Friday, March 21, 2008

Not Doing Primary Care Is Like Living In Margaritaville

Every day for this guy is like living in a perpetual Jimmy Buffet song. I wake up every day excited about going to my specialty clinic, seeing about 20 interesting patients, finishing my dictations, then heading home by 5:30pm to relax with my wife and kids...or go for a long trail run...or go fly fishing, or get to my kid's after-school events.

Notice, I omitted the several hours at the end of a long clinic day that I used to spend thinking it would be less painful to gouge my eyeballs out than to sign endless prescription refills, notes from specialists who have consulted on my patients, disability forms for people who don't really deserve disability benefits, forms for diabetic shoes, electric scooters, walkers, canes, prior-authorizations for drugs, FMLA forms, and nursing home orders. Of course, most of these forms require rumaging through the patient's chart for a few minutes to confirm diagnoses, last vist dates, current medications, blah, blah, BLAH! When that's all done after seeing 25-30 primary care patients a day (5 of whom typically break down crying in front of you), you get to sit down and call the 10 or so patients who demand your call before you get to head home to your family. When you get home at 7pm - 8pm, you get to answer your pager all night from patients who think they just might die by morning if they don't interrupt your dinner and bedtime with your wife and kids. Then, every two weeks you collect a check which is, in general, the lowest pay in the medical field. This is the life of the primary care provider.

My life went from that described above to...well...I call it Margaritaville.

Three years ago I left my primary care internal medicine job to join an academic specialty clinic. Now I know how Edison felt when the light bulb went on. Wait, you mean I actually get a raise, get to see fewer patients each day, and I don't have to do any primary care grunt work? Is this a joke? Come to office, see patients, go home? Where's the hidden camera? What's the catch? Are you going to make me vote for Hillary? Are you going to force me to be a card-carrying member of the ACLU? I don't get it.

People, please appreciate those that do the grunt work on the front lines all day, every day, for the lowest pay in our wonderful profession. I appreciate the fact that I don't have to do it anymore - and I have the utmost respect for them. I just happen to now thank God every day that I don't have to do it. And, while they are filling out endless forms, refiling prescriptions, and calling patients back from 5 pm to 7 pm every night, I get out my margarita mix and tequila, throw some ice in the blender, put my feet up, and mix up a margarita that Jose Cuervo himself would be proud of (off ivory tower grounds and on my own time, of course)

The whistle blows at my clinic now at 5:30 pm every day...a place I now refer to as 'Margaritaville'.


  1. LOFTY: you just described Path., however, I don't even have to talk to people! And I can be drunk and noone would know (maybe that's just my underlying personality).

    Can't belive you didn't go full on 'trench-coat mafia' as a primary care doc. I truly, honestly do not know how ANYONE can stand it...

    I'm certain that Obamillary has an answer though.

  2. This comment has been removed by a blog administrator.

  3. Lofty, check out the blog of a reformed primary care doc now doing ER residency. He's very good. And, since you are new to our party, check this out and see if you agree. Congratulations on being able to drink at work etotheipi. Formaldehyde will get you drunk too, but you already knew that.

  4. When a patient cries in front of you do you find that you are more likely to do something (ie order unnecessary tests and/or treatment) to pacify them rather then explain why that test/treatment isn't really needed?

    I have a story that goes along with this but I want to hear your response first.

  5. drytears,

    from the perspective of the ER doc the absolute worst place to be, legally, is in the witness box telling the jury why you didn't order a test that the patient either wanted, or was indicated based on their complaint.

    it's not uncommon, as is mentioned in the post "zebra hunting" for the family or patient to be right about 'something' being wrong. it's not common, but i have had patients (usually cardiac patients) who appear normal to say, "i feel like i am going to die" and then go into cardiac arrest within a few minutes.

    your question about crying is a good one... i personally, will 'lab 'em up' rather than take a chance. the nurses hate this, especially with patients that we know well and know to be abusers of the ER, but those folks get sick too and we can't miss it.

  6. I'm really in awe these days (in part because of blog posts like yours) of my own primary doc who I've met once and hope not to need his wealth of knowledge and experience for many years.

