5 Lies You've Been Told As A PCP

In this episode I discuss several ideas and “facts” that we as physicians often believe to be self-evidence truths but are in fact, lies, including

• The “industry standard” that nobody likes that is not based on evidence
• The lie your employer is likely telling you about your compensation
• The lie insurance companies perpetuate to patients and doctors
• The lie that academic training often instills in us
• The lie that I have the hardest time letting go of and that likely does the most damage long-term

Doximity Op-Ed: https://www.doximity.com/articles/a8ffb2d0-4eb6-4611-87c8-5dd4040e457b 

NY Times Article: https://www.nytimes.com/interactive/2021/08/22/upshot/hospital-prices.html 

The End of the 15–20 Minute Primary Care Visit: https://pmc.ncbi.nlm.nih.gov/articles/PMC4617939/#CR3 

Association of Primary Care Visit Length With Potentially Inappropriate Prescribing: https://jamanetwork.com/journals/jama-health-forum/fullarticle/2802144

SO MUCH TO DO, SO LITTLE TIME: CARE FOR THE SOCIALLY DISADVANTAGED AND THE 15-MINUTE VISIT: https://pmc.ncbi.nlm.nih.gov/articles/PMC2606692/ 

Additional Micropractice Mama Podcast Episodes To Consider:

PCPs Are Being Gaslit

Why Primary Care is Better Without Insurance

Entrepreneurship As A Feminist Act

If you're enjoying this pod, I would love to connect! Real human feedback is so deeply appreciated. Here are a few ways to reach me:

Connect with me on IG @soniasinghMD
Email me at sonia@micropracticemama.com
Learn more at www.micropracticemama.com

The Micropractice 101 E-Course is available NOW. Learn more or enroll here: https://micropracticemama.thinkific.com/courses/micropracticemama

And if you're not sick of my voice yet, check out my other podcast with Dr. Rebecca Berens: The Antisocial Doctors on Apple Podcasts or Spotify!

Sign up here for the Micropractice Memo to get weekly tips, updates and resources on all things micropractice and motherhood in medicine: https://micropracticememo.myflodesk.com/s51y9r3knn

