Family Medicine is Dying, can it be saved?

I hated my job. After nine years of school and three years of advanced specialty training I found myself waking each morning with a sense of dread that only increased as I drove to the office. My job as a Family Physician was nothing like what I had imagined. I had dreamed of making an impact in the lives of patients, counseling and serving others in times of illness and crisis. The clinic to which I was assigned had a different agenda. Relationships did not matter. What mattered was that patients had a doctor to see for their routine health care needs. Who the doctor was did not matter to the patients and who the patient was did not matter to the doctors. My colleagues were more concerned with their days off and going home on time than they were with the needs of the individuals under their care. The physicians in the medical group were all employees and they acted accordingly.

One of my greatest frustrations was my inability to take care of my patients when they were sick. Primary care doctors were not given room in their schedules for same day visits. Every sick patient was sent to an urgent care clinic. Appointments were booked only for routine care and follow up. These routine appointments were hard to get as most doctors were booked several weeks out.

I did not feel at home in such a world. I told others my feeling that if I was not available to patients in their time of need that I wasn’t their personal doctor, I was just a doctor. This was not what I thought being a Family Doctor was about. I took it upon myself to identify spots in my schedule where my sick patients could be squeezed in and I worked extra days to decrease my appointment backlog. My colleagues all took a day out of clinic after each night on call; I decided to forego those days off and work a full clinic day.

In some ways my efforts paid off. Within a few months I had openings in my schedule and patients could schedule a visit within two days. I was the only doctor who saw his sick patients in the office and was seeing 50% more patient visits that any other doctor. I was developing relationships with my patients. Patients loved it but my colleagues didn’t. I found myself ostracized and criticized and I began to look for a job in private practice.

It was my belief that a career in medicine was not meant to be an 8 to 5 job. Patient needs didn’t (and don’t) fit neatly into a schedule. I entered medicine to serve patients and knew that service would at times require putting the needs of others ahead of my own. I started to look for another job, hoping to find a place where my attitudes were valued. When I interviewed for positions in private medical groups I found that my beliefs were welcomed. I was told, “You belong in private practice.”

They were right. Working in private practice has been an incredible experience. The occasional long days, evening phone calls and weekend emergencies pale in comparison to the blessing of helping people in their time of need. The ability to adapt my schedule to the needs of patients, to squeeze people in or add them to the end of a day, has led to truly meaningful relationships. Because I own my practice I have had the opportunity to directly reap the rewards of my labors and also to charge nothing for patients enduring tough times. In my mind this is what being a family doctor is all about.

My mind is apparently out of date. While service may once have been the mark of the Family Physician, those days are disappearing. The new generation of Family Doctors is less interested in personal sacrifice. The goal is a consistent schedule that ends each day at 5 o’clock, a guaranteed salary and no after hours calls.

This change in physician attitudes was brought home recently in a conversation I had with the director of a Family Practice residency program. She bluntly told me that none of the doctors she is training has any interest in a job like mine. Current doctors are most interested in “work-life balance.” They want to help others, as long as they can do it between the hours of 9-5 Monday through Friday. After 5 PM, patients cease to be the responsibility of their primary care doctor and become the responsibility of the health care system, the hospital or medical group. They do not want to be bothered. The fact that patients in crisis will be under the care of complete strangers is perfectly acceptable to the vast majority of doctors and patients.

Therein lies the problem. We live in a world where service and sacrifice are no longer commonly held values. While the increasing complexity of medicine makes it difficult for Family Doctors to take good care of hospitalized patients (when your office is 20 minutes from the hospital you can't respond immediately), the only obstacle to going the extra mile in the office is personal preference. The new generation of physicians seems to prefer not being bothered. In the hierarchy of goals doing one’s best has been replaced by doing enough. For those who work for insurance companies, medical groups and hospitals, enough may be an acceptable goal. Those of us who work for our patients understand that only our best is enough.

If things are going to improve patients will need to become more engaged. One of the main reasons physicians are able to be less available and responsive is that patients accept it. Patients are people and people are creatures of habit, so many patients choose to accept poor service instead of dealing with the perceived hassle of changing physicians. If patient engagement increased, if patients used review sites such as Yelp! to praise excellence and critique poor service, if patients started to vote with their feet and moved to offices with better service, the rules of basic economics would force physicians and medical groups to improve. 

I am beginning to see this on a small scale in my office. Many patients have shown their appreciation on Yelp!, with prospective patients choosing my office as a result. (Hopefully this will continue, if you are a patient reading this, you can make this happen!).

