Deserving What is Accepted

t’s three a.m. at Podunk Memorial and I am on the phone with a cardiac surgeon from the Big House. His complicated surgical patient is now my complicated rehab patient, and the patient’s first day of hometown care has ended with a bang. When the nurse came in to check his vitals, she noticed that his pulse oximetry reading was in the 70s and, in her words, “he was making these funny fish sounds.” I have been awake for the eight minutes it took me to throw on scrubs and drive to the hospital, and collect the only dataI need: the patient is gray behind his non-rebreather. We don’t keep vent patients here, and he’s about to need one. Transfer is a product that sells itself.

The heart surgeon, unfortunately, is not sold. “What does the x-ray show?”

I explain that I’ve gotten here before the x-ray tech has, and before he can ask me for the ABG, I add that the phlebotomist isn’t here yet either. There is a long silence, a chastising silence I remember from my internship year, and he informs me, “Well, in the case of shortness of breath, you’d think CHF or PE.”

Thanks. Now it’s my turn for a pregnant pause. Into its space, the surgeon interjects an even more helpful, “Call our hospitalist team if you don’t think you can handle it.” And hangs up. The PA from the emergency department and I look at each other for a moment.

“Well,” he remarks eventually. “Glad he gave us that tip about the differential for shortness of breath. Now we won’t have to Google it.”

This is not the first time I have been treated like an idiot. I look a lot younger than I am and have the kind of innocent face that makes strangers ask me if I’m lost. A nurse once told me she loved seeing me give medical opinions because it was like watching a china doll talk when you pull the string. I’m pretty sure she thought she was being nice.

The thoracic surgeon didn’t know that I look like a naïve little altar girl, though. His assumptions about my intellect (or lack thereof) are based on entirely different prejudice: I am a family physician. In other words, a bottom feeder.

The director of our radiology department comes in with shoulder pain. He doesn’t respond to OMT, and his clinical presentation is congruent with an anatomical impingement of the brachial plexus. I suggest an MRI, and he agrees. His insurance company does not agree. As a family physician, I am not qualified to order an MRI for this condition. He sees an orthopedist. The orthopedist suspects an impingement of the brachial plexus, and orders an MRI. Guess what it showed?

About a month ago, I nagged one of my more dysfunctional patients into getting a formal psychiatric evaluation. The psychiatrist spoke with her, gave her the same diagnosis I had given her, and prescribed the medicine I have been trying to convince her to take for the past three years. The consultation summary read: “Type II Bipolar Disorder, inadequately managed by her PCP.” The patient brought me the report and, as she correctly discerned my outrage, tried to placate me with a syrupy, “Don’t feel bad. You did the best you could, but it’s not your specialty.”

I’m a family physician. Her whole body and all the neurotransmitters within it are my specialty. And if the shoe were on the other foot, if the psychiatrist were asked to manage a problem that took place below the chin, would he be able to prescribe his way out of a paper bag? I bet not.

Do receptionists kick you around? I know a few at specialty offices who refuse to even make my patient an appointment until I personally get on the phone to beg with her, and then will stall until I have promised to fax the last three office notes (most of which have nothing to do with the reason for the referral). Yet how many of us have been called out of the room “because a doctor’s on the phone”, only to race over, pick up the receiver and be told “please hold for Dr. X”, whose time is apparently too valuable to have called me himself? My practice group actually got together an open letter to the specialty offices in our area, requesting a more streamlined referral process that should have made everyone’s life easier. The other family physician groups wouldn’t sign it, for fear it would “offend the specialists.” No one seemed to remember that “the specialists” are not doing us a favor by agreeing to take our referrals; they are doing the thing that keeps their doors open.

An attending I knew used to remind me, “You deserve whatever you accept.” So why do I put up with this? Does some part of me believe that we really are glorified interns, the house officers charged with keeping patients alive until the “real doctor” shows up? Have we started to believe our own press, what are we not simply a different specialty, but a lesser one? How did we get here?

During the early 90’s, I worked for a group of neurosurgeons. After one particularly onerous pre-cert process, I mentioned to my boss, “What a hassle. The primary care docs have to fool around with all this gate-keeping, it must drive them crazy!” He laughed incredulously and said, “A hassle? They’ve been given the keys to the city and don’t even realize it!”

So where is our city now? The point of “gate-keeping” was that most of the time we could handle it ourselves. The point was we were well-trained doctors and, in most cases, could manage cardiology, obstetrics, psychiatry, dermatology, and pulmonology without referring on. In rural areas, many of us still do. Sometimes it is because we have kept the intellectual curiosity that led us to become “globalists” in the first place, and sometimes it is out of the necessity that comes when the wait to see and orthopedist is three months and our patient needs a joint injection today. 