Transcript

Copy

Speaker 0:01

Hey doctors. You're listening to the Micropractice Mama Podcast, a podcast for women physicians who are striving to practice primary care sustainably and creatively with autonomy, authenticity, and joy. I'm your host, Sonya Singh, internist, PCP, and proud mother of two human babies, one for a baby and one. Life-changing micropractice. I wanna empower you to push past whatever is holding you back and make the leap to launching a practice that aligns with your values and priorities, and finally allows you to take care of your patients, your family, and yourself in the ways that you want and deserve. Are you ready to make the leap? Let's do it. Hey, doctors, how is your day going? Let me tell you about my day. I am supposed to go out of town tomorrow for the weekend, just a quick trip to Florida to visit my sister-in-law and her family. And you know how there's always this pre vacation day chaos. Today I woke up and my dog, had an issue and needed. An emergency procedure, so had to go drop him off for that and then of course had to go pick him up when he was ready. My husband informed me that all of the toilets in our house appear to be breaking. There's some fundamental problem with our toilet plumbing. And. My babysitter's car just spontaneously caught fire when she was at her morning job. Luckily she's fine and she's safe and everything's okay, but wow, that is a lot for one day. And luckily Thursdays are usually my sort of admin slash micropractice mom day, so I only had one urgent visit this morning, and the rest of the day I've been able to attend to all these various crises that I've arisen. But yeah, man, there's just something about the day before you leave town where it just, I looked at my schedule and I saw one person and I was like, all right, all I have to do is see her pack, record my podcast, it's gonna be a good day. And then it wasn't, but that's okay. Anyway, I'm here and I'm gonna, I'm gonna record. I'm determined to do it today's episode is a fun one. I say that about all of the episodes. It's five lies that You Have been told as a PCP. I have mentioned that I have a side side project that I'm working on with my colleague Rebecca Barons, which is a podcast about misinformation and the way health and wellness is treated on social media. And one of the things that's become very clear to me in doing research for that podcast is. When you're in certain groups or cultures or subcultures or microcosms, th there are certain things that are just said so often, or they're just so ingrained in that microcosm that they just become accepted as true and these self-evident. Truths that no one even bothers to question or look into or, seek more information on. 'cause you're just like, yeah that's true. That's the way it is. Everyone says that. Why would I ever, question it. And it struck me that, there's a lot of things I think. Are that way in the world of medicine and definitely amongst PCPs. And I hinted at a lot of these things in the piece I wrote about PCPs being gaslit. I have a whole episode on that where I just go over that. Op-ed that I wrote for Doximity, or you can go read on Doximity, I'll put the link in the show notes. But I wanted to revisit some of these topics and, with a slightly different slant because I really think that even I like, could not appreciate how untrue some of these things were until I had some distance from traditional healthcare. And now that I have that distance, I just wanna shake people and wake them up and be like. Are you aware that this thing that you have believed and been basing your work on is maybe not true? So I wanted to go through fi the top five things that I could think of that I think were indoctrinated. No pun intended. We're indoctrinated with as part of the culture of medicine and, of our profession. And I think ultimately all of these. Things are detrimental and you know the, a lot of you probably come here for the, concrete how-tos about starting a Micropractice or A DPC. And you may think like, how is this really helpful to me? Or how is this relevant? So I'm gonna say that I think, this falls into the category of. Motivation. Highly motivational because if you are one of these people who's toying with the I idea of DBCR likes it, like sums things about it, doesn't like some things about it, maybe you have reservations about the ethics of it. Maybe you're just not sure how comfortable you feel, not taking insurance. Maybe you're like My job's okay. I think I can get by, if you're one of those people, I hope you'll listen to this episode because I think it may nudge you towards making this leap. If you're already in DPC or starting micropractice or a direct care practice, honestly, I think a lot of this stuff will reinforce stuff that you already feel. I hope it's very validating for you. Actually, I hope for everyone, it's validating. That's one of my missions in life is to convince people that. They're not crazy and their experience is valid, and they're not the only one that feels that way. So I hope this does that for you. And I think also, just exploring some of these concepts will help you talk to colleagues and patients about why DPC and direct care is just such a good choice and why so many doctors are now moving towards that model. So let's get started. The first lie that I feel a lot of PCPs have been fed and have just come to accept as normal, is that our job can be done in 15 minute increments. That 15 minute appointments are a perfectly reasonable amount of time to. Take care of a medical issue. So I want you to start by asking yourself, why do you think it is that it's become 15 minutes? Why is it that particular number that we've decided? Yeah. That seems like the right amount of time for a patient appointment. At both of my jobs, I started out with a 40 20 template. And so it was usually 40 for a new patient or somebody who was complex hospital follow-ups and then 20 minutes for everybody else. I started out with that and initially with both practices, I had a lot of autonomy over who got a 40 minute visit, so sometimes it would be, yeah, a 30 5-year-old, but just somebody who I knew had a lot of issues, a lot of questions, a lot of things to discuss, and I was able to tell my ma or the schedulers, Hey, this patient, I would leave a note. This patient always gets 40 minutes. No one ever questioned me about that. It was fine. I loved that. It seemed to work really well. 