Sunday, August 16, 2015

My Doctor, The Juggler

The job of being a doctor can sometimes be like that of your favorite sidewalk juggler.  It used to be that a good ole family doctor would have to show up in the clinic for a couple of hours, make a few house calls, and be available if anyone needed him while he played a round of golf in the afternoon (really this is quite an exaggeration but it sets the tone).  In reality, most doctors today must compartmentalize their day, prioritize the patients from most sick to least sick, and then organize a plan of attack which then needs to be carried out with sniper-like precision (also a bit of an exaggeration for most doctors but if the shoe fits…).  Each day can be like a juggling act.  Despite perfect execution, a doctor still may have to call an audible when things don’t go as planned just like a juggler might have to do when a large wind gust arises or he/she mishandles a ball.  

I like the juggling analogy because the type of work each doctor does is different based on specialty, practice type, and patient population.  Some doctors juggle soft balls, others juggle crystal balls, and some tend to toss swords, chainsaws, or flaming torches.  Some juggle in padded rooms, others while walking a tightrope, and others in crowded areas full of women and children.  Real jugglers have to manage the crowds and other street performers like doctors have to deal with impatient patients and their competitors.  Both depend on being in the right place at the right time as much as their talent on some days.  

As a kid, I still remember seeing a juggler on the street managing six or eight flaming torches at a time.  He then caught them and changed them out to swords at which time he sent them hurling into the air and rotated them as if they were on a racetrack.  It seems to me that the job of juggling swords and flaming torches has some of the same perils as a neurosurgeon operating on a patient’s brain or a cardiac surgeon bypassing a person’s heart.  One slight mistake can lead to a waterfall of failure.  

Jesters and royal jugglers have been known to juggle their majesty’s crystal and glassware.  I would consider the medical equivalent to be an obstetrician catching babies or a pediatrician diagnosing an infant’s illness.  A plastic surgeon might also lay claim to this type of subject matter, although most doctors would agree that their craft is impressively delicate but the narcissism involved subtracts a point for style when compared to birthing and caring for the innocence of youth.  

The act of juggling can be as simple as tossing two balls in the air from hand to hand or as difficult as criss-crossing eight balls at a time.  Some doctors only work in a clinic, emergency room, or hospital and, therefore, have more of a two-ball juggle job.  That being said, different single venue situations can be as frenetic as some multi-site ones depending on patient acuity and volume.  Some doctors have an eight-ball rotation in which they bounce between a busy clinic, a procedural arena, and hospital/emergency department responsibilities.  Some primary care providers in small areas have the usual eight-ball motion but also have to deal with community expectations like neighbors knocking on the back door.  This would be the equivalent of the eight-ball rotation mixed with a bowling ball.  

Let me give you a real-life example of a multi-venue situation…I spend the first couple of hours of most days in the hospital rounding on inpatients, admitting ER patients, and following up on tests and procedures.  I can generally plan to get there early enough to see every patient and have a little bit of flex time without running late.  Not all doctors have this luxury as some are tethered to multiple hospitals and/or a high volume of patients admitted during each day.  The juggling occurs when you arrive and have several unexpected admissions and/or a really sick patient who needs twice or three times the amount of attention than you expected.  

Once finished in the hospital (around 7 or 8 am), I then usually spend the rest of my day evenly split between procedures and clinic, and then at the end of the day I go back to the hospital to take care of new patients and consults as well as discharges that need to happen prior to going home.  It sounds easy…four hours doing procedures (most of my procedures are scheduled as an hour each) and four hours in clinic.  Not so fast, my friend.

To break down each venue, realize that every clinic, procedural area, and hospital function differently.  No site is the same but there are some generalities that can be formed about each.  Clinic seems to be the most misunderstood portion of a doctor’s life when considered by the lay public.  Patients often become frustrated with clinic wait times as they expect their doctor to arrive on-time to clinic and to be seen in a straightaway manner as if there is no other priority.  What most do not realize is that the clinic schedule is only the first hurdle in the triathlon of a doctor’s day.  Assuming I get through with my hospital rounds on time and start my procedures on time with no interruptions, emergencies, or unexpected waylays, I usually arrive to clinic and am greeted by my nurses who inform me that one or more patients had called and needed to be seen urgently.  A good doctor’s clinic is usually pretty full in the first place and these add-ons are necessary for excellent patient care but devastating to a schedule.  I often will inhale lunch just before walking into the first room and then sink into my groove in clinic, bouncing from room to room, usually distracted and delayed by the various nursing calls from the hospital or the ten minutes on hold with the ER as they alert me to the arrival of my next admission.  

