Why I’m Running Late

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It may not be rabbit season or duck season but it definitely seems to be doctor season.  Physicians are lined up squarely in the gun sights of the media,  government agencies and legislators, our health care industry employers and coworkers, not to mention our own dissatisfied patients, all happily acquiring hunting licenses in order to trade off taking aim.   It’s not enough any more to wear a bullet proof white coat.  It’s driving doctors to hang up their stethoscope just to get out of the line of fire. Depending on who is expressing an opinion, doctors are seen as overcompensated, demanding, whiny, too uncommitted, too overcommitted, uncaring, egotistical, close minded,  inflexible, and especially– perpetually late.

One of the most frequent complaints expressed about doctors is their lack of sensitivity to the demands of their patients’ schedule.  Doctors do run late and patients wait.  And wait.  And wait some more.  Patients get angry while waiting and this is reflected in patient (dis)satisfaction surveys which are becoming one of the tools the industry uses to judge the quality of a physician’s work and character.

I admit I’m one of those late doctors.  Perpetually 20-30 minutes behind.

I don’t share the reasons why I’m late with my patients as we sit down together in the exam room but I do apologize for my tardiness.  Taking time to explain why takes time away from the task at hand: taking care of the person sitting or lying in front of me.   At that moment, that is the most important person in the world to me.  More important than the six waiting to see me, more important than the dozens of emails, electronic portal messages and calls waiting to be returned, more important than the fact I missed lunch or need to go to the bathroom, more important even than the text message of concern from my daughter or the worry I have about a ill relative.

I’m a salaried doctor, just like more and more of my primary care colleagues these days, providing more patient care with fewer resources.  I don’t earn more by seeing more patients.  There is a work load that I’m expected to carry and my day doesn’t end until that work is done.  Some days are typically a four patient an hour schedule, but most days my colleagues and I must work in extra patients triaged to us by careful nurse screeners, and there are only so many minutes that can be squeezed out of an hour so patients end up feeling the pinch.  I really want to try to go over the list of concerns some patients bring in so they don’t need to return to clinic for another appointment, and I really do try to deal with the inevitable “oh, by the way” question when my hand is on the door knob. Anytime that happens, I run later in my schedule, but I see it as my mission to provide essential caring for the “most important person in the world” at that moment.

The patient who is angry about waiting for me to arrive in the exam room can’t know that three patients before them I saw a woman who found out that her upset stomach was caused by an unplanned and unwanted pregnancy.   Perhaps they might be more understanding if they knew that an earlier patient came in with severe self injury so deep it required repair.   Or the woman with a week of cough and new rib pain with a deep breath that could be a simple viral infection, but is showing potential signs of a pulmonary embolism caused by oral contraceptives.  Or the man with blood on the toilet paper after a bowel movement finding out he has sexually transmitted anal warts when he’s never disclosed he has sex with other men,  or the woman with bloating whose examination reveals an ominous ovarian mass, or finding incidental needle tracks on arms during an evaluation for itchiness, which leads to suspected undiagnosed chronic hepatitis.

Doctors running late are not being inconsiderate, selfish or insensitive to their patients’ needs.  Quite the opposite.  We strive to make our patients feel respected, listened to and cared for.  Most days it is a challenge to do that well and stay on time.  For those who say we are being greedy, so we need to see fewer patients, I respond that health care reform and salaried employment demands we see more patients in less time, not fewer patients in more time.  The waiting will only get longer as more doctors hang up their stethoscopes rather than become a target of anger and resentment as every day becomes “doctor season.”  Patients need to bring a book, bring knitting, schedule for the first appointment of the day.  They also need to bring along a dose of charitable grace when they see how crowded the waiting room is.  It might help to know you are not alone in your worry and misery.

But your doctor is very alone, scrambling to do the very best healing he or she can in the time available.