'cause I generally had a good sense of who needed more time and who likely didn't. And there was always curve balls of course, but there's people on your schedule that you see from a mile away is, are going to need more time. I left the first place before they had a chance to really change it, but I think they ultimately did change that as well. In my second place of work. Yeah, ultimately they did what I think so many healthcare institutions do, which is standardize all their service lines and put everybody on the same template and make everything very uniform. And when they did that, we all went to 1530. And of course when they were about to make this change, I did a whole literature review. I came prepared with printed copies of all the. Papers that I had looked up on this topic, I tried to give this whole pitch about why we should not move to 1530 and we should stick with 2040 and all the problems that were gonna arise if we did this 1530. And at the same time we had done the 1530, we switched to a central scheduling model. Not only did I not have the ability to say who I think needs 1530 is like the person who's answering the phone and Scheduling the patient had no idea who that patient was. In our old office when it was a little bit more of a small office, private practice feel, the schedulers knew who my frequent flyers were. They knew who always showed up 10 minutes late. They knew who always had 800 questions. They knew these things in advance so they would schedule appropriately. Once we moved to the central scheduling and it was this, massive big box clinic, it, we couldn't do a lot of those things. So anyway, made this whole pitch. Nobody cared. Nobody even wanted to look. I remember going in there with a stack of papers and just all excited to share this information with them as if, I was gonna enlighten them about the dangers of switching to this model. And I didn't even. Get to say, I don't, I think I talked for 30 seconds before they were like, yeah, no we're doing this. And then when I cited it as one of the reasons that I was unhappy and burning out and feeling like the job was unsustainable the answer there was, this is the industry standard. We're in the Texas Medical Center, there's a ton of healthcare systems here. She was like, go to anywhere down this. Go down the line, go down the street. See how long people are spending with patients. And you'll see let everybody is on this 15 minute schedule template. So why would we do different? This is not an evidence-based decision. Like no one has actually looked into this and decided that 15 minutes is the appropriate amount of time for a primary care visit. I found one study in my literature review where they found that 15 minute visits appeared non-inferior to 20 and 30 minute visits. In, this study they did with a few practices in the Midwest in the United States, but. But the outcomes they were looking at were return visits, hospitalizations, and referrals, and maybe one other thing within seven days of the visit, which I just think is even if you wanted to come back to the primary care office within seven days I don't know how often that would really happen. My guess is if your questions did not get satisfactorily answered, you would maybe make another appointment, but it wouldn't be three days from then. That's. Usually logistically not possible. And for most people it just doesn't make sense to do that. So anyway, and then hospitalizations within a, if you're having hospitalizations within a week of being seen by your PCP and they didn't send you to the hospital like. So you're not doing your job very well. So anyway, I just, I didn't I looked at the outcomes and I was is this really how we're measuring that it's inferior or not inferior? So anyway, that was the only one I could find that really defended the 15 minute visit. I think the reason we've arrived at 15 minutes is because the volume you get when you do a 15 minute template is probably where you can maximize your revenue or reimbursement while still on the outside taking care of the medical need. Are there some things that can be taken care of in 15 minutes? Yeah, a really straightforward, uncomplicated, patient can absolutely be taken care of in that time. The way I like to practice, even if it's a URI, I really to have the time to do education and, to, I, I really think when you invest that five extra minutes, talking to them about what is the virus, how long are you contagious, why are antibiotics not helpful? What are the different OTC things that you can use? Yes, you can put that all on a handout, and give it to 'em. There's ways around this, but even for low complexity issues, 15 minutes in a system where. Like I did this study at my job where I proved to them that it takes 11 minutes for us to room somebody, to do all of the check-in and weighing and vitals and asking them all the required questions. So if under the best of circumstances you're eating up 11 of my 15 minutes and I'm supposed to do everything in 4 or you could say 15 'cause you're assuming the next person's gonna take 11 minutes to room. But that leaves just. No margin for error, if somebody is late or some, there's a curve ball or somebody has something unexpected, which in my life, I don't know, I'm just a magnet for psychosocial complexity in patients. I, I felt like almost every patient had some other thing that they wanted to bring up or some curve ball that they introduced, basically you feel like you're in a hamster wheel. You're on a treadmill, like you're just going, and there's no room to stop and breathe or drink water or go to the restroom, whatever. I think that's how a lot of