A Part of the Exodus

I remember being in medical school and imagining what my life would be like after I finished

training. I would picture the conversations I would have with my patients, and envisioned what my waiting room would look like, with comfortable chairs and soothing artwork that put patients at ease from the moment they came in the door. I didn’t give any thought to the kind of house I would live in or the type of car I would drive, or even if I would get married or have kids; I just wanted to have the opportunity to take care of people and make their lives better.

I did actually get married immediately upon medical school graduation. I married a handsome surgeon and we had a beautiful daughter. What I did not count on is the toll that the stress would take on our marriage, which came to an end by the time I finished my internal medicine residency. Initially, I wanted to be an oncologist. Doing a fellowship was out of the question at this point, though. I was a single mom who did not want to spend three more years away from my young daughter. I took a job with a hospital in Grapevine, Texas, and was so excited that I would now make a decent living after all the hard work I had put in, the loans I had taken, and the nights I had spent away from my family.

Oncology would be a field I would think about over the coming years, and I considered going back to do the fellowship many times. What I discovered through treating internal medicine patients was that I had plenty of patients with chronic and terminal illnesses, which was the real reason I wanted to be an oncologist. I wanted to partner with patients as they navigated the rough waters of critical illness. I had gotten glimpses of this as a paramedic, and now I was living my dream by helping geriatric patients, hospice patients, patients with heart failure and diabetes. I was practicing the art and science of medicine and I loved it. I loved my patients.

Being the newest physician in the practice that I joined, I took care of all of the new Medicare patients. This meant I got a lot of folks who were pretty darn sick and took a lot of medication for their various conditions. This took time, and I learned that I enjoyed working with the elderly a lot more than I expected. When I was nineteen I spent a summer working at a nursing home. I liked that job, which might have given me a clue that I would love geriatrics, but it didn’t. It didn’t take but a year for my practice to become full of patients that were typically over 65. This was great!

It was great, but not sustainable. The overhead was over $20,000 a month and I was seeing about 11 patients a day in my first year. I had support from the hospital we were under, but that money would soon end. I was nowhere close to being burned out, I just thought the overhead was too high. I went down the road and joined Dr. David Pillow, who charged me a very modest rent. I was in the presence of greatness, learning from this icon of a doctor and paying overhead that was more than fair.

Sadly, Dr. Pillow retired soon after I joined him, and the owner of the building gave me a choice to buy it or leave as he was not going to continue to lease it. Not having any savings, I took a cash advance for the down payment and started making payments on the building. One day my biller showed me our books. When she subtracted the money that I made from working outside of the office (hospital, hospice, even six months with an ADD clinic), the office was making nothing. Nothing. It supported the staff of two and paid the bills, but it did not pay me. That day I knew something had to change. I had to get a job. Become an employee. The only way I could continue to treat the elderly was going to be on someone else’s dime.

What I found over the next few years was that the bottom line always matters. My monthly financial reviews would compare my collections to my family practice colleagues who were seeing at least 15 more patients a day than I was, and I was busy. I spent the necessary time to address my patient’s problems, review their medications, discuss side effects, call specialists, review their labs with them—just basic doctoring. One thing I learned, though not quickly enough, was that the doctors seeing more patients get more resources. My patients were complex, and it took at least twice as long to see one of them as it did for other doctors to see the younger patients who had not yet developed heart disease, lung disease, or cancer. Those were the conditions I loved seeing, but you cannot see 35 patients like that in one day, with one nurse.

Though many older physicians are leaving Medicine because of electronic health record usage requirements, I welcomed the transition. I was pretty quick to learn how to use any system you threw at me. Still, things were pretty grim when it came to revenue. As you can guess, by the time I hit about 75 percent of my patients being on Medicare, my monthly financial meetings were going badly. Risk adjustment was not something that we knew about at this time, and even at my next employed outpatient position with a hospital in Dallas, I would not stay long enough to get the relief or show the reward to the system that would be enjoyed by capturing the risk-adjusted codes or raising our quality stars.

I was getting pretty discouraged that even with 20-25 patients per day, which was a lot of work, we were underwhelming our company with the numbers. Eventually, the senior care clinic closed. My medical assistant and I were so sad that we lost the spark that we had, that our patients had when we had a clinic that was there just to serve them. They would walk in the door and our receptionist would loudly say, “How are you doing? It’s so good to see you!” My medical assistant would bring them down the hallway to the room laughing and joking around with them as she got every patient to get on that scale (even the ones who would refuse at first).

They knew that we would get their prescriptions called in, that we’d send them to only the best specialists, and that they could come in any time they were sick and we would never turn them away. The administrators had hired me with a shared vision to get these elderly folks taken care of, but eventually, the numbers would win. We would need to join a general primary care practice and lower the age of the patients that we would see. Our receptionist would no longer loudly greet patients as the came but would quietly check them out at a side window and smile as she made a follow-up appointment for them. She was still there, but it was not the same.

During my time at with the hospital system in Dallas, I was involved in leadership with the Accountable Care Organization and quality committee. I would give interviews on the radio and speak to groups on various topics related to elder health. I was able to build my leadership skills by becoming a Certified Physician Executive. This leadership experience caught the eye of Optum, and a Medicare advantage plan soon offered me a position in Dallas.

Was I burnt out? I don’t know, but I do know that I was very sad that I was not able to do what I loved by taking care of the elderly. I once again had to tell my patients goodbye. I remember telling them that if I was not there, I would be making movies. I just made my first short film, Coffee Culture. When asked about practicing Medicine, I would tell them, “Only missionary work.” I am now blessed to work in a free clinic on certain weekends in Fort Worth. Many doctors are leaving clinical medicine. This is my story.