I walk into the exam room and the patient looks up at me with a surprised expression.  ”Wow!  I didn’t expect to see you so quickly!”

I smile and turn around to walk out of the door, saying: “Sorry!  I’ll leave then and come back later.”

“No, no!”  They respond, smiling.  ”I’m happy to see you so soon.  It’s just a surprise.”

I walk back into the room with a smirk.  ”I just don’t want to offend you by being on time.  I’ll try to do better next time.”

I am not sure if I should be happy or sad with such an interchange.  On one hand, it feels good to stay on time with my appointments, holding up my end of the bargain of the schedule.  On the other hand, the patient’s surprise betrays the fact that this is not the usual state of affairs.  And it isn’t.  I generally don’t run on time and don’t expect to run on time.

When I first started practice, the stated objective was to get the person out of the office within an hour of their scheduled appointment.  This seemed a blend of realism and responsibility.  At first it was easy to stay up on things.  My schedule was sparsely filled, so I could make up time.  After sixteen years of practice, however, my schedule almost never has open slots; when it does have openings, they are quickly filled.  I still try to get them out within an hour.

I have patients scheduled, with a few notable exceptions, every fifteen minutes regardless of the appointment reason.  I don’t expect to spend exactly fifteen minutes with people; some will be quick visits lasting 5 minutes and some will take 30.  Usually this averages out to keep me within 30 minutes of the scheduled appointment – something I’ve grown accustomed to.  Some days, however, conspire against my best attempts to stay within a reasonable timeframe.  Everyone is complicated or needy on those days, and I can get 60 minutes or more behind.  I absolutely hate it when that happens.

But as guilty as I feel admitting this fact, I don’t think I will ever change things.  Some docs are obsessed with not falling behind.  I can respect that, but for me it is far more important to give every patient the time that they need.  If I have to spend 45 minutes talking to someone, I do.  My patients have learned this: they will always get my full attention and won’t be rushed.  I do respect the fact that others have their own schedules, but the purpose of the visit is to handle their medical problems.  I don’t want to hurry through a visit so I can stay on time, missing important things that take some focus or detailed questioning.

This is very hard when I am running behind.  It’s hard not to feel rushed when you are already apologetic about being behind, but that is when I am most vulnerable to missing things, and I don’t think people should be short-changed because folks earlier on the schedule took longer.  It all ends up making it hit-or-miss when people come to see me.  Sometimes I am right on time, and sometimes – especially at the end of the afternoon – I am significantly behind.

My long-term patients understand this.  They know they always get as much time as they need, even if it puts me more behind.  They understand that I get behind because of the time I spend.  They know I will chat with them and won’t get rushed.

New patients are usually surprised they get as much time as they do.  This makes me wonder what other docs do, as I am just trying to do what needs to be done.  I suspect it is because I value the personal interaction and rapport as much as I do the medical knowledge.  I am building relationships, so I will always chat, find out what’s going on in people’s lives, and learn about them personally.  Primary care is for the long-haul, and it helps to know as much as possible.

I do write blog posts between patients (like this one), because much of my best stuff comes out of the raw emotion of the office setting.  I try to do it in small chunks, mostly when I’m waiting for people to be brought to the back, or when I’m waiting on some test results.

The bottom line?  I won’t sacrifice being thorough for being on time, and I think one of the biggest parts of being thorough is to talk – even if that talk is about their grandchildren, vacation plans, or job situation.

Gotta go.  Got a patient waiting….

Dear Student:

Thank you for your consideration of my profession for your career.  I am a primary care physician and have practiced for the past 16 years in a privately-owned practice.  (At some point I intend to stop practicing and start doing the real thing.  It amazes me at how many patients let me practice on them.)

Anyhow, I thought I’d give you some advice as you go through what is perhaps your biggest decision regarding your career.  Like me, you probably once thought that choosing to become a doctor was the biggest decision, but within medicine there are many options, giving a very wide range of career choices.  It is the final choice that is, well, final.  What are you going to do with your life?  ”Being a doctor” covers so much range, that it really has little meaning.  Dr. Oz is a doctor, and he has a very different life from mine (for one, he’s not the target of Oprah’s contempt like I am – but that’s a whole other story).

