A recent editorial in the Boston Globe addressed the dearth of primary care physicians. The piece concluded: “Federal funding for new residency slots should follow reforms that address the underlying reasons - principally money - that lead doctors to choose to specialize.”Money is certainly important. But there is another obstacle to attracting primary care doctors that is more subtle, though perhaps equally important. Consider the following story.
Recently I had the opportunity to teach a group of pediatric interns and residents about contemporary child development research. As they filtered into the room, I overheard one young doctor wearing scrubs say to another, “I was up in the NICU (neonatal intensive care unit) all night - I’m going to sleep through this one.”
About halfway through the talk, I asked the group if they had ever been surprised by the things parents tell them in continuity clinic -the primary care experience doctors in training have where they follow children over a three year period.
I admit to having felt pleased when this doctor's hand shot up. She told the story of frustration trying to teach a mother how to control her three year old son’s increasingly explosive behavior. This young doctor explained how she felt like she was “beating her head against the wall” as the mother of the little boy seemed unable to follow through with anything she said. Then one day, what seemed to her “out of the blue,” the boy’s mother began to cry. She told the intern about the death of her own mother shortly after her son was born. She admitted to debilitating feelings of depression that made it hard for her to even be with her son, much less set limits as the doctor had been prescribing.
This mother’s unresolved grief was in the way of her ability to take in this young doctor’s “advice.” Her trust in the doctor, a result both of the relationship they had developed, and the implicit trust people often feel for their pediatrician, had enabled her finally to share these feelings of grief. If this problem had not been uncovered, it is likely that the intern’s continued efforts at “giving advice” would have failed.
I asked the doctor to tell us what she had been experiencing while this mother shared her story. She described feeling panicked and inadequate. Not only was she worried about the waiting room full of families who might have to wait longer if she got “stuck” with this grieving mother, but she didn’t know “what to do.” The idea that listening to this mother was actually exactly what she needed to do had not occurred to her.
This intern had conveyed to this mother that it was OK to talk about these difficult feelings. If doctors do not communicate this interest, it is not because they are not interested. It is because they fear that they will be inadequate to the task of “solving the problem.”
In addition, just as the mother needed to have her experience heard in order to be available for her child, this intern needed the support of her colleagues to help her manage her feelings. She was fortunate to have an opportunity to share with us her feelings about this upsetting experience.
To hold someone’s pain in the way that this intern had to do is not easy. Imagine hearing 10 stories of trauma and loss over the course of a week. It is very hard to hear these stories without having a place to share the burden. As a matter of self protection, doctors in training may not let on that they want to hear.
This dilemma occurs not only in training programs. Primary care clinicians are struggling under many pressures, including decreasing reimbursement necessitating more visits in less time to cover the administrative costs of accepting many different insurance plans. Doctors know the importance of listening to their patients, but don’t have the time or the emotional support to open up in this way.
Financial reward is critical for attracting doctors to primary care. In addition, our culture, including our medical education system, needs to value the role of doctor as listener, or these young clinicians will burn out before they even start.