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Rants and Raves

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I do not like outpatient medicine.¬† I didn’t like it coming into residency, and my experience thus far has only reaffirmed my distaste.¬† I do not like it in a boat, I do not like it with a goat.¬† It is no mystery to me why thousands of my colleagues are fleeing from the thought of primary care.¬† We had little exposure to it in medical school, and the disjointed, frustrating, and limited experience of outpt in residency does not leave me wanting more.¬† Having 4 hours of clinic in the middle of an 80 hour week in the ICU or on wards sucks.¬† Period.

I am reading a terrific book right now – Outliers – that discusses the 10,000 hour rule.¬† Turns out, it took about 10,000 hours of “practice” to make the Beatles sound like the Beatles and make professional athletes the best of the best.¬† When I look at the breakdown of hours I’ve spent practicing medicine thus far in residency, I have spent about 2600 hours on inpatient medicine and less than 200 (and that’s being generous) on outpatient medicine.¬† Medical school experience was similarly skewed heavy on the inpatient.¬† Clearly, I need more practice in both settings, which is reassuring as I’m not even halfway done with residency.¬† At the end of it, however, I may be close to the 10,000 hours in the inpatient setting but I’ll be nowhere close in the outpatient setting.¬† They are different enough that it matters.¬†¬† ***as a complete aside, guess how many hours you get when you average 70 hours a week for 3 years?¬† that’s right, 10,000.¬† anyone whose read the book will agree that’s exactly to be expected.¬† Of course, with the new ACGME rules – see my other rant about that – future doctors will be less likely to hit the 10 grand mark.¬† and then what?¬† longer residencies?***

There are reasons that we spend most of our time practising in the inpatient setting – the higher volume and acuity of patients, the herding together of great teachers, and the ease and availability of scheduling rotations in a world that is 24-7-365 teeming with disease and therefore opportunity to learn.

But, we like doing what we know how to do –¬†and no one I know practiced enough in the outpatient setting in medical school to like it.¬† The more¬†inpatient medicine we do, the more we know how to do, and the more comfortable we are in the inpatient setting.¬† However, the opposite is also true.

I feel incompetent, uninterested, and ineffective in the outpatient setting.¬† None of it seems to matter – what we say, the pills we prescribe, the tests we order.¬† My days this month in the clinic have been filled with patients with various psychological and¬†musculoskeletal¬†complaints that I can’t do anything about and won’t prescribe¬†controlled substances¬†for.¬† But wait, you cry – isn’t it better to face your fears, to dive into the tar pit of primary care, to hope to enact change in one patient making it all worthwhile?¬† Is it?¬† Would it be for you?¬† I’m not convinced.¬† It’s going to take more than meagre offers of minimal loan repayment to get my attention.

I’m grateful to those who choose to practice primary care and struggle with outpatient life.¬† Hurried appointments,¬†inadequate reimbursement, ¬†charting from home, follow-up on every lab/xray/mammogram, all the while shouldering the burden of responsibility for preventative and curative health care for hundreds of patients at a time (many of whom care a lot less about their health than their doctor does).¬† Thanks for all the hard and thankless work, and look for my discharge summaries in the mail.¬† While inpatient medicine has it’s own struggles, I like focusing on the acute problems of tens of patients much better.¬† After all, it’s what I’m being trained to do.