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On Being a Doctor |

Indian Summer

Diana Pi, MD
[+] Article, Author, and Disclosure Information

From Westlake, Ohio.

Requests for Single Reprints: Diana Pi, MD, 25739 Briarwood Court, Westlake, OH 44145; e-mail, diana.pi.md@gmail.com.

Ann Intern Med. 2013;158(5_Part_1):355-356. doi:10.7326/0003-4819-158-5-201303050-00012
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The town road opened up to long rows of ginkgo trees—the oldest tree on earth, I marveled, and still ubiquitous—the lustrous lemony leaves fluttering in the wind, vying with the sun for the final glory of an Indian summer.





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Leaving Is Not The Answer
Posted on March 17, 2013
Maria Maldonado, M.D.
Stamford Hospital
Conflict of Interest: None Declared
I read Indian Summer with interest and complete recognition for the situation that Dr. Pi depicted so beautifully and descriptively. The ambulatory education for our internal medicine residents is mainly seated in an Federally Qualified Health Center (FQHC). Our patient population on the whole is medically underserved, and the majority of our patients have Limited English Proficiency as well as low health literacy. The idea that a resident, who must also be precepted by a faculty member, could effectively, efficiently, in patient-centered fashion care for a patient who speaks another language with a host of chronic medical conditions in a 20 minute time slot is ludicrous. Primary care physicians are coping with a crushing patient load, reams of paperwork, and the need to demonstrate meaningful outcomes. We are being set up to fail, and are being left open to the possibility of medical error. We are sacrificing the ability to truly contemplate on what might actually be going on with our patients to obviate the need for unnecessary sub-specialty referral and diagnostic studies, ordered in defensive mode so that we don't miss anything important. Administrators speak of the need for productivity as if that is an acceptable way to frame patient care. The only professionals qualified to determine how much time is needed to adequately care for patients are those of us engaged in the care of the patient. The proposed solution for dearth of time in a patient visit is addressing one problem at a time and arranging for follow-up. This solution is not feasible in practice given the lack of access for patients, which will only become more acute as many more people enter the ranks of medically insured. Leaving the practice of primary care is not the answer. If we abandon ship in droves, those who are left will be those who accept the concept of delivering mediocre and substandard care. If we remain united as a primary care community, including those of us in private practice and those of us meaningfully engaged in the medical education of the rising generation, we can devise other solutions besides limited patient encounters. We can and must push back, and we must not be pushed into the corner by our worry that we won't be able to afford to pay back our student loans or create a stable financial environment for our families. Productivity has never been or never will be congruent with good patient care, especially now, in an environment where the public is rightfully overseeing our profession. The time has come to call for national outcry from the ACP and the AMA against this practice of unrealistic time slots for patient appointments. We have more power than we think, and it is time to wield that power before there are not enough of us left to ‘protect the dignity and legacy’ of our profession we all love so much. Maria Maldonado, M.D., F.A.C.P.Program Director, Internal Medicine Residency ProgramStamford Hospital
Public Health, Public narrative
Posted on March 19, 2013
Philip Lederer
Conflict of Interest: None Declared


Diana Pi recently described her heart-wrenching decision to leave primary care (1). Such stories are becoming more and more common. How to counteract this sense of hopelessness?

         At Harvard’s Kennedy School, the legendary community organizer Marshall Ganz teaches public narrative. He describes public narrative as “how we turn values into action — the discursive process by which individuals, communities, and nations construct identity, formulate choices, and motivate action” (2).

         Public narrative is personal storytelling— a story of self, a story of us, and a story of now.  “A story of self communicates who I am: my values, my experience, why I do what I do. A story of us communicates who we are: our shared values, our shared experience, and why we do what we do. And a story of now articulates the present as a moment of challenge, choice, and hope.”

         Inspired by Ganz’s work, I started a website, www.doctorstories.org. The idea is to present a public forum where health-care workers (not just doctors) can present their public narratives. On the website, I wrote my own story— my college experiences in the Mississippi Delta, medical school experiences in Guatemala and Botswana, and residency experiences in California and Mozambique. And more and more healthcare workers have joined me by writing theirs.

