I reconnected with Dr. Apollo (a pseudonym) after my recent Oberlin College reunion. I’m a doc, you’re a doc, let’s chat sometime. He agrees to be interviewed after reading my blog post on physician burnout. “Oh my gosh,” he says. “This is exactly what we talk about!” Scheduling the interview turns out to be a minor challenge. Apollo and his wife have been trying to update their will for four years. The night before we chat, Apollo spends the evening on the computer, finishing the electronic chart notes for his clinic patients. Then he completes the twenty-five charts pending from earlier in the week. He goes to bed at 6 am.
I send him a Facebook message that he reads at 1:27 am. The next afternoon, I catch him in the car. His wife’s driving. For a guy who commonly gets three hours of sleep a night, he sounds pretty good.
Apollo loves medicine. He was chief resident in Internal Medicine before pursuing a fellowship in Infectious Disease. He wound up in a large health system in Ohio. Germs rock his world.
Like Family Medicine and general Internal Medicine, Infectious Disease isn’t a procedure-driven specialty. Dr. Apollo is paid for “production,” for the number of wRVUs (work Relative Value Units) generated in a day – or night. The thinking specialties, Pediatrics and Internal and Family Medicine, pay far less than interventional or surgical specialties like Cardiology and Orthopedics.
The compensation system can’t even comprehend the complexity of the patients Apollo sees on a typical day. Imagine the time it would take to communicate with an elderly Latino immigrant through an interpreter. And by the way, the patient is deaf. Add a sign-language interpreter. What if I told you that the patient has multi-drug-resistant tuberculosis (add a boatload of protective gear) and is actively suicidal?
You have twenty minutes. Good luck.
Life in the hospital is equally challenging. About ten years ago, Apollo would make rounds on 6-8 patients per day, two of whom were new consults. Now he rounds on 16-20 patients per day on top of 6-8 new Infectious Disease consults. Weekends are grim with only one doc on service and an average census of 30 ID patients. Apollo spoke up in defense of quality patient care. This isn’t safe! We need more docs! Administration informed him that he could hire a moonlighter with his own money.
There was one day back in about 2002 when I was on my hospital week. My census was 18, including folks in the ICU, pre- and post-operative consultations, newborns (some of whose parents requested neonatal circumcision – another topic, another time…), small-bowel obstructions, pretty much the routine spectrum of Family Medicine. I cried that day. I think I was standing at the nurses’ station. Derica, one of my favorite nurses, did her best to reassure me. It’s okay. You’ll get through it.
Dr. Apollo is getting through it. Sort of. On top of caring for real-live patients, Apollo is also available via pager to whomever wants to chat. This is a “service” that the specialists in the system provide, an unpaid service. In procedure-driven specialties, the docs might see some procedural revenue. In the thinking specialties, these “curbside consults” are a charitable contribution to the organization.
Let’s pretend I’m in clinic again, and I’m seeing a young man with newly-diagnosed HIV disease for his hospital follow-up. I have questions about his medication regimen that require ID input. In the olden days, I would ask my RN to please contact my favorite Infectious Disease doc’s office and try to get her on the line. What would she get in return for being available to help me? A new clinic patient. And my undying loyalty and gratitude. Maybe I could work her son into my schedule for his forgotten sports physical. What goes around comes around.
Now, if I practiced in Apollo’s system, I would call a general number if I couldn’t find my MA, and request that an ID specialist call me back. I’d ask Apollo to look at my patient’s x-rays and med list, and weigh in on a follow-up course. I have no personal connection to Apollo. He’ll never see my patient. But his name is on the chart. Welcome to liability risk with no benefit whatsoever.
On a recent Wednesday, Apollo tracked these “curbside consult” phone calls. He spent four hours on the phone. Unpaid. What goes around comes back to the pocketbook of the CEO.
