Dr. Malia Reckons

Tim,

Wow! As a family doctor, your day is certainly filled with a little bit of everything! I, myself, had to Google a few of the things on your list ;-) I'm sure your days are very full and tiring to say the least. I hope your patients know how lucky they are to have you as their doctor. I've found over the years that not all doctors take the time to really listen to the answers after asking the question "How are you?" or "What seems to be the problem?".

Take care, and thanks for all that you do!
Sandi

Yes, his patients appreciate the time taken (I can speak for two of them)! FYI: I plan to have none of these problems for the next visit, even the ones I don't recognize. (Like Sandi, I'll need to google a few of them though.)

Sandi and Susan, you are both sweet. I actually feel awkward seeing the post as I almost feel I'm whining about being busy or dealing with so many various problems. Anyway, it's interesting how we doctors, or at least I, have been so indoctrinated to "work hard and suck it up" that commenting about such matters gives me mixed feelings about possible whining. That in and of itself may be worth a blog post.

Wow, this list is great...I will be graduating medical school soon and will be applying to Family Practice, and this list is exactly why I want to do Family practice. The diversity of the problems you deal with on a daily basis is great! I only hope that your patient's and the rest of America really gets the point how valuable you really are to a well functioning health care system.

Bill, thank you. I appreciate your thoughts and perspective.
Good luck with school, residency and your career. Please always remember it's not important how long the list of problems is but how deeply you can help each individual patient. Everything else is chaff and has to be separated from the wheat. The list above is nice enough and may be worth discussing, but the appointments I remember at the end of the day can't be assessed objective, they are rightly special but for subjective reasons.
Best -- Tim

I am reluctantly disabled related to numerous health concerns: fibromyalgia, myofacial pain disorder, bipolar type II, borderline hypertension, coronary heart disease, hyperlipodemia, high triglicerides, intermittant 2nd degree heart block type I, sleep apnea, irritable bowel syndrome, chronic bladder irribility, peptic ulcer disease, and a lipoma on my adrenal gland that needs watching. Except for routinely seeing a pain specialist and a psychiatrist ever three months, I see my family doctor every three months. She competently takes care of my problems. I am an RN that until 2006 worked for thirty years, mostly in hospitals. I know what competent is. I am an eample of what family physicians deal with regularly.

Great job ... loved the discussion stimulated by you in the NYT ... we do have challenging "jobs" ... I commend you (and me!) for sticking with it ... Thanks ! Tom

Dr. Malia, I don't think you have to worry about "whining"; your list is informative to a lot of people starting to think about what their doctors do, possibly for the first time, because of the healthcare reform debate. This list helps show how valuable a member of one's network a general family physician is, especially one who knows you over many years. Thanks for all you do and for helping confirm the choices of students like Bill who choose family practice over the more lucrative specialties.

This is a long and complicated list, but that doesn't surprise me. I'm amazed at the complexity of a day in the life of a family doctor. In the upcoming debate on health care legislation, what could be done to help make sure that family doctors can survive and thrive in whatever comes about? I really don't like how doctors in training are making future career choices on specializations because of the income potential (and I don't think is greed, just reality). How could we change this? I'm really interested in what you think, I'm meeting with someone from my congresswoman's office next week and I'm trying to be informed going into that meeting.

Bernard, thanks for the interest and willingness to speak to those in Washington. I actually am planning another blog post about what I think is the single best thing that can improve health care in America.

But it's important to note that the current discussions in Washington are really about health "insurance" reform and not about health "care" reform. Access to good health insurance is not the same as access to good health care -- seeing that difference is essential.

Due to life's realities, I likely won't get to that next blog post for a couple days. In the meantime, see comment #43 in the Well blog. It was posted by an ENT doc and what he describes is very similar to what I think we really need to improve health care ... which, in the end, would also save immense amounts of medical costs.