Did we get lazy? Did we get scared? My friends in states like Florida or Pennsylvania can track the narrowing of their scope right to the moment they got sued for having a bad outcome. An avoidable bad outcome, even after having done exactly the same thing they knew the specialist would have done, but without being a specialist, or having consulted one. In other words, they got sued for being a family physician. No wonder they don’t handle obstetrics anymore. Their patients barely trust them to handle rhinitis.

And yes, I feel like a moron when I call a neurologist and ask what probably sounds like a stupid question to someone who works with the brain all day long. And yes, I feel defensive when I’m reviewing an x-ray over the phone with an orthopedist and she asks me (without malice, probably) to differentiate between types of dislocations that are named after French people. Before I know it, I am practically holding my hat and shuffling my feet, even though it was ten years ago that I last read about them by that name. “Aw, shucks, Ma’am. I’m just a friendly ol’ family doc. I don’t know about that fancy book learnin’ you do.” At least I don’t call myself a “G.P.”

The maintenance man at the hospital knows a lot more about the ice machine than I do, yet he doesn’t treat me like an idiot when I ask for his help fixing it. It is assumed that I know my job, he knows his job, and everyone benefits from both of us doing our jobs well. I feel pretty confident my lawyer doesn’t hang up from a call with me and mock me to her colleagues because I can’t write up my own will.

Specialists clearly have better PR people. The television character,Greg House, MD is known for his encyclopedic understanding of both pathophysiology and human nature, and frequently sends his team to investigate not only the patient’s immune panel and blood cultures, but to interview the family, to infer from subtle behavioral clues what contributory lifestyle behaviors she is attempting to conceal, and even what her home environment is like – an osteopathic family physician if I ever saw one! Yet he isn’t. He’s double boarded in, of all things, nephrology and infectious disease. A huge proportion of his cases have nothing to do with infection or kidneys, yet it is assumed his team can handle it anyhow. Why do we assume this? Well, they are specialists. Those guys are smart.

If you think that the culture and media biases affect only our self-esteem and our image, think again. For those of us who have encountered the necessary evil of the “RVU” concept, stop and reflect what those letters mean; Relative Value Unit. Ever stop and think about why we are one of the worst paid specialties in medicine? It is not about time spent in training. It takes as long to become a family physician as it does an internist. If we did a plus-one year for Neuromusculoskeletal Medicine, even longer. When a hospital is having financial trouble, it can be pretty seductive for administrators to start stratifying their physician employees not in terms of our service to the community, but our contributions to the bottom line. If an orthopedist brings in 10 times the revenue a family physician does, who care if I have saved more lives than he has? We need him more. So let us keep him happy. When both practices are requesting funds for more space, new computers or extra staff, we need to placate the surgeon because he has more relative value to the organization. When, because we are understaffed, and have dinosaur technologies and a long wait to be seen because the physicians are doing their own photocopying, the patients can always get fed up and go elsewhere. After all, we are a dime a dozen. And there is always the emergency department. Or PA’s, since they are cheaper.

I am an osteopathic family physician. I am your cardiologist, your emergency physician, your gynecologist, your ENT, your psychiatrist, your pediatrician, your pulmonologist. And yet I am none of those things, because your cardiologist might put you on an ACE inhibitor not realizing you are trying to get pregnant. Because your orthopedist might put you on the same opioids, you’re afraid of, not remembering your cousin overdosed last year. Because your ENT will give you antibiotics for your sinuses, not taking into account their effects on your coumadin. Because your gynecologist will not manage your post-op pain, assuming your addiction history means you just need to suffer. And when the specialists do these things, I will try and untangle the web, and I hope I will be more respectful at their shortcomings than they are of mine. 

Or maybe I won’t, because maybe my administration has decided I am not enough of a cash cow to keep around. Maybe your insurance company will encourage you to get your acute care at a retail store, since primary care is so easy it can be done between the electronics aisle and the family size bags of pretzels. Maybe government-funded reimbursement cuts will have made it impossible for me to practice in your state and you will have to wait weeks for all of your medical services, not just the ones provided by specialists. And when that happens, I hope you will realize how smart, how valuable, how precious your family physicians were. And when you do, I hope you will consider creating a medical environment that supports and respects primary care: that treats family physicians as the crown jewel in the healthcare system, rather than the specialty for the dumb kids in the class. I hope you will consider putting real legislative and economic backing behind the “medical home” as an evidence-based intervention to improve your longevity, and not as some outdated, nostalgic dream of the “G.P.” I hope you will establish a relationship of care with someone who can take real care of you and your family, even if you are hospitalized at Podunk Memorial.

Because you deserve whatever you accept.