Here are the things to consider when thinking about primary care:

1.  Do you like talking to people who are not like you?

Primary care doctors spend time with humans – normal humans.  This is both good and bad, as you see all sides of people, the good, bad , crazy, annoying, funny, and vulnerable sides.  If you see mental challenge as the main reason to do something, and would simply put up with the human interaction in primary care, don’t do it.  The single most important thing I have with my patients that most non-pcp’s don’t have is relationship. I see people over their lifetime, and that gives me a unique perspective.

2.  Do you prefer variety over predictability?

Every room I walk into is different – often vastly different – from the last.  I could be walking in on a crisis or a stable recheck.   The person could be elated or crying.  They could be 90 years, or 2 days-old.  They could have something wrong with any system, and it could range from mild to life-threatening.  I’d go nuts doing the same thing every day, be it looking just at skin or just dealing with the kidney.  But some folks do better with routine and a lack of surprise, they don’t want their days to be unpredictable.

3.  Do you need to be in control?

Primary care is not about control.  Those primary care doctors who try to maintain control of their patients are both unsuccessful and unhappy.  Relationships are not always predictable, and much of what PCP’s do depends heavily on the patient’s “cooperation.”  I put the word in quotes, because the word implies that the doctor’s agenda is more important, an implication that I reject strongly.  PCP’s are part of “team patient.”  Our job is to help them, not direct them.  We give them our expertise and they make the final choice.  Surgeons, on the other hand, don’t consult the patient when operating; they don’t depend on patient compliance as they cut a person open.

4.  Are you a people-pleaser?

The flip-side to #3 is that a PCP must always practice good medicine – even if it makes people mad.  You have to learn to say “no” to people who seek drugs, who want an antibiotic, to drug reps who want you to prescribe their products, and to insurance companies that want you to work for free.  We are not co-dependents.  We don’t base what we do on the reaction we get from patients.  Often we are the only ones with the opportunity to tell them the hard truth about lifestyle choices or about their future health.  I deal daily with the consequences of people-pleasing PCP’s, who addict their patients to drugs, who create antibiotic resistance, or who give in to drug reps and give expensive prescriptions where cheaper ones are better.  Please don’t choose primary care if you are a people-pleaser.

5.  How important is social status?

PCP’s have an interesting paradox in their social status.  In the eyes of the public, we are the ones who earn less money and so must have gotten worse grades than the cardiologists and dermatologists.  In the eyes of those same specialists, however, good primary care doctors have a very large amount of respect.  We are actually the ones who run the medical show, using specialists when we think it is needed.  We need to know 90% of all specialties, and also know when we are in the 10% we don’t know for each of them.  I often get “I could never do your job” from my colleagues.  So if outward social status matters (like what kind of car you drive or how big a house you own), then don’t choose primary care.  I am not saying that PCP’s don’t have a good income (98% of my patients would like my income), just that my outward status is not nearly that of the surgeon who operates only on left ring-fingers.

6.  Do you like puzzles?

The term “gatekeeper” got applied to primary care via our friends in the HMO’s, and that term has haunted our profession since.  Good primary care is not simply triaging people and sending them to those who can offer real care.  Some PCP’s do that, but they are both lazy and unambitious.  I do whatever I can to keep people from the specialists and out of the hospital.  I need to know when to send them, but I also need to know what to do before I send them.  This endears me to my consultants, as I am sending only patients who need their expertise.  I know orthopedists will give an anti-inflammatory and probably order physical therapy for shoulder problems, so I do this before I refer the patient.  80% of my patients avoid orthopedists this way, and the ortho docs know my consults are not usually fluff.

But the real challenge of primary care is the fact that I am usually the first to see a problem.  Specialists get sifted problems – I have already thought the situation through and so they get the left-overs.  I don’t usually send people to specialists for a diagnosis, I send them for a specialized treatment for the problem I have diagnosed or strongly suspect.  I am the quarterback, the manager, the lead singer, the director of the symphony orchestra.

