Lately, I'm tempted. I'm tempted to cut corners, to avoid a raft of lab requisitions, to not notice when a patient's last Pap smear or digital rectal exam was. The temptation boils down to a euphemistic mental switcheroo: I wish to excuse shoddiness as practicality.
The circumstances? My office practice plays perpetual catch-up; people wait a minimum of three weeks to be seen. My patients tell me It takes too long to see you, or I had to go to the walk-in clinic, I couldn't wait. With such a backlog of appointments, I feel simultaneously important (how else to explain why people are willing to wait a month to see me?) and ineffectual (more and more patients are bypassing me, their primary care physician).
I envy the circumscribed responsibilities of my competitors, the walk-in docs who refill prescriptions and see coughs but not necessarily whole patients. Their medicolegal liability is higher than my own, but this risk is compensated for by the absence of call responsibilities. When I see the patients on my list, I cannot confine my inquiry to the immediate present, but must instead ponder an entire life.
When I see complicated cases, the chronically ill with multiple diseases, I'm tempted even more. I'm tempted to transform into Insta-Doc. I ruminate about adopting a one-complaint-per-visit policy; in fact, I've already printed a prototype of the “One Problem” sign for my waiting room. I'm tempted to post it when I'm over two hours behind — because a depressive patient has crashed or an elderly lady has saved up her problem roster for a single visit “so as to not waste my time” — and the waiting room is rocking with the sound of bored, destructive children. When I'm behind like this, I want to skip, I want to pull out my prescription pad, I want to put my hand on the doorknob to signal the end of the encounter.
Why?
This is where the mental sleight of hand comes in; by doing less for my patients, I rationalize, I can do more. I can see more people; I can cut my waiting list. I can be efficient, and therefore superior.
I know this is faulty logic, but it's tempting all the same. Especially when I hear the teeth-grating refrain, It takes too long to see you. For the hundredth time.
I suspect that the root cause of my discontent lies in the attitude that there are solutions to all problems, that family medicine should seek to treat patients holistically, taking all elements of existence into account, be they psychological, biological or social, even as the rest of medicine splinters into smaller and smaller subspecialties with correspondingly reduced purviews. Long ago, when I first wanted to be a doctor, I simply wanted to be a doctor, and now I'm forced to be something less: a manager of chief complaints. I feel the pressure to be a good doctor internally as I'm pressured to refer externally, and when I look at my list for the day and see it festooned with multi-problem patients, the temptation worsens. Why not give in? Wouldn't I be happier where expectations are less and remuneration is more?
Whenever I hear It takes too long to see you, I offer commiseration only. I don't argue or become defensive. But part of me resists the statement, whether it's said plaintively or angrily. I think: perhaps there's something you can get in this office that you can't get elsewhere. Perhaps in here there's something worth waiting for.
At least I hope that's the case. Otherwise, less is more, and I shall have to abandon conscientiousness in favour of a haphazard, off-the-cuff method that processes patients better than it treats them. Walk-In, Walk-Out Medicine, not Family Medicine. — Dr. Ursus