Nearly three years ago I started this blog as a journey I intended to take with my patients, plunging into the most passionate role for a physician I thought possible at the time by becoming a primary care doctor. What a learning curve it has been: in fact, I have had dozens of lessons along the way that I haven’t shared in this forum simply because I ironically became too busy trying to survive. But the journey has led me to a new step: to establish Thrive Adult Primary Care, PC — a solo Direct Primary Care (DPC) practice — with a plan to open doors in the Fall.
Recent posts have contained general information and links describing this model of care, but I want to take this opportunity to tell more of the personal story that led me here, as well as what this would mean for my patients, because at the end of the day these stories are connected. I believe deeply in the “oxygen mask” principle I had written about very early in this blog, and I find myself using that illustration again and again with patients to convince them that self-care is the key to being a high-quality caregiver to anyone or anything that depends on them. The thing is that my belief in this concept made me an utter hypocrite. It was only upon coming face-to-face with my own asphyxiation that I realized it was time for a change. Part 1 of this two-part entry synopsizes the backdrop of my decision to alter course. Part 2 will describe the philosophy of why I have chosen DPC as the next step. Read on.
I had started out feeling very optimistic. Despite being new to my job in 2014, I was an experienced educator and had five years of acute medical care under my belt, plus I am generally not afraid of working hard. I was excited 8 months into my primary care role to become a clinic preceptor for a resident of Internal Medicine from a university training program nearby. She was a delight, had an excellent attitude, and truly showed an interest in primary care. Because I haven’t asked her permission to talk about her in this blog, I’ll call her Emilia.
About two months after Emilia started coming to clinics with me, one of the other doctors in my office announced his departure — just relocating to another office but leaving behind a sizable number of his patients and basically starting over. Being the newest provider to our site and having the capacity to take on a bunch of patients, take them on I did, and they turned out to be challenging, complicated patients. Most of them made the switch early in 2016, and the drowning began. Meanwhile another doctor in the office who has been practicing for decades took his typical 4 weeks of vacation within the first two months of the year and it was my responsibility to cover his large and complex elderly patient panel during those absences. Not to mention that I was still acquiring patients who were brand new to the practice — either whose prior PCPs were retiring, or had moved, etc. It is one thing to see a patient for a specific issue and try to solve the issue (e.g., “Doc, I have a cold”, or “Doc, I sprained my ankle”) but another thing entirely to meet patients with numerous medical concerns, all of which are considered your responsibility. While trying to juggle all of this, and additionally managing a staff member on my team who was having a host of personal issues that interfered with her capacity to function at work… oh— and being a mother of two young kids and having a husband who has a busy, demanding job of his own, suffice it to say I was beyond capacity to handle any one of my responsibilities appropriately, let alone do them all well.
I had hoped my passion for teaching would provide an escape from the daily stress of work. Instead, under these circumstances, I almost dreaded the weeks when Emilia would be showing up to share clinics with me, not because I didn’t enjoy having her there but because it would set me so far behind on everything else. I regularly brought home 3 hours of extra homework every single night when there was no teaching, and it was no less than 4-5 hours of work during her rotation weeks with me. I couldn’t keep up with it while balancing home responsibilities, so there was a point when I was sure my backlog added up to about 18 hours’ worth of work. A little-known fact: at some point during this phase I actually took a sick day to manage a nervous breakdown, which my husband will vouch is unheard of for me. I spent an hour or two of the morning getting my tears and hyperventilation under control before jumping back into the electronic medical record from home to catch up, still with limited success.
In June 2016, a fourth physician — a 15-year veteran to the office — feeling similar tension and frustration announced that she was resigning completely in September. Knowing what this meant (acquiring yet another bolus of patients and all the work that came along with them) I only hesitated for one day before asking the residency program to reassign Emilia to another precepting physician outside of my office for her primary care clinic experience. It was a big decision for me, as it marked an abandonment of career focus to just “do a job.” I don’t think anyone within my organization even noticed or cared that I did it, even though it felt like a huge sacrifice to me.
After that I plugged along wondering what the future would hold, or whether the present even made sense from a professional standpoint. Minus the teaching, and as my proficiency in office medicine improved, the workload became slightly more manageable but was deeply dissatisfying. In the model of private group practice nowadays, all that matters as a physician is being a “producer” to justify our value to insurance companies so we can earn their reimbursement, since this is the only way to get paid for our work — that is, see more patients and take less time to do so, because there is also more “paperwork” (not really on paper anymore so much as via computers) to be done for these patients outside of the exam room. In order to engage in basic elements of patient care such as ordering lab work or medications, we must “code” our assessments/diagnoses according to a host of regulations and guidelines (yes, the coding is a physician responsibility). If that sounds confusing and hopelessly boring, that’s because it is. Ask any primary care provider. I don’t think any of us chose to become doctors or went through all that training so that we could stare blankly at computer screens and mouse-click our way through the day. Are you tired of going into the exam room and waiting forever only to have your doctor barely make eye contact then rush out of the room? News flash: doctors don’t like behaving that way. It’s a survival mechanism for the oxygen-deprived. More on that later.
