“I need to figure out what I’m going to wear. Are grey pants with a black blazer too different?”
J looked at the outfit I had assembled on a hanger, confused.
“It looks like a suit. Why would that be too different?”
Images of hordes of medical students in the same black suit being shuttled down the hall for residency interviews came to mind. The advice given to me in my 4th year of med school rang out:
“Don’t let the thing they remember about you be what you’re wearing! Black suits, white shirt for everyone! Pearls for the ladies and power ties for the guys.”
But that was 8 years ago. Certainly it was time for the modern female attending physician to be able to wear a non-traditional suit, right?
Besides, I had donated most of my suits away. Because #minimalism.
Because you didn’t expect to be interviewing again so soon, M.
Declining to respond to J and my inner monologue, I decided to try on the non-matching suit.
Catching a glimpse in the mirror, I saw the saddest brown eyes staring back at me.
Get a grip, M. You’re going to an interview, not a frickin’ funeral! You’re supposed to be excited.
“You look good! Very 2018,” J glibbed.
“Oh yeah, thanks. Grey and black. How bold. Thanks for the input.”
As I smoothed out my shirt underneath the lapelless blazer, I thought to myself,
Definitely not a funeral outfit. You’ve got an off-white shirt on.
It was a funeral of sorts though… to the death of my primary care career.
Choosing the outfit was like throwing the first clod of dirt onto the casket.
DEAD, DEAD, DEAD
Once upon a time, there was a young medical student.
In the first 2 weeks, she enthusiastically bought up all the med school paraphernalia – the mug, the travel mug (because you can never have too much coffee), the Class of 2011 sweatshirt, and her personal favourite – the AMWA t-shirt that read,
“Be the doctor your mother always wanted you to marry”.
She wore her ID badge, oversized scrubs and stethoscope proudly, almost inviting people to ask what she did. She even had a pre-meditated response for people who asked if she was a nurse:
“Thank you for the compliment. But I’m in med school, training to be a doctor.”
She was so excited to drink medical knowledge straight from the fire hydrant because one day, it meant she was going to “save” someone. She didn’t mind that it ripped off half her face, leaving a gaping hole that would never be filled.
She had lofty dreams of how she was going to save the world through preventive medicine. Instead of prescribing statins and insulin, she would be the doctor who’d say, “Diet and exercise for everyone!” Because if she said it with an M.D. behind her name, people would have to listen.
Med school was hard but worth it if it meant she’d be able to make her dream a reality: To work in the trenches of primary care and effect change before disease could take hold. The problem with medicine, in her mind, was there was so much focus on treating disease when it should be on prevention, especially with chronic disease accounting for the majority of healthcare expenditures in the U.S.
It was so simple back then.
Entering Med/Peds residency, she found herself caught between two worlds, never belonging to either.
Almost immediately, she came to realize Internal Medicine was the furthest thing from practicing preventive medicine. She learned to define patients by their 25+ long problem lists and how to solve them, casting aside the actual person in front of her because the list didn’t have room for their own personal goals or interests.
Going to morning report and Grand Rounds became hour long exercises of mental masturbation in which she’d watch attendings and more vocal residents clamor over each other to debate who was the most correct in their diagnostic prowess. In the meantime, she would wonder if anyone in the room had deemed it necessary to tell the patient how dire their situation was.
Returning to Pediatric medicine every 3-4 months reduced the problem lists significantly, but in rushed the social nightmares. After 3 consecutive months of Pediatric Hematology/Oncology (cancer), Pediatric ICU and working on the child abuse team, the veil of optimism had been shredded to ruins with each inflicted trauma on these innocent children.
Each central line placed, each end of life discussion, each conversation witnessed starting with, “Show me on the doll where you were touched,” left jagged scars that took an eternity to heal.
She would no longer accept the phrase,
“Things happen for a reason. It’ll all work out in the end.”
She realized the lowest depths of depravity were walking around in normal street clothes – she just hadn’t been willing to see it.
Now she saw it everywhere.
But, if this was the cost of being able to realize her dream to help others, she still deemed the training worthwhile.
“After residency”, she told herself, “it will all be better.”
She would walk along with her patients on their journey from birth to grave. She would not flinch from the ugliness of life – she had already been face to face with it, personally and professionally. She would see the person attached to the problem list. She would recognize their humanity and speak to it.
This was the doctor she would be.
WELCOME TO THE REAL WORLD
After only 3 years of getting settled into her “dream” job, she found it increasingly difficult to address people’s humanity in 15 minute increments, running from room to room chronically 20 minutes late. There was no time to personally debrief after counseling her pre-teen patient about her cutting behaviour, jumping into the next appointment to tell a patient she had breast cancer, then holding a widow’s hand while being told how difficult the last 7 months have been after her husband died.
And those were the good moments.
The system into which she was thrusted threw up obstacles to providing the care she wanted to give to patients.
The electronic medical record demanded more eye contact during visits than she could make with her patients. Prior authorizations for medications, labs and imaging galore came in to interrupt her work day. Instead of drowning in paperwork, she decided to start playing the games insurance set up – not because it was the best way to practice medicine, but because it was the only way she was allowed.
Compromise after compromise started to pull at her integrity – the loose string started unraveling the doctor she wanted to be. But the system, she could deal with.
The patients, on the other hand, unexpectedly started to turn on her.