7.  How patient are you?

I have to confess that I was not a beacon of patience when I started practice.  That being said, I have learned that one of the most powerful tools in medicine is waiting. We get to see the big picture.  We see people over months, years, and decades, and watch the progression or deterioration of conditions.  I find this most satisfying.  People who were suicidal ten years ago are now cracking jokes and are productive citizens.  One of the biggest mistakes a PCP can do is to value intervention over waiting.  We are caretakers of the big-picture.  Surgeons do their job in a few hours, radiologists in a few minutes, and oncologists in a few months or years.  But PCP’s do their job over the lifetime of the patient.  To me, that’s a plus, not a minus.

8.  Are you compassionate?

Again, this is something that has developed over time for me, but the seed of it was there early in training.  Primary care is about “care” – in all of the definitions of the word.  We care for people because we care.  It does matter to us that people are hurting.  There is a degree to which primary care is a calling or ministry, not just a job.  There will aways be a necessary detachment we have from our patients (for our own sanity), but a PCP who is simply “punching the clock” is both sad and dangerous.  You need to be able to listen and see things from people’s perspective.  You are their doctor, and they are your patients.  The possession is emotional, it is one of caring.  People judge PCP’s on how much they like them and how well they feel listened to.

There is much more to say (read the rest of my blog, as well as other primary care blogs such as Kevin MD, Musings of a Dinosaur, Jill of All Trades, and DB’s Medical Rants for a more complete picture – sorry to those I left off, there are many other good ones).  Any specialist would tell you that a very good PCP is incredibly valuable.  I love my job, as do many of my colleagues.  I want more PCP’s, but I only want you in my field if you’d raise the average.  We need good PCP’s.

Come join the fun.

From Wikipedia

My recent post on the subject of emails from patients raised more eyebrows than I expected.  It also put me in a position I am unfamiliar with: looking like a luddite.  Perhaps I am not forward-thinking enough in my reluctance to embrace this advance.  Perhaps I have gotten conservative as I grew grey.  Electronic communication is a great idea (I am doing it right now), so why not apply it to my medical practice?  Has Ned Lud gotten into my circle of influence?

This is, of course, extremely ironic.  I lived so much on the cutting edge that my butt developed calluses.  The calluses, however, were not just put there by the edge, they also came from occasional kicking.  The problem is, I have an addiction: I am addicted to change.  I am constantly looking for new and (perhaps) better ways to do things, then impatiently going after anything new and shiny.  This served us well in the sense that I got us on EMR, got it working well, and have continued to keep us away from repeating mistakes too often.  If something doesn’t work, I am quick to look for the cause, and more importantly, how to fix it.

I had all sorts of good ideas, often many at one time.  But this caused problems.  First, the ideas were sometimes stupid.  Stupid ideas don’t always look dumb before they are tried.  Often changes had unintended consequences which made things harder instead of easier.  The other problem was that too many changes at once causes change burn-out.  People get tired of change, even if the changes are just little tweaks to the system.  After a while I realized that I was actually the cause of many of the exasperated expressions I saw in the office.  I understood the following: a good idea at the wrong time is a bad idea. This has become a mantra for me in the office which has allowed me to sit on my hands when I felt the urge to change.

A good example of this is the tablet PC.  Microsoft had the idea 10 years ago, coming out with an operating system built around a touch interface.  Did it catch on?  Not really.  Why not?  Not because it didn’t work – I used these tablets and they did just fine – but because they didn’t fix an important enough problem.  So are tablet PC’s a bad idea?  Not anymore; ask apple (and the 20 gazillion apple disciples who stood in lines for iPads).

So what about email consults?  Why not take email from patients when it would suffice as an alternative to coming in to the office?  It would save us hassle (I don’t want to see people for unnecessary stuff), would potentially make money (some insurance does pay for it), and make patients happy.  Sounds great.  I want to do it.

But a good idea at the wrong time is a bad idea. We are already emailing labs, allowing patients to request appointments and refills electronically, and getting ready to make some of the medical record available 24/7 online for all of our patients.  We are also in the process of complying with “meaningful use.”  We are upgrading our system to a newer version.  Our plate is full.