Regardless of what patients accept, what insurance companies pay for or what others do, I am committed to doing my best to serve the patients God has entrusted to my care. To me, a changed life and a "Thank you, Doctor Barrett" are still the best reimbursement there is.

Finally, it seems appropriate to acknowledge that declining service and commitment are not limited to the medical profession. Personal service and caring are declining all around us. We can all complain about it but words are not enough, we need to do something about it. I encourage everyone to repeat the simple prayer I pray each day before as I drive to the office, "God, may I be your hands to today to touch the life of someone in need." And then look for opportunities to see the prayer answered.

- Bart

Thanks for reading and for sharing. Patients, Thanks in advance for the reviews you are about to leave on Yelp! and HealthGrades. :-)  I can be followed on twitter @bartbarrettmd, and can be contacted by clicking the contact button on the page for those who have questions or who are looking for someone to speak to their church or community group. Comments are welcomed.

When a Pastor is Never Wrong

He had been my patient for years, as had his family. He had several children, so there had been enough visits over the years for a relationship to develop. He was a pastor at a local church and we had much in common. My family had visited the church on a number of occasions and  he had invited me to fill in for him on a number of Sundays when he was out of town. It seemed a friendship was developing, so during one office visit we decided to schedule a lunch together. A few weeks later on a Friday I found myself sitting across from him at a local restaurant for casual conversation about life and ministry.

He told me how busy he was, how he felt as if he was stretched thin. It was Friday, and he had not even started to work on the sermon for the following Sunday. I had preached enough to know that it takes more than a few hours to compose a quality sermon and that he had not allowed himself enough time to prepare. I asked how his life had gotten so far out of balance. Teaching, and teaching well, should be one of a pastor’s top priorities. I asked what things were getting in the way.

He talked about his administrative and counseling duties, and then mentioned the church’s Wednesday night Bible study that he also taught.

“Why do you need to teach on Wednesday nights?” I asked

“We always have Bible Study on Wednesday,” he replied.

“I understand, but why does it have to be you to teach it? Why can’t you delegate that to someone else?” I knew the church had over 500 people in regular attendance and was certain there was at least one person or pastor who could help with the task.

“Well, people expect me to do it,” he replied, beginning to get a little defensive.

“Who cares what people expect?” I challenged him, “It’s Friday and you have not even started working on your message!” His facial expression led me to believe he was not used to being challenges in this way. His response was clearly intended to end the challenge.

“Well, I feel led by the Holy Spirit.” This was his trump card, his way of saying that he did not need to explain himself. He was the pastor, and he did not need to be questioned. Beyond that it seemed that he refused to be questioned about anything spiritual. That was the end of deep conversation that day, and the beginning of the end of our burgeoning friendship. We never had lunch again/

He was like a number of pastors I have encountered over the years. He was accustomed to being the unquestioned leader of the church, above and separate from the masses. It was as if he was closer to God than other people, more knowledgeable and more spiritual. If someone questioned anything he said or did it was tantamount to challenging His relationship with God, and that could not be tolerated.

I am certain that this attitude was protective for him. Pastors face an incredible amount of scrutiny, each day living their lives under a congregational microscope. Every joke, comment and facial expression is judged and evaluated, every misspoken word and mistake likely to be the topic of Sunday afternoon gossip or the subject of an angry email. When faced with such scrutiny it is easy to withdraw into a defensive cocoon.

As understandable as his defensive posture was, it was dangerous. He had no one in his life who would treat him for what he was, a normal person with normal failings, faults and struggles. He kept his faults hidden from others and surrounded himself with people who were unquestioning in their devotion to him. Because people who knew his weakness and who were willing to love him and encourage him to be better were absent from his life, his weaknesses were not addressed and he did not grow. The lack of accountability ultimately resulted in actions that disqualified him from ministry. A number of years later he left his job in disgrace. I have not seen him in years.

The pastor’s story is a sobering one for all of us. We often say that “nobody’s perfect”, but few of us are open about our imperfections. The truth is that it is when we are open with our weaknesses those who love us can come along side us and shore up those areas that need strengthening.

I have seen this in my own life. As a result of my anxiety disorder there are certain situations in which I do not do well. I struggle in particular with certain types of patient complaints. I can tend to be defensive and lose my temper when attacked. I have learned to reach out to office staff and ask them to reach out on my behalf when I feel I may not be the best person to respond to such a patient. They are able to act as intermediaries and gather information that allows me to come up with better and more gracious responses.

