What should we do with our health care rage?
Towards positive change, not burnout.
Welcome to Chief Complaint! For those of you who are new, this newsletter features intermittent musings about medicine, gender, parenting, and body liberation — all from your friendly neighborhood primary care doc. I’m so happy you’re here.
The other day in my primary care clinic, I had a patient who was “white dotted” for over an hour.
A white dot on the electronic medical record means that one of my colleagues had turned the patient’s status to “pending,” rather than “ready to be seen.”
I poked my head into the room to see what was going on. It was going to mess up my whole afternoon — I knew there would be angry patients who would have to wait because the first in line was delayed.
In the exam room sat one of my older patients, a warm, Spanish-speaking woman in her late 80s who always brought with her little clay figurines she made at home.
“Doctora!” she exclaimed. She always seems genuinely happy to see me, a rare occurrence that truly makes me feel good. (Who else is happy to see the doctor? Just ask my pediatric patients — they usually burst into tears at the sight of my face.)
“I brought you a gift.” She pressed a little clay cat into my hands.
Her adult daughter smiled apologetically and spoke to me in English. I could hear hold music blaring from the phone.
“We’re on hold with UnitedHealthcare,” she told me. “We need to update her information, or her health insurance won’t be valid for this visit.”
The hold music continued, distorted on the speakerphone.
“Bless them,” she added. “They just lost that young man.”
Eventually, they were taken off of the hold. They gave the insurance company the information that they needed. We moved on with the appointment.
All afternoon, I apologized to everyone for running late, visit after visit. One other patient that afternoon left without being seen, because they were so frustrated I was an hour behind schedule. That’s a victory, from my perspective: only one!
Life, in modern health care, went on.
But it made me think. What indignities we put up with in medicine, day in and day out. All of us: Doctors, patients, the poor UnitedHealthcare call center staffer who put my patient on hold.
Who is benefiting from this maze of a system we’ve created?
Not even the CEOs, it seems.
A physician friend who works for a big hospital system on the West Coast told me that she has a clause in her contract that requires she give six months’ notice if she quits.
She tried to negotiate it out of her contract, but her boss wouldn’t budge.
“You think six months is bad?” the boss told her. “As a manager, I have to give a year’s notice if I want to leave! You’ve got it good.”
My friend told me she pushed further: Could she talk to the legal department? Was such a clause even legal, or enforceable?
Her boss pushed right back. “If I have to give a year’s notice, imagine what it says in the CEO’s contract!”
The whole story made me feel deeply sad about the state of corporate medicine. Everyone had this stupid clause in their contracts, and not even the bosses were free from it. The CEO himself was beholden to this mammoth corporation, which seemed to be utterly out of his own control.
They had created a monster. We’ve all created a monster.
When I decided to become a primary care doctor almost ten years ago, I thought I was going in eyes wide open. I knew my appointments would be 15 minutes long, and I trusted that I’d learn to breeze through the paperwork that everyone complains about.
In some ways, I was right. I’ve learned to plow through an FMLA form in under 3 minutes, and I’m damn good at clicking my way through the electronic medical record. My signature has deteriorated over the years, as I now use a brief scribble to sign hundreds of pages of physical therapy and home health authorizations a week.
I have a beautiful repertoire of hundreds of stock phrases that I can plop into a patient note with a few keystrokes: “History and exam consistent with viral upper respiratory infection. Encouraged supportive care. Discussed detailed ER precautions.” (What — you thought your doctor was writing notes specifically about you?)
I thought I knew what I was getting myself into. I didn’t realize how much worse it could get.
Each day, the treatment plans I recommend are denied by insurance companies, the news delivered by fax (fax!) to my office. Truly, this happens daily — if not multiple times a day.
It’s demoralizing to have my expertise undermined over and over again. Are you sure you want to do that, Dr. Gordon? the faxes from the insurance companies ask. Are you sure that’s a good idea?
But forget me. It’s more than demoralizing for my patients. It’s life-threatening.
The asthma inhaler my 7-year-old patient needs to comfortably draw air into her lungs? Denied. No matter that it was covered last year and seemed to be helping; it’s no longer on formulary, the insurance company renegotiated its contract with the pharmacy benefit manager, which means that my patient can’t breathe.
The abdominal CT I ordered to check for cancer in a patient rapidly losing weight? Denied. He’s only had symptoms for a few months, so it’s not medically necessary, says a faceless doctor employed somewhere in the bureaucratic maze, someone who has never met this patient in front of me, terrified by what’s happening to her body.
When the UnitedHealthcare CEO Brian Thompson was murdered earlier this month, my colleagues and I couldn’t stop talking about the news. Many of my patients are insured by UnitedHealthcare, and many of them continue to bring up his death in conversation with me. They point to their insurance cards. “What a horrible thing,” they say. Everyone seems bewildered by how awful the story is.
It’s tragedy on top of tragedy: gun violence, the violence of our corporate health care system, the violence of our American health insurance models, the violence of an online mob delighting in his death. It all feels so hopeless.
How did we get here? And more importantly, where do we go from here?
Over the last few years, as I’ve gotten more competent at my job, I’ve been concerned to notice a sense of burnout settling in to my day-to-day work. The adrenaline of medical training has worn off. Everything is no longer so new and overwhelming that I have the brain space to start to think more critically about the systems we use and they harm they can cause.
As a trainee, I saw it as a sign of my competence if I could figure out how to receive a faxed medical record from another hospital system.
These days, I’m less worried about getting a good grade and more worried about doing my work, and I have different concerns. Why do ask our students, who are presumably there to learn medicine, to send and receive faxes? Why are we faxing in the first place? Why can’t hospitals share medical records electronically? Why are the electronic records that we do share so hard to extract useful medical information from?
Why do we take it as a given that our poor patients, our patients of color, our undocumented and disenfranchised patients, will simply be denied the care they need?
Those questions can wear a gal out real fast, and it’s easy to turn to a sense of ennui as a way to cope. But as I think about starting a new year, under a new presidential administration, I also want to think about what I can do to make it better.
Over the last year or so, I’ve found it very meaningful to try to improve one small corner of our health care system: advocating for size-inclusive medicine and an end to fatphobia in health care. It’s exciting to work with new colleagues on clinical advocacy projects and to share stories about our progress as a writer and journalist. I genuinely believe our work is making the system better, and it’s preventing me from falling into a pit of despair.
There’s so much more work to do, though. I’m inspired by the creativity of great journalists who keep the health care monster in check, non-profit organizations that advocate for change, students who see the system with fresh eyes and refuse to accept it, and yes, all of my fellow clinicians, doing their best to be kind to their patients, 15-minutes at a time.
I’m curious to hear your thoughts, those of you who work in health care and those of you who utilize health care. (So, all of us.) Where do you direct your health care rage? What inspires hope, for you, as we approach 2025?
A note about patient confidentiality: Trust is at the core of all of my relationships with my patients, and as such, I don’t share their stories publicly. Any story you read here — or in any of my writing that isn’t in the electronic medical record where I write thousands of words a day, ha ha — either has details removed so patients can’t be identified, details changed, or is a composite story that combines information from multiple patients.
The essence of every story I share is true.