Friday Reflection 36: Why Don’t Doctors Want to See Patients?
At a Thanksgiving gathering, a middle-aged doctor talks to an older relative. While enjoying a pre-feast cocktail, the relative asks, “Why is it that doctors don’t want to see patients?” The doctor bumbles through a reply.
I was the doctor in this “case.” The relative, who will remain anonymous, is a wonderful, intelligent, accomplished person who has had access to some of the best healthcare in our country. After my half-hearted attempt at a reply, we looked at each other blankly and went back to our cocktails – I think I was drinking a negroni. The question has been eating at me ever since. This is my attempt to answer it.
First, two disclaimers.
Disclaimer #1
I love what I do. I hope that anyone who has read any of these articles knows that. If this is your first “Friday Reflection”, maybe stop and pick out a couple of others to read first.[1] I consider it a privilege to practice medicine. To paraphrase from the introduction to Ending Medical Reversal: medicine, practiced well, is beautiful. As a human pursuit, it is pure -- caring for the suffering. Empathy and the ability to anticipate a patient’s changing needs are the hallmarks of an excellent physician. Clinical medicine can also be one of the most satisfying of intellectual pursuits. The diagnostic process and development of an effective management plan, done well, are elegant, thoughtful, and parsimonious. The fact that this cognitive activity is only a means to a greater end makes it even more magnificent.
Disclaimer #2
I loathe listening to people complain about being a doctor. Sure, everyone complains about their job but complaining about being a doctor, really? It is unseemly to gripe about a job that is paying you enough to be in the top 10-15% of wage earners in America.[2] It is also a job that thousands of people would have done had they been able. Then there is the fact that a career in medicine grants you respect and privilege. Lastly, most doctors, through education, degrees, and privilege, have the option to pivot into other fields if they are unhappy.
Disclaimers managed, back to the question, “Why don’t doctors want to see patients?” I could start by asking, “Is that even true?” That question probably doesn’t matter. If a patient senses it, it is either true or we are communicating it. There is, undoubtedly, some truth to my relative’s observation. I have heard dread from colleagues about a clinic session, a day in the OR, or a call night. A former section chief once told a colleague, “You have to figure out funding so you can get out of clinical medicine before it kills you.”[3]
And then we have all that “burnout” data. Physician burnout rates hit 63% in 2021.
So let’s accept that a lot of doctors are not happy, probably not happy seeing patients. Why?
When I started to reply on Thanksgiving I said, “It is a really hard job.” This response felt weak. Lots of jobs are “really hard.” But medicine really is hard. Doctors deal with hurt, sick, scared, anxious, dying people every day. We also deal with the families of hurt, sick, scared, anxious, dying people – family members with whom we often have no relationship.
As a doctor, you cannot have a “bad day” – a day when you don’t perform at your best. You might be tired, depressed, or under-the-weather, but your “status” cannot hamper the quality of your work, wherever that work is: the office, OR, ER, or hospital.
And if you do have an off day, and somebody pays for it, you never forget.
Medical practice is the classic high-stress combination of great responsibility and little control. If you are caring for people, that responsibility is inescapable and you can’t control when people need you.
Customer service can be trying, and I’ll argue that being a doctor is the most difficult customer service field. Imagine a person on the bus with whom you desperately avoid eye contact. Then imagine this person coming to your office and having to spend an hour with them, alone, trying to help with any problem they present.[4] Or imagine the most self-important, entitled person you can, someone who treats everyone as a subordinate, and then imagine dealing with them when they are scared and powerless.[5]
I loathe the term “work-life balance.” Maybe this is because in my field (primary care internal medicine) and many others, the attribute that makes you a treasured doctor – ready availability – makes the idea that “work” and “life” can be separated absurd.
As a doctor, your patient is your boss. We all, sometimes, hate our bosses. This is especially true if it is understandable that your boss might need you, and can call on you at any time.
Even on the days I am able to limit work to, let’s say, a nine-hour day, and nobody calls after hours, the worry about patients can follow me. After three decades of practice, I have learned that making decisions to lessen my anxiety is usually in both my and my patients’ best interest. However, the dozens of decisions I make every day have consequences. I worry about these consequences — sometimes a little, sometimes a lot. I cannot count the number of times I have woken in the middle of the night second guessing a clinical decision.
