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.