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Why I Work at the Fringe.

This article is making the rounds among physicians on Twitter. Much of the information in the article, unfortunately, is accurate.

For some of the reasons stated there, I left the “traditional” health care system and pursued work at the “fringe”.

Part of this is due to my clinical interests: I like working at the intersections of different fields. For example, I like the intersection of psychiatry and hospital medicine, which is called psychosomatic medicine. Another example is my interest in public psychiatry, which focuses on the intersection of social factors and mental health (e.g., individuals with psychiatric and substance use conditions in the context of homelessness and poverty).[1. Really, though, all of medicine could be “psychosomatic medicine” or “public psychiatry”; the divisions between mind, body, and environment are arbitrary.]

Part of this, though, was my sense that the system would not let me be the kind of doctor I want to be.

For a brief period I worked in a clinic where I had slots for four new intakes a day (60 minutes each) and 15-minute follow-up appointments for the rest of the day. If my schedule was completely filled with follow-up appointments, I could have seen up to 34 patients a day. (I never got to this point because I quit well before my panel got full.)

In reality, the 15-minute appointments were 12-minute appointments. I needed about three minutes to type out some notes to myself for clinical documentation.[2. I don’t like typing my note while I am seeing a patient. I’m not fully attending to either one when I do that.]

Because I was building a new practice, people with a wide variety of conditions and concerns came to see me. I was advised to refer patients out of the medical center who were “too sick”. This included individuals who were frequently in and out of psychiatric hospitals, had significant psychiatric symptoms, or otherwise had other stressors in their lives that made them “difficult“.

In other words, they told me to refer out the people who needed specialist care the most.

The reality, too, was that no psychiatrist could provide quality care to these individuals in 12 minutes. Imagine someone with depression so severe that he lacks the energy or interest to share his current distress with you. Or someone who is psychotic and insists that her ex-husband is tracking her through all the electronics in her home. Or someone who is so anxious about leaving his house that his attendance to the clinic is worthy of celebration.

Obtaining an accurate history guides diagnosis, which then guides treatment. An insufficient history can thus lead to haphazard interventions. You can see how the 15-minute appointment model results in heavy reliance upon (potentially unnecessary) medications. If someone says he feels depressed, it’s difficult to validate his emotional experience, provide education about his condition and non-pharmacological ways to manage it (e.g., behavioral activation, sleep hygiene, etc.), and have a discussion about medications, which should always include risks, benefits, and alternatives, in 12 minutes.

It is much easier to write a script and ask someone to return in a month. (This inspired my post about the Automated Psychiatrist Machine.)

Furthermore, this clinic was in a medical center with a group of primary care physicians. Primary care doctors referred their patients with diagnoses of schizophrenia and bipolar disorder to the psychiatry clinic (as they should). These individuals, however, were “too sick”. Never mind that, unlike the primary care physicians, we psychiatrists had the training to diagnose, treat, and manage these individuals with significant psychiatric conditions.

Thus, these patients often returned to their poor primary care physicians, who tried to care for them the best they could… which often entailed medication regimens that were unnecessary. (Primary care physicians deserve no blame for this: How are they supposed to know?)

This clinic also “rewarded” psychiatrists for “productivity”. The more patients a psychiatrist saw, the more money the psychiatrist would earn. This led to “cherry-picking” patients. Psychiatrists would keep patients who either had minor conditions or symptoms that had resolved, because those are the patients you can adequately see in 12 minutes. As a consequence, patients with more debilitating symptoms could not access the clinic. The psychiatrists had no incentives in either time or money to send these “cherry-picked” patients back to their primary care doctors.

My frustration and disillusionment compelled me to leave the job. I returned to positions at the “fringe” to work with patients who often are also not part of the system or patients that the system had failed. Consider the man who has been homeless for the past ten years and is too paranoid to access any health care service. Or the woman who was beaten and molested as a child, sent to foster care and group homes, never completed high school, “aged out” of youth care, and now has no resources or support.

I couldn’t wait for the system to change, so I sought out settings where both my skills would be useful and I could be the kind of doctor I want to be. There may not be many physician jobs at the “fringe” and certainly not all physicians want to work there. When we physicians vote with our feet, though, we show what we value, the kind of care patients deserve, and how the system must change.