Also, if you get a chance, peruse my last blog post that was something of a response to some of the comments in the NY Times. It's linked here --
http://drmaliareckons.posterous.com/why-patients-go-to-the-doctor-medical-blog

It would be fascinating to see even more detailed breakdown... amount of time spent with each. Discussion with staff (about what sorts of things) Time dealing with insurance. If you're interested, and can collect the data, I'll do an information graphic that visually shows your day.

Very interesting and to me the comments from the NYT readers were thought provoking. The comments from physicians seemed to run from "that's why I love family practice" to "that's why I couldn't stand family practice and got into a specialty". Also a great deal of comments on how it is too much work for too little money. Well, the idea of starting out $200K in debt is something that seriously needs to be addressed. But I also get a sense that many entering (or practicing) medicine are truly concerned about making a lot of money. I think one of the more challenging aspects to becoming a physician in our current system is that you are trained to care for patients, think and act scientifically, deal with difficult life and death decisions and then, as soon as you get to the point of where you are the primary person directly responsible for the patient, you are now asked to be a businessman. It just seems odd to me and wonder how most physicians feel about it. If you could earn a fair salary and just care for patients whould you want that? Or would most opt for some form of ability to increase their incomes by being business people? Not that there is a right or wrong answer but it might tell us something about the physician community as a whole.

@ Glenn and Sally G --
Question of "just seeing patients" and "running a business" gets complicated as we do live in a capitalist world, and, no matter what we would like to strive for, there's something to be said about market economies.
For physicians, when we hand over the reins of the financial matters and the running of the business (think of HMOs perhaps), a lot of control is given up regarding the running of the office such as hiring/firing staff and designing support systems for the practical matters of medicine. And that can trickle down to the actual practice of medicine and the care provided the patients. Thus, many docs feel a moral obligation to stay in, or return to, private practice even when that leads to a cut in salary and new headaches that are still better than what they suffered through in the setting when they thought they "only needed to see the patients."
One final point, however, is that the above does not represent all larger systems and HMOs as some are well run and integrate physician desires/needs well.
But i think this sheds light on how the situation gets clouded by multiple factors, and the "business" of medicine can relate to the better "practice" of patient care.

<tr><td></td></tr>

It's what makes primary care so challenging and interesting. Our specialty is probably one of the most difficult!

Incidentally some feel that NPs and PAs can do primary care. In my experience it is too broad for them to do an adequate job.
http://davisliumd.blogspot.com/2009/08/nurse-practitioners-not-answer-for.html

--
Davis Liu, MD
Author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System
Website: www.davisliumd.com
Blog: www.davisliumd.blogspot.com
Twitter: davisliumd

Tim,
Been a long time since we've talked. Glad to see your blog is getting so much press. It's a remarkable testimony to the breadth and depth of what we do. I think the comment from the physician who's been a family doc and is now a specialist is telling, that what we do is much harder. I think it's probably also more rewarding with all the relationships we form and the stimulation of the variety of issues.
Philip

To Sally G:

In my opinion, NPs and PAs work best in highly focused areas either specialty care or a subset within primary care - wound care or other areas where there is precise and widely agreed treatments and protocols known as "precision medicine". This is why one will find NPs at retail / walk-in clinics. In areas of "intuitive medicine" a trained doctor I believe does far better in accurate diagnosis, treatment, and cost.

Davis Liu, MD
Author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System
Website: www.davisliumd.com
Blog: www.davisliumd.blogspot.com
Twitter: davisliumd

@ Phil Zazove -- great to hear from you! Thanks for the comments. Yes, the relationships we have on the job, just like outside of work, are the essence of satisfaction and make everything more rewarding.
By the way, I watched the comments from the NYTimes "Well" blog and appreciated Dr Thomas Schwenk's thoughts. Please send my best regards to him if you will.

@ Davis Liu -- personally, I agree with you, and I think the medical world agrees too as more and more it seems the NPs and PAs are working in specialists' office and on special care teams with focused responsibilities. I don't know the answer, but my first guess is that arrangement benefits the specialists a good deal financially but I do not think it helps save the health care system any money. Would love ot know if anyone knows about research on the matter.

Dr. Liu: