Sunday, October 18, 2009

A Day in a Primary Care Doctor's Moccasins

Until you walk in another man’s moccasins, you can’t imagine the smell.

Robert Byrne, 1928 - , American Chess master

Preface: The October issue of Connecticut Medicine contained a remarkable article by Edward J. Volpintesta, a 65 year old solo family physician in Bethel, Connecticut. The article is a diary of the day of a primary care doctor – from start at 7:15 A.M. to finish at 4PM.

I reprint it because I have long maintained pundits like myself and health reformers in Washington should spend a day in the office of busy solo practitioner. Only then would we begin to appreciate the travails of primary care – the hours spent on such non-reimbursable activities as paperwork, phone calls, and prescription writing and renewals.

These activities require knowledge possessed only by the physician. In my opinion, these activities, because of the time and know-how required, ought to be reimbursed. In one fell swoop, that would make primary care more rewarding and would close the satisfaction and monetary gap between primary care and specialty care.

A reprint of the full article follows.

A Portrait of the Primary-Care Physician at Age 65

Edward J. Volpintesta, MD,

Connecticut Medicine, October, 2009, pages 559-560

Health information technology and other electronic assistance will do little to change the heart and soul of primary care.

Explaining the illness, its prognosis, and alleviating the fears that go along with it are time and energy-intensive. Dealing with a sudden death or a complication of a medication, or social ills like divorce or a child hooked on drugs, or how to deal with an aging and needy parent are a few examples of what primary care doctors do.
To exemplify this I have described a “typical” day in my office.

1. In office at 7:15 are. Spend 35 minutes collating fax reports that collected during the night and deciding which need immediate attention that day (nine lab and imaging reports, two visiting nurse reports that needed review and signature and return; for prescription renewals from pharmacies; one request of records form insurers, one nursing home discharge from to be reviewed and signed and returned, and one emergency room record).

2. Death certificate filled out form patient who died suddenly over weekend. Called family and explained probable cause of death and offered condolences (several minutes).

3. Filled out four fax forms for refill of medical to local pharmacy.

4. Telephone conversation (sever minutes) with patient who recently was found to have a mass in left upper abdomen noted incidentally on CAT scan of chest done by pulmonologists looking for cause of chronic cough. I discussed with him and ordered CAT of abdomen and pelvis. Phoned in prescription for premedication with steroids because of hazel nut allergy.

5. Telephone conversation (several minutes) with patient regarding abnormal CAT-PET scan of lesion of left lung. Wants to get a medical center in New York City. Long discussion explaining that this problem could be handled locally.

6. Telephone conversation with patient regarding his need for a prescription to be phoned to mail-order pharmacy. He gave me fax number which didn’t work because it was really a phone number. Called him back to clear up problem.

7. Telephone conversation with patient recently started on insulin. Called me to say that sugar is over 300 before breakfast. Brief discussion with her. Insulin increased. Told her to call me back with prelaunch glucose value.

8. Telephone conversation with patient with history of diverticulitis. Has what she thinks is another attack. She called here gastroenterologist but he was on vacation. Told her to come in immediately to see me.

9. Office visit. Patient with otitis media treated several days ago. Got worse over weekend and went to emergency room. She was very concerned because worked as receptionist in hotel and couldn’t hear well. Wanted to see ENT specialists. I called the specialist but the voice mail was not working properly... Finally go thorough on fifth try. Patient as elderly and I had spent several minutes explaining how to get to ENT office. I drew a map for here. In the meantime she suddenly started crying about how her life had been hard since her husband died and told me of sad and frightening experiences she had while working in a bank.

10. Telephone conversation with daughter of patient whose elderly father had been to ER complaining of fatigue. Had been in office a few days ago and inconclusive Lyme tests; that done in the ER were diagnostic. Was supposed to have a stress test today but daughter concerned that he is too weak to do it. Test cancelled.

11. Office visit. Patient with bacterial elbow bursitis. Seen in ER few days ago and given I.V. antibiotic. Gett6ign worse. I set up infectious disease consult.

12. Telephone conversation. Dialysis patient’s wife called to discuss his A1C.
changed medication. Wife upset because patient smoking more than pack of cigarettes a day. Told her I would speak to him.

13. Telephone conversation. Previous patient with insulin adjustment says that prelunch glucose was 400. Mad adjustment. Told to call me tomorrow.

14. Office visit. Patient seen in follow-up for depression. Sees a psychologist who told her to see me for medication for break-through panic attacks.

15. Office visit. Patient seen for neck pain. Afte4r he leaves comes back 10 minutes later asking me to look at area on face that he scratched and had bled.

16. Office visit. Elderly patient comes in after having seen a chiropractor for back pain. Is sobbing. Has been depressed and is self-mediating with pain medication. Has seen psychiatrist in the past but has stopped because he feels he wasn’t being help. I call wife and arrange for crisis intervention at hospital. I write down list of his cardiac medications for him and wife who accompanies him to take to hospital. Patient is admitted for psychiatric care.

17. Office visit. Sutures removed from patient’s chin.

18. Office visit. Patient seen in follow-up for hypertension.

19. Office visit. Patient seen for tracheitis.

20. Telephone conversation with patient. Had some antibiotic left who has lung mass (item 4). Very upset. Crying. Wants to go to center in New York City for care. She was waiting to hear form pulmonary consultant who I had called earlier for a consult. I called him again and was told that he got my message and would call her.

21. Telephone conversation. Patient has cystitis symptoms. Had some antibiotic left over from previous infection? Already took a few. I phoned in some more. Told here to follow up with me.

I finished by day at 4 pm. When I arrived home, I received a call from a patient with a toothache. Her dentist would see her tomorrow but wouldn’t order pain medication until he saw here. So I phoned an analgesic to a local pharmacy.

I did not receive any phone calls for the rest of the evening.

In some cases the telephone conversations were more time-consuming and challenging than the office visits. When I started my practice 35 years ago, I would see about 35 patients in a full day and about half that number on my half days. I occasionally make hospital and nursing home visits but not regularly. I use hospitalists and delegated nursing home care as well.

Clearly, a new paradigm of primary care is evolving. Attending to patients’ social and psychological needs and the many administrative details that compete for primary-care doctors’ attention has become almost overwhelming. My method of changing to keep up with modern medicine is to keep my patient load low, about 15 patients on a full day (three days a week) and seven or eight on a half day (two days a week).

This approach allows me to maintain my equanimity. It’s the only ways that can come even halfway close to bang the physician I want to be.

Other physicians’ days will be more or less complicated in proportion to their abilities, their ages, their financial goals, and the lifestyle that they desire.
It would be informative to know what other primary care doctors’ days in the office and elsewhere are like.

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at,, and for $31.95 (hardcover), $21.95 (softcover), and $6.95 (electronic). For information on speaking fees and arrangements, call 860-395-1501.

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