By Cindy Rubin, MD
“Why do they book your well-child checks for 15 minutes?” my medical student asked me yesterday. I laughed. I couldn’t help it. Gut reaction – like when you laugh instead of cry. I explained that all of our appointments are 15 minutes – well-checks (regardless of age), to colds, to suicidality or chest pain. I work for a large hospital system, and that is how patients are booked. I the only pediatrician who gives my teens 30-minute well-checks (and I take a pay hit for this). What seems to matter more than taking good care of our patients and spending time with them when they need us, is our numbers. Plain and simple. Get ‘em in, get ‘em out.
I have developed a reputation in my office for always running behind. When I started outpatient pediatrics 12 years ago, I rarely ran late. I rushed from patient to patient, proud of myself that I was always on time. Occasionally, a more complicated patient would come in and need extra time, or I would get behind for some other reason, but it was rare. Over the last several years, something shifted. I am now almost invariably running late, as much as an hour, every single day. Even on “slow” days, I am often still running behind. I have been wondering what led to this shift. My hours per week are the same since I started this job. My time per patient is the same.
I finally figured it out. That shift? That shift was me getting to know my patients and their families better. That shift was me transforming from a rookie physician to a seasoned pediatrician who won’t leave patients in their time of need, when they are vulnerable, need questions answered, are going through a crisis. My patients want to talk, to tell me about their wins and losses, to ooze pride in their children. And I want to hear these things. I want to prescribe an antidepressant right then and there when the child is depressed, anxious, and can’t get in with a therapist for weeks, rather than asking them to come back to discuss their mental health issues because I am running behind. This is why I went into medicine. I want to build relationships, to see these kids and their families grow up, and to help keep them healthy both physically and emotionally. Apparently, I should be able to do all of that in 15 minutes.
Though I was running behind even before COVID-19 hit the U.S., the pandemic has put a unique strain on our pediatric visits. Many more children are depressed, anxious, socially isolated, gaining weight from less activity, doing poorly in school. Many parents are also isolated and happy to get out of the house and have someone to talk to … about anything! And then there are all of the questions about COVID, and the extra time it takes to don and doff PPE, and the frequency of being short-staffed due to layoffs or sick days – none of which gets us extra time built into our schedules. Every extra minute spent adds up throughout the day, leads to us running behind, which in turn makes patients unhappy and puts a strain on us as well. I miss out on my lunch because I work through it. I miss dinner and bedtime with my kids because I finish late with patients and then stay longer to respond to the messages and lab results waiting for my response. And then I am up past midnight finishing my charts because I couldn’t chart as I went through my workday for fear of running even more behind. One of my patients must have seen this in my eyes when I walked in to address her ongoing anxiety recently. As she sat there tapping her knee and explaining her story to me, she said, “You need to take care of yourself. Go get a glass of water when you finish with me.” I almost cried.
This is not a sustainable model. I expect to have some long, stressful days because it comes with the job. But not every single workday. But if I make my appointments longer, or I put in some empty time slots throughout my day, my employer will ding me for not making my target productivity numbers, or for not working my full FTE (because 15 minutes to catch up counts as 0.25 hour when I am not “on-the-clock.”)
I have become a “problem” in my office. How can we get Dr. Rubin to run on time? Let’s knock on the door so she will stop taking care of an important patient care problem and move onto the next patient. Let’s add in those “catch-up” breaks even though she then has to add on more hours at the end of the day to meet her clinic hours quota, so patients wait less, but her family never sees her?
Instead, let’s fix the actual problem. Please, let’s fix the system.
Let’s make appointment visits longer across the board. Let’s create a robust scheduling protocol so that complicated patients or problems get even more time. Let’s ensure sufficient staffing to help support physicians so that we are not filling out paperwork for hours after the patients have gone home. Let’s base physician salaries on the worth of the services they provide, and not on patient volume, so that the incentive is to provide good care and not to see more patients for the sake of seeing more patients, and so we don’t have to decide whether to take our “vacation days,” or work those days to improve our “numbers.” (Did you know that most primary care physicians are paying back hundreds of thousands of dollars in student loans, but are being paid less than $60 per hour if you add in all the non-patient-facing hours of work they do? Compare that to the $300 to 600 per hour that many lawyers, CPAs, and financial advisors make even though they have had the same or fewer years of education and training.)
Let’s cut back on unnecessary administrators who eat up revenue. Let’s stop thinking about medicine as a consumer business, but instead as a health care system designed to provide the best possible care for our patients (not customers!). Let’s help patients realize that we are doctors, not salespeople. We cannot always predict what will walk through the door, and though we would like to run on time just as much as our patients, sometimes our patients need more than 15 minutes. We must remind patients that they will get that extra time when they need it.
I could go on and on. I come back from work both exhausted and infuriated most days – with very little energy to focus on my kids, my husband, myself. And if I do rush through my day and leave unfinished business behind, I feel like I have failed my patients. Something needs to change – either for me or for the system as a whole, in order to be able to continue to do this rewarding and necessary work. I want to practice medicine the way I always intended: thoughtfully, thoroughly, with feeling, all the while trying to model these qualities for the next generation of physicians. I don’t want to feel selfish for hoping to spend more time with my family, who needs me, who needs my energy, my time, my caring that has mostly been expended at work these days.
We need to stop blaming the doctors. We need to see this for what it is: a broken system. A system in the process of breaking the very doctors who make up its framework. Please let’s call it like it is, and let doctors take back medicine for the sake of the patients who need them, and for the doctors who care for them.