In the first post of this series I described the Dream of Family Practice: the idealized notion of a career as a family doctor, delivering babies and seeing patients through the life span. The DoFP was such a strong motivating concept, I ended up training for rural practice despite my school's strong urban/tertiary care orientation and my mother's strong objections--she didn't want me to move away from the city where she lives. Yet the DoFP was stronger than all of these influences, and within a few years I was in Rural starting my first job. This post describes how the reality diverged from the dream.
When I arrived in Rural I was determined to do it all: see patients for primary care, admit them to the hospital, assist surgeries, deliver babies--everything. In fact, this is what I did for the first three years post-residency. I was employed by a federally-funded clinic where I saw adults and children for primary care and pregnant women for prenatal care. I did I&Ds, skin biopsies, colposcopies, IUD insertions and endometrial biopsies. I saw patients for 30-32 hours per week, slugged through charts and paperwork another 10 hours per week, and took call every Thursday and one weekend per month.
At first it was great fun: I'd leave the house early to make hospital rounds, go to my morning clinic, do paperwork over the lunch hour, see patients in afternoon clinic, finish paperwork after clinic closed, and return to the hospital to check up on studies and consultations which I'd requested in the morning. If I was on call, I admitted patients and delivered babies in the evening and into the wee small hours of the morning. For a while I tried to go to clinic after being awake all night--after all, I'd done this during residency--but soon I noticed other doctors cancelled their clinic after a long call night, and pretty soon I started doing this too. No sense in seeing your patients if all you can do is fall asleep on the exam table and leave them no where to sit.
If the only problem I encountered in primary care was the sense of frazzlement which arises from having to be in so many places all the time, I would probably still be doing the kind of medicine I described above, despite the 12-hour clinic days and red-eye long haul of call. As time passed, however, a few other insurmountable problems arose:
1. The patient population was completely different from the one I'd known during residency.
In residency, 85% of the patients I saw were Mexican and spoke only Spanish. Mexican culture respects doctors and health care, so most people I saw in clinic listened to my advice and tried hard to follow it. We were very busy and had few if any resources for referrals, so patients often had to wait in our waiting rooms for a long time to be seen or to have their needs met. Yet there were few complaints or expressions of anger, even though many of them walked or took hour-long bus rides to get to clinic. I loved my patients and didn't mind spending hours after clinic catching up on notes or running half an hour behind schedule because that half-hour was spent showing a newly-diagnosed diabetic how to check blood sugars and keep a diet diary. I felt purposeful and knew I was doing good, even if it was only a small amount of good.
When I moved to Rural, I knew my patient population would be different--dominantly Caucasian but poor and underserved--and all underserved populations are the same, right? Wrong! I hadn't been in Rural for very long before I began to suspect I'd landed on a different planet. I had to learn to deal with
- People who yelled at the front desk staff when they had to wait half an hour.
- People who kept talking on cell phones when I walked into the exam room.
- People who cussed out our triage nurses when they were informed a clinic appointment was required before their prescriptions would be refilled.
- People who stormed out of exam rooms after I told them they weren't going to be eligible for weight loss surgery if they couldn't make basic changes to their lifestyle or diet.
- Disturbed people cursing and threatening clinic staff for what most reasonable people would consider minor annoyances such as waiting for prescriptions to be written or a six-week delay before a follow-up appointment.
Even though I had to rub my eyes in disbelief some days, it appeared I was still on Planet Earth but had somehow fallen in with a community of people who had been raised by wolves. None of the behaviors listed above had ever happened at my residency clinic, and I found myself spending a disturbing amount of time managing people's expectations and making "behavioral contracts" with some of the offenders before I would agree to continue their care. It should go without saying that this is not what I went into medicine to do.
2. The majority of problems I was seeing in clinic involved management of chronic pain, substance abuse and mental illness--not primary care medicine.
I had the dubious pleasure of inheriting dozens of patients from a local doctor who'd changed his practice to accept only prenatal patients and holistic medicine consultations. All of his patients were told to find a new primary care physician. A few of his patients I ended up taking on included
- A 57 year-old woman with a diagnosis of fibromyalgia who was taking a high dose of OxyContin three times a day as well as Ritalin for what was described as "chronic fatigue."
