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July/ August 2013 A Day in the Life of a Primary Care Doctor

A harried pediatrician tells her story.

By Candice Chen

Candice Chen at work
Tick tock: Candice Chen, like many primary care physicians, tries to give her patients the time they need while staying ahead of the clock.

I’m a primary care pediatrician in a clinic in Southeast Washington, D.C., that provides health care to a largely poor, urban, and underserved community. On Monday mornings, I look forward to going to work. I’m excited to see my patients—the babies, children, teens, and families I’ve watched grow up—and face the challenge of figuring out how best to help. I started working in this community during my residency training almost twelve years ago, and I’ve stayed here ever since.

As much as I love my work, however, my days are stressful and hectic and there is never, ever enough time. I start the day by looking at my schedule, which is typically booked full with patients scheduled every fifteen minutes, and the anxiety begins. My 8:30 a.m. appointment shows up at 8:44—just within our fifteen-minute late policy. By the time this family checks in and is in a room, it’s well after 9:00, and my later appointments have started to arrive. I feel the pressure of people waiting, but when I go into that first room, I can’t bring myself to rush this parent who’s worried about her child. I sit down, quiet my anxiety, and listen to what the parent has to say. Meanwhile, I’m trying to find out, what were the results of the emergency room tests? What were the results of the tests we ordered last time? What did the specialist do? I ask these questions, knowing that time is ticking.

If all of my scheduled patients show up, I spend the morning running from room to room and my lunch hour becomes fifteen minutes. If no one else is in the hallway after I leave a room, I run. The couple of seconds I save probably don’t make a real difference to a waiting family, but it’s all I can do. I apologize frequently to families for running late. Some families are forgiving; some aren’t. I feel bad that my patients have to wait, and, being human, I feel worse when they’re upset with me. By the end of the day, I’m physically and emotionally exhausted.

Some observers might make the obvious suggestion—stop scheduling appointments every fifteen minutes. But in the U.S. health care system, the only way to make more is to do more. In my clinic, those extra visits pay for important patient services, like a care manager, social work, and mental health and dental care. They also pay the salaries of the staff members who are needed to keep the clinic open five days a week.

Compared to other sectors of the health care system, primary care is disadvantaged. Primary care services are generally compensated less than other specialties, so even when a primary care doctor can see more patients, he or she still can’t earn as much as, say, a cardiologist or a surgeon. Primary care doctors make one-third the average income of orthopedic surgeons, according to the Medical Group Management Association. But a bigger problem is that this payment difference means primary care practices can’t hire the additional staff or make the investments that will allow doctors to focus on doctoring and not on the million little administrative tasks that come along with providing health care.

In my case, these administrative tasks often mean a day that is filled with frustration and less time for patients. There’s the very long automated recording when I call an insurance company to see why they rejected paying for someone’s medication. There’s the time spent on hold while waiting for a specialist to discuss a patient’s case. Electronic health records have helped in many ways, but our system always seems to run too slowly. When I open a new window on my computer to order lab tests or send a prescription, the pause is just long enough to remind me that people are waiting, but it’s not enough time to do anything else.

Given that primary care doctors are caught between the time pressure of seeing as many patients as possible and keeping up with paperwork—and are less well paid than their colleagues in specialized medicine—I’m not surprised that fewer and fewer medical students are choosing to go into primary care. It shouldn’t be this way. On those rare days when I have the space to spend more time with families and do the things needed to provide the best care, I go home knowing I have the best job in the world. I go home remembering the little victories, like keeping a patient with asthma from having to go to the emergency room; the feel-good moments, like the toddler who runs down the hall to give me a knee-level hug; and, above all, the joy of knowing that a child I’m treating will survive, will be healthy, and will be happy again.

Candice Chen is an assistant research professor of health policy at George Washington University. She is also a primary care pediatrician for an underserved community in Southeast Washington, D.C.

Comments

  • swarna on July 16, 2013 10:37 AM:

    I do agree 100 % .That looks like my day

  • RimKitty on July 17, 2013 10:55 AM:

    What can we do?

    Having spent a great deal of time at doctors offices, hospitals etc, taking care of sons, husbands, brothers and parents, I have seen this terrible injustice to primary care doctors played out a thousand times. If anything, primary care physicians deserve to be paid far more than their counterparts.

    The cardiologist walks in the hospital and visits my son for less than 4 minutes, telling him nothing and charges $800. The primary care physician comes to see him after his day is done at 10 pm at night, answers all his questions, makes sure all the other specialists and their tunnel vision haven't forgotten the patient is human, then calls his loved ones to tell them what's going on.

    What can we do? Seriously. How do we get the compensation up for the most important physicians we have? We need more primary care docs and we are getting less.

  • gregor on July 17, 2013 2:52 PM:

    Bummer.

    I cannot decide whether or not to send the link to this post to my daughter who just started her pediatric residency in mid-June 2013.

  • Anonymous on July 17, 2013 6:50 PM:

    Agree.
    Like the author, I am a pediatrician and love my little patients, enjoy (most of) my families - but it's really hard at this time to recommend that the medical students that rotate with me, and who are graduating with an average of about 250 thousand dollars of debt, go into primary care.

  • feisty on July 18, 2013 4:29 PM:

    My $.02 as the spouse of an Internist (Internal Medicine): Anything resembling independent PC practice is a bad career choice for a physician, unless doc has as much business training as, say, heart care. You don't see many family hardware stores opening in the shadows of Home Depot and Lowes!

    My spouse is at this 27 years now, is co-partner in an independent (yet hospital affiliated) practice with another internist and nurse practitioner and support staff. They are GREAT with medicine and patient care, pretty lame with business and net income. they know their accounting reports (they are helped by a physicians' admin. consortium).

    It's just plain inefficient: Too many support staff, too many long appoinments (some 30 or 45 min. as needed) for the complex multi-issue patients, high office costs, modest reimbursements. Doc is with patients about 45 hrs. a week, 50 weeks a year, in a modest office.

    It took 24 years' PC practice to finally net just a tiny bit over $100,000, and that's about where well always be; everyone assumes income is double or triple that. No benefits since it is essentially a sole proprietor business.

    I wish doc would close the practice and join a mega-health network, but the loss of independence and the patients (some known for 20+years) is why she keeps going. So med students and new docs with debt and high hopes, beware, the health marketplace wants speed, turnover, EZ flow-thru in PC.

    And I don't blame Obamacare, it's medicine with an MBA nowadays.