But even more importantly, we need to continue offering care.  We have to keep this plane flying while we rebuild it.  People are getting sick and wanting care while we attempt to change.  Implementing e-visits is a huge task – very disruptive of our current processes.  In the long run this should be a good thing, but one of the main reasons we have been successful in not only adopting EMR, but also being quite profitable as a private primary care office, is that we approach change very cautiously.  The bigger the change, the more planning is required.  We do change; we just take time to make sure we do it well.

That’s not Luddism, it’s being careful.

You can get 15% off mens’ scrubs with code “mens_value”

I got a question on the Facebook page for my podcast: What’s a nice thing to do when your doctor is retiring? My PCP is retiring in a couple months and while I scramble to find someone else (he’s given me some recommendations), I wonder if there is some gesture I could make to show my appreciation…

My response was to that a nice note was worth more than any gift.  Then I got a note from the daughter of a patient today:

Dear Dr. Lamberts:

I am the daughter of ….. He is a new patient of yours.  I understand you are responsible for finding the problem with my dad’s cholesterol and I think you for being so alert to something being wrong,  I heard him say many times that you saved his life.

Thank you Dr. Lamberts.  I am forever grateful.

That’s what you should do to make your doctor feel good!  My gut response is, “Of course I was trying to find anything that is wrong.  I am only doing my job.  I’d be upset with myself if I didn’t find his cholesterol!”.  That is true, and everyone should only expect good care from their doctor.  The nature of my job puts me in the position to save people’s lives, so it’s not exceptionally noble that I do it (I think he might have overstated it a bit in this case).  But a word of thanks is always appreciated.

I don’t feel under-appreciated, and this kind of card is not necessary.  There is some benefit to “do my good works in secret,” knowing I am helping people even when people don’t send me cards.  I also know I don’t practice perfect medicine.

This applies to all the people who do us good in life.  We need to be aware of the good others do for us and make sure they know we appreciate it.

Right now, I just appreciate that note.

(Yes, the cards are for sale – by someone other than me – see here for details)

Dr. Wes (a cardiology blogger who all should read) wrote a very compelling post about technology and the bondage it can create for doctors.:

The devaluation of doctors’ time continues unabated.

As we move into our new era of health care delivery with millions more needing physician time (and other health care provider’s time, for that matter) – we’re seeing a powerful force emerge – a subtle marketing of limitless physician availability facilitated by the advance of the electronic medical record, social media, and smart phones.

Doctors, you see, must be always present, always available, always giving

This sounds like dire words, but the degree to which it has resonated around the web among doctors is telling.  He continues:

Increasingly the question becomes – if we choose future doctors on their willingness to sacrifice for others without expectation of appropriate boundaries and compensation – will we be drawing from the same pool of people as the ones who will make the best technically-skilled clinicians? What type of person will enter medicine if they know that their personal life will always take second place to patient care?

Dr. Brian V (long last name, but another one who you all should read) adds his voice to this:

It started with the pager and it’s evolved to real-time social media.

I’ve seen it too many times:  Physicians excited to please open the door to unlimited patient email only to see themselves shutting their families out at night as they answer questions – all for free.  And those physicians who suggest that emails should carry a fee are indicted for greed.

We have been on EMR for 14 years, yet we don’t accept email from our patients.  We could do it, but we don’t – and both of these doctors hit on the head the reason why we don’t.  The goal of IT in our office can be summed up in one word: efficiency. The practice of medicine has become dominated with non-clinical tasks.

• We have to gather information and organize it.
• We have to serve as an “information central” for our patients, collecting from disparate sources to make informed choices.
• We have to comply with the maze of government and insurance industry rules.
• We have to give information to patients and to other medical providers.

So what actually happens in our office is less medicine and more information management.  IT allows us to do this in less time, leaving more time for our patients.

Accepting emails from patients at this point would mean more time spent doing unreimbursed tasks.  Actually, it would potentially decrease our revenue, handling problems outside of the office (for free) instead of being paid for our services.  Doing so would give us three options:

1. Working extra hours to make up for lost revenue.
2. Giving free care via email and just accepting less pay, seeing less patients total.
3. Spending less time with each patient to make up for the decreased revenue.

