The sin of the rvu

I could never have fathomed how badly residency and medicine in the US could try to beat the compassion out of me. We all went into medical school with bright eyes, touting our love and desire to help people as our primary motivation for pursuing this career. It is likely what made us special, what marketed us as exceptional beyond the grades, MCAT scores, and extracurriculars. And yet a year and half into residency I am finding persistently berated by moral injury of a desire to help people in a system that seemingly strives to make it nearly impossible to do that.

A few months ago my residency transitioned all of our appointments to 30 minute slots, a subtle but heinously impactful change from a mix of 30-45 minutes appointments prior. Independent of new patient or established, routine or presenting with a dozen chronic diseases, we have 30 minutes to meet another human being, learn what makes them who they are and why they strive for health, and make recommendations to help influence their lives. The system is set up this way because of financial incentives to decrease duration of visits while maintaining revenue, a meaningless need to reach the arbitrary number of 1650 patient encounters before the end of residency, and a need to supply care for seemingly infinite demand with extremely limited supply.

The population we manage at mine and most residencies’ clinics are infinitely complex with housing insecurity, polysubstance use, complex mental health issues, and frequently very severe despondency and suicidality. It is a population that rarely comes to healthcare for routine health maintenance; that is a privilege of a wealthier population with stable employer subsidized health insurance, ample childcare, free time, and transportation. Our population on the other hand comes to us when they are desperate. I love them and I want to help them but when attempting to discuss blood sugars and substance use to a patient who often has had the crap beat out of them by life, I feel wholly inadequate. This system is infuriating and nearly daily I go home pulling at my hair and wanting to scream at the dissonance between the care I want to provide and the total joke of healthcare that I am able to give.

I take these patients’ stories home with me and think about how best to help. I think about what I may have missed in 30 minutes of attempting to influence the health of a person I have never met. I laugh at the infinitely specialized care this country provides to the well off, where a gynecologist is recruited for a simple pap smear, a cardiologist tweaking blood pressure meds, a psychiatrist adjusting a simple anti-depressant. Meanwhile I face having a patient with a likely skull fracture coming into clinic who refuses to go the emergency room for a CT scan because she cannot afford it. She may have bacteria creeping into the fluid around her brain but even a $30 copay racks up debt. I think about my obstetric patient who left a hospital 150 miles away against medical advice and drove herself to my hospital instead of getting the ambulance because there is no way she would be able to afford diapers for her newborn if she had to pay off medical transport bills. I routinely encourage people with horrible PTSD from awful domestic violence to establish with a therapist only to face the frustrating reality that therapy is a luxury to help middle to upper class depression, not a service accessible to those often in desperate need.

It is an infuriating system that feels designed to break me. I realize and know wholeheartedly that despite its flaws, there is no viable solution for this beyond single payer healthcare. No for profit healthcare will ever result in beneficial or even reasonable care for patients. Even I, as a physician, who is well insured will persistently avoid going to the doctor. Despite having insurance, I have absolutely no idea what the bill will be walking out the door of another physician’s clinic. That fear that I have just from visiting another clinician’s office undermines our credibility too. I frequently have patients comment on the benefit of their visit to my wallet. How completely jacked up of a system do we have that patient’s are thinking about the transaction in healthcare rather than pure empathy of their provider and my desire to help?

The system is forked for all of us but some frequently justify it in comparison to worse alternatives. Some of my attendings have touted 30 minutes appointments as luxurious compared to most family medicine providers as if pointing out how royally moronic other people’s schedules are justifies how subtly less moronic ours are. The crazy thing is, they’re right. My specific residency is super cush. But my god, do not ever justify atrocities by pointing out worse atrocities. Others blame the younger generation, calling us soft, saying 80 hour work week restrictions are silly. Maybe we just care more; maybe we care more when we feel that compassion slipping away in the face of exhausting work. The “that’s how it’s always been done” argument pervades through our culture like a festering sore. It needs to be revamped. Our population is suffering because of it.

3 thoughts on “The sin of the rvu”

  1. Look into functional medicine. My functional medicine doctor spends hours with me and digs to find the root cause of my problems. They look at your body as a system, not isolated, specialized parts. And now, with genetic testing, they can get an even bigger picture of what is going on.

    1. Yes, but ask your functional medicine doctor how they get paid enough to keep the lights on. Do they take insurance, or do they limit their practice to people who can pay cash out of pocket? Have they paid off their student loans? Who pays for the expensive genetic tests?

      Grayson- spot on as usual. It hurts in attending life too. The new 2021 E&M coding changes have helped significantly, but we are still under constant pressure to see more patients and deal with fewer issues per visit.

  2. Excellent article Grayson. Thanks for the firsthand insight from someone working within our dysfunctional medical/healthcare system.

    Keep trudging through. Your compassion and insight will likely lead to the change we need to the “healthcare system” adored by the right in this country.

    Sadly, America IS a “third world healthcare provider” to its citizens st the present time. However, our researchers, doctors, physical therapists and nurses are not. BE THE CHANGE!

    Finally, you need to get a secure certificate for your website. I had to give a fake name and email for this reply because your site/host does not encrypt information traveling to and from it!

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