Thursday, March 3, 2016
One physician's journey to direct primary care, a burnout tale
Donald Ross (an obvious pseudonym) has practiced in a medium sized town for around 20 years. I count him as a protégé as we worked together during his residency. As a clinician educator, we work with many interns and residents and sometimes we develop lifelong relationships.
Donald Ross and I share a love of golf, ACC basketball (although we root for rival teams), and internal medicine. We periodically communicate through Facebook. Recently, he posted on Facebook that he was leaving his current group practice to start a retainer practice. I have visited him as a guest lecturer in the past, and we either talk or exchange messages periodically. This announcement piqued my interest so I arranged to call him and learn more. He has given me permission to tell his story.
Donald proceed to tell me a classic burnout story. I suspect all my readers know that physician burnout is an epidemic. Donald's story is classic. As family physicians and internists increasingly become employees, the practice leadership defines rules and expectations. Most such practices embrace electronic records.
How did that impact Donald? His schedule included 20-minute increments. Between patients he would try to write his notes and handle electronic tasks. He noticed that he was becoming increasingly unhappy with medical practice.
With the growth of hospital medicine, he (like many internists) quit following his own patients in the hospital.
His tipping point came when a patient's daughter fired him because he no longer spent enough time interacting with her mother and her. She opined that he had changed from the enthusiastic young internist they once knew.
With great soul searching he decided that he needed a different style of practice, 1 that allowed him to rediscover his joy of medicine. The article linked above said it well: “Physicians are getting tired of the “turnstyle” medicine they are being forced to practice—seeing more patients in less time—rather than building the relationships that inspired them to enter the profession. Increasingly, however, the physician-patient relationship is being supplanted by the economic demands of a medical machine.”
So Donald spent 4 months saying goodbye to some patients, arranging a new physician to see them, and recruiting some patients. He told me that many patients were more than willingly to pay the retainer fee to follow him, but that others chose not. He did not think that personal wealth was the deciding factor.
He now works in a free clinic a half-day each week and is planning to do some mission work with his church. He wrote about a recent day: “By the way, went to the hospital to see two patients today after my 7:00 am Pharmacy and Therapeutics meeting (required to keep my privileges)..met with the rounding Hospitalist and gave them background info who seemed surprised and pleased to have some help…saw my patients (who were appreciative) and went back to my office to see my 9 patients today….who says I am not busy!”
My colleague, Tom Huddle and I, wrote about the ethics of retainer practice in 2011. In response to numerous letter we responded and included this concluding paragraph: “Although medicine is not just a job, it is, contrary to Dr. Webster's view, business as well as service. We should welcome retainer medicine, integrated health care systems like Kaiser Permanente, and other attempts to combine high-quality health care with physician and patient satisfaction. And we should permit physicians to make their own decisions in regard to political participation and the importance of societal health compared with other societal goods. Physicians who form retainer practices should offer some free care; if they otherwise conduct their medical practice in conformity with the ideals of professional ethics (excluding any putative bearing of professional ethics on politics), they are exhibiting anything but ‘a rather thin view of moral responsibility’. In performing exemplary professional work, they are providing society exactly what it asks of them and, in so doing, giving the medical profession everything that our profession should demand of us.”
Donald's story speaks loudly. He is a very dedicated primary care internist. As we talked I could tell how making this decision involved great self-reflection. We talked about the joy of being a physician and how the many administrative burdens and payment requirements had sucked the joy out of his career. He told me how happy he is spending adequate time with his patients. His patients all have his cell phone number. He calls them to discuss their test results. He has returned to practicing the medicine we trained him to practice. He sounded relieved and very happy, looking forward to many productive years.
My friend and colleague, Yul Ejnes,MD, FACP, recently wrote about the quadruple aim. The fourth aim involves health care workers health, especially mental health. As he writes:
Improving the care of individual patients, bettering the health of populations, and lowering health care expenses—that covers everything, right? Not so, according to Drs. Thomas Bodenheimer and Christine Sinsky. In 2014, they published a paper in the Annals of Family Medicine titled “From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider.” In it, they very effectively made the case that our ability to achieve the triple aim is jeopardized by the burnout of physicians and other health care providers. They proposed adding a fourth dimension to the 3 in the triple aim: “the goal of improving the work life of health care providers, including clinicians and staff.”
A TV series from the late 50s and early 60s featured this line in closing: ”There are eight million stories in the naked city. This has been one of them.” We do not have 8 million physicians, but we have many. This rant tells the story of one physician. He is not alone.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
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Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
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Other blogs of note:
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
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The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.