- A 45 year-old man seeking "permanent disability" for relatively mild carpal tunnel disease for which he refused to continue hand therapy and for which he paid out of pocket for acupuncture, expressing his dissatisfaction with the Worker's Compensation program for "refusing to pay for the treatment of my choice."
- Several patients on truly disturbing combinations of opioid medications. One regimen I can recall involved Duragesic, methadone, Percocet and oral Dilaudid--two long-acting and two short-acting opioids prescribed in the same patient. I'm still scratching my head trying to figure out the rationale for such a regimen. The patient's diagnosis was cervical spondylosis, but all available imaging showed no significant anatomical abnormality.
In this doctor's defense, the majority of patients I inherited from him were highly-functioning, delightful people who truly needed primary care. But I spent most of my time dealing the problems of the minority of his patients who were on bewildering medication regimens or who felt the health care system owed them a certifcate of permanent disability.
To make the situation worse, Rural County is known for one of the highest ratios of Schedule II prescriptions per capita in the country. A certain, critical minority of those Schedule II prescriptions are diverted to illegal street sales, so if you are a doctor in my community who wishes to provide enlightened pain management to legitimate patients--and they do exist--you must involve yourself in the kind of surveillance parole officers do: random drug tests, pill counts, difficult confrontations, and punitive measures. I took on the care of a man who suffered from back pain but never seemed to make it to physical therapy or radiology appointments. He was taking a moderate dose of OxyContin twice a day. I suspected him of diverting a portion of his prescription to the street, so I insisted on a narcotic "contract" which permitted urine drug testing. On the first attempt to get a urine sample from him, he diluted the sample with water so it would return a negative result (dumb thing to do--we check the temperature of a urine specimen to make sure it is fresh). On the second attempt, the test was positive for methamphetamine. That was the end of our primary care relationship, not that any primary care medicine had ever taken place between us. Needless to say, this is not what I went into medicine to do.
Finally, Rural County is home to the usual number of mentally ill people but suffers from the absence of any effective mental health service infrastructure. For Medicaid patients, the only available mental health care is a walk-in screening at a downtown crisis clinic. There are only three psychiatrists in the area and they see insured patients only. A revolving door of locum tenens staff the small inpatient psych ward. The local psychotherapists only accept Medicaid for pediatric referrals. So the bulk of ambulatory mental health in Rural is provided by primary care providers. My FQHC clinic offers brief psychotherapy in an effort to provide some kind of support, but our mental health program is precarious at best--high staff turnover, no psychiatric support for medication consultation, and a very acute population really stress any system. I can't tell you how many times I've walked into an exam room and had a patient burst into tears or tell me of disturbing hallucinations, and then been told there was nothing we could do. Any help I could offer them came at the expense of hours on the phone arguing with the county's mental health providers. Needless to say, psychiatric case management is not what I went into medicine to do.
3. The primary care community, including my family practice colleagues, didn't believe in the DoFP.
The DoFP depends to a great degree upon a team concept. I had a great team of young doctors to work with when I was a resident, and even though there were a few people who let me down, most of the time I knew my team had my back, and they knew I had theirs. We used to see each other's patients in clinic when the on-call residents had to run to an emergency, and do admissions for each other when a service resident was getting crushed to death. When I was chief resident, I told the interns, "Medicine doesn't work unless we help each other" and I meant it.
It was a crushing disappointment, therefore, to discover that my fellow family doctors--the backbone of primary care in this community--didn't subscribe to a team approach at all. We shared inpatient call within the FQHC network, and the number of times I had other doctor's patients dumped on me or received snide remarks about my inpatient management was astonishing. Even worse, within my clinic the doctors had widely-diverging styles of management and some refused to take care of issues arising in other doctor's patients when the other doctor was sick or out of town. For example, when my colleagues are on vacation, I sign home health orders, refill appropriate Schedule II medicines, adjust warfarin doses for sub/supratherapeutic INRs and levothyroxine doses for abnormal TSH levels. Just part of the team service. However, whenever I went on vacation, I returned to an inbox full of charts on which "Save for Chan" had been written across the same kinds of requests. Whenever we tried to discuss this issue at our provider meetings, I was told the others didn't "feel comfortable addressing these issues" on patients they didn't know well. Oh, sorry the practice of primary care medicine within a group practice is beyond you, dear colleague.
