Friday, February 15, 2013

My mother's last day

It was a crazy day for my mother, a newly hired physician at a clinic, where she works 3 days a week. By noon, she had already seen 14 patients in 3 hours, she felt very behind on her documentation, and she was starving with no prospect of eating lunch.  Then, a middle-aged man with asymptomatic high blood pressure arrived complaining of “cold” symptoms.  She explained to him that while he did indeed have a virus, his blood pressure was sky high and would require medications to bring it down.  She ordered clonidine for him and he sat down while she went on to see several more patients.

She returned after about an hour to find that his blood pressure was 198/124, unchanged.  Tired, hungry and frustrated, she asked the clinic manager if they had nitroglycerin.  She knew they didn’t. She asked the clinic manager, “How can you not have nitroglycerin?”  My mom then asked if the patient could have a bus token to go to the emergency room for treatment, and the clinic manager said “No, just call an ambulance.”  My mother replied, “An ambulance is unnecessary, he is perfectly stable.” 

The clinic manager proceeded to call 911 despite the doctor’s objection.  At this point, the doctor lost it.  “How can a clinic that has been around this long not be stocked with medications like nitroglycerin and albuterol.  I have never worked in such an ill prepared facility. And it is unnecessary to waste tax payer money on an ambulance for a patient who could simply take the bus.”  The clinic manager disrespectfully retorted, calling her unprofessional, inappropriate and worst of all, she said, “Your patients don’t even like you.” 

My mother, the highly educated, extremely experienced physician, then proceeded to walk out.  She said, “Since you never actually sent me a contract, I have no obligation to stay and work here.  Don’t worry. I won’t be back.  Maybe you can find a different doctor for your patients not to like.”

My mom has been practicing ambulatory primary care for decades, and she has always had one priority: that her patients like her.  She cares more about whether or not they like her than anything else, except their safety.  When I ask her why she doesn’t retire, she always says, “so I won’t go crazy at home with your dad!”

She has related many problems at this family practice in Southern California since she took the part time gig 3 months ago.  She complains regularly about the usual stuff:  “Everybody wants Vicodin and Percocet and Soma and Xanax for chronic pain that has no obvious cause.  They want a 4 month supply with 3 or 4 refills.  They are crazy.  But even when I say no and explain why it is not safe, they complain, and the medical director writes the prescriptions for them behind my back!”  She had never been so pressured to write narcotic prescriptions at this level in her career and could not believe the lengths the clinic would go to please the patients, despite safety concerns. 

She told me about the ridiculous number of unnecessary tests the medical director encouraged the physicians to order, including annual MRIs of joints causing chronic pain.  When she asked him why he had ordered an MRI of the shoulder on a patient she had seen weeks before to whom she spent a lot of time explaining why she did not need the test based on her physical exam, the medical director replied “Why are you wasting time doing a physical exam?  Just order the test, it’s what she wanted.”

My mom could retire at any moment.  She does not depend on her job for income to survive, and she certainly does not have to support a family or anyone through college at this point in her life.  I can only imagine how pervasive these dilemmas are for practicing physicians out there in the community who do.   I wonder how often physicians must submit themselves to risky, expensive practices that have questionable efficacy because some clinic manager who works for some administrator says “the patient is always right.”  I'm guessing, daily, maybe hourly.  

As physicians, we are supposed to be stewards of society’s health care resources. We hold a fiduciary duty to our patients and society.  We are to put everyone’s welfare above our own.  I mean, ultimately, many of the patients demanding narcotics are dead as prescription opioids now cause more accidental deaths in this country than car accidents.

But, how realistic is it to expect that level of sainthood from physicians?  We are human, too.  We have student loans, mortgages, spouses and children to support.  And even when we take it upon ourselves to put the welfare of society and patient safety above all else, we are often met with disrespect, disdain, and even threats to our paycheck.  And the real kicker is that our own colleagues often undermine our medical decisions just to get ahead.

All I can say is wow, this the real deal: the US healthcare system.  Good luck with your fix, feds.  You have no idea what you’re dealing with.

Komo Gursahani MD MBA
Fellow, Bander Center for Medical Business Ethics
Saint Louis University School of Medicine