primary care doctors feel. There is some evidence that shorter visits lead to more inappropriate prescribing practices. So more unnecessary antibiotics, more opiates, more benzodiazepines. I can absolutely see that, because those are very quick ways to end the conversation. It's much harder to talk somebody out of needing antibodies, thinking they want antibiotics than to just give them the antibiotic and move on. I think that this is. Probably honestly understudied. I wish there were more. I'll link a couple of studies on 15 minute visits in the show notes. I wish this was better studied, but this is not some evidence-based solution. This is not something that patients like, this is not something the doctors like. It's just become the industry standard probably for volume and revenue purposes. When you are made to feel like everyone else is doing this in 15 minutes why can't you do it in 15 minutes? I just want you to know you're not crazy. Like I don't think that's a reasonable amount of time to provide good comprehensive guideline based care, which I've said this fact a zillion times. There was a study where they looked at what would it, what amount of time would it take to provide guideline directed comprehensive primary care to a typical patient panel, and the answer was 27 hours a day. So you know it's impossible. It's just an impo. It's an impossible feat. I think perhaps the. A bitter pill that we need to swallow or the inconvenient truth that would come from studying this. And my next lie that I'm gonna talk about is that perhaps doctors now, because of the amount of data that we have, the administrative burden, just all the inefficiencies of our system because of all of that perhaps. PCPs just need to have smaller panels. Like maybe that's the reality. And one of the big criticisms of DPC is that maybe we're contributing to the doctor shortage because we take care of fewer patients. But maybe doctors are just not capable. Of taking care of that large of a panel. In today's day and age, now the solution to this is team-based care. And, any administrator or physician leader is gonna be like, yeah, that's why we have team-based care. You gotta offload all of that other stuff and let you know the other p members of the team do it. And again, this is like one of those situations like value-based care, which it sounds great in theory, but so often it's. Implemented so badly where the other people on the team are, if anybody on the team then is not doing their job correctly, a lot of stuff falls apart, falls through the cracks. If the team members are not communicating about what they're doing, then stuff gets done multiple times. People don't even know that it's been done there's so many places where team-based care, just totally falls apart if somebody does not actually care about doing it right. Which honestly, I don't think a lot of systems really care about doing it. Okay, so that was number one. The next lie is that your pay accounts for all your administrative work and call so. In primary care, there is a lot of stuff that we do that is not face-to-face clinical care. And that's usually going through your inbox, reviewing your lab results, imaging results calling patients if you need to for some of those. FMLA, paperwork. There's a lot, just even just signing all the home health and the PT and all of that stuff takes a long time. I think most employers would say, yeah that's all part of the expectations of your job. That's rolled in there. But the reality is that the administrative portion of our job has completely ballooned over the last 30 or 40 years. It has really ramped up. So there are studies that show that for every hour of clinical face-to-face work that you're doing, you're typically adding one to two hours of administrative work somewhere in your week. And again, I think that's probably why that 27 hours a day number comes up is because there's just so much more documentation, there's so much more data to be, reviewed and managed. We're working in a totally different, paradigm than we were when compensation models were first developed. There's just no way that we are being paid an appropriate amount for all of that work. That work is mostly invisible, and as I talked about in. An episode about Micropractice as a feminist act where I talked a little bit about the gender inequity in medicine, as primary care becomes more female as an occupation becomes feminized, invisible work tends to become more common, and uncompensated work tends to become more common. And so I think we're just watching that happen right before our eyes. It is becoming, increasingly female primary care is becoming increasingly female, and we're seeing this huge influx of administrative and invisible labor and pay is not keeping up with that. So that's a problem. And, there's so many examples I can think of in my professional career where I've been doing something and thinking. I don't think I'm getting paid for this. I remember at one point I wanted to do an enrichment talk, like a lunch and learn talk for our medical assistants about why we do certain things. Like why do we do mammograms and how many lives does that save? I wanted to give the questions that they were asking some weight and ethos and meaning. And I was like, oh, I kinda wanna do something like this. I pitched this idea to my boss. And she was like, yeah, that sounds great. And I was okay, I'm gonna probably spend some time working on this and creating the PowerPoint and giving the talk and I'm wondering how I might be, compensated for that time, and she was just like, oh supporting the clinic and improving quality in the clinic is part of your job description. And I just, I was dumbfounded because I was like, no other doctor is giving presentations at lunch. They're just eating their lunch or working, like nobody, nobody else is taking extra time out of their life to do this. So I don't really understand how that's. Just part of my overall expectations. Like I, that whole our argument of yeah, it's just part of the expectations