Last time, I wrote about some of the challenges of being a community physician in a solo or small group practice. In this post, I want to focus on what the “doing” of Family Medicine feels like to me, based on my brief glimpse. Before I begin, I want to foreground my experiences by acknowledging that I’ve only seen one practice, in one particular (and particularly litigious) part of the country. However, based on speaking with other students, I’ve heard some similar things at other places. Your mileage may vary.
IMPORTANT NOTE: NONE OF THE PATIENTS DISCUSSED IN THIS POST ARE REAL. THEY ARE COMPOSITES, ANALOGIES, AND ANY RESEMBLANCE TO ANY ACTUAL PERSON OR ENCOUNTER IS PURELY COINCIDENTAL. THE PRACTICE SITUATION I DESCRIBE IS ALSO A COMPOSITE AND ANY RESEMBLANCE TO ANY ACTUAL PRACTICE IS PURELY COINCIDENTAL.
What is the practice of Family Medicine Like?
THE CAST OF CHARACTERS: The clinic I worked in is a solo practice with a very pleasant lady who is the lead MD and owner (“the Lion”) and several salaried NP, PA and even a couple DOs (“the Giraffes”) who work more or less independently depending on the situation. This is a contrast to the previous practice I worked in, where the NP and PAs would constantly (>5x/day) call in their MD or DO colleagues to confirm and oversee their work. There are a few (1-2) full-time equivalent RN and several (3-6) full-time equivalent MA positions (“the Acacia Trees”). The RN’s seem to do mostly phone triage, call-backs and the rare procedure or two. The MA’s do most of the direct patient-facing support work (vitals, blood draws, EKGs, etc). In addition, there are 3-6 front desk staff, billers and coders (think of them like the soil under the trees, the roots of Mt. Kilamanjaro … you get the picture) who really keep the place running.
THE SCOPE OF PRACTICE:
As you may be able to infer, this practice only sees adults and adolescents over the age of 13 (and, for all practical purposes, they are usually over 18). No pregnant women, no kids, no pelvic/breast exams, no growth charts. Oh, and not too many elderly (>80 y/o) patients either. All in all, it seems like a pretty accurate slice of life covering folks from 20-80 years old. This means that I have to do a lot of studying on my own, though, since the Family Medicine boards encompass both young children and basic OB, as well as some emergent/urgent care topics that this practice avoids.
A TYPICAL DAY IN FAMILY MEDICINE:
Well, today is monday, so I’m sitting in starbucks avoiding a drenching rainstorm (really? in August?) instead of working. That’s because my preceptor (supervising/teaching MD) only works 30 hours a week. Fine by me, I have more time to spend with my girlfriend and our dogs, and I can keep up with the board review questions I have to do to cover all the topics we don’t see in clinic. If it were tuesday, here’s what it would look like:
7:00 AM Wake up, let the dogs out, shower and get dressed.
7:30 AM Drive to starbucks and eat breakfast, then do 30 board review questions or a couple online cases to study
8:25 AM Drive to clinic, which starts at 8:30. No need to pre-round or show up early: there would be nothing to do.
8:35 AM First patient walks in. It’s a quick visit since they just came in to have their blood drawn (but we get to bill it as an “expanded” visit if we examine them … we’ll see them again if they have any abnormal lab test results in two weeks for another “expanded” visit). The goal for the seasoned NP/PA’s would be to get in and out in less than 10 minutes. My goal is to actually counsel Mr. Alberts about something positive, however brief, and make sure there isn’t anything acutely wrong with him (there almost never is, with the emphasis on almost). Since even brief counseling, as opposed to mouthing “eat a low fat low cholesterol diet and stop smoking”, takes 5 minutes, it often takes me 10-15 minutes for these visits. Importantly, it also takes me longer because I don’t know these patients as well and I have to take a few minutes to read their chart before I go in. The charts are truly difficult to comprehend and none of them have problem lists, so I often just flip back to the last annual physical and hope I can read the previous person’s handwriting.
8:52 AM Finish writing my note on Mr. Alberts (he’s generally well), while waiting for my preceptor to come out of his second visit of the morning. The waiting often lasts 5-20 minutes, but today I get lucky and it’s only a brief while. My preceptor and I go in together after he reads my note.
8:55 AM We leave Mr. Alberts after Dr. Barney confirms my exam, I print out Mr. A’s prescription refills, and he makes an appointment for followup in a few weeks or months depending on the plan. Four patients are waiting to be seen: two “total physicals”, a “lab visit” and a surgical clearance. I ask if I can take one of the total physicals. The goal of the physical, as far as I can tell, is to do the same exam for every patient in the shortest time possible (less than 15 minutes). I never succeed, mostly because I talk to the patient (actually, I ask very brief open-ended questions and spend 95% of the time listening).
