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.
My perspective, not entirely in disagreement, is different.
I think a lot of dissatisfaction among doctors is due to lack of freedom. An NP goes to school for a couple of years and then can work for anyone who wants to hire them, but an MD (+/- another graduate degree) gets you 3-7 years of residency at a specialty you may or may not want plus or minus another year or two or three of fellowship.
I entered medicine to treat chronic pain. I've branched out into addiction, and it's good work and I'm reasonably happy, but I spent so much time doing things that weren't that at all, and is remarkable how we just accept that as normal. If every lawyer had to work for three years as a public defender, the legal profession would revolt.
Some training and quality control is necessary, of course, but I found my brief time as a resident on a hospitalist service was definitely teaching me not to want to see patients. And I liked my colleagues and I cared about my patients. I'm just not an internist.
Thank you for another insightful commentary on the state of medicine. I went back and listened (again) to the old Reflections podcasts. I cried (again) on dignity in dying.
You bring commonsense, medicine, and humility together. As a physician I look forward to these pearls.
First post...I totally support the author's right to "reflect" or even "vent". Great. Do it with your friends and family, or even here in "public" if you want some kind of feedback. If it's because you want to enlighten others, then I have to give some feedback.
You "loathe listening to people complain about being a doctor". I loathe listening to people, especially other doctors, imply that doctors don't have the right to vocalize their dissatisfaction with certain aspects of their job/profession...no matter how much they are paid. Everyone has the right to share their experiences and perspective with others...positive and negative. That's what I teach my severely indebted medical students who delay their income-earning years.
Here's the good part of this essay..."the dozens of decisions I make every day have consequences. I worry about these consequences". That's the nail on the head. Many people don't realize/appreciate this, and for that I do complain (share my perspective).
As a physician, I enjoy seeing the patient but its the EMR/documentation that's the burden and the lack of time for the patient. 15 min appointment is not enough time for a complex follow up, let alone a 30 min spot for a new patient.
A long time ago, I saw a few doctors about my chronic fatigue. I was treated as an honest, intelligent person and he didn't just assume the problems were in my head.
Even today, more than 20 years later, it stands out as a very good and positive memory. They probably don't remember me, but I remember them as a good friend.
Thank you for sharing and it did make me reflect. I think your comment on impotency struck me most. I would expand it though beyond systemic societal problems to include the majority of our scope of practice. We apply imprecise tools with imperfect knowledge and all the while the perception of our "bosses" is that we know for sure what we are doing will work.
It would be interesting to hear how much this sentiment differs between generations. Is it possible that the paperwork, insurance red tape, dwindling profits, reduced time spent getting to know a patient, and over-medicalization of the US has made it more unpleasant to be a doctor?
On the other hand, is it possible that the army-style training of 24(+?) hour rotations and sleep deprivation leads doctors to develop unhealthy lifestyles that make you more prone to depression and disliking life and your job. For sure, as a mom, the difference between screaming at my kids at 9pm and gently corraling them to go to bed is whether I got a good night's sleep.
I feel like if you guys were able to take care of yourselves the way you want your patients to, maybe it would make a difference on how much you enjoy seeing patients. Maybe more group practices where you're not always on-call every night would help.
1) I agree, the combination of bureaucracy/administrative work + an often unacknowledged emotional toll are probably the big culprits, in different proportions for different people. Thankfully I find my work gratifying, but holy moly the difference between what I imagined a doctor's job was like when I was a kid vs. what it's actually like...
2) "As a doctor, your patient is your boss."
I once said something like this to a patient I was treating, who happened to be psychiatrically hospitalized at the time. I immediately realized how crazy it must have sounded given the context, and sure enough he didn't miss the opportunity to remind me (angrily) that people typically don't have the ability to keep their bosses hospitalized in a psychiatric unit.
It takes two doctors to declare a patient clinically insane: but it only takes one vindictive patient (or relative) to drive a vulnerable and self-doubting Doctor to suicide by making a brilliantly constructed but malicious malpractice claim.
I certainly agree with the descriptions of the positive aspects and rewards of medical practice but would modify a couple of statements in order to provide a better understanding of the problem.
1) "I loathe listening to people complain about being a doctor."
I would bet that more than 95% of the complaints are not about being a doctor but rather are deploring the degradation of the practice of medicine that third party intervention has inevitably brought about. Corporatization and bureaucratization have depersonalized the doctor-patient relationship to the point where neither party is very satisfied.