If I am lucky, I am able to keep up with the phone calls, electronic medical record, and patient load.  The biggest issue in clinic for me (which is so hard for the outsider patient to understand) occurs when a followup visit scheduled to take ten minutes takes forty-five minutes.  These “special” visits often involve true illness(es) like chest pain or congestive heart failure but can also be non-urgent delays.  One of the most common delays occurs due to a patient’s reaction to a piece of medical news that is exaggerated due to depression, anxiety, or current situation in life.  I usually have one patient cry all the way through their twenty-five minute visit per day and another patient per day will spend fifteen minutes telling me about his or her financial/marital/familial/religious woes that are not absolutely medically necessary but impossible to avoid.  There is no way to judge or plan for these delays, and thus a doctor is left to juggle the remaining patient’s anger and unhappiness while still trying to provide good care.  

Often times, clinic wait times are ridiculous due to emergencies related to non-clinic issues.  A partner will call occasionally to ask for advice or assistance with a difficult procedure…a patient will code or get into trouble in the hospital…a friend of a friend of a friend will become sick and need phone advice relayed via your spouse or mother (usually a twenty minute conversation)…an emergency will come into the ER which takes precedence over the more stable clinic patients (this is the equivalent of the juggler taking a sword to the chest as it usually blows up the clinic schedule)…a technology issue will arise in which the electronic medical record is slow or not working at all and will slow things down…a nurse will get sick during clinic and have to go home, leaving an understaffed clinic…and the excuses go on and on.  

This rant has covered most of the reasons why being a doctor is similar to being a juggler, but is by no means a comprehensive list.  We haven’t even considered the “business” side of medicine in which a doctor is forced to juggle insurance companies and their insane preauthorization requests, mounds of paperwork, hospital administrators, frivolous lawsuits, competition between other groups/doctors/etc, and a whole host of other issues.  We haven’t pondered the governmental regulations that are being enforced to make the practice of medicine about as messy as juggling ice cream cones in the dead of summer.  We don’t have time to mull over the quality metrics that all doctors are supposed to achieve yet seem to change on a daily basis.  I would be remiss if I didn’t mention that most doctors juggle the strains and stresses of their job with their responsibilities as a spouse or significant other, parent, sibling, and friend.  

In a way, all jobs have a juggling component and so I want to make it clear that this is not a plea for sympathy or respect.  My hope in this story was to give an insight into my profession’s challenges so that the lay public might understand the different scenarios which affect a doctor’s ability to meet their expectations.  Some days are flawless and others are littered with dropped swords.  

Written by David Jones, MD- owner/blogger at, a physician peer ratings website.  

Sunday, August 2, 2015

Pulling My Hair Out…A Doctor’s Struggles with Patient Noncompliance and Managing Unrealistic Expectations

Several days a month, I come home from a long day at work feeling exasperated, frustrated, mentally dilapidated, and just plain tired.  Oftentimes, I feel like pulling my hair out…and for a middle-aged already balding physician, this presents a big problem.  The actual physical work varies by the day, but I have found that certain patient interactions can take a toll on me way more than the actual bodily stress does.  

Patient noncompliance seems to be one of my biggest stressors and it can take various forms.  It can be as simple as grandpa not caring to take his medications, grandma not being able to afford her meds, or crazy cousin Eddie not keeping his appointments.  I cannot tell you how many patients come into my office weekly and tell my nurses that he/she just ran out of meds and did not think to get them refilled.  Some patients truly think that one (or the last) bottle of meds “cured” their high blood pressure, others are just lazy and tell me that they never got around to going by the pharmacy again even though they clearly dropped in somewhere to pick up the pack of cigarettes in their front pocket.  Cost is a huge issue and with the exorbitant prices of some non-generic pharmaceuticals added to the fixed cost co-pays and outrageous deductibles, the price of healthcare can strangle some poor patients.  I have empathy for patients most times, however it is striking to see a poorly controlled diabetic walk into clinic with a McDonald’s bag and an iPhone (and iPad) then tell you that he/she cannot afford generic meds.  

The issue of noncompliance with medical appointments deserves special attention as there are days in which I have 1 out of 5 patients no-show.  This reckless and avoidable habit wreaks havoc on clinics nationwide.  Not only do no-shows mean lost revenue, but they also take away a spot that an otherwise sick person could have had.  Add to it, the patient who no-shows then has be rescheduled (assuming they want to be seen in the future) at their convenience which then bogs down the already tight schedule even more.  Some clinics and doctors have put in place policies to dissuade patients from no-showing like forcing the patient to pay a fixed cost if no cancellation within 24 or 48 hours of the appointment.  My office does not currently use this policy, however I suspect we will see more like-scenarios in the future to counteract this situation. 