I am busy enough that I don’t want anyone to have to come in for things I could handle remotely.  Email communication with patients sounds ideal in many ways.  But unfortunately, the business case for this is so bad that we can’t open ourselves up to patient emails.  One answer would be to have a minimal charge for an e-visit ($20?), which would be credited toward an office visit if the e-visit warranted that the person come in to be seen.  The amount needs to be enough to ward off frivolous questions, and would have to be applicable to ALL insurances (including Medicare and Medicaid).

Email also works well with the idea of the “medical home,” which reimburses doctors for overall care of populations.  (I give my opinion on the medical home in this post.)

Until this happens – until we are somehow paid for giving care outside of the office – this useful technology will remain unused.  Is it greedy to not want to give things away for free?  Is it greedy for me to not want to spend less time with my family, make less money, or spend less time with patients?  Is it greedy to think I am worth $20?

If so, you can call me greedy.

I have a unique vantage point when it comes to the issue universal cholesterol screening in children, when compared to most pediatricians.  My unique view stems from the fact that I am also an internist who deals with those children after they grow up on KFC Double Downs.  The AAP’s recommendations are supposed to be forward-thinking, addressing the increased rates of obesity in our country (in case you hadn’t heard) and responding in kind.

The study that raised this issue recently appeared in the Journal Pediatrics, and it found the following (from a report on the study by TIME:

Among the 5,798 children who would not have been screened, nearly 10% had elevated LDL cholesterol levels (above 130 mg/dL), according to the study, published in the August issue of Pediatrics. And 1.7% had levels high enough (above 160 mg/dL) to warrant cholesterol-lowering medications. Indeed, of all the children in the study whose LDL levels were above 160, one-third were in the group who would not have been screened.

The current guidelines were put in place in the 1990s, and at the time, experts predicted that high cholesterol would be missed in as many as 25% of children, says Neal. But doctors assumed that in most cases, these children would have only slightly elevated cholesterol levels that would eventually be detected when they became adults and would be lowered with diet and exercise.

Neal’s data show that may not be the case. Further, Neal says, the findings apply not only to heart-disease risk but also to the risk of diabetes, since high cholesterol at a young age is a strong predictor of prediabetes and diabetes. “We worry about that because if these children don’t change their ways, then they are going to have Type 2 diabetes,” he says. “It’s something we would become more aware of if more children were screened.”

So it seems obvious that we should be screening these children, right?  I am fairly certain that many of my pediatric colleagues will become more aggressive on cholesterol screening because of this article.  I think this is a mistake.

In my post, 10 Rules For Good Medicine, I stated in rule #1: ?Order as few tests as possible.  No test should be ordered for informational purposes only; the question, “What will I do with these results?” should always be answerable.  If it is not, the test should not be done.  The validity of this comment was debated by Dr. Centor on Kevin, MD, and I stand by that statement.  We don’t order tests to heap on guilt.  We don’t order tests to “just know” things.  The reason to order a test is to make a decision: should I treat this patient, or should further testing be done?

In this case, I think nearly all cholesterol testing by a pediatrician is on very thin ice from an evidence standpoint, and for that reason, I don’t check cholesterol in children or in teens unless there is a family history of premature coronary heart disease (under age 40).  Furthermore, I think that any doctors who are doing so should stop until there is more evidence.  But why shouldn’t we find out if kids have high cholesterol?  What’s the harm in finding out?  Here’s the harm:

1. We don’t have a clear understanding of what high cholesterol numbers mean in children.
2. We don’t know if treating cholesterol in children reduces heart disease risk.
3. We don’t know the long-term harm in children and teens of using cholesterol-lowering medications.

Isn’t it clear that high cholesterol causes heart disease?  Isn’t it clear that lowering cholesterol prevents heart disease?

No.

High cholesterol is associated with a higher risk of heart disease.  Lowering cholesterol in certain specific situations with certain specific medications is associated with a lower rate of heart disease.  We need to be very careful in this.  Why?  Because much of the claims of alternative medicine are based on the inference that association implies causality. It may be that cholesterol itself (LDL and HDL in particular) is one of the agents that causes heart disease, but that hasn’t been proven.  Why did Vytorin, which lowers cholesterol more than Zocor, not also lower the rate of heart attacks or fatal cardiac events?  (Vytorin contains Zocor plus one other medicine that lowers cholesterol more.)  The fact that it doesn’t, suggests that cholesterol doesn’t tell the whole story.