In the age of Dr. Google and Dr. Oz, she realized she spent more time defending her recommendations than actually promoting health. The knowledge that took 8 years to acquire was disregarded in an instant. The majority of the time, patients wanted a PEZ dispenser – antibiotics, narcotics, diet pills or labs based on some Pinterest article that was going viral on the internet. When she didn’t acquiesce, she wasn’t prepared for the onslaught of insults that came barreling her way.
She found she could not provide any quick fixes that would undo 10 to 20 years of unhealthy habits, and certainly not in a 15 minute discussion.
She was accused of not taking patients’ concerns seriously and of not caring. Again and again and again. For 3 years.
All of this, everything, I did so I could help you! Could you not see I did this for you?!, she wanted to scream at them.
Instead, she took it in silence and plotted her escape.
WAS THIS JOURNEY WORTH THE COST?
These last 11 months, I’ve been telling my story of burnout, but I suppose I should rename it Death of a Primary Care Physician’s Career.
I’m letting go of the person, the doctor, I wanted to be.
Ironically, she is the person who dug this 6 foot hole for me, and now I’m laying her in it after 3 long years.
I’m no Mother Theresa. I’m not a limitless well of compassion and empathy. I’m not a martyr.
I wasn’t meant to be this shining beacon of hope, optimism and wellness – to even have thought of myself in this way seems so silly and childish now. I see all the joyful excitement of medical students and residents on Instagram and can only shake my head with regret and bittersweet nostalgia.
Some day, it will be their turn too.
I am joining the mass exodus of primary care doctors going into other arenas of medicine: administrative non-clinical work, shift work such as hospitalist/urgent care, utilization reviews for insurance, pharma and consulting.
I, for one, am heading into the hospitalist track to see if I can still practice medicine and help people, but save my mind and soul from being sucked into a black hole. Because the medical machine will take it from you until you have nothing left to give, to the tune of 400 doctors per year on average, for those keeping track.
During my last camping trip, I laid back in my hammock struck by how high the trees towered over me. Watching the trees sway back and forth with the breeze, I noticed the broken limbs on the lower trunks with remnants of fallen branches scattered across the forest floor.
How sad to be discarded once there’s no more use for you, I thought to myself.
Returning my gaze upward, the leaves in the forest canopy continued flickering in the wind.
If the tree had concerned itself with keeping what was no longer useful, would it still have survived?
It paid no mind to the fallen branches – it just kept reaching for the sun.
I’d like to believe I’m just reaching higher, but I wonder – did the tree feel the loss of each broken limb?
Does the canopy look down on the pieces of its rotting carcass and mourn?
Get a grip, M.
It’s just a tree.
And this is just life.
Congratulations – this makes you officially an adult.
***
For Act Two of Three, click HERE
***
Photo taken at The Gifford Pinchot National Forest.
Beautifully written, as always. Good luck with the new gig. I know you will be great, and I hope you find it to be fulfilling. If it does not work, don’t be afraid to keep trying new things until you find the right fit.
*And it did not matter what color suit you wore.
Hah.. I appreciate the post script! I was likely displacing my anxiety about the whole situation and fixating on the outfit – hindsight is 20/20.
I’m hoping the new gig will be a good fit as I try to be intentional with my choices, but I thought I was doing that with my choice to go into primary care. Lesson learned – at least I know I can utilize the pain to move me forward.
Or at least write about it and make others feel bad with me 😉
Thank you for the kind comment as always, VBMD.
I saw your article as a forward, I don’t follow blogs etc.
As a Family Medicine doc thirty years in practice, I have so much to say. But first and foremost, I find it all sad that your reaction was as it was. I have found the opposite, life keeps getting better, the technology is making my life easier and my time with patients just gets better and better.
Obviously, this is not the space to continue and besides I have patients to see but I believe to my core that there is a way to do primary care the right way and not get burned out
I again maintain that people that get burned out, picked primary care for the wrong reasons. Focus on the patients and not the small stuff and the rewards beyond money will be amazing.
M,
Great summary and well written. Saying goodbye to a dream and an imagined future self is always painful.
As family doc, I find the non-family doc journey to Primary Care that you outlined interesting. I actually found patients in the “real” world far more pleasant than in residency. However, I also found them far less needing of my help but equally as needy.
I think the downside of IM and Peds training is the marginalization of the outpatient setting in favor of the inpatient. It denies trainees the experience they need to know what the are getting into before they sign a contract-if they make the valiant attempt at primary care that you did. I bet you were in quite the minority.
I wish you good luck and better sleep!
I definitely had to search out my outpatient experiences, but fortunately I was supported by a great residency director who owned his own outpatient private practice and still rounded on the inpatient service (an absolute relic from another time these days).
Still, I would say residents and med students are so shielded from the reality of what medicine is these days – where you spend more time dealing with insurance games, paperwork and coding issues than actually spending time with patients. If I had shadowed a doctor who had me stay with them until 6:30 in the office watching them do paperwork, then head home, have dinner with their family then restart the paperwork again at 8 at night, I may have thought twice about my decision.
As a fourth-year medical student, this terrifies me. Curious as to why doctors are doing so much paperwork, prior auths, etc. You are paid to see patients (and chart for billable visits), not to fill out forms, right? Can you have a nurse, medical assistant, or receptionist do the bulk of this paperwork? I mean, I’m assuming you make more than a medical assistant does, so in theory, wouldn’t seeing more patients and paying someone else to fill out as many forms as possible be better both financially and emotionally?
I’m so sorry you haven’t been exposed to the reality of primary care. Studies have shown that for every hour of face to face patient contact, it generates 2 hours of paperwork.