9:00 After struggling to read the previous chart note, and looking over the history form that the MA has filled out (which is usually horribly incomplete, for example: there is no “checkbox” for diabetes in the Past Medical History section), I knock on the door and enter after a few seconds pause. Mrs. Jiminez is a pleasant looking obese 32 year old hispanic lady with a gown tied, but open to the front. I’ll just say this: the exam gown is one of the most dehumanizing things that we do to people in medicine. Even the “covered” parts are barely concealed thanks to the cheap, translucent paper. At this practice, the medical assistants ask patients to change into the gown BEFORE the physician enters (instead of having the patient change after the physician takes their history). And although the gowns are one-size-fits all, they barely fit the largest size patient, particularly when they worn open in the front (which is needed for an EKG, but not for a physical).
From the moment I walk in the room, Mrs. Jiminez gives me a quizzical stare, sizing me up. When I introduce myself as a medical student, and ask if it would be alright if I speak with her until my preceptor is ready to come in, Mrs. Jiminez hesitates for a second. Whenever this happens (approximately 1 in 5 patients), I immediately interject and rephrase my question as “Would you prefer to wait until Dr. Barney is ready? It’s important that you are completely comfortable here.” Roughly one in three patients either say yes or hesitate long enough that I understand their meaning, and immediately step out. In this case, Mrs. Jiminez is in the majority, and says that she understands that it is important that students learn, since she was once a student herself, but she wants to make sure that she will in fact see one of the doctors since “every time I come here it seems like I don’t see them.” Yeesh, we’re not really off to a good start. I ensure her that Dr. Barney will be in to see her after I’m done with my exam, or whenever he is ready, whichever comes first.
And, then, we’re off to the races. As per standard practice, I start the interview with open ended questions “What brings you here today?” “How has your health been recently? Any changes since your last visit here?” “Tell me about a typical day in your life?” and get more specific as we go on. Mrs. J. is embarassed to report that she has a new sexual partner (“If I had only come in two weeks ago, I wouldn’t have to say yes to that question!”) but seems candid about basically every aspect of her life. As the interview progresses, I am surprised at how easily the questions come to mind. I glance at my watch and realize 15 minutes have elapsed, and I try to wrap things up and move on to the physical, asking Mrs. J to turn her gown around to the front (so that only the back is open).
Time to think as I recheck her blood pressure, pulse, respiratory rate and assess her general condition, grooming, think about her mental status based on the history. BMI 33, BP well controlled on meds to 130s/70s, no history of hyperlipidemia or hyperglycemia, non smoker. Guess I’ll examine some cranial nerves (my preceptor does this, probably just so that we can write PERRLA EOMI), but not in a rigorous fashion because she has no neurologic complaints or deficits and I’m supposed to be out of here in 5 minutes. Rule out sclera icterus, pale conjunctiva, look in the ears and oropharynx.
Abuse her fundi with the ophthalmoscope – YES! OPTIC DISCS! THIS IS SO AWESOME! I can’t contain how happy I feel – the first time I’ve really seen a pair of optic discs in a living breathing, non-actor patient, without a teacher basically holding the ophthalmoscope. No hemorrhages, cotton wool spots, AV nicking, discs sharp. I share my joy with Mrs. J, who looks back at me with bemusement and politely asks if I am done blinding her. First do no harm … right … sorry Mrs. J.
Check out the neck, thyroid, bruits, lymph nodes, range of motion, tenderness. Listen to the lungs and heart (why? mostly so that I can have a minute to think about what else I should be doing. What’s the yield of looking for a new II/VI murmur in an asymptomatic thirtysomething year old … probably pretty low ). Check out the abdomen (think, inspect, auscultate x 6, percuss liver, and palpate x 6) after asking the patient to lie down and re-drape. My preceptor doesn’t do this, choosing instead to either examine women over the gown (I am not okay with doing this) or lifting their gown (also unacceptable, reveals the undergarments and ladyparts, and just overall feels creepy. I get super-uncomfortable when he does this even in men … honestly how hard is it to take the five seconds and show the patient that you are at least *thinking* about preserving their dignity …). Ask the patient to re-adjust her gown (while I turn around and write some notes in my most leigible scribble) and sit up by the side of the bed. Reflexes (why do we even check these in asymptomatic patients?), then musculoskeletal exam and some brief neurologic assessments (romberg, pronator drift, sensation, proprioception). Is there evidence for any of this actually making a difference? Silence the skeptical voice, finish the exam, resolve to look some of this stuff up when I get home tonight if I’m not completely exhausted when I’m done studying.
After I walk out of the room, though, it’s easy to think of dozens of things I could have or should have asked about. Seatbelts. Bicycle helmets. Guns (we’re not in Florida). Swimming Pools. McDoubles with Cheese. tDAP boosters. Action Plans. Should I have checked her gait? It’s a lot for a student to juggle (and, my preceptor never asks any of these questions). Usually (and this visit is no exception), I pop back in to ask one or two extra questions after I am done. This is generally considered poor form (it’s “illegal” in our graded standardized patient encounters), but I’d rather lose style points than miss something important or valuable.
While we’re waiting, Mrs. J gets an EKG, pulmonary function tests, tympanogram and audiometry. This is where Dr. Boss Lady’s practice makes most of its revenue. Although an annual physical might only fetch $40-$60 from managed care, having a medical assistant set up an EKG, PFT or T&A (as I like to call it) can double or triple that.