Most remarkably, I have seen that asking for help has caused my staff to have greater respect and love for me. No one is perfect, and my willingness to admit that and deal with that is viewed as a positive and not a negative characteristic. It also allows me to grow and improve at a safe and less anxious pace.

The pastor's sad story has meaning for all of us. None of us are perfect, and all of us need people in out lives who know our imperfections and who are willing to help us get through them.

-          Bart

Mean Doctor Learns to Be Nice

“Why are you always so mean?”

The question surprised me. I was meeting with the business manager of our medical group about some issues I had with the billing and support staff. My expectations had not been met and several requests had been ignored so I arranged a meeting with her to address my concerns. I was not the most tactful person in my business relationships but I thought bluntness was acceptable in the businesses arena. I had high standards and was a firm negotiator but I did not think I was mean.

She obviously disagreed with my personal assessment and apparently had a number of employees who agreed with her. The staff were intimidated by me and felt that I had a tendency to make demands and deliver ultimatums. I paused a moment to reflect on previous interactions before I responded to her questions. It only took me a few moments to realize the truth implied in her words. I was mean at times. Why? The answer came to me a moment later.

“Because you don’t respond when I ask nicely,” I said, “I tried that and was ignored. I learned that when I was mean, people listened.” I went on, “I would much rather be nice. If you promise to listen when I ask nicely, I won’t be mean again.”

“Deal!” she replied.

That was over 20 years ago and we still have a business relationship. She is the manager of the management company that administers my medical group and handles all of my billing and insurance contracts and we interact frequently. We have worked together on numerous projects and dealt with many complex issues. Meanness and anger have never once been necessary. She kept her promise and I have done my best to keep mine.

The lessons learned from that conversation have had a profound impact on the way I run my practice. My staff and I work hard to make sure there is never a need for patients to raise their voice or make demands. Complaints are rare because patients know we will always do our best to meet their needs and exceed their expectations.

I have been mean and I have been nice. I have learned that nice is better.

-          bart

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The Irrelevant Church

“Relevance has always been a priority and value for us as a church." So wrote a leader of a large church as he articulated the reasons for the youth oriented emphasis of his church. The leaders were deeply concerned about the fact that young people were migrating away from church and the leaders were striving to address the disturbing trend.

I admire the leader's passion and cannot argue with his stated goal of reaching out to young adults who are outside the faith. What I do argue with is the misguided emphasis on social relevance as a priority and purpose of the church. My argument begins with the definition of relevance and with its inappropriate place on a church’s list of priorities.

The definition of relevance most often put forth by church leaders is an approach that addresses the concerns and needs of the intended audience, young people. Young people today seem to be more concerned with how the church interacts with the less fortunate or marginalized and less concerned with traditional values such as morality, purity and holiness. Church leaders often cite studies by researchers such as George Barna showing that the millennial generation considers Christians to be harsh, judgmental and unloving. The most common reasons given for this negative impression are the "church’s" positions on hot button issues such as same sex marriage and sexual morality.

No one wants to be called harsh and judgmental, especially churches.  In an effort to counteract negative perceptions churches are beginning to emphasize programs that “prove” Christians to be nice people. Community service projects, neighborhood beautification efforts, after school tutoring programs, food banks and the like abound. All are worthy and noble causes, but the priority given to these works and their promotion suggests that service is not the only goal. The goal is to also show that the church is relevant to modern culture.

Relevance is defined in more superficial ways as well. Many churches intentionally remove all possible signs of pretense or formality. I know of one church in South Orange County that went to great lengths to obscure its pipe organ from view. It was beautiful, but it was not relevant. Many churches have taken steps to remove any semblance of formality and casual dress is the standard pulpit and platform attire. Informality is the new ideal, with parishioners often arriving in shorts and flip flops and carrying lattes into worship services. Concert style lighting and bands playing contemporary Christian music are all intended to add to the cultural accessibility.

While there is nothing inherently wrong with any of these changes and one can argue against formality in worship there is one thing of which I am certain. None of these changes in focus or style has anything to do with relevance.

The relevance of the church is not defined by the culture in which it exists. It is instead defined by the message that is preached and the God who is served. Some of the greatest works of God in the present day can be found in cultures where the Christian message has been declared not only irrelevant but illegal. An example is communist China, where millions of Christians worship in “underground” house churches whose message defies, rather than appeals to, the dominant culture.

The pursuit of relevance is dangerous. Circumstances will inevitably arise in which the doctrines and teachings of the church will be considered outdated and judgmental. The temptation to compromise values, alter emphasis or change focus may be difficult to resist. The church should instead pursue truth, holiness and grace, in any style it can.