The bottom line?  I am not testing kids for cholesterol because I don’t want information I can’t use.  Sure, I can use it to scare parents and kids, but I don’t think scare tactics really work.  It doesn’t change smokers’ behavior to tell them how deadly cigarettes are.  Besides, since there is no proof that giving a kid Lipitor will help him more than it harms him (you don’t give it to girls because of birth defect risk).  So you end up giving the same “eat right and exercise” talk you give if you hadn’t checked cholesterol in the first place.

I’m sure the drug companies wouldn’t mind if kids were tested, though.

(See Gary Schwitzer’s Coverage on this study for more perspective on it.)

I’ve been practicing for sixteen years now, doing both internal medicine and pediatrics.  One of the joys of that is watching kids under my care grow up and not having to give up their care just because they get older.  The spectrum is wide, with some kids growing up in “normal” families with “normal lives,” others in “abnormal” families, and yet others with inherently “abnormal” lives due to illness or disability.

But the kids aren’t the only thing that has changed over the past sixteen years, their doctor has changed as well.  My comfort zones have widened, not getting rattled by “abnormal” as I once did.  I used to feel uncomfortable with the mentally and emotionally disabled, now I am not.  I used to feel sorry for parents with “abnormal” children.  I used to feel bad for kids who were “abnormal;” I still do now, but not nearly as much.

Of course, they all are well-aware that they have an “abnormal” doctor.  OK, you can lose the quotes on that one.

These emotions have been most transformed in my attitude toward autistic children.  Autism used to make me very uncomfortable.  I felt awkward talking to their parents.  I tried to avoid the topic.  How the parents must wish their kids were “normal,” and how the kids would wish they were “normal” (if they could).  I felt pity.

But as the years have gone by, I’ve discovered an amazing transformation: I now really like my autistic patients.  These are often some of the more enjoyable visits.  I’ve also noticed that, contrary to society’s perception, the parents of autistic kids are not in mourning.  They are not living in a constant state of “what could have been.”  They are often smiling.

Society likes to take a group of people, call them “abnormal” and feel sorry for them.  Disabled children are the center of our societal pity, with the torch-bearers for this being Jenny McCarthy and the other avid anti-vaccine folks.  Unlike the lepers of biblical times, these kids and their parents don’t have to cry out “leper, leper!” to be avoided by others; they are avoided by default, pitied for what others don’t understand.

But as I have gotten to watch these kids grow up and have become closer to their parents, I’ve noticed the following:

• They get better over time.  Children I once felt sorry for I am having conversations with.  They are not “normal” – they are unique.  Autistic kids mature over time, just like “normal” kids.  Autistic kids become more aware over time, just like “normal” kids.
• There is an innocence and a lack of guile that is endearing.  They don’t lie to me, they don’t beat around the bush on issues.  Sometimes I get surprised by what they say, with it’s bluntness, but I don’t mind that anymore.
• They are generally happy.  They don’t seem to carry the anxiety that has become rampant in our society.  They do get angry and obstinate – sometimes at a very high volume – but once that dies down, they become content once more.
• As they gain function, they also gain a unique sense of humor. I don’t think I can explain it better than this, but I often find myself laughing when I’m seeing them.
• The parents are proud of them.  Once they can drop their societal defensiveness from universal pity, they delight in the accomplishments of their children.  Perhaps this is because they don’t  take things for granted; perhaps they don’t feel entitled to “normal.”

I’m not saying that there isn’t hard stuff that’s unique to raising autistic kids.  I am not saying that we shouldn’t be devoting resources to helping these kids and figuring out the cause of autism.  What I am saying is that we need to get beyond the pity.  These kids are not lepers.  They are unique people with their own strengths and weaknesses.  They bring me joy when I see them – more joy than many “normal” kids bring.

