Remember in Jurassic Park when Ian Malcolm describes Chaos Theory to Ellie Satler, watching a drop of water roll down her hand? It might roll to one side or the other based on any number of differences in the hair on her hand, subcutaneous blood flow, imperfections in her skin, all tiny variations in a complex system, affecting the outcome. The scene came to mind last week when in 24 hours, my teen daughter and I had our worst doctor visit ever, followed by one of the best. Through the lenses of a fellow physician, concerned mother, and patient, I saw two physicians whose development in the complex world of medicine have had very different outcomes. We saw firsthand how moral injury to physicians, described by Drs. Talbot and Dean appears in different guises. First, we had a follow-up with a late-career pediatric cardiologist in a Big City “not for profit” health system about her ongoing POTS (postural orthostatic tachycardia syndrome) symptoms. They are life-impacting and scary. She has missed a lot of school, and she recently fell into a wall during another syncopal episode, before getting up and going to school to take a midterm exam to complete her semester on time. Our first visit with this physician was reasonable and informative and ruled out structural and electrophysiologic heart disease. Last week’s follow-up, in contrast, was horrible. He quickly set an antagonistic tone, interrupting us both at every sentence. He discounted her efforts to follow his recommendations and questioned whether I had read the POTS literature given to us on our last visit. I could not answer without interruption. He implied that I lied about the direction from his staff about the intake paperwork. He insisted that her myriad symptoms, all consistent with POTS in the literature that he gave us, needed to be checked out by other subspecialists. He then pressed me to practice “tough love” in making my daughter, a nearly straight-A student, “tough out” bad days, when she is ashen and vomits stomach acid while light-headed, to go to school. As exasperated as I was, she offered to show him a picture of the hole in the wall and the vomit on the rug from her last syncopal episode. He showed little interest in her story until I reminded him that I am a physician with a good understanding of the physiology and pharmacology he was explaining. He was upset that I had not made that clear earlier. (How could I have with constant interruption?) His demeanor shifted. He seemed chagrined and slightly more open to supporting a waiver for her school policy of needing a physician’s note to excuse every absence. We discussed more rationally at this point whether to change her medication regimen, and he agreed to support the waiver. My daughter and I sat in the car, fuming and venting before I could drive away. I repeated my support to help her feel better to achieve her life and school goals. I apologized for his dismissal of her concerns and efforts and assured her that we will never see him again. The next day, we had her first appointment with our new primary physician, who practices in a direct primary care (DPC) model. This mid-career physician and I met previously, and we discussed her motivations for moving to DPC. Frustration with payor interference, fractionated care, office overhead, and financial pressures to see too many patients all played a role. She now values unhurried, thorough appointments, and close communication with her patients between visits. She finds good lab and test values and the best prescription prices for her clients. We spent over an hour with her, carefully discussing my daughter’s health and concerns. She epitomized open-ended interviewing, good listening skills, and recapping plans and concerns. We discussed my daughter’s and my goals for her health and how to achieve them cost-effectively. She was patient, kind and gained my daughter’s trust and buy-in to work on the changes she needed to make. Simple, right? We left feeling buoyed to have someone in our corner. Where does the moral injury come in? Doctor number one, long forged in subspeciality corporate medicine, has numbers to see, procedures to perform and charge, reams of redundant insurance click boxes. He is busy; no time to listen. Patients bring nuisance forms daily. He sees a busy clinic load before rounding at the hospital on another quota to satisfy his corporate overlords. I get it. From an anesthesiologist’s vantage, I have heard all this from many angles and have felt it myself. But who benefits when the patient leaves angry and dismissed? Is this how he imagined his career would go? I suspect not. He wanted to help children with heart disease – a beautiful goal! Why did his demeanor change when he realized that I am a physician? Did that make my observations of my daughter’s health and concerns more valid? It should not have. Our DPC physician has created a truly patient-centered model. She creates a positive, cost-effective health environment, building trust and buy-in with her patients, truly laying the path for improved health. She spends time with her patients without the constraints of excess documentation for regulation and payors or a corporate quota. These doctors are not drops of water but human beings who brought different backgrounds to their medical careers. Their choices were not random, nor were the forces driving their practices. Physicians cannot lose focus on the important objectives in medicine – improving human life and caring for others in the way they need. Our medical system thwarts us at every turn, with fee-for-service structure, paralyzing insurance and regulatory procedures, and demoralizing production pressure. Too many physicians are at the edge of defeat. Experiencing a success story as a patient was very heartening. Please don’t stop fighting for what brought you to medicine. Source
