I recently saw this opinion article in the Washington Post, suggesting that pediatricians are not doing so great. The article really hit home for me so naturally I tweeted it. But then I started thinking about all of the things I wanted to say about it and decided the thread would be too long and I should just blog about my thoughts. So here they are.
The night before I read the article, I was spending time with my niece and son who were home from college for spring break. My niece asked me if I like my job. I hesitated for a moment and gave this response, “I love my career but I don’t particularly like my job.” My son looked at me strangely and asked, “what’s the difference?” I then went on to say how much I absolutely love taking care of children and their families. My favorite part of the day is spending time in the room with my patients. What I don’t love is all of the other work that seems to be expanding at a rapid pace. Interestingly, my friend from residency visited a few days later and out of nowhere she asked me a similar question. “Do you still like being a pediatrician?” I described the conversation I had with my niece and son and she agreed entirely.
The practice of pediatrics is very different now than it used to be. The electronic medical record has revolutionized patient care and also the work of providing that care. However, it has had it’s down sides. I often think back on my early career and compare it to 2023 and think, how did I get here? How did I go from seeing 40 patients a day to 20 patients a day and yet I’m more exhausted and more burnt out than I’ve ever been? I almost feel like I have to justify my level of burn out. Shouldn’t I be able to handle this? But burn out is not just related to patient volume. On top of the systems issues discussed in the article (more later), I have my own personal story.
Personal story
In 2018 my husband was diagnosed with stage 4 colon cancer. Right before the COVID-19 pandemic, I wrote a post about it, mostly to tell other moms that when you have a lot going on, there is no expectation of perfection. His diagnosis taught me quite a bit, but professionally, I realized I did not have to continue being a “yes” person. It was ok that I wasn’t on every committee or involved with all of the work of the group. I didn’t need to know everything that was going on or be in charge. It was the first time I realized how much I needed to prioritize my family over my career. Not so easy however, when you’ve climbed the ladder as I had. I had responsibilities.
Fast forward to March 2020 and the pandemic hit. We were locked down, the kids were home, and patient volume plummeted. I worried about our financial safety while I was at home, but also worried about our physical safety while I was at work, unsure of what we were facing with this new virus. I simultaneously became bored of my house, desiring to go on a summer vacation, while also continuing to fear exposure and wishing I could work from home. At work, we had a lot of tough decisions to make. As a leader, I was involved with the constant pivoting and decision making regarding our practice and our safety. As the Director of Marketing, I was responsible for patient communication. As lead physician I spent as much time on adjusting work schedules as I did on patient care. It was exhausting to say the least. I had never experienced emotional and mental exhaustion like this. I always thought you had to be busy or physically moving to be fatigued at the end of the day, but I was wrong.
3 years later we are still dealing with the emotional fall out of working on the front lines through a global pandemic. Personally, I’m still balancing being a caregiver for my husband, a mom, and a pediatrician. But why else are pediatricians as a group feeling so depleted? The article goes through a lot of issues including low staffing, decreased access to hospital care for pediatric patients around the country, low reimbursement for our specialty, and a massive increase in our need to treat mental health disorders. The EMR has also created an increased amount of work that we often don’t have any help with. The dreaded InBasket.
A day in the life
First of all, I want to say that the company I work for is amazing. We are a safety net pediatric provider accepting almost all insurances. We have service lines that most smaller pediatric groups are not able to provide like lactation, nutrition counseling, telehealth 7 days a week and after hours care. Furthermore, we are all trained in basic level mental health treatment. I truly believe San Diego is lucky to have us. They have also cared for me better than I could ever imagine through all of my personal hardships.
What we are struggling with is the same thing all pediatric groups are struggling with. Work is getting more complex and cumbersome but support staff levels are challenging. With the increased volume of mental health patients and expanded mental health screenings for teens at their check ups, our appointments are longer. This means less appointment slots for sick patients, which became a major issue in the fall of 2022 when we experienced a tripledemic. It also means frequently running behind and spending the whole day moving from room to room. This leaves very little time to do our other tasks. In fact, we have many tasks on a daily basis aside from direct patient care, but no time set aside to do it. Many of us take this work home which significantly impacts our family time and our well being. Now, before you say “you signed up for this”, no not really. When I left training there was limited electronic record use without any patient emails. All of the practices I trained in had nurses working directly with physicians to authorize refills, call in advice, and call in results. Charting was significantly quicker on paper charts without buttons to push and items to review, or risk getting audited. This is not the same medical system.
Here is a list of just some of the things we may need to do each day (may vary from physician to physician depending on their level of support staff or nursing):
- Review all results and send them on patient portal or call family
- Review charts being sent from specialists
- Send prescription refills as they come in from the pharmacy
- Respond to patient phone calls
- Respond to patient emails (many of which should be appointments)
- Re-submit or change prescriptions either due to shortages or insurance denial
- Re-order referrals as urgent because many specialists are booked for months
- Ask for prior authorization and fill out forms justifying medications and treatments that have been denied
- Fill out forms for school, sports and camp
- Make decisions on expired orders and send reminders to patients to get tests complete
- Have meetings about the running of our office
Of course our primary job, aside from direct patient care, is documenting the visit which includes the history, physical exam, and the diagnosis and treatment plan. Which also is often completed after hours. In fact, many doctors feel like the work in the EMR is so overwhelming, they choose to work part time so they can spend more time catching up. This is really a sad state of affairs when all we want to do is see patients, bond with the families, and give them the time and care they deserve. It certainly doesn’t help with the ongoing physician shortage in the country either.
Healthcare is broken. Especially primary care. The amount of work required of us continues to go up. Reimbursement remains significantly lower than specialist reimbursement. Insurance denials increase our work load and erode patient relationships. And overall public trust and respect for health care is in the toilet following the politicization of the pandemic. While I may be facing my own personal challenges and I also take on a lot of leadership roles, it’s safe to say that you don’t need to have a partner with cancer to feel burned out as a pediatrician.