I just had a very, very frustrating day in my family medicine clinic, to top off a relatively frustrating week. I think I’ve learned a lot about the kind of doctor I want to be, and the kind of practice I want to have, over the course of the last two rotations.
1. I don’t mind high volume outpatient primary care as much as I thought. I would have thought that I would be put off by the demand to see patients in 15-20 minute chunks, but the reality is that 75% of the patients can actually be adequately addressed in that timeframe. 90-95% of the diagnosis is made by history taking, with physical exam adding little (and, in fact, often only muddying the waters in the rare event that there are significant findings). The other 25% of patients, though, really do need more than a 15-20 minute appointment, although seldom more than 30-40 minutes. Banging out a complete physical (including a relatively complete neuro exam) in 20 minutes, with another 20 minutes for history, is definitely do-able.
2. Today, I was seriously criticized for eliciting a relatively serious complaint on Review of Systems that was unrelated to the patient’s chief complaint. As a naive medical student, I’ve been asking all of my patients review of systems questions just like they taught us in medical school. Lo and behold, this one guy had new onset PND + chest pain last week and never told anyone (his next appt with cardiology was in several months). Then I got yelled at when I told my preceptor what I had found. Yes, that’s right, instead of being praised for finding a potentially life-threatening condition that would have gone undiagnosed for months, I was criticized for “eliciting complaints” and exposing the practice to some nebulous medicolegal liability, or creating more work for people during lunch (it was 1:02 when I went in to see the patient, and this practice takes an hour for lunch every day from 1 – 2 …). Now, I wouldn’t even remark on this if it wasn’t completely and totally in keeping with what I’ve observed over the past week. Which brings me to …
3. I don’t want to work in an environment where physicians or staff constantly bitch about their patients. I find those sort of comments absolutely soul crushing. I’m not saying that you have to love every patient, or every bad decision, that walks in the door. But if it seriously bothers you that a woman tells you she’s 59 and a half instead of 59, or when an elderly lady wants to talk for an extra ten minutes, I don’t want to be within earshot of you. Ever. Yeah, I know, everyone is busy all the time, and all those LOLs in NAD can make you run late, but the goal isn’t to get THROUGH your patient list for the day, the goal is to actually make a positive difference in their health. I humbly submit that you cannot do that if you are constantly (and I do mean constantly) complaining about them.
4. Enough already with the antibiotics! 20/20 afebrile patients with a CC of ear pain, cough or throat pain received antibiotics. I have never seen anyone treated with symptomatic therapy.
5. Enough already with the diagnostic tests! I’ve seen more screening CXRs and PFTs ordered on asymptomatic patients than I care to count.
I have learned a ton about myself and the kind of medicine I want to practice. I can’t wait to see what tomorrow will bring …