The feeling of outpatient medicine

So, after a mighty two weeks on the job in a single clinic, I’ve decided that I’m qualified to say what life is like in outpatient adult medicine (and, if you’ll buy that, you’d love my oceanfront property in Arizona at this time of year).

1. It’s busy. I don’t have any downtime. We don’t get coffee. We don’t schmooze. Some days we eat lunch for 20 minutes. There is some driving between hospital and clinic and other clinics, but the days are full. There’s not really any room for second thoughts or any decisionmaking – whenever you have a free minute, there’s either another patient or more paperwork to fill out.

2. The hours aren’t overwhelming, but they aren hardly cushy by real world standards. Most days are 8 -6 or 9-7 (eg 10 hour days), and I don’t even have the regular call responsibilities. I also get to leave when only paperwork and phone calls remain, so my preceptor stays probably an hour later than I do and sometimes starts an hour before I do. And the pace is completely unlike office work (see #1).

3. Optimizing work flow is the sine qua non of outpatient medicine. It’s a complicated business, requiring a staff with a diverse range of skillsets. Still, one monkeywrench in the system can result in incredible delays. EMR seems to be pivotal but no one has it (my practices this month do not have EMR and the hospitals only use it in a weird hybrid system which seems to be ugly and unpleasant).

4. God it would be nice to not have to deal with a thousand different pharmacies, twelve different EMRs, eighty insurers.

5. A good primary care physician is really unlike any other. It’s a rare breed – you have to have the humility to refer many of the more interesting (read: esoteric) conditions to specialists, but then ultimately your patients will often come back to you for a second opinion, so you will be accountable for your opinion. You have to be on the ball, coordinating complex care for (often difficult) patients. You have to know your bread and butter drugs. And, no two primary care physicians are the same – some practices are basically geriatrics, some are mostly healthy young folks, some are a mix.

6. There is a certain beauty in having a relationship that evolves over time with your patients. It gives you an incredible leeway to take the long view regarding their medical problems. Since you know your patients will be back, you don’t have to tackle everything at once. You don’t have to have the definitive answer for everything at every visit, but you do have to continue helping your patients make positive steps toward managing their problems.

7. Curing disease is rarely an option on the table. Controlling and managing disease is (almost always) the goal. It can be frustrating that patients expect you to give them medical solutions for what are often problems with social / behavioral etiologies (e.g. CAD/HTN/DM secondary to our preposterous american diet and our ballooning BMIs). At the same time, you can offer these patients the opportunity to live into their seventies and eighties, and sometimes even beyond.

8. Patients are agents and not passive slabs of meat. They ask questions and make decisions every day that influence your treatments, both obviously (bumping their INR) and insidiously (“just a 5 pound weight gain”).

So, in conclusion, here are some themes from my first two weeks of outpatient medicine clinic at University Medical School:

1. It’s a busy and demanding work – not for the faint of heart.

2. You have to enjoy working with your patients, in spite of their choices.

3. You have to be comfortable with management instead of cure, relationships instead of one-shot deals, and active patients who don’t always make the decisions you would want them to make.

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