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The traffic cop

I was dumbfounded more than 30 years ago when the neurologist in our HMO referred to one of our primary care colleagues as “the traffic cop.” At the time, we had eight young residency-trained family docs in our multispecialty group. We were uniformly passionate about our patients and the practice of medicine. We interacted with each other in our office, at the hospital and socially. So why was this singular family doc perceived to be an outlier? The answer: “This doc was akin to the traffic cop directing traffic – you go here, you go there.” My curiosity was piqued. I subsequently realized that my neurology colleague’s admonition was correct as I reviewed the “cop’s” progress notes. The “cop” did indeed make an inordinate number of referrals sans attempts at workups. Consequently, I avoided referring my patients to him, but otherwise, I lost interest … until recently.

Personally, I eschewed the osteopathic tradition of primary care. My uncle was an osteopathic orthopedic surgeon, so I presumed that it was acceptable for me to deviate from expectations. I never disliked my experiences in primary care. In fact, I spent additional hours as a student in primary care offices. As a resident, I moonlighted frequently in ERs. But my true love was treating (and learning) about complex diseases. I had settled on an OBG residency early during my second year of medical school. I lived and breathed gynecological (GYN) oncology, pathology and complicated GYN surgery early in my second year of residency. For multiple reasons, the dream of becoming a GYN oncologist was never fulfilled. For a short while, I pursued my next love – GYN pathology. But at the last minute, I backed out of enrolling in that program. Shortly thereafter, I found my new home in the HMO practicing general obstetrics and gynecology (OBG). I worked insane hours, built an extremely busy practice and made a good income. Nevertheless, I was restless and bored.

It took years to sort out my conflicts. Ultimately, I began to “hang out” with the maternal fetal medicine (MFM) doctors in the antenatal testing unit while on call for labor and delivery (L&D). Before long, I was applying for MFM fellowships. I envisioned my future practice performing genetic counseling and complicated prenatal ultrasound and looked forward to no longer being sleep deprived doing routine OB. Fortuitously, my career-long attraction to critically ill, complicated patients superseded my preliminary vision. My fellowship director and mentor was an international expert in preeclampsia and hypertension in pregnancy. Our program and division had its own obstetric ICU. By the end of my first month, I was tasked with reviewing almost 28 cases of peripartum cardiomyopathy. I didn’t dare say no. I was too embarrassed to admit that I knew nothing about cardiology, echocardiograms, or even cardiac physiology. So, I sucked it up, “dug out” my old medical school physiology texts and began reviewing the charts. Before long, additional reviews of medical complications of pregnancy were added to my plate – stroke, HUS/TTP, thrombosis. To be honest, I hadn’t given much thought to my atypical career progression until recently. My home infusion nurse recently graduated from a master of science in nursing (MSN) program and with my encouragement matriculated into a certified registered nurse practitioner (CRNP) program. I inquired what encouraged her to make these mid-career/mid-life choices. Curiously, her answer was similar to mine 25 years earlier – boredom. It wasn’t income – she was taking a steep cut in salary (as had I) and would never recoup the lost money. She was sacrificing time away from her family (as did I). I then recalled the tale of the traffic cop. I began to wonder if sub-specialization is/was playing a role in the current “epidemic” of burnout and dissatisfaction with medicine?

Over the past 22 years, I’ve personally had seven different university-trained internal medicine PCPs. They are/were all good, caring docs. Retrospectively, I’ve noticed an increasing trend for them to be like “the traffic cop.” Sometimes, overzealous lab and imaging are ordered as a buffer before the inevitable referral. Alternatively, some of my PCPs were therapeutic nihilists and eschewed complicated testing or referrals under the guise that the proposed treatment was worse than the disease I was suffering from. Like most patients, I acquiesced to the idiosyncrasies of my docs as I/we are at their mercy for our authorizations, referrals, refills, etc. Correspondingly, I’m sure those “administrative chores” are the bane of existence for the PCPs and contribute to the accusations of unnecessary paperwork that detract from patient care and personal fulfillment.

Another transformation I’ve noted has been the trend toward employing hospitalists. In contrast, rounding on your inpatients individually or as part of a small group compelled primary care docs to maintain a diverse level of acuity in diagnosis and treatment. It also necessitated their interaction with colleagues and subspecialists. Although hours spent rounding, calls and emergency trips to the hospital negatively impacted scheduling and “private time,” it also facilitated healthy interactions between physician “team” members and provided docs (and their patients) with a better continuity of care.

Clearly the transition from each doc rounding on their individual patient(s) to call groups improved time management for each individual physician. The transition to hospitalist provided less disruption of office hours, more sleep time, and appeared to be a welcome reprieve. Or, has it been an unintended consequence that has contributed in part to the depersonalization referenced in narratives of burnout? During the same time frame, I’ve received care from at least 50 different specialists and sub-specialists. The traffic cop analogy is reciprocal. Similar to my PCPs avoidance of complexities and disappearance from my hospital care, I’ve noticed more and more of my sub-specialists paying less and less attention to my issues outside of their specific field. Their discomfort with diseases outside of their limited specialty sphere is palpable. My surgeon(s) no longer even attempt a pre-surgical history and physical; those are all delegated to my PCP. My care is increasingly disjointed. By default, I’ve been “forced” to be my own surrogate PCP and traffic cop. Many times, I need to research where and who to see, when to seek consults and when to advocate for labs or imaging. I worry about how my family members and friends without my medical resources and knowledge navigate the system.

As I’ve written previously, it’s easy to blame EMRs and related technology for the epidemic of depersonalization, but … are we overlooking the traffic cop’s role?

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