The most glaring evidence of noncompliance seems to be rooted in local cultures.  My urban dwelling patients who are middle to upper class seem to have very little noncompliance.   Occasionally patients will return to my clinic earlier than scheduled to tell me that they have stopped a medication or therapy due to a misunderstanding or side effect.  My lower socioeconomic class patients, especially those who are illiterate, understandably seem to have the hardest time.  Most troublesome, however, are the rural patients who seem to march to a different drum beat.  When I go to an outreach clinic for a full day (and the patients know that I am in the clinic in their community all day), I often have late afternoon patients show up early in the morning and vice versa.   When asked by my nurses about their early or late arrival, they mostly say that they just thought that they could show up early (or late) and be seen.  I also have a tremendous amount of no-show/rescheduling, and I have patients who do not seem to be interested in their care/health/treatment/medications.  The Humpty Dumpty approach to medicine is strong in these locales.  

I have now grown accustomed to patient noncompliance and the ensuing disasters. Despite thorough education by multiple medical personnel, I have had multiple episodes in which a stent patient will stop his/her Plavix one month after a heart stent (and 11 months earlier than ordered).  This puts them at risk for clotting of the stent which can be life-threatening.  Cessation of blood pressure medications can also cause a similar emergency in which patients will develop chest pain, stroke symptoms, or have a heart attack due to lack of vital meds.  My patients with atrial fibrillation (a heart arrhythmia that can cause strokes unless treated with a blood thinner) often will stop their blood thinner due to a simple nosebleed, hemorrhoidal bleed, or trivial laceration/scratch on the arm or leg.  As expected, they then come into the ER with a large stroke from the AFib and wonder why.  

The other scenario that regularly causes me to want to pull my already scant hair out involves patient and family expectations.  As with the noncompliance section, I cannot give you a complete list of unrealistic patient expectations, rather I will just mention a couple of good examples.  Let me start by saying that all patients and families should have high expectations of doctors, nurses, staff, and their medical care.  The most common cause of trouble with these expectations in my experience has occurred AFTER a patient (and/or family) is educated about a disease process and told how to expect the course to go.

Cancer diagnoses and treatment plans often lead to incongruent patient-doctor expectations and thus can be frustrating for both sides.  Oncologists often have to balance the diagnosis/treatment of a metastatic cancer (which is almost always fatal and treatment plans are usually meant to prolong life while reducing pain and suffering) with the mental/psychological burden that has been placed on the patient.  Crushing the spirit of a patient too soon after diagnosis can  be extremely troublesome to the doctor-patient relationship.  

Emergency room patients and doctors often have a difference of expectations when it comes to being seen in a timely manner.  The patient often thinks solely about his/her presentation and symptoms, usually pain/trauma/etc.  The doctor must be tasked primarily with triaging patients from most sick to least sick and then endeavoring to see all patients as quickly as possible.  Most lay people do not understand the triage process and wonder why a patient who is having chest pain but appears comfortable is seen before the patient with a non-life threatening trauma.  ER doctors suffer quite a bit of stress from patient and family complaints due to the triage process which, for the most part, is out of their control.  

The above two examples are not everyday occurrences for me as a cardiologist.  My dealings with unrealistic expectations leading to frustration seem to be related to three situations:  post-heart attack or stroke apathy with repeat event, medication noncompliance leading to an unexpected event, and denial causing a false sense of well-being despite uncontrolled risk factors.  The second example has already been discussed above but is worth a repeat mention as a large percentage of patient events occurs due to medication noncompliance.  If insurers are ever able to capture this cause/effect in action, they are likely to try to unload the financial ramifications onto the patient.  

Certain patients take an apathetic approach to their life after an event like a heart attack or stroke.  They give up, or at least they stop caring about the healthy side of life.  They then set themselves up for a repeat event.  The family rather than the patient is usually the side who has unrealistic expectations when this event happens.  I often hear from them:  “how could you let Daddy have another heart attack when he just had one two years ago?  Don’t you think you should have treated him more aggressively?”  Unfortunately, this approach then pushes the physician to throw the patient under the bus by examining the reasons why Daddy had another event:  usually smoking, eating poorly, not taking meds, etc.  No matter the approach, the doctor-patient relationship is stressed.  

Finally, I bang my head against the wall and rip the hair from my scalp on a regular basis due to the patients who come into my clinic with diabetes, high blood pressure, high cholesterol, family history of heart disease, and tobacco abuse yet refuse to do anything about any of these disease processes.  These patients clearly expect not to have events despite overwhelming evidence to the contrary.  I have no answer for these unrealistic expectations nor do I hope to discover a cure for noncompliance.  

We can only hope that there is a culture shift and/or a new approach to educating patients and families which will alter compliance and expectations. 

David Jones, MD is the owner of, a healthcare ratings website dedicated to physician peer ratings, and a practicing adult cardiologist.