a weekend a month keeps the doc in town
Retaining doctors, physician assistants, nurses, and nurse practitioners in rural areas is often very challenging. Once a provider leaves, it often takes longer than average to replace him or her. Unfortunately, this happens frequently. I should know, I was one such provider.
Providers often cite the burden of covering the Emergency Department as a reason for leaving. That was the inspiration for the company behind what I currently do. It is cheaper to pay a temporary physician to cover occasionally so that the local MDs get a break, don’t burn out, and don’t leave than hire one full time doc or replace a burned-out one.
This often places me in an interesting situation. Often times, I find patients and local providers very thankful for my presence. I receive far more gratitude currently than I ever received from my patients and partners when I was a staff doctor.
I earn some of that gratitude. Keeping local docs who have roots in their communities practicing is a worthwhile goal. If helping cover a shortage on the odd weekend or holiday supports the local docs, I am glad to do it.
the prodigal parent returns
On the other hand, I often feel myself the deadbeat dad who shows up with ice cream and a trip to the amusement park on a birthday, only to disappear for another year. The guilt I feel can be a little intense sometimes. My wife thinks I should give myself a break.
Having been the local doc, I know how it can be.
The appreciation for being there day(and night) in and day out is often scant and irregular. Patients often take Steady Eddy, MD for granted. The doc who is present whenever needed rarely gets a significant show of appreciation until their retirement party.
Why is this? Humans seem to appreciate assistance in a moment of increased anxiety, dread, or pain more than the relationship, maintenance, and prevention that a long term physician provides.
This is an understandable human response. These events brand our emotional hides much more strongly than functional and reliable relationships do, even if the latter is better for us. Though understandable, it is a BAD way to build a health system.
pounds and pounds of cure
I became a primary care doctor because I believe in prevention over cure. I believe in helping people to live well, not just continue to exist. Sadly, that is not the way our health system rewards doctors. Apparently, because an ounce of prevention is worth a pound of cure our system pays doctors an ounce for preventing and a pound for curing.
By extension, I believe most people in the healthcare system have come to value expensive, painful, high risk cures over consistent preventative behavior. This seems likely to doom our system to failure by any objective measure of a health system. For a time, I tried to swim upstream, but the current was too strong.
The ED is a place for life-saving and band-aids. I see so many wounded and broken people in the Emergency Department. Most ED docs are not trained in primary care, despite the fact that huge amounts of what we do in the ED is actually primary care. In the ED, we patch people up and send them back to their PCP, if have one.
On the other hand, just because I am in the ED, doesn’t mean I stop being a family doc. I know what these people need.
They need an anchor of consistency and rationality in their lives. They need a consistent relationship with someone who will compassionately hold them to account when their behavior slips. Whatever I have to offer in the ED is rarely what they really need.
Again, the guy who temporarily patches the broken dam gets paid better and celebrated more than the guy keeping the dam from breaking in the first place. Now I swim with the flow, patching holes as I go, and feel a little dirty about it.
One of the greatest aspects of the High Plains is the size of the sky and the lack of city lights. Standing under the full immensity of the universe during a call night, I often revel in my own insignificance.
Life is a great tapestry. The individual is only an insignificant thread in an immense and miraculous pattern. – Albert Einstein
Looking up at the stars, I cannot forget that I, too, am a pawn in this system. I have no influence over our medical system, other than voting with my feet. This seems unsatisfactory, as one is only able to vote for realities that already exist. We are unable to create a new or better reality through “voting with our feet.”
As I labor on in our flawed system, I cannot help but wonder:
When the deeds of my doctoring are counted, how will they tally?
Does the good I do outweigh the system’s inadequacies?
Should I make this much money, given that I am propping up such a flawed system?
“Whatever you do will be insignificant, but it is very important that you do it.” – Mahatma Ghandi
If, even despite our cosmic insignificance, value exists in doing the work, then maybe results of the system are not my responsibility. Perhaps simply showing up and trying to be a positive influence in the cascading stream is enough.
A stone in a mountain stream does not stop the stream, rarely even significantly redirecting the flow. However, I have found many a beautiful, shimmering trout in the pools surrounding those large stones. The stone did not built a system designed to provide me with a trout to eat, but is essential to the process nonetheless.
Am I such a stone, simply slowing down the crashing cascade enough to allow local doctors enough breathing room to survive, and hopefully thrive? If so, is that good enough? I don’t know, but at least its something.