You also described my life as an addictions therapist; now that I’m reluctantly retired and do pro bono work for nurses in recovery and the occasional individual, the LIFESTYLE you describe so wonderfully stays with me. I don’t mind it at all now that there is no admin crap. Nothing worse than that! What always amazed me was that occasionally I would dread a certain individual simply because that person may have rotated through a half dozen times, and I felt like I had failed them. I know I didn’t but then one day they got up on the bike and started riding it. And of course not unlike you, I am mourn the losses. Thanks for always being human in your well earned Superman cape!
I am humbled by this post. First and foremost the thought of you not liking medicine or being a doctor never crossed my mind, Dr. Cifu. Your posts are thoughtful, passionate, and transparent. You delve into the good, the bad, and the ugly about medicine in general and your doctor-patient relationships. By the end of each of your posts it is always clear you are doing what you love and wouldn't trade it for the world. I spend my career in the trenches, donning garb to prevent fleas, bedbugs, and roaches from attaching to my clothing. I get yelled at and verbally attacked. I endure things I would never have endured had I not chosen, practice, and love my career choice. Do I not want to see patients? Yes, at times and not all of my patients. I know the most challenging and difficult ones are those that need me most. It doesn't make it easier, but it pushes me forward to practice in my specialty.
In Ontario Canada - family doctors abused covid allowances - at one point my doctor called me from his car speaker while out for a job. It’s not that they didn’t “want” to see people, they didn’t have to and they took advantage of it whole cloth
Concierge medicine, is only available for the very wealthy patient and the more senior wealthier physician.It’s used mainly for primary care. It does not translate well if and when the patient requires subspecialty care, , surgeries etc. We need voices like Dr. Cifu to shine light on the reality that medicine has become for most drs and patients.It is cumbersome and disastrous.I don’t see how pts seeing their MRIs and labs on a pat portal ( often before the dr has seen it , and usually weeks before they can discuss the results with the dr) benefits patient care at all. people go on Reddit, Quora and the like to “ research” and ask for help! This is BAD
Wow, Adam. I could not agree more. I retired 19 months ago after a 40+ career including 30+ year in pediatric lung transplantation. what a privilege! The clinical activity of the program has dropped pretty drastically for a variety of complex reasons. I am now 2/3 of the way into writing a book about my experience. The tentative title will be "Second Wind: my 30 years in pediatric lung transplantation". I hope that many of you will read it. I will be 76 years old next month. I have the task of writing the story of the vast majority of my patients dying before surviving even 10 years after transplant surgery. From the point of view of families, patients, and most of us involved in the work, the effort was definitely worthwhile but so many doctors have DISCOURAGED patients and families. They have taken the tack that even five years of vastly improved life cannot be worth the financial and emotional and psychological cost of the tough journey embedded in that blessed trust relationship with which I had the divine blessing in which to participate for the 30 years.
Jim Ryser, I read your sub stack post and it was really wonderful. What a life of intersection with the medical establishment. I'm glad you had such wonderful doctors and care givers along the way. Your fortitude through it all was/is quite amazing. Have you written a book, or considering? Best to you.
Thank you DocH! It’s been a great journey! I made records back in the 90’s (Google “Jimmy Ryser”) but doubt I’ll do much book writing! I still do music for The Hunting Public and a few other YouTube shows I love but maybe someday I’ll write more than I do here! Thank you so much for checking in!
Elegant and provocative, as usual, Dr Cifu! I think much of the answer lies in the tension between your declared joys from the field "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" and most care, where the diagnosis is either well known (knee or back pain), or obscure and hard to ameliorate in a given patient (fatigue, post-viral cough). The time space and energy to do that cognitive activity well, to manage expectations, do something somewhat helpful (and reasonably satisfy both you and the patient) can be in short supply. Concierge medicine is one answer, but out of reach of most individuals, and is in some sense a betrayal of our values to treat all individuals in society. Thanks for writing this fruitful essay!