I ended up feeling completely unsupported and exploited by the very people who should have had my back, and whose backs I certainly protected before my illusions were shattered. This was a huge reason for my decision to leave primary care. When I started hospitalist work, I rediscovered an element of team spirit, and this has saved rural medicine for me.
4. I couldn't achieve my personal goals on the maximum potential salary in primary care.
I've discussed some of the financial realities I've had to confront since becoming a fully-fledged doctor in the MEconomics post series. I don't plan to rehash all of these here. The main point to understand is the maximum annual salary I could expect to earn doing the DoFP at my FQHC practice is $116,000. This amount depends upon the following assumptions:
- 36 hours of direct patient care per week
- 4 hours of paid administrative time--the actual number of hours spend doing administrative tasks is closer to 10 or 12 per week
- 4 weeknights and one Sat/Sun weekend on call every month, for which I would be paid for 18 hours of work
- 35 births per year (about 3/month), each of which reimburses $300
- 2 weeks of vacation per year
- No cancelled clinics. (We are not paid for clinics we miss due to inpatient responsibilities.) All of the 35 babies I mentioned earlier would have to be born between 6-8am, 12:30-1:30pm, or 5pm-2am on weekdays for this to happen.
Now, the FQHC job included a minimal benefits plan--50% of Blue Cross health insurance, $1000/year of CME money, 503b plan (own contributions only), and profit-sharing (which amounted to all of $2000 for 2006, 7-year vesting)--so the actual value of the job is about $125,000 if you include the benefits. I received two years of tax-free federal loan repayment at $25,000, which translated into about another $32,500 of benefit during those two years. So my job was worth about $157,500 during loan-repayment years, assuming everything I listed above.
However, remember $41,500 of this amount was paid in benefits only, and didn't result in actual money in the bank. Furthermore, the $116,000 maximum direct salary actually never rose over $95,000 due to real-life practice limitations such as
- Only 30-32 hours of direct patient care per week possible without going completely insane.
- Actual administrative time resulted in a net reduction in earnings, if you break down salary by actual number of hours worked.
- Cancelled clinics are a reality of providing OB care. Family Practice Management editors estimate each birth a family doctor attends results in two hours of lost clinic time, so my (low) estimate of three births per month would translate into six hours lost every month. The true impact of each birth is greater than this, but even accepting a low estimate, these unpaid hours reduce the potential income for attending births significantly.
Now, I'm sure you can argue that $95,000 in direct salary is twice the national average for a two-person family, so surely I can't cry poor--and you'd be right. However, I didn't say my salary wasn't enough for me to keep body and soul together. I said it was insufficient to meet my personal goals, which included home ownership and sustainable lifestyle practices, such as installing a solar hot water and electricity system on my roof. Given the rapid rise in property prices in California between 2001-2004, including Rural County, I could not have bought a house on $95,000 of direct income a year, much less solarized my lifestyle.
I might have compromised my personal goals if I'd felt my work with Rural's under-served population was resulting in any significant good or even a moderate degree of professional satisfaction, but it wasn't. And as the doctors in my FQHC network wanted to shed their inpatient responsibilities, it made sense for me to turn my efforts to inpatient care. After all, I rationalized, I'd be taking care of the same patients, only I'd be seeing them in the hospital, where their primary care doctors didn't have time to see them. In a way, I was still providing a crucial health care service in the community. This made the decision to give up primary care a tiny bit easier.
So I became a hospitalist and reduced my role in clinic to prenatal care only, and so far I have few regrets. In the next post in this series, I'll discuss those regrets in more detail and brainstorm solutions that might bring me back into the primary care fold later in my career.