I want to be clear in stating that the office and even the organization where I worked are not the enemy. If you have been following along or have looked through this blog you may notice that I lost my only brother to suicide in September 2015 at the age of 42, as well as a 39-year-old dear friend of mine to breast cancer in October 2016. The staff and colleagues in my office were more understanding and uplifting than I could ever have hoped or asked for through these tragedies. Not to mention several other personal needs or issues that have been met with kindness and support without question or critique. Among corporate health care entities out there, I believe my recent employer is one of the more open-minded and forward-thinking groups that exist in the present day (and the site where I was stationed is exceptionally staffed with wonderful people which made leaving a tough decision), partially because they have still been relatively limited in size. But fundamentally, they are still subject to the greater U.S. Health Care System which is deeply damaged. The problem, like any corporate or government structure that gets too big to care, is “the system.” This, too, is something addressed in more detail in Part 2.
To keep myself afloat, I see a therapist from time to time who I trust immensely. Towards the end of 2016 she gave me a bit of advice that stunned me: she recommended mindfulness. I almost laughed her out of the room because my husband had been trying to get me on board for years — bless his heart for his patience (which he probably picked up by becoming mindful!). Anyhow to make this long story a little shorter, my tune has taken a 180-degree turn and I will also be blogging about mindfulness meditation as a topic unto itself in the near future. However, when I first started trying to meditate I was in for a rude awakening. It was quite uncomfortable to discover how most of the content of my thoughts was so deeply self-critical that it would regularly, albeit subconsciously, paralyze me. Then one evening it pretty literally shocked me.
‘The moment’ happened just before 2017, at the midpoint of the week between Christmas and New Year. It was so simple as to be almost banal, but it was the wake-up call that changed my life. All I was doing was putting away leftovers, and I spilled some rice on the countertop. And the following words audibly exited my mouth: “You good for nothing piece o’—“
I stopped suddenly… suddenly mindful, somehow. Suddenly aware of what I was saying, although unaware of what drove me to say it. I guess you could say I was suddenly aware of my unawareness. It dawned on me that I say things like this to myself all the time, mostly silently, then the implications of the statement rattle me for the rest of the day, night, etc. I realized that without this moment of awareness, I would have proceeded to elaborate on the thought by following it up with things like, “I’m a terrible mother, I’m a terrible wife, I’m a terrible homemaker, I’m not even a good doctor, look at me: I can’t even put away leftovers.”
Multiple instances of self-flogging flashed through my consciousness, leading to a moment back when my oldest son (now nearly 8) was barely a year old and I tore into him for spilling dry Cheerios on the kitchen floor — apparently as an extension of my interpretation that his missteps reflect on my quality as a mother. The irony struck me that if anyone else had made the same move of spilling rice, there would have been no such critique. If anything, I would have taken the forgiving and reassuring stance — essentially the stance that any observer would have taken toward me in that moment. This entire mental trip happened within roughly 10-15 seconds following the spill and my associated commentary, and was so penetrating that I had to steady myself by grasping onto that same rice-covered countertop.
I finally managed to clean up the rice and put away the leftovers without further incident. But reflecting on it for the next few days, I came up with the first New Year’s Resolution I had made in quite a long time. I resolved to stop blaming myself for being who I am. I needed to be at least as kind and compassionate with myself as I am with others. All the guilt and self-blame doesn’t undo a single bad choice I may have made in the past and in fact only poises me to make new bad choices in the future by the same transference that caused me to scream at my little son for a silly error that is really a matter of course for being a toddler. I had to learn to let go of certain expectations and re-prioritize.
The mindfulness thing took hold for me even more as 2017 began. It was a fascinating experience to discover how being kinder to myself and focusing on the present moment did not detract from my consideration towards others, rather enhanced my ability to be compassionate instead of inclined to redistribute the pain of guilt or self-criticism for past mistakes. It also, interestingly, honed my attention to the countless inefficiencies that make our jobs difficult in the world of health care: individually small but collectively copious useless tasks and time-eaters that chip away at the resolve of genuinely caring people at every level of medical office staffing.
I made some effort to generate discussion in administrative circles and innovatively address some of these process matters, only to realize rather quickly that my concerns were #1) not new and #2) not going anywhere. Meanwhile despite having reduced my hours to part-time, work continued to follow me out of the office and interfere with the quality of my home life. After one or two unsavory encounters along my supervisory chain of command, I made the decision to pull the plug without a plan and prepared my letter of resignation.
If I didn’t have a plan, how did I come up with Direct Primary Care as a next step? If you made it this far in the blog post, your eyes are probably burning by now anyway, so I will drop the low-down to answer this question in Part 2. Stay tuned.