    I cringe in shame remembering that, as a young mom of a one-year-old, I made a frantic call in the evening to the doctor after the baby somehow got a piece of popcorn (fluffed) deep in her ear and we couldn't get it out. He did sound a little angry when he called back and told me to reverse the hose on the vacuum and suck it out! I was shocked! But he was such a good doctor I almost did just that! Instead, I decided that the piece of popcorn was probably too large to get to her brain and should wait til morning to go into his office. Naturally, the popcorn worked its way out during the night. The doctor never mentioned the incident, but the whole thing was a great lesson for me.

    rambling old woman

  7. Ah, I only want to see my doctor when I hurt (I am a man and I don't hurt much and crying is out) or I think he might actually help me - but normally I don't bother the doctor, just pay the bills not covered by insurance. I am happy you are getting a better family life, enjoy. Really, when he met me for the first time and said I had to stop running until he was sure I wasn't going to die - I stopped listening to him about what he knew not -- and he was using my wife as his source for my conditions? bad form.

  8. 911doc,

    Thanks for the reply.

    Today I saw my PCP for follow up regarding tests my Pulmo ordered. When my Pulmo called me he said that my lungs were fine and that my SOB could be caused by my heart and that my cough was most likly due to the Indomethacin I take daily. I asked him where I was supposed to go from here and he suggested an echocardiogram.

    Today when I saw my PCP when I mentioned the echo she balked and said it was completly unnecessary. She blamed my indo on everything and since I refused to stop it she told me to learn to "breathe around my cough" and suggested meditation classes. I freaked out here cause the cough wasn't as concerning to me as the SOB was... and I started crying and I told her I just didn't understand how 6 months ago I was able to work-out regularly and now couldn't make it up 2 flights of stairs w/o some major difficulty breathing.

    Then right after I started crying she said that she was going to order the echo... then she also mentioned that she wanted me to do pulmonary rehab.

    It just seemed like she only ordered these tests to make me stop crying. Which upsets me... yet it does help to know something is being done.

    So I guess this just leaves me and my dr in an akward position.

  9. I was a General Medical Officer/flight surgeon in the Air Force paying back my HPSP scholarship while I decided what I really wanted to do for residency. I was still somewhat idealistic and thought that I wanted to be the good ole family doctor. Then one Sunday morning at 630 am I was awakened by a phone call with some old geezer wanting to know what his cholesterol results were from friday. I decided right then and there that I would be an anesthesiologist.

  10. Even among the patients that don't cry -- it takes about 5 seconds to realize that they are just depressed/stressed/unhappy. However it still usually took a couple thousand dollars of testing to also convince the patient and remove any inkling of doubt I had.

  11. drytears, you need to consider getting a different PCP as soon as possible. Your current doctor may be 100% right, but if she is, she is not educating you properly.

  12. Anon 9.58 -

    Thats actually what lead to me breaking down and crying when the dr stated that I looked up happy after her dicussion about "breathing around my cough"

    It's just too hard for me to get a new PCP, I live in a small town where there are a very few... and then I eventually had to get one near my school and I'm just sick of the shuffling of charts and having to go through my history again and again and again!

  13. I'm liberal with tests. I figure they keep me out of trouble. The worst thing I can do is refuse to do something that the patient thinks they need...and be wrong.

    I'm occasionally surprised, but because of my training and years of practice, I'm seldom wrong when I tell a patient that a particular study isn't necessary and will almost certainly be negative.

    As to the patient education issue. I'm not talking about anyone in particular who is posting...I'm talking about my experience.

    I spend more time explaining things to patients than most docs do. I try my best to connect to the patient's level and explain why I am or am not doing a certain test. I usually tell the patient up front whether or not they're likely to be admitted.

    I'm increasingly irritated by people who don't listen or pay any attention. I feel proud of myself and how well I know that I explained myself to a patient only to have the nurse come and get me an hour later saying "the people in room 3 don't understand why you're admitting him".

    And BTW, crying just pisses me off!