Yes, we get paid based on patient contact hours. So you know when you finish up doing the paperwork? On unpaid time – late into the evening (some nights I didn’t leave the office til 7), weekends and “vacation”. A lot of the paperwork requires knowledge of the patient’s history, so other people aren’t equipped to fill out everything.
It’s just assumed doctors will do this on our off time, and you can see it in how our days are scheduled. Did you ever work with a doctor who had built in paperwork time instead of q10-15 office visits? I’d highly doubt it.
Sorry, but this is the reality of the world you will work in. Better you know it now than later.
I used to think that I wanted a part primary care and part hospitalist job. There is a so much happiness in watching healthy kids grow up. But what pushed me away from primary care was how hard it is. The pressure to keep up and the 15min visits! Most days (that aren’t crazy) I can spend an hour talking to someone if I want. I might not get my notes done that day, but that’s OK.
I hope you find hospitalist work more enjoyable. Yes, your time with people and the relationships you build will be more fleeting, but maybe that isn’t a bad thing.
Maybe this is the birth of a hospitalist?!
Haha.. perhaps, but the title wouldn’t have been as catchy/click-baity 😉
We’ll see how this new venture goes. As with all things, the initial excitement of a shiny and new object/quest will fade, so I’ll have to reassess then. Who knows what will happen in 6 months?
Will you still be taking care of stinky grown ups? Or just awesome bugger faces?
I’ll be taking care of offending odors of all ages 🤣. But the grown ups can’t make up for their stench with cute faces.
Yay! I’m so glad you will get to see kids still! Playing the belly drums and picking noses is still the best part of my day 😊
Quite honestly, if I didn’t have kids to look forward to at work, I’d probably already be hanging out in the jungle somewhere to escape my student loans, living off the land in some makeshift tiny house.
M you really are a true wordsmith. Especially love the lasting image of the tree with broken limbs at the base analogy.
Congratulations on taking a step in a positive direction for you and trying to get back to what medicine is about. I know it is easy to become complacent and stick in a situation even if it is not ideal and slowly get burned in the process (there was this brilliant blogger not too long ago that posted something about frogs in a cauldron).
I’m glad you are jumping out of the pot that I may have stayed too long in. Hope the waters are more to your liking in the next cauldron
Thank you for your kind words, Xrayvsn!
I’m glad the frogs stuck with you – I have you to thank for their inception! 🐸
You need to write a book, M. The way that you write wraps people into your story. It’s truly incredible.
I am glad that you have found an alternative route in medicine (note: not alternative medicine). I hope that it works out the way you are anticipating and stems off the rising tides of burnout.
In the end, medicine is still a job. And you have every right to keep looking until you find the right job to make you happy.
Looking forward to part 2 and part 3.
TPP
I agree re: writing a book. The writing style and wordsmithing is superb. Maybe M could write “The House of God” for the next/current generation?
That would be an incredible feat! I’m flattered you think that would even be a thing I could do!
Hah.. I had a patient who tried to convince me to go into alternative medicine because I was into diet and exercise first over meds! I’m still hoping to make traditional medicine work for me before I start prescribing urine aliquots PO to cure allergies (that’s a real thing people are being told!).
I have toyed with the idea of writing a book, but not sure what that would even look like. Perhaps I’ll have to pick your brain after I read yours!
This is a beautiful exposition—you express so eloquently the tragedy of American medical training and practice…I am sure that your deep desire to live a life of meaning and beauty will lead to fulfillment in one way or another…
Thank you for your kind words! I hope I can live up to them!
I echo what everyone else has said, very well written.
I wish you the very best of luck!
Thank you so much! To you as well!
I second Vagabond and TPP, and I’ve even got a title to suggest: “The House of Dog,” an absurdist update from an optimistic feminist dealing with burnout in medicine. If I reserve now, can I score an autographed copy?
I think William Kristol wrote, “A conservative is a liberal mugged by reality.” My wife and I, faithful progressive optimists, constantly refer to this quote whenever another scale falls from our eyes due to an experience in the ED.
We haven’t been completely beaten in submission, but that doesn’t stop medicine from trying.
Wishing you the opportunity to practice less medicine more humanely in the new role, and to find some head space and restoration in the process.
Fondly,
CD
Oh my.. I don’t know if I could live up to “The House of God” fame, but thank you for suggesting I could!
If I do write a book, of course I’d send an autographed copy to my original supporters 😊
To your comment about the scales falling from our eyes – I often wonder if it would be better to rip off the bandaid quickly or to peel it off slowly. The sooner we see the reality of what things are, the sooner we’re able to address it.
Great article. I think you will love the new gig. My buddy changed from outpatient FM to hospitalist and loves it. I have contemplated doing the same. Currently w 3 kids and likely one more, the 4 day work week and pay are hard to give up. Likely someday I will, when the timing is right. I think inpatient is more pure medicine. Enjoy!
I work 70 less days a year and make 50% more as a hospitalist than I did as a traditional family doc(clinic and hospital). I also never have paperwork accumulating when I am not at work. I haven’t done a prior auth or filled out FMLA paperwork since I started this new gig.
In my soul, I am a traditional family doctor. But the business of medicine beat that to death. I don’t have my dream job anymore. But I do have my life back.
I put you in the same boat with the author. You went into medicine for the wrong reasons. You should get out, find yourself a banking job. Good money, no stress. if you really are committed to being a Dr, you would still be in Primary care. As a hospitalist, you are basically on high class welfare. Every hospitalist program loses money. Commit your life to caring for the patients instead of milking the industry for as much as you can get.