Ebola almost killed Dr. Apollo. Three of his colleagues had recently left the department. The new hire came from California and lacked familiarity with the facility, the staff, and the computers. Ebola hit. Who do you turn to when Ebola hits? Your Infectious Disease specialists, duh. In one week, Apollo pulled three all-nighters. One day, he had eight hours of (unpaid) meetings and saw 18 patients in the hospital.
Apollo is burning out. It’s a smoldering burn, gathering energy over the last several years. His department continues to hemorrhage docs and the system continues to just not get it. (Medical students and residents get it. The applicant pool for Infectious Disease is in a three-year decline.) Dr. Apollo took a stand last year, demanding compensation for the curbside consults, input into clinic support staff hiring, and more time with complex patients in his clinic schedule.
The organization basically said – Prove how much time you’re spending on the curbsides! All the calls are recorded, and somewhere in the system that data is available. Is it available to the docs appropriately asking for compensation? No. Clinic support staff decisions continue to be made without physician input. In response to the need for more time with complex patients, an administrator said, “Fine. You just can’t lose productivity.” And suggested that Apollo add time slots earlier in the day and work through lunch.
“It feels like we have so little autonomy,” Dr. Apollo says. On a recent day in clinic, a nurse asked Apollo to add a patient in to his schedule. He said no, please put them in tomorrow’s schedule. The patient was stuffed into his day anyhow. “What did you do?” I ask. “I just saw the patient,” he replies. What else can he do?
Dr. Apollo recently attended a medical conference on physician burnout. His pager went off so many times that he had to leave. #irony
I ask Dr. Apollo about his greatest joy, if there is any joy left at all. “I think probably it’s that there are certain patients that I do love taking care of.” He enjoys the social justice aspect of infectious disease, particularly in regard to refugee populations. “In the past month, every time I see a refugee, I thank them for coming to Ohio. I say, ‘The state is so much better because you came here.’”
What recharges his batteries? An appreciative patient. A successful strategy to improve the efficiency of patient care. Academic projects such as putting together a talk or a reading.
There’s no time.
The hamster wheel of productivity strips the organization of opportunities for creativity and innovation.
There’s not even room for creativity in a chart note. The doc’s assessment winds up being a list of diagnoses instead of the thought process behind the list. “Medicine is about storytelling. We even comment on it it our notes! ‘The patient is a poor historian.’ We value that!”
The story is lost. And the therapeutic relationship suffers. It’s “like a factory model of healthcare,” Apollo notes. (His son concurs from the backseat.) “I try to keep eye contact [with the patient while typing on the computer]. I can type fairly well without looking at the keyboard.” Sometimes he glances down and finds a paragraph of gibberish.
Dr. Apollo is plotting his escape. He’s researching other Internal Medicine fellowship options. What time do docs leave clinic? What’s the average number of patient visits in a day? Would he be able to incorporate his love of infectious nasties? Do the docs recognize their own children? This is a bold and radical step for a middle-aged man, to take a drastic (but temporary) paycut for the promise of eventual sanity.
I ask what change he would make on a macro level, a BIG THING. “Single-payer,” Apollo says immediately. He cites a graph of the steadily increasing number of physicians over the past several decades, overlaid with the exponential increase in administrators.
If Dr. Apollo switches subspecialties, maybe he’ll have the time to help with the Revolution.
I ask where he hopes to wind up after completing yet another fellowship. He’d consider staying in his current organization. I’m shocked. In spite of everything? “The [redacted to prevent more physicians from flocking to this subspecialty] docs love it! I don’t want to burn bridges.” And he wouldn’t want to leave his home state.
Better the devil you know?
Dr. Apollo is convinced that necessary changes to the US healthcare system will be driven by patients. I agree. If patients understood the abusive system that gobbles down young idealistic medical students and spits out jaded, ulcer-riddled automatons, surely they would protest. “If doctors advocate for themselves,” Apollo continues, “it’ll look self-serving.”
What then must we do? I’m a patient. You’re a patient. Please. Speak up! Get on the phone. Grab your computer. Tell that CEO to stop killing your doctor or there will be no doctors left to kill.
Apollo is the Greek god of healing. And herding. Convenient.