Life as a Gastroenterologist: July 2011 to Now

Excerpted from What It’s Like to Become a Doctor: A Year-by-Year Journey from Medical Student to Practicing Physician (American Association for Physician Leadership, 2016).
Copyright © 2021 by American Association for Physician Leadership®.

I passed the board exam in November 2011 to become a gastroenterologist. This $2,500 gastroenterology board exam is yet another test in our quest to become a “real doctor.” This is the last exam I have to take until I recertify in internal medicine in 7 years. I recertify in gastroenterology every 10 years. Of course, there are other mandatory medical education courses I must take yearly and conferences I must attend (and money I must spend) in order to keep up with the requirements of board certification.

I now see patients in the office two days a week and I perform procedures three days a week. I take weekend call and weeknight call on a rotating basis. Weekend call is rigorous—similar to fellowship. The positive aspects are that we can make our own decisions and do not have to run everything by an attending doctor. I am enjoying my life and am proud to have made it through this long, arduous journey. I feel like I have met my calling and am serving the greater good. I truly enjoy serving my patients and using my knowledge to help them.

Stresses of the Profession

However, even after training, there are still issues that plague our profession and break us down. These are issues that threaten the hearts of practicing doctors because they add undue stress in an already chaotic environment.

Inconsistent Schedules

One issue involves our lack of a consistent schedule and its effect on our personal lives. Our families never know if we will be home for dinner or whether we can take the kids to soccer practice, which can create stress. It’s simply out of our control most of the time.

For example, I usually perform endoscopic procedures from 8:00 a.m. to 5:00 p.m. three days per week. I perform these procedures on 16 patients per day. One day, I finished my second to last case at 4:45 p.m. We were running a bit behind, as usual, due to the increasing amount of computer work required. My last patient felt it was not important to arrive on time—45 minutes prior to his scheduled procedure—and arrived instead at 5:00 p.m. He needed an interpreter, and his required driver chose to leave the site. By the time the nurses were able to assess the patient, place an IV, and do all the preoperative history, it was 5:30 p.m. By the time I talked with the patient through the interpreter, sedated the patient, and completed the procedure, it was 5:50 p.m. And of course, the patient’s driver was not there, so we had to wait for the driver to arrive. I didn’t walk out until 6:30 p.m.—90 minutes late.

Sadly, examples like this are typical. Doctors always need to put patients first, which explains why we miss our kids’ sporting events or school plays on a fairly regular basis. We do not clock in and out of work. We call our patients back “after work” and make sure they are safe and cared for, at whatever hour that may be. This idea of always being available hurts our health as well as our relationships with our own families. It is a mental war that we battle daily, knowing that we can be paged at any moment. But we are doctors; we can handle it.

Multitasking

Another issue involves the need to multitask constantly. When patients call their doctors, their doctors are busy taking care of other patients. Answering their calls, their questions, adds to the stressful work doctors are already doing. The nurse triages the calls, but we still have to read the computer messages and respond to the patients. Often, we call the patient personally and try to figure out over the phone what the next steps are. Because we are seeing patients every half hour, we are doing this additional work at lunch, after work, or in between patients.

For example, I may be calling a patient about her liver failure after I just diagnosed colon cancer in a patient via a colonoscopy. I once received a call at 2:00 a.m. from a patient who had suffered from abdominal pain for three years. She was angry and said no other doctor treated her for this pain. I had never met this patient, but she wanted me to prescribe narcotic pain medication. Although I empathized with her, late-night calls are meant for urgent issues, not issues that have been present for years. These extra pages we answer at night make us more fatigued, disrupt our sleep patterns, and affect us physically the next day. Nothing is harder than having to drive to the hospital at 2:00 a.m. for an urgent bleeding case, return home at 4:00 a.m., and then have to wake up at 6:30 a.m. to work another 11-hour day.

No Downtime

Another related issue is that we are never off-duty—even when we are on vacation. For example, the weekend before Christmas, I had a very busy service. I finished my weekend on Monday morning with plans of having Christmas off. However, during my Christmas vacation, I spent many hours checking my nurse emails and answering pages from other doctors. If patients’ results came in while I was on vacation, I talked to them about their diagnoses. I even went in on Christmas Eve to help a colleague. I have given patients’ diagnoses over the phone while on vacation. This is what doctors do for their colleagues and patients every day. We are never off from work. I always pack my laptop so I can check patients’ results on a nightly basis and place follow-up calls. I have to ensure I have Internet access at all times, as the electronic medical record stalks us without mercy.