You are of course entitled to your opinion. But I wanted to be a doctor since I was 4. of course had no idea about money at that time.
I want to spend 30 minutes with patients. But neither employed or private practice allow that. Being in private practice doesn’t magically make overhead go away. We were hitting $35,000 month/overhead. At $100 for a level 4 visit that is 350 visits a month to make $0. You are at 87 visits/week or 17/day to make $0. If you are wanting to take 30 minutes with each patient you are at 8.5 hrs/day, 5 days/week, 48 weeks/year to make $0.
If you’re willing to do that to make nada/zip/zilch than you are a better man than me. You win.
I was putting in 12-13 hrs a day to see 25 in clinic and also see 3-4 at the hospital. That covered my mortgage(bought at less than 2x’s annual income so no ‘doctor house’, student loan payments, health insurance for my family which was $1900/month, standard daily living expenses,and managed to put a small amount into savings for retirement). I hardly ever saw my kids. Would come home after they had had supper to help get them into bed,and would then go back to the office to get notes and paperwork done. If that is what being a doctor means to you, then I guess I’m no longer a doctor. I’m Ok with that.
As are you, entitled to your opinion. But, if you want to spend that much time with each patient, you should need a lot less overhead. It is not social hour, you are taking care of their medical needs primarily. There will certainly be time to take care of social parts in certain situations. I have lots of patients that I see that I would consider friends and I only know them through the office. But when they are here, it is medical. Get them healthy, keep them healthy. You can’t see 12 people in a half a day and make that kind of overhead profitable. So change your overhead (Different office, different staff?) or see 15 in a half day. That little extra work is going to really pay off down the line. Private practice can be anything you want it to be, but there are trade-offs.
Moving into hospitalist medicine does not make you any less of a doctor.
Staying in the previous position you were in sounds like you felt you were less of a parent and a partner to your significant other. At the end of the day, you need to do what’s right for you and the people you love. We’ve all been coached into this lifestyle of self-denial and doing what’s best for our patients, but at the end of the day, you are still important to your family and they NEED you in their lives.
Don’t ever be made to feel guilty about that. Don’t ever be made to feel like you’re less than because you have other pieces of your identity that aren’t wrapped up in being a doctor.
Keep on living life. Better to be a human being and parent who doctors than doctor who used to be a human being.
I am glad you haven’t entirely given up medicine just going to the hospital instead of outpatient. I do believe that young physicians should consider private practice and not medicine working for a business. My partners and I are happy in our practice as we own our own office and call our own shots. If I need more time with a patient I can take it! I feel that I am important in my patients’ lives and that I am helpful to them because I’m practicing real medicine not corporate medicine. It may sound scary but join an established private practice and you will reap the rewards. BTW we need another partner!
I was very intentional in selecting private practice coming out of residency, and unfortunately it did not pan out for me. Even private practices owned by physicians can be poorly run, as I came to discover over the last 3 years. There’s, of course, a lot more to that story but ultimately there are no more private practices for me to join in the area as they have all essentially been bought out by the bigger hospital/healthcare systems.
For the most part, I do believe us physicians leaving primary care still love medicine and our patients, but the practice of medicine is now dictated by corporations and insurance companies. If I were to come back to primary care, it would absolutely be direct primary care, but until I am more financial secure with paying off my student loans, I will be biding my time doing hospitalist medicine.
If we follow the money trail, where does it lead? insurance company board rooms? pharmaceutical industry invasion of medical school curriculum? medicare policy makers? “elected” officials who follow the dictates of whomever paid for their elections?
The money trail isn’t very hard to trace – a fellow physician blogger just did a post on this recently:
https://doctorenough.com/2018/12/10/the-bad-guys-in-healthcare-arent-who-you-think-they-are/
There is the dream of medicine and the reality. This speaks for the need for college career alignment specialist to help people match with a satisfying career.
If said college career alignment specialist could anticipate what the actual practice of medicine would be 12 years in the future, then I might agree with you.
However, medicine has changed drastically in that time. That is the unfortunate thing about medicine – we are very pigeon holed into specific career tracks and have a lot of difficulty pivoting into other careers if we find that reality did not end up matching the dream. PA’s and NPs have a lot more flexibility in terms of switching specialties, unlike MD’s and DO’s, especially if they subspecialized and did fellowships. The only options then are to subspecialize even further, switch jobs in the hopes they may have a different patient population/work in a different culture OR to cut back entirely. This last option is becoming more and more prevalent, compounding the physician shortage – this is the unfortunate reality that we live in.
M, I’ve not read you before but you seem to be running a parallel track to mine. I started practicing in 8/2015 and have signed a contract to start as a hospitalist in 1/2019. The transition has left me feeling disheartened and disillusioned. I came in to medicine asking “What is it people need and how can I provide that?” And now feel like all I can think of is “How do I provide for my family and not hate my job?” Thank you so much for giving voice to this experience. You remind me that I am not alone and at least for me that is no small thing.
Thank you so much for your comment – this is why I continue to write because I, too, was in the same place as you. I found no support amongst my older colleagues and was too hesitant to find it in my peers who were now scattered across the country after residency.
After starting the blog almost a year ago and hearing other people’s stories, I can say with absolute certainty: we are not alone.
And, the numbers back us up. Primary care docs are leaving in droves EVERYWHERE. The physician burnout stats are appalling. The number of docs who would encourage their children to go into medicine is dwindling. Those who are ignoring this and instead choose to belittle their colleagues who are going through this struggle live in a different reality, one that you and I don’t need to be a part of.