Andy Davis, I don't see concierge medicine as any betrayal. For some of us, it is the only thing that will keep us in the game longer. I worked as IM PCP in a "big box" system for just over 20 years. They made it clear they did not value me (in many ways). As I spent a decade (or more) doing everything I could to improve my "efficiency", I was made to feel that something was wrong with me. Nobody ever brought up the simple fact that current medical industry is not geared to value the way a female PCP will interact with and manage a majority female patient panel. The entire reimbursement system is highly geared to favor the way male physicians (again, speaking only for PCPs here) see a more balanced patient panel (a balance of male and female patients, not a 5:1 mix!). Of course, each physician has our own balance of strengths and weaknesses, so this is a generalization not a pronouncement for everyone. Eventually, my supervisor said "maybe this just isn't a good fit for you!" - huh, after practicing for 20 years, I'm just going to find that out? (and coming from a highly popular female internal medicine PCP w/ good patient care, good patient "experience" scores etc etc). So I left. And started a concierge practice. Modest fees and it is still a labor-intensive practice as medicine is a complicated field. When you are told implicitly and explicitly that you are not valued, you have to try something else. The other option is to "burn out" and get out completely. I didn't do that!
Part of the problem is that in the entire history of modern medicine, we have yet to truly reorganize the way we manage and "deliver" care. The whole practice of medicine still really rests on the labor-intensive one-on-one interaction between patient and doctor. And local communities do nothing to organize and manage referrals to specialists as a community, leaving specialists bombarded with the flow of referrals and trying to "take them as they come". Until we revolutionize, in some way, how we organize care, we will be stuck with this rusty wheel clunking to a catastrophic end as the baby boomers decimate our resources. Maybe doctors don't really need to see everyone with a sore knee before they go to physical therapy! Maybe not every stable elderly patient with a fib or a mildly dilated thoracic aorta needs a yearly visit with a cardiologist. More coordination and collaboration with PCP and specialist care; finding the correct level of care for common, low-level musculoskeletal complaints, etc etc would all go a long way to improve how we manage a population's health. (and no - chat bots are not the way; nurses armed with "dot phrases" are not the way). Pumping out more PAs and ARNPs to jump into the mix with us is a temporizing and inadequate response. Until all that happens, I'm hanging in there with my concierge practice as long as I can.
My perspective, not entirely in disagreement, is different.
I think a lot of dissatisfaction among doctors is due to lack of freedom. An NP goes to school for a couple of years and then can work for anyone who wants to hire them, but an MD (+/- another graduate degree) gets you 3-7 years of residency at a specialty you may or may not want plus or minus another year or two or three of fellowship.
I entered medicine to treat chronic pain. I've branched out into addiction, and it's good work and I'm reasonably happy, but I spent so much time doing things that weren't that at all, and is remarkable how we just accept that as normal. If every lawyer had to work for three years as a public defender, the legal profession would revolt.
Some training and quality control is necessary, of course, but I found my brief time as a resident on a hospitalist service was definitely teaching me not to want to see patients. And I liked my colleagues and I cared about my patients. I'm just not an internist.
Thank you for another insightful commentary on the state of medicine. I went back and listened (again) to the old Reflections podcasts. I cried (again) on dignity in dying.
You bring commonsense, medicine, and humility together. As a physician I look forward to these pearls.
Thanks so much Matthew. Adam.
First post...I totally support the author's right to "reflect" or even "vent". Great. Do it with your friends and family, or even here in "public" if you want some kind of feedback. If it's because you want to enlighten others, then I have to give some feedback.
You "loathe listening to people complain about being a doctor". I loathe listening to people, especially other doctors, imply that doctors don't have the right to vocalize their dissatisfaction with certain aspects of their job/profession...no matter how much they are paid. Everyone has the right to share their experiences and perspective with others...positive and negative. That's what I teach my severely indebted medical students who delay their income-earning years.
Here's the good part of this essay..."the dozens of decisions I make every day have consequences. I worry about these consequences". That's the nail on the head. Many people don't realize/appreciate this, and for that I do complain (share my perspective).
As a physician, I enjoy seeing the patient but its the EMR/documentation that's the burden and the lack of time for the patient. 15 min appointment is not enough time for a complex follow up, let alone a 30 min spot for a new patient.
A long time ago, I saw a few doctors about my chronic fatigue. I was treated as an honest, intelligent person and he didn't just assume the problems were in my head.
Even today, more than 20 years later, it stands out as a very good and positive memory. They probably don't remember me, but I remember them as a good friend.
Thank you for sharing and it did make me reflect. I think your comment on impotency struck me most. I would expand it though beyond systemic societal problems to include the majority of our scope of practice. We apply imprecise tools with imperfect knowledge and all the while the perception of our "bosses" is that we know for sure what we are doing will work.