         How to get started writing a public narrative? Ganz states, “When you write— the important thing is to really focus on the details- who you are, where you’re from, what drew you to health care in the first place, the justice side of health care in particular, and to the belief that you could actually do something about it. The key to an effective public narrative is not only telling us what you did, but why you did it, and not in terms of “justice out there,” but rather the sources of “justice in here,” in you!”(3)

            Finally, social media provides an unprecedented opportunity to connect with people around the world. Find me on Twitter at @philiplederer


Regarding Dr. Pi's Essay
Posted on April 5, 2013
Nina Ainslie. M.D.
Retired - no affiliation
Conflict of Interest: None Declared

In her essay of 5 March 2013, Dr. Dianna Pi describes why she left primary care medicine. I recently retired after 31 years of primary care practice. Retirement has been a huge relief, although I enjoy my half day a week volunteering in a clinic for uninsured patients. I have loved medicine; it was my calling. In the end, however, in the words of a nurse friend, I was worn slick. Over time primary care has become harder.

 When I started in practice, there were fewer medications and treatments, so I did not have patients on 15 to 20 meds, surviving for years with multiple complex problems. Such patients are commonplace now. When I started in practice, appointment lengths were reasonable. A patient could be seen and a note dictated within the time allotted. Now electronic notes take twice as long to write, contain proportionally less pertinent information, and are unreadable due to excess required documentation. Meanwhile, appointment lengths get shorter.

When I started in practice, I was not judged on “productivity,” a term that should mean “health produced” rather than “dollars earned.” When I started in practice, my patients had me as their doctor and I got to know them well. I practiced patient-centered medicine. There was no such thing as a Patient-Centered Medical Home, a euphemism for financially-centered care in which the care of patients is spread out among “team” members, with the result that no one knows the patient very well, and physicians can be stretched more thinly to cover more patients. We lament that few students choose primary care, but primary care has become too stressful, complicated and frustrating not only because of the issues outlined above, but because those issues arise partly from the need to see enough patients to generate enough income. Better pay would help because it would allow physicians to see fewer patients in a day and to spend the needed time with them. Spending 45 minutes with a complex multi-diseased patient is surely worth as much as a 15 minute cataract operation. Until primary care is reimbursed sufficiently to allow physicians time to do a good job, it cannot be truly patient-centered and few medical students will want to do it.


Nina Ainslie, MD

416 Edgerton Ave.

Manhattan, KS 66502

A Better Choice
Posted on September 25, 2013
Allan R. Kelly, MD FACP, Robert H. Kelly, MD FACP
Premium Medical Home
Conflict of Interest: None Declared

To the Editor:

Diana Pi brings to our attention a serious problem in her moving essay, Indian Summer (AIM, 158, 355-356): mature, intelligent, expert clinicians leaving primary care internal medicine. Dr. Pi suspects the problem is hospital and clinic management. We think the problem is much more fundamental than that. Being a good clinician cannot be measured by a CPT code, yet that is how our work has been defined and reduced.

Her work, and all clinical medicine, is valued by metrics of billing and productivity defined by the CPT guidelines. The need to conform to a 99213 code (office visit, intermediate), and all the other thousands of codes in the CPT system, leads to incentives and distortions in medical practice that cause too many good doctors like Dr. Pi to leave their clinics and patients.

For similar reasons, here in Fort Worth, every few months another primary care internist or family practice doctor in his or her 40’s or 50’s leaves the office/hospital practice of internal medicine. The widespread use of mid-level providers can take up the slack and patients are getting a good 99213 when they go to a provider. But neither patient nor physician sets out to provide or obtain a 99213.

Dr. Pi and doctors like her (including us) need to have a better choice than either being a provider of 99213’s or leaving internal medicine. Patients, too, deserve a choice other than another 99213. Experience, loyalty, accessibility, even wisdom are what some people want and these values are not included in a CPT code or valued by RVU’s.

Our take on this is that employment contracts and CPT codes are not working well for long term primary care internal medicine, especially in geriatrics. We do not advocate ‘concierge medicine’. We advocate instead for internists and the elderly and chronically ill to have a choice in how they value medical care. We ask that AIM bring into focus innovative alternatives that will keep internists like Dr. Pi in primary care, working for the good of their patients. We describe one widely affordable and simple proposal at our web-site, PremiumMedicalHome.com.

Allan R. Kelly, MD FACP Robert H. Kelly, MD FACP
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