Keep doing what’s right for you and your family and know that there are many of us out here rooting for your success.
Best.
I still say, you licked the profession for the wrong reasons. Life is hard, this is real life stuff, but nothing compared to what your patients are going through, (cancer, heart failure, amputations etc). Focus on the patients, don’t sweat the small stuff and the profession can be rewarding. If hospitalist is the solution, then that answers the question, you went into this for the wrong reasons.
Yes, your opinion has been heard.
Multiple times, actually. And this is the first and last response I will give to you.
Your comments are neither helpful nor insightful. You are entitled to your opinion, which is why I will not delete your comments off my blog. But for you to continue to harp on other people’s experiences is to deny people their truths just because you have had a different experience. I am happy for you that you love primary care, I really am. But there are many of us who are choosing other paths, and we do this with intention and with a lot of struggle, and voices such as yours just compound the turmoil.
If you want to tell us all that we’re wrong for leaving primary care, feel free to think that. At the end of the day though, we’re not the only ones leaving primary care and the numbers back us up. Please enjoy the knowledge that you will be one of the last primary care doctors left.
But you no longer have a place here on this forum. This blog was not for you.
Be well.
I truly appreciate you not deleting me. I really do. I am also honored that you read them. I have not stated my position well. For that I apologize. I do NOT want Drs to leave primary care. Rather, I want you to stay but find a way to make it work. Running away is just potentially just finding different problems and in the end, still not happy. My son is looking at going into medicine. This is his idea, I have not pushed him one way or the other. It can be extremely rewarding. But there is a balance. I just want people to put money lower on the list. Drs by nature are smart people. We could be successful financially in lots of different careers. Find all the parts of medicine that make you happy. Focus on those. Focus on the fact that you have the ability to help people in a way that no others can. If you are unhappy with current situation, change the situation but not leave. Find a different partner, different office, different staff, whatever it takes, but don’t quit. Work through the issues, don’t run away from them. This is my last post.
Thank you for your clarification. I agree with you for the most part, but in talking with many who are in the same boat I am, we aren’t leaving for financial purposes. Of those who have moved to different primary care offices, their experiences have not vastly improved. Many of us do not have control over our work situations as one would hope, so we make choices for our survival.
I hear you on potentially running into unforeseen problems, and that is a concern for me as well. But sometimes the devil you don’t know might be better than the one you do.
Again, thanks for clarifying your position.
I feel for your difficulties and will just offer a suggestion not to absolutely give up on the possibility of a Family Practice career. I have spent six years in the ER and then the last 26 years working in a hospital run Family Health Center in upstate New York. We have overall a very appreciative clientele and that has not changed over the years. What made all the difference for me is that I went from the old two day work week in the ER to three 11-12 hour days in primary care. This provided the very much needed breathing room to live my life and the energy to give 100% while at work. I’m sure that was the key to avoiding burnout.
I spend a few minutes before each visit with the computer record then put it in the corner of the exam room and turn toward the person I care for. The dreams of preventive care have of course been dampened, but over time some do quit smoking, choose to eat better, raise there families in a healthier way. Those who don’t also need our care, maybe even more. I believe we do make a difference.
I could go on but the concept of three days a week has allowed me to be supercharged at work and to stay for the long haul. Primary care can be and is rewarding and I plan to continue for another decade or so. Best of luck to you.
Thank you for your comment. Cutting back at work would absolutely be helpful with burnout, but unfortunately is not an option for me at this time due to the insane amount of student loans I incurred during med school. Primary care was and is rewarding and I have established great relationships – there is no denying this. Unfortunately, the way primary care is going is not sustainable. With declining reimbursements, increasing overhead and the constant fights with getting things covered by insurance companies, my practice has been under a vice that continues to squeeze more and more tightly. Either I stay and get squashed or try something different.
It may just be a slight breather and I may end up returning to primary care in the future.. we shall see.
This is a major issue with PCP. They knew what they were signing up for but I believe the reasons they signed up were wrong. I have been doing this 25 years. I love getting up each morning, rounds at the hospital, office hours, phone call at night. All of it. I love being able and am willing to be there for my patients. It is what i signed up for. Have I seen an evolution? Yes! Our EMR has transformed my career for the better. We were the first adopter in our community. It has its evil parts. There is still a lot of paperwork for being paperless, but that is just a small part of what it takes to be a Dr. Being a Dr goes back to my initial point. I love what I do. I love being able to make a difference in their lives. Anyone that doesn’t love what they do, should get out. Better still, you shouldn’t have signed up in the first place. That way someone who would have been there for their patient no matter what obstacles are in their way would now be able to call themselves….Dr and love everyday.
well written but incredibly SAD — you simply chose the wrong work situation – NOT the wrong profession or specialty
Try a private practice primary care position or even direct medicine approach — you can control your time and interactions better — you can’t change the patients and likely can’t change the genetics or even affect the ACE (all the current rage) – but you can save lives and impact people and families
Wouldn’t trade the last 42 yrs of family medicine for anything !!
The “system” is preventing us from caring for our patients and from saving “the system” money. Go figure. Some form of a cash practice appears to be the best route for providing our patients inexpensive quality care.