Thanks Adam, for sharing this.
It would be interesting to hear how much this sentiment differs between generations. Is it possible that the paperwork, insurance red tape, dwindling profits, reduced time spent getting to know a patient, and over-medicalization of the US has made it more unpleasant to be a doctor?
On the other hand, is it possible that the army-style training of 24(+?) hour rotations and sleep deprivation leads doctors to develop unhealthy lifestyles that make you more prone to depression and disliking life and your job. For sure, as a mom, the difference between screaming at my kids at 9pm and gently corraling them to go to bed is whether I got a good night's sleep.
I feel like if you guys were able to take care of yourselves the way you want your patients to, maybe it would make a difference on how much you enjoy seeing patients. Maybe more group practices where you're not always on-call every night would help.
1) I agree, the combination of bureaucracy/administrative work + an often unacknowledged emotional toll are probably the big culprits, in different proportions for different people. Thankfully I find my work gratifying, but holy moly the difference between what I imagined a doctor's job was like when I was a kid vs. what it's actually like...
2) "As a doctor, your patient is your boss."
I once said something like this to a patient I was treating, who happened to be psychiatrically hospitalized at the time. I immediately realized how crazy it must have sounded given the context, and sure enough he didn't miss the opportunity to remind me (angrily) that people typically don't have the ability to keep their bosses hospitalized in a psychiatric unit.
It takes two doctors to declare a patient clinically insane: but it only takes one vindictive patient (or relative) to drive a vulnerable and self-doubting Doctor to suicide by making a brilliantly constructed but malicious malpractice claim.
Doctors should not be allowed to marry other doctors. Its like incest.
I certainly agree with the descriptions of the positive aspects and rewards of medical practice but would modify a couple of statements in order to provide a better understanding of the problem.
1) "I loathe listening to people complain about being a doctor."
I would bet that more than 95% of the complaints are not about being a doctor but rather are deploring the degradation of the practice of medicine that third party intervention has inevitably brought about. Corporatization and bureaucratization have depersonalized the doctor-patient relationship to the point where neither party is very satisfied.
2)"As a doctor, your patient is your boss."
See #1 above. If only that was still true.
You also described my life as an addictions therapist; now that I’m reluctantly retired and do pro bono work for nurses in recovery and the occasional individual, the LIFESTYLE you describe so wonderfully stays with me. I don’t mind it at all now that there is no admin crap. Nothing worse than that! What always amazed me was that occasionally I would dread a certain individual simply because that person may have rotated through a half dozen times, and I felt like I had failed them. I know I didn’t but then one day they got up on the bike and started riding it. And of course not unlike you, I am mourn the losses. Thanks for always being human in your well earned Superman cape!
I am humbled by this post. First and foremost the thought of you not liking medicine or being a doctor never crossed my mind, Dr. Cifu. Your posts are thoughtful, passionate, and transparent. You delve into the good, the bad, and the ugly about medicine in general and your doctor-patient relationships. By the end of each of your posts it is always clear you are doing what you love and wouldn't trade it for the world. I spend my career in the trenches, donning garb to prevent fleas, bedbugs, and roaches from attaching to my clothing. I get yelled at and verbally attacked. I endure things I would never have endured had I not chosen, practice, and love my career choice. Do I not want to see patients? Yes, at times and not all of my patients. I know the most challenging and difficult ones are those that need me most. It doesn't make it easier, but it pushes me forward to practice in my specialty.
Linda, I agree completely!
Beautiful. Thank you.Adam.
In Ontario Canada - family doctors abused covid allowances - at one point my doctor called me from his car speaker while out for a job. It’s not that they didn’t “want” to see people, they didn’t have to and they took advantage of it whole cloth
ouch
Concierge medicine, is only available for the very wealthy patient and the more senior wealthier physician.It’s used mainly for primary care. It does not translate well if and when the patient requires subspecialty care, , surgeries etc. We need voices like Dr. Cifu to shine light on the reality that medicine has become for most drs and patients.It is cumbersome and disastrous.I don’t see how pts seeing their MRIs and labs on a pat portal ( often before the dr has seen it , and usually weeks before they can discuss the results with the dr) benefits patient care at all. people go on Reddit, Quora and the like to “ research” and ask for help! This is BAD
Wow, Adam. I could not agree more. I retired 19 months ago after a 40+ career including 30+ year in pediatric lung transplantation. what a privilege! The clinical activity of the program has dropped pretty drastically for a variety of complex reasons. I am now 2/3 of the way into writing a book about my experience. The tentative title will be "Second Wind: my 30 years in pediatric lung transplantation". I hope that many of you will read it. I will be 76 years old next month. I have the task of writing the story of the vast majority of my patients dying before surviving even 10 years after transplant surgery. From the point of view of families, patients, and most of us involved in the work, the effort was definitely worthwhile but so many doctors have DISCOURAGED patients and families. They have taken the tack that even five years of vastly improved life cannot be worth the financial and emotional and psychological cost of the tough journey embedded in that blessed trust relationship with which I had the divine blessing in which to participate for the 30 years.
