I teach residents in a community-based family medicine residency, a job both rewarding and eye-opening. Recently, one of my residents sat in my office just after completing a morning patient session. The nurses had already been in to see me earlier because this resident was again behind schedule and patients were complaining about the wait. This day the resident had finished just over an hour late, a common occurrence for him. He looked at me, almost pleading, for an answer on what he should be doing differently.
The nurses are frustrated with this resident because they receive the brunt of the patients’ frustrations. The preceptors know they will be waiting long past the session for him to review his caseload. Of course, the resident feels this pressure. He had been struggling with this since his intern year, and although he had made marked improvement with his efficiency and pre-visit planning, he still lagged behind.
Over the past few months, everyone from the clerical staff to the program director has asked this resident to hurry up, yet everyone knows that he is one of our best residents. His patients know that he listens to them and cares for them. Once he gets into the room, all the time they had to wait seems to be forgotten because they have his undivided attention. He takes the time to read the chart and goes beyond the chief complaint, looking for ways to improve their overall health and overcoming barriers to compliance. He actively searches out resources in a demographic that struggles for even basic necessities. This is the doctor you want your grandmother to have.
My meeting with the resident makes me ponder difficult questions. I wonder, have we created this problem ourselves? Have we scheduled too many patients to be manageable? How many is too many? Recently, on a social media group of healthcare providers I belong to, the discussion of how long we are allotted for patient visits came up. One provider, a pediatrician, indicated she had 10 minutes allotted for sick visits and this appalled most of the group. How do you even take an appropriate history or examine a patient in that period of time? This 10-minute visit might work for a straightforward ear infection in a well-known patient with no comorbidities, but that is rarely what walks through the door.
We are robbing our patients of the resource of our time and I truly believe their health is suffering for it.
For my resident going the extra mile for all of his patients, the system does not allow for the hand-on-the-doorknob confession of suicidal thoughts or the unanticipated positive pregnancy test. Patients are scheduled for slots designed for simple, single problems and when they diverge from this the schedule suffers and other patients wait. I sympathize with the patients that are sitting in the waiting room not understanding why their 10 o’clock appointment time has come and gone; but I also know that the most important patient is the one in the exam room and each patient will get that opportunity. In an ideal world there would be enough doctors such that all the patients could see their doctor when they had the need without long wait times, but this is not an ideal world that we live in.
I struggle on how to counsel my resident. I am often running behind myself, trying to explain why a specific medication is necessary or why the medical test on the commercial is not actually all it claims to be, trying to be the resource my patients need and deserve.
I do not want the resident to be less thorough. I do not want him to cut corners or skimp on the care he provides. I tell him we all struggle with unreasonable time expectations, all of us have had the patient with urgent health needs that throws off our morning and ultimately, we are the ones responsible for the quality of the care we provide our patients. But, I am not sure that provided any sort of solution to his problem.