I’m not a doctor (a doctor friend and sister writer reposted this), but I accompanied my mother to many a doctor visit before she died 8 months ago at 102. I was appalled by what she expected of doctors. Irritated by the lack of understanding and compassion by some of her doctors and, simultaneously, sympathetic at what they had to put up with. And I was deeply grateful for the few who treated her like the strong human she was traveling this mapless pot-hole filled road of old age as best she could. My favorites were a near-retirement hospitalist along with a new glaucoma specialist and a young PCP still, perhaps, not burned out. For all her doctors, though, I had utmost respect for the difficult profession they had chosen. Those who irritated me were, I think as I read your blog, the ones who were in the wrong specialty and would have better served both patients and themselves by having the courage to find a place where they could fall in love again. Blessings on the journey.
I doubt if you will find hospitalist work fulfilling if you really want to make a difference in patients lives because you will not appreciate what happens to them over time. In my rural family practice in a FQHC, I work with underserved patients who may not search the internet but who may not be able to read. The first visit may be frustrating but you will see them again and again and the chances are they will change and get better under your care, even true for the opioid dependent patients (on MAT therapy). Patients invite me to talk about medical topics at their church (I am not religious) where I am welcomed as a superstar. Others bring me fresh fish and shrimp. I have many variations of telling them to walk more and eat less, in a motivational interviewing way, tailored to their background and beliefs.
I agree EMRs and prior authorizations for simple meds are frustrating, I do not usually type as I talk with patients because I think that good history taking and physical exam skills – espececially when mRIs and specialists are not available – are more important. Yes, I spend evenings finishing my notes. If I need to spend 40 minutes with a patient who has been misdiagnosed over the years, I will do it, even though it screws up my schedule, and on the ride home I am pleased.
Others may say ‘But you don;’t have a life!’ But I do.
Consider working in an FQHC serving people who will be grateful for your attention and caring. You will be tired, but happy at the end of the day.. I am after 40+ years.
I am glad to hear you work with a patient population who appreciates you.
I too, have spent the time when I need to, and I know my patients appreciate it when I do. However, when at the end of the day patients are upset because they have been waiting for me to see them and I also have 5 messages sitting in my inbox of patients who are irate for one reason or another, this does not lead to happiness at the end of my day, especially when spending the extra time at work leads to less time with my family.
Perhaps it’s the patient population I work with. Or perhaps it’s a generational difference between us. But for me, this simply was not sustainable.
Well said, but it left me longing for a better outcome than losing a potentially great family doc to the hospitalist machine.
I am old enough to haveI rounded my own hospital patients before office hours for years, sometimes going from a delivery, to the ICU, to the office, and stopping for a house call on the way home. I was happy in a rural practice, but those days are gone. They say it was inefficient, but I made enough money, and patients could afford their medical care even if they didn’t have insurance.
I hope that someday soon caring persons like you can again be personal Physicians to real persons, not “providers” who feed a bloated industry.
That is my hope as well. But, in the meantime I’m going to keep on swimming and see what happens to medicine in the future.. perhaps I will find myself jumping back into primary care in the future if the pendulum swings.
I’m not holding my breath though.
What strikes me about the comments here is that there clearly are primary care doctors out there who love what they do. With respect to the ones who are working within the traditional model (i.e. not DPC where patient load and insurance hassles can be decreased), I suspect that their love for the job is based on intrinsic – not extrinsic – factors.
In other words, some docs here have suggested that you just need to change your group, your overhead, your staff, etc in order to achieve practice nirvana, as they have. Sorry, but I’m calling BS. Docs who love it all likely feel that way because it is intrinsic to who they are. Maybe they need to feel needed 24 hours a day, so they love the midnight phone calls. Maybe their ego needs to be stroked, so they love having people coming at them from all sides, asking them for an opinion. Maybe their dedication to the concept of medicine as a calling is so unwavering that every fight with an insurance company allows them to notch another dopamine-enhanced win.
None of this is meant to disparage these folks. On the contrary, I wish we had more people like this, because then Medicine wouldn’t be careening toward the same fate as our climate-changing planet (too dramatic a reference, maybe?).
But, for any of them to suggest that PCPs leaving primary care are leaving because they went into Medicine for the wrong reasons (money, etc) is absurd. Like you said, M, it denies struggling docs their truth, and it makes them feel like failures. You are anything but a failure. Now go write the sequel to House of God and make something of your life.
Have to say it’s too bad you didn’t come to family medicine, overall I think the residencies and life after are a bit more humane. Good luck with the new gig, BUT if it doesn’t work out as you would like, come look at Paladina Health. I’ve had a great career in primary care, but a recent geriatric job was burning me out (volume, lack of admin support) and I left and joined Paladina. This is a primary care job that IS what you were dreaming of – and med-peds OR FM are good fits for it. Growing fast and needing more docs. Come look us up sometime.
“How sad to be discarded once there’s no more use for you”
This post reminds me so much of Kafka’s Metamorphoses. You slave and slave and kill yourself to provide for others, and in the meantime you don’t realize what you’ve slowly become (jaded, cynical, emotionally exhausted; or in the book’s case, animalistic and inhumane) And suddenly the very people you tried to help disregard your own humanity, until finally, they kill you.
Interesting, would you consider this book a metaphor for modern medicine? Asking as a somewhat still optimistic med student.
Yes, I would absolutely consider this an apt metaphor for modern medicine.
Or just life in general. Physicians are not the only ones who experience this – from the many stories I hear from my patients, we all experience this to some degree. I’ve heard it from other people who work in healthcare, people who work in other industries, even parents who have invested so much of themselves into their children, just to be put away into nursing homes never to be visited again.
With that being said, please keep your optimism about you. It will hopefully fuel the change that is so needed.
