It's Saturday morning, the last day of my 6-day workweek. Twelve hours have elapsed since I finished my previous shift at the after-hours care center. Although it's a good 15 minutes before we open for business, I'm glad to see that the only other vehicle in the parking lot is that of the medical assistant.
I step in through the front door, valise in hand, to find my assistant seated behind the reception desk. “How does it look?” I ask him.
“Ten appointments so far, last one at 10:30 a.m.”
I do a quick mental calculation—roughly 9 minutes allotted for each patient. And there's no telling how many additional walk-ins might show up over the course of the morning.
“Is the nurse coming in today?” I ask.
My medical assistant shakes his head. “Doctor didn't call her.”
No nurse. This means I will have to perform all of the vital signs on each patient myself—weight, temperature, pulse, pulse oximetry, respiratory rate, perhaps BP—before actually examining the patient, running any in-house laboratory tests, prescribing medication, and writing up the three-page encounter form.
The first patient is relatively easy: a 6-month-old infant with a monilial diaper rash. Thankfully, the child appears well. To be complete, I examine the buccal mucosa and document thrush. This infant will need two medications: an ointment for the diaper area and an oral suspension.
Hastily I scribble the prescriptions and instruct the mother how to administer the medications. She seems satisfied with my explanations. I dash out the door and pick up the clipboard with the encounter form for the patient waiting in the adjacent examination room.
Here I am greeted by a middle-aged father who has brought his teenage son in for a cough of 3-day duration. Quickly, I tick through the questions in my mental list: “What does the cough sound like—dry, productive? Any fever? Other folks at home sick? Did he get his influenza vaccine this year?”
I proceed with the examination. Bibasilar crackles greet my ears through the stethoscope. The boy doesn't appear to be that ill. Mycoplasma, most likely. I write out a prescription for a macrolide antibiotic and hand it to the father along with instructions for follow-up.
My next patient is an 8-year-old boy complaining of a sore throat for 2 hours. He has no fever, headache, or abdominal pain. “I wouldn't have brought him in otherwise,” his father says, “except he's supposed to go to a party this afternoon. If he's got strep, I don't want to expose the other kids.”
I'm reasonably certain this boy doesn't have a strep throat, but I offer to run a test for the parent's peace of mind. Reluctantly, the boy opens his mouth and allows me to swab his throat.
“Be back with the results in 5 minutes,” I tell the father over my shoulder as I rush out of the room.
I step into the laboratory, start the test, and set the timer. Meantime, there's another patient waiting to be seen—an 8-month-old premature infant with cough and low-grade fever for 24 hours. Halfway through his evaluation, the timer sounds in the laboratory. I excuse myself to read the result of the test (negative) and inform the father that his son is cleared to attend the party. Relieved, the pair saunters down the hallway to the front while I dash back to my waiting patient.
And so the morning goes: child after child, agitated parent after agitated parent, one prescription after another. For 2 hours, I race back and forth. Finally, at 11:30 a.m., I sit down at my desk, exhausted. Piled high before my eyes, 15 charts wait to be completed. I take a deep breath and start to scribble. The telephone beeps by my elbow.
Instinctively, I reach for the receiver. “You've got another patient waiting,” my medical assistant tells me.
I slide the receiver back into its cradle and pull myself to my feet. My legs ache. My back hurts. I've got a pounding headache. After 35 years striving to practice the art of medicine, I've realized that modern medical practice has devolved into a series of business transactions. I have 6 years to go before I can retire. As I walk down the corridor to see my next patient, I find myself wondering how I will survive.