Thank you for everything you did. Looking forward to reading your book. And if physicians who happen to see this comment need a little jolt from somebody who is extremely grateful for their service, read here. https://open.substack.com/pub/jimryser/p/memories-of-favorite-docs-who-helped?r=15g3mk&utm_campaign=post&utm_medium=web
Jim Ryser, I read your sub stack post and it was really wonderful. What a life of intersection with the medical establishment. I'm glad you had such wonderful doctors and care givers along the way. Your fortitude through it all was/is quite amazing. Have you written a book, or considering? Best to you.
Thank you DocH! It’s been a great journey! I made records back in the 90’s (Google “Jimmy Ryser”) but doubt I’ll do much book writing! I still do music for The Hunting Public and a few other YouTube shows I love but maybe someday I’ll write more than I do here! Thank you so much for checking in!
Elegant and provocative, as usual, Dr Cifu! I think much of the answer lies in the tension between your declared joys from the field "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" and most care, where the diagnosis is either well known (knee or back pain), or obscure and hard to ameliorate in a given patient (fatigue, post-viral cough). The time space and energy to do that cognitive activity well, to manage expectations, do something somewhat helpful (and reasonably satisfy both you and the patient) can be in short supply. Concierge medicine is one answer, but out of reach of most individuals, and is in some sense a betrayal of our values to treat all individuals in society. Thanks for writing this fruitful essay!
Andy Davis, I don't see concierge medicine as any betrayal. For some of us, it is the only thing that will keep us in the game longer. I worked as IM PCP in a "big box" system for just over 20 years. They made it clear they did not value me (in many ways). As I spent a decade (or more) doing everything I could to improve my "efficiency", I was made to feel that something was wrong with me. Nobody ever brought up the simple fact that current medical industry is not geared to value the way a female PCP will interact with and manage a majority female patient panel. The entire reimbursement system is highly geared to favor the way male physicians (again, speaking only for PCPs here) see a more balanced patient panel (a balance of male and female patients, not a 5:1 mix!). Of course, each physician has our own balance of strengths and weaknesses, so this is a generalization not a pronouncement for everyone. Eventually, my supervisor said "maybe this just isn't a good fit for you!" - huh, after practicing for 20 years, I'm just going to find that out? (and coming from a highly popular female internal medicine PCP w/ good patient care, good patient "experience" scores etc etc). So I left. And started a concierge practice. Modest fees and it is still a labor-intensive practice as medicine is a complicated field. When you are told implicitly and explicitly that you are not valued, you have to try something else. The other option is to "burn out" and get out completely. I didn't do that!
Part of the problem is that in the entire history of modern medicine, we have yet to truly reorganize the way we manage and "deliver" care. The whole practice of medicine still really rests on the labor-intensive one-on-one interaction between patient and doctor. And local communities do nothing to organize and manage referrals to specialists as a community, leaving specialists bombarded with the flow of referrals and trying to "take them as they come". Until we revolutionize, in some way, how we organize care, we will be stuck with this rusty wheel clunking to a catastrophic end as the baby boomers decimate our resources. Maybe doctors don't really need to see everyone with a sore knee before they go to physical therapy! Maybe not every stable elderly patient with a fib or a mildly dilated thoracic aorta needs a yearly visit with a cardiologist. More coordination and collaboration with PCP and specialist care; finding the correct level of care for common, low-level musculoskeletal complaints, etc etc would all go a long way to improve how we manage a population's health. (and no - chat bots are not the way; nurses armed with "dot phrases" are not the way). Pumping out more PAs and ARNPs to jump into the mix with us is a temporizing and inadequate response. Until all that happens, I'm hanging in there with my concierge practice as long as I can.