Wow, yes, this. Thank you for your post. I found it by searching death and primary care thinking of a title for a yet to be written article describing feelings so similar to this, maybe feels rather dark after reading all of the positive responses from year-experienced PCPs but has been going around my head for weeks. I’m two years out of MP residency working in outpt hospital owned practice. I love doctoring, taking care of multiple generations of families was what my dream job had been going through training. And now I’m doing it. But every week we are told we need to see more patients, do more to meet metrics, click more from BPAs, send more messages to get care for patients. Even though we are meeting our RVU goals. And we see more pts then have more paperwork. I’m still thinking through what next step is best but this is not sustainable.
Bram,
The more I allowed myself to think about what rankled me so much about medicine was not that I had started to hate the actual practice of medicine or interacting with patients, it was exactly what you outlined above – the increased pressure to “perform” despite us providing good, even excellent care to our patients. When we started off on this journey, we never thought we would be accountable to healthcare organizations moreso than our patients, yet here we are.
It’s not that we have tired from doctoring, we’ve tired from wading through the bullshit and the hoops we are forced to jump through in order for us to do what we trained for – to take care of actual patients.
Moreover, the message that what we are not enough is constantly reinforced by healthcare administration and insurance. There’s always one more metric to chase after, one more checkbox added to click, one more useless meeting to attend. Now we have to tend to these items rather than looking at our patients in the eye when they come in to our clinics.
No wonder we’re demoralized. No wonder our generation is fading out faster than our predecessors. We never were really given the chance to practice when the focus was actually on our patients, not tending to some EMR and irrelevant clinical documentation requirements that add nothing to patient care.
This is the reality of the world we live in, unfortunately. So much so that it inspired you to write an article with the same title! Have you written other articles? Send them my way!
Best,
M
I’m sure this thread is long dead (just doing this response for cathartic reasons at this point) but I googled “I hate being a primary care doctor” and it came up. Thank you so much to the author for your very insightful and therapeutic. I have been doing outpatient primary care and initially OB and inpatient with ICU privileges when I first got out. I am exhausted spiritually and mentally now in 2019 by what is called Primary Care. It did NOT look like this in 1991. “They knew what they were signing up for” NO THEY DID NOT! 2019 is not 1991. The focus now is not on patient care (unless virtual so the HEIDIS scores look good but the patient is a number), kindness, patient family support, and the human touch that once was primary care. Douglas Hoy, you sound like the same judgmental and holier-than-thou “”doctor- administrators – afraid they will ever have to touch a patient again now that they’re in the C-suite” I deal with every day. (I’m sure you’ll say your patients love you – but they don’t love the judgment you cant hide). I’m just sayin’ your checking account looks pretty good to make that statement. Some of us have 2 sets aging parents in nursing homes, kids in college and haven’t paid off the mortgage. I asked both sets of parents if they’d live on the streets so I could “cut expenses” and they both said no. What are you gonna do? Now artificial quality measures like Pres-Ganey scores and HEIDIS measure compliance rule our lives. You’re probably excited by MOC as well, a money grab for “quality” but patients “keep” asking to see if I’m current (sarcasm). Many of us are employed one day and not the next based on these Press-Ganey scores (didn’t happen to me but another colleague at a prior practice was given the “box to pack up your stuff and be escorted out of the building”. You are a judgmental dinosaur, Douglas Hoy, but I win ( not that I care to but you seem to be a high school football jock type, “suck it up and like it” type) having done this for 28 years and you only 25. I’ve done hospital medicine, strictly outpatient work, for profit outpatient work, occupational medicine, DPC model, ER medicine, DPC, cash basis only, and non profit work. Doctors were afraid to do the “business side” of medicine and turned it over to the MBA’s – whose only moral responsibility is to turn a profit for the company. People die if we make a mistake – if they do the stock price goes down and shareholders get pissed, accountants who track money wrong have “data entry errors” and not malpractice. I romanticized about this profession, just as the author of this article. Times change and primary care changed. I didn’t know what I signed up for in 1985 for what would become 2019- nobody did, you “judgmental doctor”. Had harsher language but cleaned it up.
Thanks OC Doc, for bringing my comments back to life. Things to know about me. I have done and continue to do all that you are doing except the OB, Kudos to you for that. This will not surprise you but I have been called a dinosaur more than once. I was never a jock but a proud band geek, I have 3 aging parents (father passed away 6 years ago), but they are lucky in their 80’s and living on their own. Put one kid through 6 years of college, still have 2 in school. Never been an administrator, never will be. I was chief of staff once, but I doubt I will be asked again. I am not financially wealthy, but emotionally rich. In my world, that is better.
My initial comments were stirred by my associate leaving our 2 person practice because he couldn’t handle it. Despite selling my sole to make him happy, he left anyway. I hear he is happy. He left a mess.
You bring up a lot of very accurate points. Nobody envisioned the check boxing, button clicking that is today’s medical record. But I would not want to go back to paper charts ever. Those are the parts that people find annoying and interfering with the Dr-Pt relationship. All the acronyms we need to satisfy and in our hearts we know they serve no benefit to the pt. If I have one more insurance company turn down someone for DME because my chart doesn’t say Face to Face, I am likely to throw something. But we can use these tools to improve communication. I, in my head, have found ways to put that to good use. i email my patients through the EMR and for those that use it love that i can communicate and send info this way. Can save them an office visit. Don’t tell the hippa police but for pt that I am close to, and I have many, I give out my cell and text them. Phone calls are always better but i find people like having things written down.