  14. dear dry tears,

    we do not give medical advice to individuals on this site but let me speak in some generalities.

    first, go to the medcard site linked on the sidebar. get the card or not, there is a discount for mdod members and the code is 'mdod'. even if you don't get the card download the hisotry form and fill it out. get all your records in that form and keep the card or a homemade version of it with you as it will really help any future physicians that see you.

    secondly, do a little reading on panic disorder and panic attacks. it sounds like this is what your pcp is hinting at and there's no shame in it. folks have panic attacks all the time and the symptoms are distressing. the key is ruling out more dangerous diseases, which it sounds like your pulmonologist is trying to do. get the echo, and when it's normal, consider the other possibilities above.

    best of luck.

  15. I think it's true that sometimes crying in the doctor's office could be caused more by many other stresses going on at the time than what's happening in his office right then. But, how's he to know? I've never cried while with my doctor. I'm usually too intent on listening (I'll sort it out later -- which may not be the best approach)and anxious to get the visit over with.

    When I failed the flight test for my private pilots license I burst out crying. I'd had a horrendous morning in the office, had never met the examiner before, and was so anxious to get the test over with. But she just ignored the tears, went over what I needed to practice and scheduled a retest. I'm a grownup, calmed myself down and flew the plane back to its home (a rental). Passed the test on the retake. But doctors seem in a whole different category from the rest of the world in so many ways. I don't think you can ever escape that.

    rambling old woman

  16. I have only ever cried one time in a doctor's office. Not when I got the cancer diagnosis, for that I was fine. When not even a year after the cancer ordeal began and I had a huge cyst on my ovary that my doctor all of a sudden seemed worried about and wanted to do a bunch of blood work and schedule surgery to remove/biopsy that cyst.

    I couldn't control it, I just cried silent tears, which got a thousand times worse when he hugged me and started being really nice to me. Not that I would prefer him to have been mean, but that is what made the tears take so long to stop. My friend calls him the kissing doctor now because every time I see him he is hugging me or kissing me on the cheek.

    Totally off subject, just sharing again (and I have no coffee in my system right now).

    On subject of the post, I am always in awe of my doctors when they call me at times when I think they really should not be working any more. My endo frequently calls me at 10 at night after I have seen him in the office at 9 am. I know he works crazy long hours, and I also know my primary doctor does for the same reason.

    I know the cookies I bring don't help with that, but I hope they at least show my doctors that I appreciate how hard they work and do notice that they work so much and so hard for me.

  17. 911doc-

    Thanks! I wasn't in any way asking for advice. Thanks for the tip with the medical card... I do have a medical folder which has all of my records that I have been given copies of. However... everytime yo go to see a dr you end up telling someone why you are there are least 3 times! The recepionist when you make the appt, the nurse when you check in, and then the doctor... and even moretimes if there is a med student, intern or resident. That is what really fusterates me.

    I think why I broke down and cried was because I was sick of being passed through the system and being told something different each time. No one mentioned the fact that it could be psychosomatic... I realize it could be that only before they give me that dx I would just like to make sure all other dxs are exhausted (which in my opinion all drs should do because you never know what could show up).

    Hmmm... with all of my troubles I have experienced with primary care and specialists... I think it would just be easier to show up in the ER.... J/K!! :)

  18. Listen, when I say that 1 out of 6 patients that I used to see in primary care cry, not poking fun or a criticism, just reality. Most of these folks are depressed and stressed. I learned very quickly that I had to become a good listener and that I needed to learn to treat anxiety and depression very well. Makes me feel fortunate that my life is pretty darn nice compared to many people. It's a tough job to be a compassionate primary care doc when so much emotional baggage dumped on you every day. You become part counselor, part friend, part physician. Good PCPs are worth their weight in gold. Lofty

  19. Had a crying patient as an intern. Turned out her son was in prison...for raping a girl. A 13 year old girl. I did my best Alan Alda Hawkeye Pierce listening to her go on about the unfairness of the courts, rape laws, slutty way 13 year olds dress nows a days, etc.