9:28 Present Mrs. J. to Dr. Barney. Totally ham-handed and awkward. Summarizing patients is still very hard for me. I always forget at least one important detail or get something backwards, and I’m usually rewarded with the “you’re a fucking idiot, what is taking you so damn long” look that I have come to know and love … As we leaf back through the chart together, I realize that there is something weird about her last physical exam sheet – I can actually read it! That means it wasn’t filled out in Dr. Barney’s handwriting, except for a few choice scribbles that I can’t read. That means that Dr. B went back in to see that patient after someone else saw them … that means it was a medical student … and it hits me. This is why she was complaining about never seeing Dr. B. or The Boss Lady – Mrs. J comes once a year for a physical, always in July or August, and always gets a medical student to examine her. Sucks.
9:35 Dr. B. bangs out a brief over-the-clothes exam and Mrs. J is on her way to collect her prescriptions. Not too bad for an 8:30 appointment, but we’re now six patients behind.
The rest of the day is a blur – I probably see 12 patients on my own, another 12 with Dr. B, and Dr. B sees twice as many without me, in addition to my patients. We get an hour for lunch, where I eat horribly unhealthy pizza or fried something or other that pharma reps have ordered for the office. More than 100 patients come through the doors on a typical day when two “providers” e.g. DO, MD, NP or PA’s are working.
4:17 PM As quickly as it started, the deluge slows to a trickle, and after the last few patients are ushered out the side door, I’m given leave. I take it. One of the rules of medical school: eat when you can, sleep when you can, study when you can, but most importantly, leave when you can.
DOWN THE RABBIT HOLE
Every patient with a medical concern other than essential hypertension or impaired glucose tolerance has a specialist for each medical problem. Every abnormal or borderline EKG gets an echocardiogram and 24-hour holter monitor. Every abnormal PFT result gets chest XR’s and antibiotics. Every cough gets antibiotics, albuterol and chest XR’s. Every afebrile sore throat gets broad-spectrum, top-of-the-line antibiotics. Every recurrence of a UTI gets sent to nephrology/urology. Every dizzy patient gets sent to neurology. CT abdomen-pelvis C & S contrast is ordered several times, on women, men and even an unlucky stray dog who wandered into the exam room and peed in the corner (obviously stress incontinence…). Sometimes I wonder if I am living in a parody of evidence-based medicine.
The dissonance is dizzying: while at work, I have to put on my blinders, pull out my referral sheet, and get the radiology reports ready. I order PFTs and EKGs on healthy 22 year olds, and then order echoes and holters when they have sinus bradycardia. I know exactly what antibiotics I should be giving (or, exactly when I shouldn’t be giving antibiotics), but I ignore that voice and type “levaquin #20 BID” into the prescription computer. When I leave, I put my blinders away, and click option C (“treat with reassurance”) when presented with a 19 year old comfortable-looking afebrile female with a mildly erythematous oropharynx, headache and cough. I suppose it’s good practice for the world of inpatient medicine, where I’ll have to learn how to satisfy the whims of different attendings. But man, its a trip …
The past two weeks have been a blast. I feel like I am finally settling into a rhythym where I can learn, work and have somewhat of a life (although my workouts have suffered a bit since I’m prioritizing studying over working out). That is very do-able with family medicine.
Family medicine is a hell of a speciality. If done right, it’s one of the most challenging things out there. Your patients come in fresh, they haven’t been worked over by a dozen specialists, and you have to decide what to do with them. That’s a lot of responsibility. Did I mention that you’ll have to learn and re-learn the mercurial preventative services guidelines for every possible permutation of patient (43 year old never-smokers who worked in a shipyard, were born in Equatorial Guinea, and are ocassionally sexually active with martians … no problem!) and every possible family and social situation. Deliver some babies, splint some thumbs, admit patients to the hospital, round on them, discharge them, and then go back and do it all again the next day.
If done wrong, it’s a dreary exercise in punching the clock and not getting sued. Thanks to all of the pressures mentioned in part 1 of this post, much of the Marcus Welby family doctor model has been thoroughly demolished. What is left is seldom pretty to watch, if you have any idea what you’re looking at. Concierge medicine looks pretty good in comparison to some of the practices out there. There simply isn’t time to think, have respectful and human interactions with your patients, and make a living that will pay malpractice premiums, medical school debt, and leave you with enough to support a family as a single wage earner, without working at least 60 hours a week for the rest of your life (for those of you watching at home, that means 7a-5p Monday-Saturday). Probably more like 80 hours a week if you really do it right.
In conclusion I don’t think traditional private practice family medicine is for me. I don’t want to run a small business. I like managing people, but I don’t like being in an isolated environment. I want to be in academia. I want to be pushed every day. That said, there are things that I like about its scope, breadth, and the relationships you can form with your patients. There are times when you really get to think, if you can afford it. Three thousand words later, that’s all I’ve got for now.