My beef about the topic is, I find people use a lot of energy by complaining, fretting, worrying about things out of our control. If we just focus on the patient, you will be happier. You will likely feel better and have more free time as people waste a lot of emotional strength complaining about things we cannot control.
The other beef is the people that complain about the amount of time they put in. This is not a 9 to 5 job, yet with the newer Drs not working in hospitals, they try to make it 9 to 5 but…..want paid like those of us, I am sure you included, that put in routinely 12-14 hours a day. They should get pain 3/4 of what we are paid. I believe reimbursement should be tied to if you work in the hospital as well as the office. It is better care and should be rewarded.
Thanks for bringing my comments back to life. Open, Honest discussions are how things get changed. If either of our opinions strike a cord with someone, you never know what may happen. Would love to hear a response.
I appreciate your perspective that only 25 years in primary care can bring.
However, I do want to make a point – speaking for myself who chose primary care knowing that it would not be reimbursed as well as other arenas in medicine AND for several others of my generation, it was NEVER about the money.
I find it fascinating that all of the Medscape surveys and whatnot all ask if burnout would be improved if we would get paid more, but that’s such a cop out solution that is only a temporizing measure. I don’t mind putting in 12-14 hour days at the hospital, especially if it was because I spent extra time discussing their new cancer diagnosis or with terrified parents their baby’s new diagnosis of infantile spasms. That’s time well spent, and I don’t regret that at all.
The frustrating thing is being expected to do more in the same amount of time with less resources, while being expected to provide the same level of quality care with more complicated patients. What is upsetting is the administrative burden of clicking 1000 things in Epic to get a button to turn green. Or spending 40 minutes of my day yesterday to sign off on a death certificate electronically because administration decided that would be part of my new work flow and changed it from a simple 5 minute process to 40 minutes – but remember, you need to admit X amount of patients in the same time. When checklists like that pull us away from the meaningful work we’ve trained so hard to do, that is when we start displacing our frustration to our work hours, compensation and lost time with our own family and friends.
Why continue to work so hard just to tend to the menial tasks of the system that are low yield for our patients AND for us?
I’m glad you’ve found a way to make it work for you and you were blessed with an optimism that I can’t seem to hack into. But for many of us, our threshold for the system’s bullshit is wearing thin or completely gone.
My answer for why continue is simple. We have the best job in the world. Where else can you have this much of an immediate impact on someones life. With some of these people, I am closer to them than friends because we have been through so much. I couldn’t think of anything else I would rather do. If i need to click a button 1000 times to be able to keep doing this, I will click it 2000! My former partner said i am addicted to helping people. I take that as a compliment. I make sure to find balance and since my kids are done with the HS sports scene, it is easier. I hope everyone reading this can find their happy place.
I was going to leave this one alone, but I know a lot of people read through these comments so I couldn’t let this one slide.
I truly am happy that you are fulfilled by your career/profession/doctor life/balance. But for the rest of us who have a different vision of what balance is, who DON’T want to work 12-14 hour days and are also fulfilled by things other than work, taking pride in being able to jump through more and more meaningless hoops that the system demands from us is unacceptable.
Many of us fall into a savior complex, and while it feels good while you’re doing it, it does not allow for healthy boundaries for most people. It leads to sacrificing our personal needs and by extension, our family’s needs as caring for others takes our time and energy away from them.
We are not a limitless resource and the glorification of the over-extension of ourselves is part of the reason why so many of us are burned out. “Just think about the patients,” is a mantra administrators use to keep us quiet and in our place, because at our cores, we still care about our patients. It’s a justification we’ll repeat to ourselves to put up with unacceptable working environments until we can’t take it anymore, and then we choose to walk away. So please don’t be surprised if many people find your reasoning triggering and you’re responded with hostility.
Again, kudos to you for making it work. Perhaps we are lesser beings and will never be able to elevate ourselves to your level of awesome.
But this blog exists to help reassure other people struggling with burnout and moral injury that they are not the only ones who feel this way.
OC Doc,
Your anger and frustration are palpable even without the harsher language, and I’m so sorry you’ve had to watch the profession you loved jump off a cliff to its downfall. I keep telling myself the only constant is change, as cliche as it is. So when I had had enough of primary care after a measly 3 years compared to your 28, I forced myself to make a change. It wasn’t easy and I’m still unsure whether I made the right decision, especially since I’m still operating within the same medical system that burned me out on primary care in the first place.
As aggravating as Dr. Hoy’s comments were to me initially, I have to agree with him that focusing on the patients has been the only thing that’s kept me in clinical medicine. The truth is, we are so angry because we still love what we do. We love taking care of people. Thus we hate what the system has become because it ends up hurting the patients that we set out to care for. I’ve absolutely displaced my anger from time to time to patients who take out their frustration on me because I’m an available target, but when I allow myself to take a step back, I realize it’s because they’re also trying to navigate this joke of a system. We’re all furious.
The only constant is change. So as I’m trying to figure out what my next step is going to be, I’m pretty sure it’s going to involve side stepping the system and starting a DPC/cash basis only model. I’d love to hear your thoughts on that since your experience would be a wealth of knowledge. Email me if you have anything you’d like to share!
Thanks for commenting, and believe me, this thread is far from long dead. It’s been the most shared post even now, despite the fact that it was written almost a year ago (I just couldn’t bring myself to publish it for 3 months).
M
You would be lucky if doctors do not leave US.
I’m pretty sure it’s going to involve side stepping the system and starting a cash basis only model. It leads to sacrificing our personal needs and by extension, our family’s needs as caring. I am closer to them than friends because we have been through so much.