Normal is overrated.  Normal is arbitrary and evasive.  Nobody is normal; we all bring our own uniqueness to this world that should be appreciated for what it is.  A very large portion of the “normal” people I see are anxious and unhappy.  I doubt the suicide rate among autistic teens is anywhere near that of “normal” teens.

So, to all of you “normal” people out there I say: get over it.  Don’t be afraid, and please lose the pity.  After you involve yourself with these and other kids with disabilities your life won’t be “normal,” but who needs “normal” anyway?  We all need to lose a little “normal.”

To all of those autistic kids I’ve seen I say: thanks for teaching me the arbitrary nature of “normal.”

I was planning on leaving behind the seriousness of the past few posts and going back to my usual inane writing, but some of the comments have made it too hard for me to keep quiet.  The response has been largely positive, and overall it has been overwhelming.  More people have read or commented on my letter to patients with chronic disease than any in recent history.  I am grateful that it is circulating around the web for others to contemplate, perhaps understanding the intent of what I wrote and improving their relationship with their doctors in the process.

The purpose of the letter was to give some helpful insight into the emotion on the other side of the equation.  I can’t understand what it is like to have a chronic illness without having the disease, but it is still fruitful for me to try to figure this out.  In the same way, patients with chronic illnesses benefit from a better understanding of the doctors they see so frequently and depend on so greatly.  I can sympathize, but I can’t feel the pain.  Still, I do need to listen closely to patients so I can have the best relationship possible.

Some folks felt that I was saying that doctors need their egos stroked and to be treated special, but that is not what I meant to say.  Each person needs to be understood and treated as their situation dictates.  People with chronic illness want to be understood (as witnessed by the incredible response to my letter!) and treated based on that understanding.  Doctors want to be understood as well.  So let me tell you my side of the story.  What is it like to sit in my chair?  I don’t say this for sympathy or pats on the back, I say it to be understood.  If I am better understood by my patients (and readers), my relationship with them is better, which is good for both of us.  I think I represent a fair percentage of primary care docs in these ways.

1. I care about my patients – As hard as I try to “just do the job,” and not expend the emotion I do during the day, I couldn’t live with myself if I let my patients down.  They depend on me for a lot, they pay for my service, and they deserve my best.  I’ve been told I do this to a pathological degree (along with my llama obsession), but it is there.  I want to help them.  I get frustrated at my powerlessness and am genuinely happy when they do well.

2.  I am tired – Each day demands an emotional price.  Some days the demand is not so high, others suck the life out of me.  Being “needed” cuts two ways; on one side it is nice to truly help people when they need the most help, it’s satisfying to see your life making a difference.  On the other side, it is a never-ending river of need, pain, and crises to be handled.  Being patted on the back (or patting myself) is nice, but it doesn’t mean anything for the future.  Each day brings new hands to hold, needs to meet, problems to be solved.  Each day is as much a burden as it is an opportunity.  That burden won’t leave me until I take down my shingle, yet the opportunities to make a difference will make it hard to take that shingle down.

3.  I also run a business – In terms of priorities, I need to pay my staff, pay the rent, and pay my personal bills to even have the chance to take care of patients.  I get frustrated when patients insinuate that I value money too much.  I get very frustrated by that, actually.  People seem more willing to pay for cable TV, cigarettes, or eating out than to pay me for what I do.  I earn less than most other medical specialists, yet some people resent my income.  The mess of a system we have works against primary care and works against complex patients.  If I spend 30 minutes with a complex patients (I do spend 30 minutes with people regularly), I am paid about 50% more than if I see a 5 minute ear infection visit.  Doing the math says that my mind is not valued and that I should see more ear infections and less chronic patients.  All of this adds to my daily stress.

4.  I am actually a person, not just a doctor – I have four children and a wife, and being a dad and a husband isn’t easy when I come from work with the emotional life sucked out of me.  I struggle with my own emotions and I get sick.  I worry a lot about money, and I feel insecure about the fact that despite being a doctor, I am not saving enough.  Hence I also struggle with working too much.  Life’s not easy for anyone, and despite my title I am not exempt.