When the church is defined by holiness, grace and truth, cultural relevance becomes- irrelevant! 

- Bart

A MasterCard Weekend. Priceless.

Some life goals are noble, some are selfless and some seem silly. All are important to the person who sets them. As I accept the reality of my 55th birthday (and eligibility for the senior discount at Sizzler and IHOP) I am blessed in knowing most of my life goals have been met. I have a wonderful marriage, incredible children and a rewarding career. This week I was able to do something I have wanted to do since I was a child.

When I was a kid baseball was one of the few sources of joy in my life. I collected baseball cards, cherished each Dodger card and even memorized the stats on the back. I read every baseball book in the local library including biographies of Hall of Famers and histories of the game. One of my most embarrassing childhood memories was the day in 5th grade that I was so engrossed in the biography of Cleveland Indians pitcher Bob Feller that I sat right through the pledge of allegiance.

After cartoons on summer Saturdays was the Major League Baseball game of the week on NBC. Tony Kubek did the play by play and Joe Garagiola was the color man. I learned about all of the teams and the players and knew all of the ballparks in all of the cities. Two ballparks stood out from all of the others, Fenway Park in Boston and Wrigley Field in Chicago. Fenway had the Green Monster in left field. Wrigley had the bricks and the ivy on the outfield walls. Wrigley also had the distinction of being the only baseball stadium without lights. Every game at Wrigley was a day game. Attending games at each stadium has been on my to do list for almost 50 years.

I made it to Fenway in 2015. Last spring Lisa and I took a trip to Cape Cod. While there we took a day trip into Boston and I was able to go to the ballpark. It was a wonderful experience. The only thing missing was my son, who shares my love of baseball but wasn't on that trip with us. Fenway left me with a strong desire to make a trip to Wrigley with my son. The challenge was finding a time we could go. He married 4 years ago and just started his legal career. A long vacation together wasn't feasible. If we were going to make a trip to Chicago it would have to be a weekend trip just for a ball game, which wasn't practical. I am a frugal person and did not think I could justify spending money on round trip airfare and hotel just to see a baseball game.

A few months ago I changed my mind. I decided that a weekend with my son going to one of America’s greatest ballparks was worth the cost. The potential of a lifetime father/son memory was something I could not resist. I called my son and made plans to go to Chicago for two days over the Labor Day weekend. Friday afternoon Nate and I boarded a plane to O'Hare. We woke Saturday morning and walked the mile from our hotel to Wrigley Field. We arrived early enough to walk around the stadium, joining the crowds viewing the statues of Cubs greats outside. Every name had meaning to me- Ernie Banks, Billy Williams, Ron Santo and Harry Caray. We lined up early to enter the stadium as soon as the gates opened.

Our seats were a few rows up in the second section on the first level, behind the screen looking down the third base line. We settled in and took a moment to survey our surroundings. There is less foul territory than at modern stadiums and lower walls so we were close to the playing field. We soaked in the sights, looking out across the field to the ivy covered walls, down the foul lines where the brick walls seemed just inches away from fair territory, above the centerfield wall to the large manual scoreboard, as green as the monster in Fenway, and beyond to the bleachers built on the roof-tops across Waveland Avenue. My son and I had made it, we were at Wrigley field. My son said, “It’s kind of silly, but I could tear up right now.” He was not alone.

Nine exciting innings later, after many close plays and a few heartbreaking mistakes, the Cubs lost by a run. Thousands of unhappy fans headed for the exits. We joined them on the journey but did not share their emotions. It had been a wonderful day.

We returned the next day to sit in the bleachers. We arrived at the stadium 3 hours before the game and took our place in line. The bleachers at Wrigley are general admission, no assigned seating. We wanted to get their early enough to to get good seats. We ended up in the second row in left-centerfield. Perfect seats with a perfect view of the action. The game started slow but featured a 9th inning comeback by the Cubs that sent the game into extra innings. We stayed long enough to see Aroldis Chapman the Cubs reliever hit 100 mph on the radar gun and then made our way to the exit for the walk back to the hotel and the Uber ride to the airport. As we walked we talked about our two day whirlwind of a trip. I decided it was a MasterCard weekend. The airfare, hotel and game tickets had cost well over a thousand dollars, but the opportunity for me to spend a weekend with my son at Wrigley was absolutely priceless. Lives are sometimes measured in moments and memories and this weekend was filled with wonderful ones.

- Bart