Relating to the idea of “never being off from work,” we treat patients at all hours of the day. Whether it is driving in during a snowstorm at 3:00 a.m. or driving in to save someone after they choke on Thanksgiving dinner, we are available. We do not get compensated more for treating patients during weekend, holiday, or nighttime hours. I bring this up because of a real-life example related to this “overtime work.”

My air conditioner died on a Sunday a few weeks ago. When I called the HVAC service, they stated they charge a double hourly rate on a Sunday. In addition, they charge more than $100 just to pull into the driveway! Furthermore, I knew they can charge whatever they want to, given the demand in the hot weather. I, of course, declined that quote and lived in the heat for two days.

As doctors, we do not get paid more for arriving in the middle of the night or working on Sundays or holidays. We are there for our patients no matter what or when. We see them at all times and will never refuse care. I’m frustrated when I hear that a friend was able to get double the hourly pay for working overtime or friends in the service industry can charge a premium on a weekend. But again, we are doctors; we can handle it.

Thankfully, the challenges of residency taught me to be flexible and to remain calm. This job requires patience, persistence, and a level mind. After all, we are trying to help patients at their most vulnerable moments. We need to rely on our own inner strength, training, and knowledge to synthesize a plan for them, no matter when or why they call us. We have to be on at all times.

Rules and Regulations

As if all this weren’t enough, we also must deal with institutional regulations that increase our stress and workload. Patient satisfaction scores are one example. Patients now can rate us according to how they think we did at the office or how satisfied they were. Those scores can affect our compensation. But, it is a very subjective system. While I agree that all doctors need to be respectful, patient satisfaction scores have not been shown to improve patient outcomes. In fact, a major study showed that patients who give higher patient satisfaction scores have a higher chance of death!

Our goal as doctors is to heal patients. If giving a pain medication or prescribing an antibiotic is done just to make a patient happy and improve a satisfaction score, there is something wrong. That antibiotic could cause a fatal reaction. We know the results of these surveys are invalid, as patients often comment about things that are not even related to their health. For example, patients have stated that their coffee was not warm enough in the waiting room. Or that the walls in the office did not match. Or that they didn’t like a doctor because he was drinking a Diet Coke.

It is hard for patients to be “satisfied” if they are very sick or have chronic pain symptoms and all of the health problems are not fixed at a 30-minute office visit.

Doctors should not be compared to employees at a hotel resort or a cruise line. Customers have a different mindset on a cruise than they do when they are sick at a doctor’s office. People have no problem paying for a $10 margarita, but they do have trouble paying $25 for an office copay if they are miserable and sick. We are treating vulnerable sick patients who do not need “customer service.” They need to be healed. Patients need to let us use our years of training to help them get better, not to make them satisfied or happy. Patients need to realize that what makes them happy is not always the best care. The emphasis on patient satisfaction pressures doctors to acquiesce to demands for medications or unnecessary diagnostic tests.

I agree that doctors need to be respectful and professional while visiting patients. But to tie compensation to how patients judge me when they are vulnerable is not right. It is hard for patients to be “satisfied” if they are very sick or have chronic pain symptoms and all of the health problems are not fixed at a 30-minute office visit. It is impossible for a patient to know what went into the years of training or the nuances to their disease process in order to know if we did a “good job” or not. The doctor–patient relationship is sacred and complex. It takes time for this to grow. It is not as quick and easy as refreshing a daiquiri on a cruise ship. We are doctors who have trained for 14 years to heal patients and visit with patients during times when they are vulnerable and, frankly, not happy.

Related to this idea is the reputation that doctors are always “late” and that patients wait in the waiting rooms at least 30 minutes to an hour before their appointment, making them unsatisfied and angry. This is true. Patients often wait beyond their normal appointment time. But there is much more going on there than meets the eye. Medicine is not black and white science. It is the art of healing patients at their most vulnerable moments from an emotional and physical standpoint. This art takes time, and some patients take longer than others. An elderly patient who takes 25 medications and needs help using the restroom during the visit takes longer than a 25-year-old with a cold. In our field, 9 out of 10 patients fall into the complex category. One may then wonder why doctors do not account for the time lag. The simple answer to that is that our government wants us to see more patients, do more, document more, get evaluated more, get sued more, yet get compensated less.

M. Dawn Linn, DO, wrote a blog on her Rapha Family Wellness website (www.raphafamilywellness.com/blog) that addresses this issue quite well. It is entitled, “Why in the. . . . does a doctor schedule my appointment for 2:40, and then keep my ass in the office for at least 30 minutes?” Her response to that question:

While in a perfect world each patient would come in with a simple problem, (i.e., I stubbed my toe, I have poison ivy), they don’t. More commonly a day goes like this . . .