I’m not yet hanging my stethoscope up though some days I’m so weary by the end, I’m not sure my brain between the ear buds is still functioning.  I don’t wear a bullet proof white coat since I refuse to be defensive.  If it really is doctor season, I’ll just continue on apologizing as I walk into each exam room, my focus directed for that moment to the needs of the “most important person in the whole world.”

And that human being deserves every minute I can give them.

 

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The Doctor’s Waiting Room Vladimir Makovsky 1870

Cat-Like Observation

photo by Nate Gibson
photo by Nate Gibson

Even doctors must become patients eventually, and often challenging patients at that.  We know enough to be dangerous but not enough to be in charge.  We want to question everything but try not to.  We can tend to be catastrophic thinkers because that is how we are trained to be, but fear being alarmists.  We want our care providers to actually like us, when we know they inwardly cringe knowing they are dealing with another physician.  We wouldn’t want to take care of us either.

Due to intermittent changes in vision in one eye, I have recently been getting some practice at trying to be a model patient.  Unfortunately, I have become an ‘interesting’ patient, something no patient really wants to be.  That means the symptoms are not classic, the diagnostic tests not straight forward, the exam findings not clear cut, the differential diagnosis list very long.   It also usually means a visit to a tertiary care center for a visit with a sub-subspecialist to try to pick the brain of one of the handful of living physicians who thoroughly understands one aspect of complex human physiology and anatomy.  As a primary care physician who always sees an entire forest when I approach a patient, it is a unique experience to watch a colleague at work who truly concentrates on understanding one leaf on one tree.

A public academic training institution’s subspecialty care outpatient clinic is a fascinating place to spend a few hours.  The waiting room was packed to capacity with people from all walks of life sharing our afternoon together because of a shared concern about one small but crucial part of our bodies — our retinas.  We were all told the average time spent in clinic could be three hours or more and we all knew it was worth the wait so didn’t mind a bit.   Despite the long wait, not one of us would have thought to object when a couple of sheriff deputies accompanying a shackled county jail inmate dressed in his orange jumpsuit were escorted right into an exam room, rather than taking the only empty seats in the waiting room next to several elderly ladies.   We figured he was more than welcome to jump to the head of the line.

Finally my turn came to be seen first by a technician, and then a resident physician, then more testing with more technicians, and finally by the subspecialist attending physician himself.  I appreciated his gracious greeting acknowledging me as a colleague, but also his unhesitating willingness to be my doctor so I could be his patient.  His assessment after his exam  and review of everything that had been done:  there was no clear cause for my symptoms,  so my diagnosis would carry an “undifferentiated” label rather than the currently less preferred “idiopathic” label.   In other words, he didn’t know for sure what was up with my retina and as an expert he didn’t like to admit that, but there it was.

He then smiled and said “so for now we’ll treat you with MICCO.”

MICCO?  I knew there are many new unique pharmaceutical names that I have not been able to keep up with, but this was a brand new one to me that I figured only a sub-subspecialist would know about and be able to prescribe.

So he explained: Masterful Inactivity Coupled with Cat-like Observation.

In other words, do nothing for the moment but keep a close eye on it and be ready to pounce the minute something changes. Watchful waiting.

I am relieved to only be under watchful surveillance for now even though my diagnosis, its etiology and prognosis is unclear.  I realize it is a treatment strategy I need to use more in my own clinical practice.    It helps solidify that doctor/patient partnership, especially when the patient is a doctor;  I am content to do nothing but watch for now,  knowing I’m being watched.

It was an afternoon well spent in the sub-subspecialty world, as I come away with a commonsense piece of advice very appropriate for some patients in my own primary care practice:

Right now it might appear I’m doing nothing, but doing nothing makes the most sense and is the least risky option.  I’m keeping my unblinking eye on you, ready to spring into action if warranted.

Treatment plan: MICCO prn

photo by Nate Gibson
photo by Nate Gibson
photo by Nate Gibson
photo by Nate Gibson
photo by Nate Gibson
photo by Nate Gibson