My 8 year old kids and I like to watch the Planet Earth BBC documentaries. Often there are predator prey hunts such as when a pack of fierce and cunning dogs gives chase to a much larger and potentially dangerous animal such as a wildebeest. In most cases the huge prey are startled. They immediately panic and run, often attempting to shelter the young and weak within the center of their massive collective. On occasion however, the herd will stop, turn, and face the dogs head on with huge antlers pointed menacingly, panting with breath steaming from their nostrils. The dogs have no recourse. They must give up the hunt, as they are no match for the entire herd. Their hunt depends on isolating one weak or small calf. With indignation, and without alternative, they turn, and walk away.
That image of that massive facade of wildebeest is symbolic of how I view my place in the entangled mess that is the American health care system. In this scenario I am, of course, the wildebeest.
I went into medicine with one goal - to master my craft and serve patients. I never had any interest in how the health “system” ran. I wanted nothing to do with the so called business of medicine. I was answering a calling, and the number crunching and insurance contracts could be dealt with by others. I saw myself as a patient advocate who could help others navigate the labyrinth of the healthcare system in order to get the care they needed. The system was a behemoth, but it was not necessarily a problem for me to solve. I kept my nose down, and worked hard to do my job well.
After a time though, I got beat down. I was beat down by the increasing piles of busywork created by insurance requirements which led to eternal clicking in the electronic health record. Insurance companies were putting up barriers in the form of increasing co-pays which led patients to email or call more often. There were also barriers to ordering tests or medications. Often the prior authorizations were blatent deterants serving no purpose other than to keep patients from getting tests or medictions they needed. Overhead grew to accomodate these insurance demands, and time with patients was cut as I tried to make up for the expenses. At clinic I felt like I was playing Whack-A-Mole. I would arrive at clinic each day full of vim and vigor. I would be focused and energetic, ready to tackle the challenges of a new day only to find that I was an hour behind the minute I logged into my computer. By 11am I was so bogged down with phone calls, nurse questions, nursing home correspondences, prior authorizations, patient emails and office visits, that I knew I would never be able to stay on top of it all. By 3pm, after a lunch consumed from a paper bag in front of my computer screen, I would start to feel foggy and less able to focus and be efficient. By 5pm, I was forcing myself to pay attention to what my patients were saying. I was forcing myself to just do one more note, or to reply to just one more email. Eventually, I would turn off the computer, knowing that later that evening I would be forced to log in again and complete another 1-2 hours of clicking lest I be even more behind the following day.
Through the years, I could feel the non-patient care related work mounting. I tried limiting my patient care hours. I tried hiring additional help at home and at the office including a medical scribe who did most of the computer clicking for me. I went to conferences on physician burn out. No matter what I did, the system kept creating more work for me. Patient care was not improving. No matter how much I tried to cut back, more work related to insurance requirements mounted. I was seeing less patients, but I was working just as much. I was cutting back on the only thing that was actually enjoyable - direct patient care. OB was one of the few areas of my job that I still derived a lot of enjoyment and meaning from, but that required tremendous family and physical sacrifice.
For six years I struggled with these challenges. I dealt with mounting anxiety, depression and burnout. I saw a psychologist and asked him to help me navigate my situation. I told him I was having a mid life crisis. I asked him to help me formulate a plan for happiness and success. It felt hopeless. At this point in my life I had just had my third child - an absolute blessing and a miracle (or as my husband would say “a statistical anomaly”), but a huge, shall we say, “kink “in my life as well. As I looked at my new baby and my two other school aged children, then looked at my calendar and took in my physically deconditioned, postpartum body and mind, I knew that something had to change. I knew that the constant unpredictability of being on OB call 24/7 was something I did not want to do again with a young child. Without OB though, I was staring into the dark abyss of full time outpatient medicine. I was staring at the exhausting churn and burn of seeing 24 patients a day, many of whom are rightfully disgruntled even before they walk in the door.
Then there came what for me amounted to an enlightenment. For whatever reason, much like the heard of wildebeest, I turned around and faced the system head on. I looked at it, and I saw it for the pack of dogs that it was. I looked and I saw that the system did not have to have power over me. I saw it for its greed and its flaws. I stared right at that pack of dogs, and I knew that I could stand up to it. Then I looked around me, and I saw all of the others who had turned around and done the same thing. I saw the strength that we brought to each other. I saw so many others who were already enlightened and were already doing direct primary care. I looked around further and found others who had no idea that they could stand up and turn around. Friends, family, and co-workers could see that there was another way and it gave them hope.
So here I stand, at the beginning of my journey, nostrils flaring, resolute in my convictions, and drawing on the strength of all those who have gone before me. They and I know that this direct primary care movement is a powerful resistance movement that offers an alternative to the massively wasteful system that is the American healthcare system. Here we stand: strong, resolute, powerful and ready for action.