We’ve been busy since the turn of the new year (and it’s almost April!) with exciting new developments on the horizon for the clinic in the next year. Stay tuned for updates on a new space (maybe!), adding a provider (or two?), and additional nursing staff to care for you. As busy as we’ve been, though, I had the opportunity to slip away from it all and took a much-needed vacation with my husband and his extended family. A few days in the sun, riding bikes, fishing, and watching basketball (my bracket’s busted — how’s yours?) gave me the recharge I needed to dive back in this week.
For whatever reason, being 35,000 feet in the air makes me reflective. During one of my flights, I had a flurry of thought, and the reason I decided to get into this whole mess of DPC to begin with spilled out of me. I want to share it with you all because if you don’t know why — or you can’t convey why — you’re doing something, what’s the point in doing it?
In line with my desire to have a career that served others, I had the opportunity to do my residency in family medicine at a federally qualified health center (an institution specifically tasked with taking care of indigent populations) in Denver that also served as the refugee intake clinic for the metro. We saw all walks of life and tended to each and every person in the same way, under the same constraints and system that dominates healthcare.
As I moved on in my training, more and more patients were added to my schedule. At first I was expected to see 12 patients in a day — then it crept to 16, then to 18, then to 20, and bloomed to 22 at the end of my training. A schedule like that meant I was rotating through a patient visit every 20 minutes. And if I wanted to place any orders, coordinate care, look up the best medical evidence, seek advice (I was, after all, in training), or simply document the visit, that time face-to-face with the patient was squeezed to about 10-12 minutes. This time crunch was further complicated by the fact that over half of our visits were translated — leaving half the amount of time to realistically care for and communicate with someone.
This was my reality: if I wanted to help a vulnerable population, I needed to figure out how to learn about their concern, ask clarifying questions, and communicate back a plan of action to them in 6 minutes if they were non-English-speaking; 12 minutes if they spoke English. It didn’t matter that in order to be in my clinic that afternoon they took off work, had to navigate several bus lines, waited all afternoon as I slowly became more and more delayed in my schedule, and had multiple issues to discuss. None of that mattered. The 12 minutes mattered. Because if I ran late, I people would get angry. If I ran late, people would cancel. If I ran late, fewer patients could be seen. And if I ran late, the clinic lost money.
So I created a routine for getting through each visit: I’d enter the exam room, flip on the computer, pull up a timer in the bottom right corner of the screen — 12:00 exactly — and explain, “We only have 12 minutes, so please prioritize the most important concern you came with today.” Then I’d click start, and the timer would tick away. 11:59. 11:58.
During my last year in training, the behavioral health professor scheduled a visit where she’d record my interaction with a patient and we’d play it back to review for plusses and minuses after the session. Days in the clinic were always exhausting, so when we finally sat down at the end of the day to review my visit with an Iraqi refugee, I was actually grateful to be excused from the onslaught of patients visits. The professor explained how this would work: we’d watch the video together, either of us could pause it to reflect on what was going on, and we’d come up with things that I did well and things that could be done better.
She hit play, and the screen buzzed to life, showing me — seated, back turned, hair a little unkempt and creased in ways that made me cringe, hunched over the computer, explaining my timer and my spiel about prioritizing — and the man. He sat, facing the camera, his view cast just to the left of the screen. His skin was a chestnut brown, his hair dark and groomed nicely, and his frame carried a little more weight than it should have. His clothes were generic but clean, and, arms crossed, he began his story in fluid Arabic.
His story was the story of the Refugee: he had fled due to war and violence. As he shared his story, the interpreter would interject to fill me in, and even before she could finish interpreting, he’d begin again. He had lost siblings, children, and friends. He lost his home — the interpreter breaking his cadence — his profession, his identity. He was suffering intolerable pain — abdominal pain, pain from bones broken during torture, joints that no longer worked.
The timer on the video showed that a little over 4 minutes had elapsed since the start of the video. And had I been able to see it in the video, the timer on my computer screen would have told me I had about 7 1/2 minutes left. And I knew — both as the doctor in the video, listening, and now as the person watching the video, being reviewed — that the timer was ticking down. In the video, I sat, not speaking, nodding and intermittently making noises of understanding, not interrupting.
My professor clicked pause and asked how I thought the visit had gone so far, seeing as a third of it had transpired.
I don’t think I managed to say a word before I realized I was swallowing hard, gazing to the ceiling, feeling my eyes well up.
Everything — EVERYTHING — about that visit was terrible. It was terrible that this is the world we live in. It was terrible that this man had so much hardship. It was terrible that I didn’t have the skills to do the “right thing” — interrupt and reorient the patient. And it was terrible that I sat there, feeling simply impotent.
What I wanted to say was this: While I know medicine can’t solve all of this man’s problems, I — as another, caring human being — want to sit with him and hear his story. I want to be present, and empathetic, and bear witness. I want to nod, and make him feel heard. I want him to know that he is the most important person to me right now. And yes, we’ll talk about his high blood pressure, his pain, his debilitated joints in good time. And I don’t really know if we’ll ever truly cure any of them, but we’ll get there. We’ll work on it. But the only thing I can offer this man in this moment is to be with him. And everything about the system is keeping me from offering the most basic element of being human: compassion and love.
But instead, I probably mumbled something bland about not being focused or whatever and let the tears flow.
At the end of my residency, months after this encounter, I realized couldn’t keep being a doctor and care — truly care — if I stayed, so I left the system. Because it is a broken system. And it was breaking me, too.
So I set out to work for my patients — and only my patients. I wanted to take the third parties out of the room. I wanted to return the control of the healthcare industry to the physicians, who, in turn, are responsive to patients sitting in front of them. I wanted the opportunity to be present with patients. To care.
This is why we, at KCDPC, ask ourselves on a daily basis: how can we show those we serve that we care — in all of our actions? More tangibly, how can we bring the patient back to the center of the healthcare experience? We hope you feel that we’re achieving this aim, and we always welcome feedback to make your experience better — after all, you are why we do what we do.
Allison Edwards, MD
March 18, 2018