Wednesday, November 9, 2011

Family Medicine: Caring and Working are Clashing

Family Physician (FP) perspective:  Patients call for appointments with Family Physicians for lots of reasons.  They may be acutely ill, chronically ill or chronically well.  The lines between the categories are often blurred.  They blur more when the patient arrives for the scheduled appointment.  The patient has many needs and wants, many of which are "extras" in the eyes of the physician but "mandatories" in the life of the patient and the system in which they live and work.

The FP wants to make a difference in someone's life each day, to help patients to know that they matter.  The doctor wants to feel satisfied that they are still aligned with the desire to help people, not detoured by the avalanche of ever-increasing administrative and regulatory demands on their time (and soul).

The physician is hopeful that the daily schedule will flow nicely, allowing the work to be done.  Helping versus working.  It's becoming an "either/or" for the physician instead of a "both/and", losing instead of winning.  The FP knows that the patient has many expectations, some of which align nicely with the physician's expected work flow, some of which don't.

 How many times a day will the physician feel heavy hearted at not responding to the extra needs expressed by the patient during a scheduled appointment?  How many times a day will the physician respond to a need of the patient beyond that expressed when the appointment was made?  How much guilt and disappointment will the physician build up by the end of the scheduled work day as they get "behinder and behinder" (sometimes getting an extra jolt when the last patient asks for a bit of time to call the spouse about picking up a child at sports practice or day care, etc.) ?

The physician and office staff care about the patient, which sometimes aligns with the work flow and sometimes doesn't.  Caring isn't as "schedulable" as working.  Working and caring sometimes fit like a hand in a glove, and sometimes they clash viciously.  Financial issues, which I've mentioned in numerous previous posts, drive the squeeze.  Big hearts may forget schedules and go the extra mile for the patient.  The push of this era in healthcare (one word = the financial part as opposed to two words- health care which = the human/people part) is often stressful and sub-sensitive.

How might the Family Physician get back on track with actual patient needs as health care transformation happens?  I've posted numerous times about the Human Centered Health Home (HCHH).  The Patient Centered Medical Home (PCMH) is the current national strategy, which has lots of merits.  I'll post more about it later.

What do you think?


  1. I'm probably your nightmare patient.

    Oh ..most likely we'd have a good rapport ..but I ask questions, I want to bond and feel supported and here comes the "C" word. I'm chatty.

    Years ago wasn't so bad ...but after reading these kinds of posts ..I can see that an automoton pt ..sticking just to the facts mam and out the door is easiest.

    But's my body and I have to feel a connection and trust and I never feel that with a cold personality.

    It is all frustrating and sad. I have docs that do go the extra mile with me ...but now (and have been thinking about it) I feel if I care about them ...I should just be quiet to get out the door for them.

    Now... my pcp that had to close his practice ...he was delightfully chatty and I know I had longer appts. I assume he did that with others. And it probably hurt him.

    I heard he is doing well in his corporate job ...but that he really misses his patients. This doc was forced to close and would not have done it if not for low reimbursements and expensive overhead.

    I will always remember the long, strong hug he gave me and the prayer he said the end of my last appt. I couldn't even leave the room because I had too stop my tears. Nurse came in with tissues. I walked out sniffling and then when I was with receptionist cried again ..she cried and the woman coming out after me with her young children was also crying.

    So ...You good docs truly matter to your patients ..the ones you've bonded with. And I am guessing even some of the ones that you don't know are fond of you. My husband was upset Dr was leaving too and he had only known him for a year and was always wanting to get in and out. But all patients that stay develop a familiarity and trust for you to see them privately with private health concerns.

  2. Thanks for your comment, Sea Spray. Paragraph 2 represents the goal of the Family Physician. The patient goals, whether "chatty" or not fit within the bounds of the physician's goals. The "extras" that usually seem not to have been part of the patient's purpose for seeing the doctor may become a primary stressor on physician time and schedules, but may be the critical issue that needs medical attention. We have to respond to their pressing needs.
    Chatty plus extras may be the biggest challenge, but our mutual styles in communicating issues and clarifying boundaries have to evolve during the relationship of patient and physician over time. You and your physician had it figured out. Congratulations for that. He apparently had business issues that didn't fit with his patient care goals or the modern era of healthcare. We have to figure out a better business model for caring physicians to be able to continue to serve patients.

  3. I am really going to be more mindful of time constraints and remember ...they are not friends ...even if they feel like it. :)

    yes ...knowing his personality ...I can absolutely see he would've felt frustration at the time constraints.

    One day I heard him chatting so delightfully with an elderly woman during the exam and she sounded so sweet. It made me smile.

    he was very close to his own parents and I was his last patient the day his mom was being set up for hospice. I could see he was distracted and right after he did whatever he did for me ...I told him to go because I know he needed to be with his mom and I hugged him for the first time and could see he appreciated it. It was so sad ...seeing the sadness and concern on his face ...evidence of his breaking heart. A strong Christian man and his parents had had a healing ministry in Scotland at one time. Dad was a doc too. So ...he knew where she was going.

    But after my mom died a couple of years later ...he told me it is normal to feel lost when you lose a parent. It was only a month later and I wasn't experiencing that feeling ...but I did further down the road. It helped to know it was normal. I really miss this doctor.,, but I am glad to have known him. Just so hard to transition to another one ...even tho I do like him. But feels so much colder by comparison and i know it's not fair to judge yet because these things take time to build. But we had the whole Christian talking things going on and he prayed with me when he thought to or I asked and like I said ...I loved his quoting CS Lewis at certain times when the quote fit. :)

    I know that all things work together for good.