Then there is the issue that we are so often impotent to fix the problem at hand. I am not referring to the truth that, in the end, everybody dies. It is that so many of the problems that afflict my patients are bigger than a disease that I can treat . Every day I deal with the stress of urban violence, the nutritional impact of food deserts and highly processed diets, and the sedentary lifestyle necessitated by our jobs and built environment. Counseling relaxation and prescribing medications for anxiety, hypertension, or diabetes is like applying a Band-Aid to a gushing, arterial laceration.
The entry point to all of these “hardships” is seeing a patient. Not only does each twenty-minute visit lead to twenty more minutes of administrative burden, the visits also lead to the contact with the suffering, the loss of control, the anxiety, and the powerlessness described above. Is it not understandable that doctors sometimes recoil at the idea of seeing a patient?
Mario Cuomo said that politicians campaign in poetry but govern in prose. Medicine is the same. In the abstract, the practice of medicine is poetry, filled with grace, sacrifice, and beneficence. But the practice of medicine is prose, a grind of stress and drudgery. Medicine, in the ideal, gets me out of bed each day. I am profoundly satisfied with, and proud of, my work. There is nothing I would rather do. The reality of medicine, however, makes me complain when someone shows up for that 4:40 Friday afternoon appointment that I chose to include on my schedule.
Photo courtesy of Louis Galvez
[1] I think this is my favorite; this got the most likes; and this one got the most comments. This one was, by far, the least popular. I kind of liked it...
[2] Given that about 40% of doctors are married to other doctors, it is likely that their family income is actually in the top 1-5%.
[3] Yes, this was from the head of a section of general internal medicine. It was a clue that this person was not the greatest section chief and would not last in that position.
[4] I had a hard time writing this. The fact that I treat people that I would never cross paths with otherwise is one of my favorite parts of the job. This is especially true because these people often become the patients with whom you develop a profound, mutual connection. I had to put this in a footnote as I am trying to make a point here.
[5] Succession, Episode 2, Season 1 has a scene that gives you a pretty good sense of this dynamic.
In many cases, the patient is not the boss and this is the problem. The boss is the administrator. The doctor works for a hospital or a large group or a corporate entity. This is who dictates to them what must be done. The doctor needs to make the larger group happy. This is often, but not always, done by making the patient happy (not always even possible). The patient can sense that they are not in charge and that the doctor is trying their best to please someone else. This may contribute to a sense that the doctor doesn't want to see the patient.
Another issue that might contribute to the general public feeling as though doctors don't want to see patients is that the staff does not work for the doctor. They, too, work for the larger organization. Patients encounter the staff before they ever step foot in the office. The person answering the phone might have been told a hundred times by the doctor to fit in emergency patients. But the staff doesn't work for the doctor. Typically one would think that they would have been instructed by the administrators to schedule as much as possible. However, it seems that in my more rural area, the staff is instructed to fill spots in the computer schedule. The patient can sense that when they call for an appointment and are told that they can't be seen for a long time no matter how much they need to.
I personally have been told by my child's established pediatric practice that there were no appointments available for a suspected strep throat and if I really want him to be seen I need to take him to the ER. I then did what I was trying not to do and prescribed the damned antibiotic myself. But that is a privilege afforded to doctors and the lay person does not have that option. The typical patient sure as hell can get the idea from that kind of interaction (which is extraordinarily common in a "not city" where I live) that doctors don't want to see patients.
I have also referred out my own patients for care, specifically requesting them to be seen ASAP. I do this at the regional care centers located 2 hours each direction. I only do this as a last resort, typically for someone with cancer. I have been told by both our regional centers (one two hours to the south and one two hours to the east) that biopsy proven cancers are not urgent and can wait a full month to be seen for an initial evaluation. This is much different than it was even 10 years ago when I could call and have my newly diagnosed cancer patients seen within a couple of days. Try looking someone in the eye, telling them they have cancer, and then telling them they need to wait a month for their appointment to start evaluating the extent of it and to start formulating a plan. This will certainly contribute to the general public's perception that doctors don't want to treat patients. Mine, too, if we are being honest.
The definition of stress, is responsibility without control. When doctor's owned their practices and made their own policies they were much more satisfied. Now, it seems that most doctors work for a healthcare system. This system tells them which office they will report to, how long they have with each patient, how many patients they must see everyday, and often their compensation is based on ridiculous satisfaction surveys.