taking call. It's just part of the expectations. There's no pay associated with it. I really think that we have to start pushing back against that is not, that really doesn't make any sense. I don't, if you've ever worked with a lawyer and faced billable hours, you understand that even a five minute phone call they get compensated for. So I don't know why we're constantly doing work for free and think that it's, not okay to push back. Anyway, number two lie. Is that you your pay accounts for all of that invisible labor? It doesn't. It just doesn't. All right. Number three is. Insurance makes healthcare more affordable for patients. So I talk about this a little bit and there's another episode called primary, why Primary Care is Better Without Insurance. Highly recommend listening to that if this concept is new to you. Also recommend highly, this is required reading. I don't think I've ever mentioned it on the podcast before, but there is a fabulous interactive New York Times article. It's from a few years ago. It is from 2021 and the title is hospitals and Insurers didn't want you to see these prices. Here's why. It's required reading for all doctors, honestly, but especially if you're considering direct care touring with this idea or just interested in this whole intersection of economics and healthcare costs and all this stuff. Anyway, it's required reading. I'm gonna put a link in the show notes. Please check it out. Here's a quote from it. Okay. It provides numerous examples of major health insurers. Some of the world's largest companies with billions in annual profits negotiating surprisingly unfavorable rates for their customers. In many cases, insured patients are getting prices that are higher than they would if they pretended to have no coverage at all. So the interactive piece of this is they show you a bunch of different places in the country where you can get an MRI or an hip replacement or various things, and it shows you with different insurance plans and no insurance what that thing would cost. And so you start to get a sense of what the true cost of that service or that product or whatever it is. And what the list prices quote, the list prices are for these things at different places and they vary wildly from place to place, which seems like that shouldn't be the case. And ultimately it's all kind of monopoly money. The insurers really have very little in. Incentive to negotiate a good rate. The more it looks like the service or procedure costs, the more it looks like they're giving you a discount when they cover, part of it. And then for the hospitals, they're playing this game where, they expect like some of these things to be denied and for some of it to never get paid or they could get it fully paid. And so they have no incentive to. Make the price low, like they're gonna put this huge inflated ticket price on there. And at best you, they're gonna get 80% coverage maybe. And then at worst they're gonna charge that crazy amount to the patient, so I think both of the, the insurers and hospital systems in on labs and all these places they just don't have incentive to do the right thing for the patient or to lower the cost for the patient. They don't. Everyone's playing with other people's money, and so what you get is these crazy inflated healthcare costs and it's not actually cheaper for the patient. Now, a lot of things in healthcare. Have legitimately high true costs. Like when you are hospitals, when you're in an ICU, when you're getting chemotherapy, when you're getting brand new biologics, all of those things are truly expensive. And so there's a lot of things for which you really do need your insurance because those things are very quickly and easily going to bankrupt you. And so I'm not saying insurance is just not necessary. It is absolutely necessary, but where it is best used. It's a very flawed system first of all. But where it is best used and most necessary is for those very high cost healthcare needs, not for your basic, preventive primary care, which can be done with very limited technology and no fancy meds and no fancy equipment, and mostly just a good doctor's brain and care. Anyway, this idea that, insurance is gonna make things cheaper for people. It is just a myth. It's just not true. So anyway, take a look at that article. If you don't believe me, go back and listen to the, primary care is better without insurance episode, and send me your feedback if you disagree. All right. Number four, related to number three, is that working outside of insurance or not accepting insurance. Is unethical. I think there's a lot of doctors that just kneejerk believe this, like it is just in, it is core in their beliefs that it's oh, that person doesn't accept insurance. Oh my God, they've sold their soul. They're going concierge. They're, they're just closing their door to patients in need. That's just not true. That is just not true in part because of what I said in the last lie, which is that insurance, first of all in itself is inequitable. I live in a state where you don't have to have insurance where it's not mandatory, right? Here you have to first be employed and be employed at a place that offers you insurance to even have insurance, or you have to buy it in the marketplace. And honestly, I. If your income is low enough and you qualify for a NOCO plan or a very cheap plan, great that the system works for you. You will have access to somebody. It will not be easy access, and there will be a lot of annoying hoops to jump through. You may not get to pick who there's all kinds of problems with it, but yes, you will get basic coverage and so if something very bad happens to you, you end up in the hospital. That is a great. Thing for you, but there's a ton of people in the middle where they don't qualify for these low cost or no cost health plans through the marketplace. They don't have an employer that is offering them health insurance or they do have an employer offering them health insurance, but the cost is so much out of their paycheck that they feel that they