You expect your doctor to listen.  You expect a sharp mind, a good thought process, a smile, and a solution to your problem.

I walk into those expectations over 100 times each week.  Each patient I see is expecting my best.  That is what they pay me for: a professionally-trained person who can help them get healthy or stay that way.  If I was the patient, I would expect the same of my doctor.  I would assume it.

But it isn't always easy.  Last week I had to deal with an incredibly busy schedule, a bad case of child neglect, and an accidental death due to a Tylenol overdose.  My son is starting to interview for college, and there are the usual trials of being a father (with three teenagers) and husband.  I was also fighting a cold, and wasn't getting as much sleep as I needed.  Giving 100% when I walked into each exam room was not easy. 

Before I go in to see a patient, I try to clear my mind of distractions and walk into each room fully focused.  The problems I face don't always tax my thinking: I may be seeing a healthy baby, an ear infection, or a stable hypertensive patient.  The problem is that I don't know when the tough case will show up.  I don't know which well-child exam will have the abdominal mass, which ear infected child will be bordering on sepsis, or which hypertensive will have subtle unstable heart disease.  They will be out there, but I don't know when and where.

Jerome Groopman, in his book How Doctors Think, describes primary care medicine in the following way:

Imagine watching a train go by.  You are looking for one face in the window.  Car after car passes.  If you become distracted or inattentive, you risk missing the person.  Or, if the train picks up too much speed, the faces begin to blur and you can't see the one you are seeking.

Quoting a pediatrician, he goes on:

"It's much harder than the proverbial needle in a haystack, because the haystack is not moving.  Each day there is a steady flow of children before your eyes.  You are doing well-baby checks, examinations for school, making sure each one is up to date on his vaccinations.  It can become rote, and you stop observing closely.  Then you have the endless number of kids who are cranky and have a fever, and it's almost always a virus or a strep throat.  They can all blur.  But then there is that one time it's meningitis."  (from Chapter 4)

The key is to always be on the lookout, always attentive, and as methodical as possible.  I try hard to do everything the same way each time so that I always go through the necessary steps.  Having done this for the past fourteen years, I am pretty good at turning my brain to "doctor mode."

But I have come to recognize that this does take a toll on me - especially during times like last week, when there are many emotional things trying to drag me down, and many interruptions and distractions to my daily routine.  To add to the analogy, it is like looking for that face on the train while in a crowd of shouting people.  It is habit, and I can do it; but it takes its toll.

I am not looking for sympathy.  I am no different from other primary care physicians in this way.  It is important to remember this reality when you hear primary care physicians complaining about the unfair payment system.  We may sound like whiners - and sometimes we are just whining - but it is easy to become jaded. Life for the PCP consists of carrying this burden on a daily basis and then being rewarded with lower pay, more responsibility, increasing scrutiny, and less appreciation for the job we do.

Finally, let me point out that I am the tip of the iceberg.  I am one of the few PCP's who is vocalizing this fact.  Most PCP's are carrying this burden without a podium on which to complain or an audience to hear it.  I can voice my concerns to the public and at least get some people hearing my complaints, but most PCP's just dealing with the stress, taking a deep breath, and walking into the next exam room trying to give 100%.

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