I’m a primary care pediatrician in a clinic in Southeast Washington, D.C., that provides health care to a largely poor, urban, and underserved community. On Monday mornings, I look forward to going to work. I’m excited to see my patients—the babies, children, teens, and families I’ve watched grow up—and face the challenge of figuring out how best to help. I started working in this community during my residency training almost twelve years ago, and I’ve stayed here ever since.
As much as I love my work, however, my days are stressful and hectic and there is never, ever enough time. I start the day by looking at my schedule, which is typically booked full with patients scheduled every fifteen minutes, and the anxiety begins. My 8:30 a.m. appointment shows up at 8:44—just within our fifteen-minute late policy. By the time this family checks in and is in a room, it’s well after 9:00, and my later appointments have started to arrive. I feel the pressure of people waiting, but when I go into that first room, I can’t bring myself to rush this parent who’s worried about her child. I sit down, quiet my anxiety, and listen to what the parent has to say. Meanwhile, I’m trying to find out, what were the results of the emergency room tests? What were the results of the tests we ordered last time? What did the specialist do? I ask these questions, knowing that time is ticking.
If all of my scheduled patients show up, I spend the morning running from room to room and my lunch hour becomes fifteen minutes. If no one else is in the hallway after I leave a room, I run. The couple of seconds I save probably don’t make a real difference to a waiting family, but it’s all I can do. I apologize frequently to families for running late. Some families are forgiving; some aren’t. I feel bad that my patients have to wait, and, being human, I feel worse when they’re upset with me. By the end of the day, I’m physically and emotionally exhausted.
Some observers might make the obvious suggestion—stop scheduling appointments every fifteen minutes. But in the U.S. health care system, the only way to make more is to do more. In my clinic, those extra visits pay for important patient services, like a care manager, social work, and mental health and dental care. They also pay the salaries of the staff members who are needed to keep the clinic open five days a week.
Compared to other sectors of the health care system, primary care is disadvantaged. Primary care services are generally compensated less than other specialties, so even when a primary care doctor can see more patients, he or she still can’t earn as much as, say, a cardiologist or a surgeon. Primary care doctors make one-third the average income of orthopedic surgeons, according to the Medical Group Management Association. But a bigger problem is that this payment difference means primary care practices can’t hire the additional staff or make the investments that will allow doctors to focus on doctoring and not on the million little administrative tasks that come along with providing health care.
In my case, these administrative tasks often mean a day that is filled with frustration and less time for patients. There’s the very long automated recording when I call an insurance company to see why they rejected paying for someone’s medication. There’s the time spent on hold while waiting for a specialist to discuss a patient’s case. Electronic health records have helped in many ways, but our system always seems to run too slowly. When I open a new window on my computer to order lab tests or send a prescription, the pause is just long enough to remind me that people are waiting, but it’s not enough time to do anything else.
Given that primary care doctors are caught between the time pressure of seeing as many patients as possible and keeping up with paperwork—and are less well paid than their colleagues in specialized medicine—I’m not surprised that fewer and fewer medical students are choosing to go into primary care. It shouldn’t be this way. On those rare days when I have the space to spend more time with families and do the things needed to provide the best care, I go home knowing I have the best job in the world. I go home remembering the little victories, like keeping a patient with asthma from having to go to the emergency room; the feel-good moments, like the toddler who runs down the hall to give me a knee-level hug; and, above all, the joy of knowing that a child I’m treating will survive, will be healthy, and will be happy again.