cannot afford it. And it just insurance fundamentally in the first place, the way it is set up in this country, because it is not single payer or universal healthcare is inequitable. You're starting with that. Okay. So next I find that most people who have this belief are people who work in academics or maybe at the VA or maybe in an FQHC, which, if you're an fqhc you. I bow down to you and you can criticize me. I, you, I give you permission. Everybody else, I feel, and even for FQHCs, they're funded in a different way than the rest of healthcare. So in academics, and I trained in academic centers. I worked in an academic center for several years before I moved to Texas. You are so insulated from the financial realities of just community healthcare. Because in academic centers you're getting a lot of different sources of funding. You're getting some federal funding, you're getting research grants you're money is flowing into that organization from multiple channels. You're not just. Surviving on the reimbursement you're getting from those patients. So when you see these private practices out in the world and that they're no longer accepting Medicaid or they're dropping certain insurance plans, that's not because they're greedy or because they don't wanna serve that population. They're just like, oh no, we only want the fines. The finest insurances, it's because they financially cannot justify accepting those plans anymore because the reimbursement is so low. And, in these businesses, that's their revenue. That's where the money is coming from. And they have bills to pay, they have to keep the lights on. They have to pay their employees, they have to possibly pay for their employees benefits. They make those decisions because it just does not make financial sense. The business has to remain solvent. The bus, the business has to maintain itself. I think there's pe, there's certain group of doctors that is very quick to turn their nose up at, anyone who is not taking insurance or who drops insurance but only accept certain insurances. But I find that the vast majority of people who have that opinion are in some way insulated from the realities of what it is like to just be a doctor in the community without any other source of funding, trying to make a living doing insurance-based patient care. That is a really hard thing to do, and especially if you're in a non procedural specialty, like primary care, like endocrinology, like pediatrics. And so that's why you see all these practices dying, that's why it's so hard for them to stay afloat or they suddenly start doing aesthetics or IV vitamins or, go that route because there just isn't enough money in the reimbursements. Okay. So that's my rant. That's my rant on that not accepting insurance is unethical. Okay. Next thing, which kind of builds upon this too, last one, my last lie that a lot of you have been told. And this is the one that I would say it is still deep inside me. And it's part of my fibers and I don't know if I will ever extract it. And I'm sure that's true for a lot of you too. And I think part of it was this was part of, maybe even part of who I was before I even entered medicine. And medicine just rewarded me for this quality. And so it became strengthened. And the lie is that self-sacrifice is admirable. I see this in myself. I see this in so many of my friends. I see this in my husband. I see this all around me in medicine. Think of the resident who shows up and has the flu and just keeps working. Think about the, colleague you had that was in labor and having contractions, but was like, I'm gonna finish my clinic day. Think about, the doctor who's just always adding patients on when they call and ask to be seen, no matter how full the schedule is, even if it means she's there until 7:00 PM finishing her notes. Think about, the doctor who, came back on a day that they actually weren't on because they just wanted to follow up with a patient or something. There's so many examples where we do these things and we admire those people. And, I, like I, I sent a prescription for a medication probably. Like an hour or two after I gave birth, and I was still answering patient messages like while I was having contractions. So I am not above this. I it, this is a very hard thing to let go of. And I'm not saying that you have to let go of it completely, but I think this admiration for. Self-sacrifice is part of what has put us in this position in primary care where we do this incredible amount of invisible or uncompensated or poorly compensated work and we justify it to ourselves and our superiors. Justify it as well as being the right thing to do and part of service and part of our mission and our calling and our dedication to our patients. A common example I can think of is so often when I would have, when I would have a bad result from something like, a mammogram that looked highly suspicious for malignancy, a CT that had a mass, things like that. I would almost always. Make those phone calls at the end of the day that I got the result, when I've done closing all the other charts, like when, it was actually time to go home rather than have that patient schedule an appointment, which always was a few days out, if at best. And then, if I was gonna add them on, I, you've probably heard about my disdain for add-ons, it just. Takes time away from other people and you're rushing. I don't like any of that. So anyway, I would always make those phone calls at the end of the day, and sometimes those phone calls would be like 40 minutes long. And I knew I was getting paid peanuts for those, but I was like, this is the right thing to do like this. If I had a likely malignancy on my mammogram or on my CT or whatever, I would want to have an unrushed, compassionate, thoughtful conversation with my doctor about it. And I would wanna have that in a timely manner. And I think that's what all of us do or most of us do, but we're not paid for that. And I, I think there's this feeling of like when I was doing those phone calls, I almost had this feeling of yeah I get it. I don't care. I don't need to be like, this is just, this is so deeply important and it's the right thing for the patient. I was never thinking about compensation in those situations. I really started thinking about it more around the COVID time. 