  20. Just curious if your favorite soda is Mountain Dew. The only reason I say that, is the rest of what you have written sounds nearly identical to someone I know of.
    One thing about PCP's is if they're not the ones signing the forms, checking charts, etc., what tiny paycheck they do get is spent on those working under them.
    Good insight on your article

  21. Wouldn't be so bad answering phone calls if we could bill for it, like lawyers do. Shortly after my release from Gitmo I sent a short e-mail to my attorney, thanking him for his great work. Unfortunately I did sort of ask a legal question. Got my answer, along with a bill for $300/hr x .25 hrs. Too bad Marcus Welby always did stuff free of charge.

  22. Yeah, I've never really understood why doctors don't charge for phone calls. It's one of the reasons I try really really hard never to call my doctor, and then if I just have to, I only call the office and try to talk to the nurse instead.

    When I was growing up, my doctor was the father of a friend of mine. I was over at their house from time to time. I don't recall seeing him there too often. Maybe he was holed up in a den somewhere talking to patients. They had two telephone lines, and one of them was just his call line. I always felt sort of sorry for him having to answer patient calls in the evenings. Somehow he managed to maintain a caring and compassionate demeanor with his patients. Well, at least with me.

  23. Saturday am, I saw a lady who came to the ER a few hours after I&D of an abscess on her belly.

    The hole made by my partner less than 3 hours earlier was about a centimeter. She was blubbering and wailing.

    I went and looked at the site, and it looked good to me. I said: "look, I know that these hurt, but I drained a larger abscess than this on myself and came to work the next day".

    She blubbered away and said "are you saying that it doesn't hurt"? "No" I replied, "it just doesn't hurt as much as you're acting".

    After a tirade of curses, tears, and wailing, I just stood at the foot of her stretcher and clapped. After my standing ovation, I asked the nurse to order up an academy award for the lady.

    For some reason, she didn't think I was very I left her room and went to see the guy who was having a heart attack.

    The bad news is that her tiny abscess site probably still hurts...the good news is that the guy with the AMI did very well.

  24. After a tirade of curses, tears, and wailing, I just stood at the foot of her stretcher and clapped. After my standing ovation, I asked the nurse to order up an academy award for the lady.

    By GOD, that is the funniest thing I've heard in a long time. May I please, please, please use this in my book? You appear to have channeled one of my main characters.

  25. I forgot to mention that you'd get full attribution in my Acknowledgments...

  26. Lynn: You can certainly use me! I'd be honored. I've still got your first book on my nightstand. I promise to start it soon!

  27. I only cried at the doctor once since becoming an adult. I was a first time mom with a baby daughter, who for some stinking reason couldn't suck. So she couldn't nurse. Being the dutiful mother that I am, I pumped, and fed the child every 2 hours. Pumping, feeding the child, changing her, washing said pump, and bottles, I didn't sleep. For two weeks.

    I finally broke down at the pediatrician's office, when he told me that I was experiencing the worst of both worlds (breast-feeding and bottle feeding) and that it was ok for me to call it quits. I dont' know why this made me burst into a blubbering mess, but it did. It was like he gave me the ok to quit. That and I was delirious from lack of sleep.

    I took her home explained to her that it was her last chance to breast feed because I wouldn't be pumping any more. She latched on and had no problem after that. Only later did we find out that she had a genetic condition, and hypotonia to go along with her club feet and hip dysplasia.

    I don't cry at the doctor. It's too interesting to hear what the doctor has to say. Of course, I've never been in real pain either. I suppose if I'd ever experienced real pain, I might cry.

  28. erdoc85,
    you kick ass if you really did that. i am so ready to end this that i will adopt your tactics, get fired, then sue under the american's with sensibilities act. retirement here i come baby!

    great to see you again. looking forward to your next book. would love 'donovan's paradigm', signed copy, will pay top $$! contact me thru super secret email and i'll send you a paypal payment for same!

  29. "My mother never breast fed me, she said she liked me as a friend"

    Boy, I miss Rodney Dangerfield

  30. 911: I really did that, no embellishment in that post. She just pissed me off.