5. I hate bad doctors – Many of the comments to the letter I wrote were lamentations about doctors who suck.  Unfortunately, doctors who take bad care of their patients make my life miserable too.  I have to clean up their messes, I have to re-teach their patients on what medicine should look like.  I have to wean their patients off of addictive drugs that they didn’t have the guts to deny. I am personally frustrated when I send a person to a specialist and they don’t do anything or upset my patient, and I hate the fact that they almost never communicate with me.  It makes my already hard job even harder.

6. My blog is a refuge and a tool – I am thankful that I have this blog as a means to vent, to use another part of my brain (some may argue that point on some of my posts), and to make a difference.  I actually have a voice in the whole healthcare reform debate.  I actually can reach a large number of people and make their medical experience better (which was the most gratifying thing to hear in the comments to my letter).  I’ve made practically no money doing this, but I’ve gotten a whole lot out of it.

That’s my story.  Like it or not, it is what it is.  I am just a guy who happens to be a doctor – the same as the rest of the doctors out there.  There will always be angry people and idiots on both sides of the doctor/patient relationship, but no matter what, the doctor-patient encounter is a human thing.  Love is human, war is human, murder is human, and so is childbirth.  You can’t put humanity into a bottle, you can’t throw a single label on it.  The highest calling is to enter into another’s life, to see things from their perspective, and to add good to it.

That goes for all of us, regardless of letters behind our names.

Thanks for listening.

I went to a patient’s funeral this past weekend.  I generally don’t do that for people whose relationship I’ve built in the exam room.  It’s a complex set of emotions, but invariably some family member will start telling others what a nice doctor I am and how much the person had liked me as a doctor.  It’s awkward getting a eulogy (literally: good words) spoken about me at someone else’s funeral.  This patient I had known prior to them becoming my patient, and his wife had been very nice to us when we first moved here from up north.

But that’s not why I am writing this.  As I was sitting in the service, the thought occurred to me that a patient’s funeral would be considered by many to be a failure for a doctor.  Certainly there are times when that is the case – when the doctor could have intervened and didn’t, or intervened incorrectly, causing the person to die earlier than they could have.  Every doctor has some moments where regrets over missed or incorrect diagnosis take their toll.  We are imperfect humans, we have bad days, and we don’t always give our patients our best.  We have limits.

Yet if patient death was the measure of a doctor’s failure, then all doctors would be 100% failures in the big picture.  Doctors are not the only imperfect thing; the human body is frail, people make bad choices about their own health, and life itself is hard and unpredictable.  In reality, doctors are putting  a finger in a dike that is crumbling to pieces.  We are stalling, holding off the inevitable when we succeed, and standing and watching the inevitable when we fail.

This doesn’t just apply to death, it also applies to suffering.  The huge number of comments on my last post bear witness to the vast numbers of people with chronic pain, illness, and suffering.  It some ways, for a doctor, the death of a patient is easier to deal with than the impotence felt when we are unable to help a suffering person.  There is always the question of whether we are missing something that could help.  There is the pressure from the expectant face that hopes we can fix what has been unfixable up to now, and the weight of the defeated faces of those who have lost that hope.  It’s hard to stay above the emotion of those encounters when your stated job is to fight disease and minimize suffering.

Which brings me back to the funeral service.  After the service I greeted the man’s wife with a hug, reminding her that I am available to her if she needs anything.  She thanked me for the care I gave to her husband and for the ways I’ve helped her through this time.  In a lot of ways, it was my presence that mattered most.

The word “sympathy” comes from the root words meaning “to feel with.”  The word “compassion” comes from the root words meaning “to suffer with.”  I remember once looking at a beautiful mountain vista by myself, thinking how much better it would be if there was someone to share it with.  The addition of that person wouldn’t add to the beauty, but it would somehow validate it if someone else shared the awe and wonder I felt at that moment.  My role as doctor is not just to stand with people, but to help them.  Yet I cannot forget that I do see their pain without veil, I do experience the difficulty people live, they don’t hide their tears from me; and that fact somehow made it better for them.

Perhaps that is what many of the docs who flee the chronically ill patient are missing: you don’t always have to fix things to make them better.  You don’t always have to relieve suffering to give care.  It’s great when you do, but in the end the most important thing is to be there.  To feel with and suffer with people as they make their journey through this life.