'cause I started doing a ton of phone calls before we got fully ramped up with virtual or for a lot of patients at, in the very beginning, especially the elderly patients. They just could not figure out, like I had somebody trying to do a virtual visit with me on our Kindle and I was like, let me just call you, and I. I remember at that time, again, starting off with just being like, this is the right thing for the patients. There's just, this is the best I'm providing the care that they need at the best way I can at this moment. But then at the end of the year when my compensation was based on my productivity and the RVs for those were Nothing, and then the next year's salary was based on that productivity. I, I felt the pain. I was like, oh my God, I felt like I was doing so much work, but it's clearly not reflected in that. And that's where I started thinking about it. But again, now that I'm farther away, I see the bigger picture of just how much that self sacrifice or that commitment to serving patients is used against us and used to exploit us, honestly, that is exploited in order to provide free and low cost labor to big employers. And the point I wanna make about self-sacrifice is that. There's no free lunch. Someone somewhere is gonna pay a price for those sacrifices that we're making. Every time you bend over backwards for a patient or do something for free or whatever, it's not really free. And I think a lot of us justify it in our own minds and say, okay, yeah, but that's my time. It's my time. I'm giving up. It's my lunch. I'm giving up. It's me not drinking the water. It's me not gonna the bathroom. Like I'm, I am paying the price for this and I'm okay with that. Which is what I would tell myself often is yeah, I'm willing to take this hit. That's fine. I'll do it. It's not a big deal. But I think we're a little bit in denial about the price that all these other people around us are possibly paying. It's not just you, often it's your family, it's your children, it's your partner. And maybe even more importantly, it's your colleagues who now have the expectation to do the same thing. It's the doctors that come after you that are now walking into, lower pay than is appropriate. Or, visits that are inappropriately short or a work environment that is unsupportive. And ultimately, honestly, I think if you keep tracing it down, it's really, it's still the patients that pay the price. Because what do we do when we perpetuate this unsustainable burnout inducing broken healthcare system? We just. Create doctors that are burned out and people that are cutting corners or people that don't have adequate time for their job or don't have adequate payment for their job, or have expectations that are completely impossible or unrealistic, and ultimately the patients are going to pay the price for that. So I think we have to stop diluting ourselves and thinking that is admirable. That is what we should be working towards. Those people are, the people we should look up to. I still admire them in some way, but. I have stopped telling myself that's who I wanna be, because I think in the long term, being that person does not serve anybody well, not you, not the patient, not the people around you, not your colleagues, not your family. The end game is not good. Along those lines, I think. Asking for money, for invisible labor, asking for more support, which usually costs money or asking for more time with your patients, which is going to, cause your employers to lose money. All of those things are very quickly painted as being greedy and self-serving. And I really want us to flip. The script on that and point out that it's not, it is what is right for your long-term ability to be a productive doctor and to be mentally and physically sane. And it is advocating for a system that actually supports providing high quality, comprehensive healthcare. Alright. So that was the last one. That self-sacrifice is admirable. Okay, so just to review the ones that I said, the five lies, your job can be done in 15 minute increments. That's a lie. You, your pay accounts for all of your administrative work and call in non face-to-face care. That's a lie. I feel like I'm in like Monte or what is it? Maori when they do the lie detector test and they say the results. Okay. Insurance makes healthcare more affordable for patients. That's a lie. Working outside of insurance or not accepting insurance is unethical. That's a lie. And lastly, self-sacrifice is admirable again. That's a lie. That is my TED talk on this topic. I hope you enjoyed it. I hope it was validating. I hope there was something here that made you think. And I hope if you're interested in finding more information, you will go to the show notes and look at some of the references that I'm gonna put down there and some of the other episodes that are peripherally related to this episode that may help you delve further into this. As always, I would love your feedback. You can write me at sonya@micropracticemama.com. I love love getting emails from you. I do try to respond to all of them. I am just gonna say quickly a reminder about the next webinar. I've had a couple people email me and say, oh, I was listening to old episodes. You talked about a webinar. It's already over. Like, how can I get a recording? I'm gonna try to do these, every three to four months hopefully, and so there's always gonna be an opportunity for another one. But the next one as of this recording is gonna be September 10th, which is a Wednesday at 8:00 PM Central time via Zoom. And the link to register for that is gonna be in the show notes. So make sure you go there and register just so you have it on your calendar. You have the link ready and I'll hopefully see some of you there. Alright, enjoy. Nice week.

34:23

Okay.