Mrs. Jones is 76 and has smoked nearly her entire life. She made an appointment for a lump that she has noticed come up on her arm. A quick visit . . . today. I think they might be nothing but since I’m not sure I send her to a surgeon who also thinks they might be nothing but takes one off anyway. Remember Mrs. Jones because she will come up in a moment.

A few days later I am seeing Mr. Green who is 78 and following up on his thyroid medication. Should be simple enough except that Mr. Green’s wife of 56 years has just passed away. She, too, was my patient. He is crying, unable to sleep, full of anxiety and depressed. I, too, start to cry and console and pray for him right there in the room. Only after we have that discussion are we able to move on to his “medical” care.

One reason we are late: we console.

Right after him I go in to see a chronically uncontrolled diabetic. It would be easy to think that she is simply noncompliant, but the fact is that she cannot afford her medications and so she only takes them every few days. I am aware that there are patient assistance programs available online but she does not have Internet access so I take the time to help her fill out the appropriate paperwork for this.

One reason we are late: we care.

Remember Mrs. Jones? The surgeon is now on the phone and wants to talk to me. Turns out those lumps she had are stage IV lung cancer and he has sent for a CT scan which he is sending the results of to my office. She is at my front desk asking for these results . . . she has no idea she has cancer. So, yes, I work her in, “adding on extra patients at the last minute and it makes everyone suffer.” Not only do I get the joy of explaining to her that she has cancer that came up as suddenly as a spring rain, I get to call her husband on the phone and explain it to him while she cries in my office. I call the oncologist to set up her appointment for the very next day. I get to be the one who tells her that she doesn’t have very long to live.

One reason we are late: we take time.

Yes, this was a real day. And, yes, often I am AT LEAST 30 minutes behind, at the very least. That particular day I was 90 minutes behind. But I can guarantee you that not another person that day was upset with me because each of them has learned that I am the type of doctor who would do the exact same thing for each of them.

So the next time your doctor is 30 minutes late, instead of playing Candy Crush or Facebook on your phone and constantly looking at the clock, look around the office or the waiting room. Say a silent prayer for those there with you, because you have no idea why they are there, just like they have no clue about what you suffer. But I do. I carry it home with me every night. I work my nurses too hard for too little pay because I demand that my patients are taken care of. They do more than just bring patients back to rooms. They call in your refills, fill out your paperwork, write notes for school or work, find samples and coupons, play with your kids, look up your immunization records, talk to your spouse on the phone who is worried about your recent visit to the ER. Sometimes they spend more than two hours on the phone with an insurance company for Mrs. Little, trying to figure out why they will no longer cover her medication for her multiple sclerosis that has been the only thing that has allowed her to function for the past 5 years. And sometimes I even have to argue about it with somebody on the other line.

One reason we are late: we are advocates.

And sometimes even the doctor has issues, like the day I learned (in the middle of my morning) that my mother had breast cancer. I’m sure you were in the waiting room complaining about my being behind while I was in the bathroom crying and trying to freshen up because I still had patients to take care of.

One reason we are late: we are human.

Yes, in a perfect world, we would never be behind, but we would also ONLY see healthy young people whose biggest complaint is how far behind we are in our schedule. And, while it would be nice to think that your $20 copay is paying for my “bigger McMansion,” the truth is that I work 60 hours a week running my own clinic (actually IN the clinic) and another 4 hours every night (after my kids go to bed) and another 12–24 hours in an ER 2 hours away on the weekends in order to pay my staff less than what they deserve and try to chunk away at the $270,000 in student loans that I willingly took on so I could hear people complain about themselves (or me and my office) all day long. Take time to think about that the next time you’re waiting 30 minutes and maybe you’ll realize that 30 minutes really isn’t as long as you think.

Required computer documentation is another example of institutional regulations that hamper our care. Doctors are now consumed with checking boxes, implementing EMRs, and transitioning to a new coding system for billing—all while seeing increasing patient loads and meeting increasingly steep clinical demands. We notice that we now have to document more metrics on the computer that were handed down as a requirement from our institution. Even though we know it doesn’t improve health outcomes, we still have to abide by the regulations. This breaks us down for many reasons:

1. Computers freeze intermittently throughout the day. Patients think we are behind, yet we are simply at the mercy of the hour glass on the computer.

2. Increasing documentation requirements pull us away from one-on-one interactions with our patients. It forces us to stare at a screen and document metrics while the patient talks; our patients are not getting better care from this.

3. We have no access to the computer chart during the multiple “downtimes” per week. This is poor care, as the medical record is vital to optimal patient care, especially during urgent cases. This hurts that sacred patient–physician relationship. Yet we can handle these setbacks; we are doctors.