PCPs in my area gradually give up and leave. But I can’t go back to the clinic. I can’t.
Your comment about patients being totally unwilling to wait really resonated with me.
Even now, in the ED where I work full time, I regularly get patients who are upset about waiting an hour to be seen. One. Hour. In the EMERGENCY DEPARTMENT.
It never seems to occur to them that perhaps I spent that hour putting someone’s face back together or trying to save a child or comforting someone after a very serious diagnosis (or desperately trying to get a few words into my charts). It just blows my mind. I want to shake them sometimes and remind them that in other countries people will walk for literally days, half dead, just to get to somewhere where they have the chance at some kind of medical care.
I don’t know where the burnout thing goes. I really don’t. It’s hard to think about. Thanks for your blog. It helps to hear what others are going through.
Thanks for reading and commenting! I, too, don’t know where I’m going with this burnout thing. Or this blog thing, for that matter. It feels like I’m burned out by everything – my job, then the blog burned me out so I had to step away for a few weeks. I tried reconnecting with friends and ironically I told my husband last weekend he had to stop making so many plans because I just couldn’t take doing something 5 out of 7 nights a week!
I think part of my issue is my type A personality – everything is 100% at all times. I’m learning to find the middle way a la Buddhism, but it is hard, especially with our profession.
We are constantly pulled into people’s extremes, especially you as you’re working in the ED. There is no time to regroup – just today I had back to back appointments for a woman’s physical where we spent much of the time talking about her stages of grief after her husband died in January (actually, the one I wrote about for being the first patient I lost as an attending), then immediately walked into the next appointment where I thought I was seeing the patient for a med follow up but ended up being a full recounting of her last month in alcoholic inpatient detox spurred on by an argument with her abusive husband.
You better believe I was emotionally spent after just those 2 encounters, and it’s worse when you’ve been taking care of these people AND their families for the last 3 years. But, the expectation is you just put it aside and run into the next patient room.
Everything is broken. People are broken. And that’s partly why we went into medicine, because we felt we could help fix things. Some things can’t be fixed. I can’t expect myself to fix every single one of my 1800 patients on my panel, especially if they don’t put an iota of effort in themselves. You can’t please 100% of your patients, whether they’ve only been waiting 5 minutes or an hour.
Protect yourself at all costs. It’s not being selfish. It doesn’t make you a bad doctor.
You deserve better than becoming involved into someone else’s collateral damage.
I have decided to leave primary care after 26 years of practice to take a position in the employee health unit at the va medical center where I have worked as an aprn. I was so mentally exhausted by all the demands placed on me by my complex patients who did not take responsibility for their own health care giving 120% to my job everyday at the expense of my own physical and psychological well being. That being said now I feel a sense of anxiety over abandoning my most needy patients who rely on me and love me. I have committed to my new position and do feel that I am going to go through with the transfer but looking for advice from those who have faced a similar situation.
Hi Karen,
I can appreciate the angst of leaving your patients – I struggled with that for 3 months til I served out the remainder of my contract in primary care and still feel it off and on even now. If you read on through my journey to my posts from Oct 2018 onward, I write a lot about that. The only advice I can give you is:
1) Your patients who truly love you will want you to do what’s best for you
2) It gets easier with time.
You can’t take care of others unless you are in a place where you can care for yourself. You choosing to create a better life for yourself is not selfish or self-indulgent, it’s NECESSARY. As someone who wallowed in the guilt for a long time, I will tell you it is possible to leave that behind (or at least most of it). It’s hard, but it’s worth it.
Best of luck to you,
M
Thank you so much for your reply. In speaking with other primary care providers who have left it seems to be a common struggle. I think we all go into primary care for our deep desire to help others and foster relationships. But after working non stop all day and leaving with still so much to attend to I think as you said necessary to make this change. I have been plagued with a multitude of minor illnesses this past year including the flu (so sick for 2 weeks with that). I know stress and sleep deprivation have played a role. My family friends and coworkers have all encouraged me to make this change. So I need to let go and start taking care of myself. Thank you for your words, they are a great help.
All I can say is I am also a PCP in family medicine and I read your blog article, it feels like I wrote it. I feel your struggles, I am quitting this December and am looking for something (anything) else to do because I am at my wits end.
I also reached my wits end last year and moved into hospitalist medicine – I pretty much document everything from about August 2018 to present day.
I’m not going to say this move was the right answer, but I did discover things about myself along the way:
1) My threshold for other people’s crap does not need to be so high
2) I can say NO and if I say no long enough, people start to respect that as a full sentence
3) Moving on is HARD but we are strong enough to do it.
Much love to you my friend, and I hope you find something else that aligns with what YOU want your life to be, not what other people dictate to you what your days look like.
Feel free to message/email me if you need some moral support! Sometimes it’s enough to know you’re not the only one who feels this way.