Why I Work at the Fringe.

This arti­cle is mak­ing the rounds among physi­cians on Twit­ter. Much of the infor­ma­tion in the arti­cle, unfor­tu­nately, is accurate.

For some of the rea­sons stated there, I left the “tra­di­tional” health care sys­tem and pur­sued work at the “fringe”.

Part of this is due to my clin­i­cal inter­ests: I like work­ing at the inter­sec­tions of dif­fer­ent fields. For exam­ple, I like the inter­sec­tion of psy­chi­a­try and hos­pi­tal med­i­cine, which is called psy­cho­so­matic med­i­cine. Another exam­ple is my inter­est in pub­lic psy­chi­a­try, which focuses on the inter­sec­tion of social fac­tors and men­tal health (e.g., indi­vid­u­als with psy­chi­atric and sub­stance use con­di­tions in the con­text of home­less­ness and poverty).1

Part of this, though, was my sense that the sys­tem would not let me be the kind of doc­tor I want to be.

For a brief period I worked in a clinic where I had slots for four new intakes a day (60 min­utes each) and 15-minute follow-up appoint­ments for the rest of the day. If my sched­ule was com­pletely filled with follow-up appoint­ments, I could have seen up to 34 patients a day. (I never got to this point because I quit well before my panel got full.)

In real­ity, the 15-minute appoint­ments were 12-minute appoint­ments. I needed about three min­utes to type out some notes to myself for clin­i­cal doc­u­men­ta­tion.2

Because I was build­ing a new prac­tice, peo­ple with a wide vari­ety of con­di­tions and con­cerns came to see me. I was advised to refer patients out of the med­ical cen­ter who were “too sick”. This included indi­vid­u­als who were fre­quently in and out of psy­chi­atric hos­pi­tals, had sig­nif­i­cant psy­chi­atric symp­toms, or oth­er­wise had other stres­sors in their lives that made them “dif­fi­cult”.

In other words, they told me to refer out the peo­ple who needed spe­cial­ist care the most.

The real­ity, too, was that no psy­chi­a­trist could pro­vide qual­ity care to these indi­vid­u­als in 12 min­utes. Imag­ine some­one with depres­sion so severe that he lacks the energy or inter­est to share his cur­rent dis­tress with you. Or some­one who is psy­chotic and insists that her ex-husband is track­ing her through all the elec­tron­ics in her home. Or some­one who is so anx­ious about leav­ing his house that his atten­dance to the clinic is wor­thy of celebration.

Obtain­ing an accu­rate his­tory guides diag­no­sis, which then guides treat­ment. An insuf­fi­cient his­tory can thus lead to hap­haz­ard inter­ven­tions. You can see how the 15-minute appoint­ment model results in heavy reliance upon (poten­tially unnec­es­sary) med­ica­tions. If some­one says he feels depressed, it’s dif­fi­cult to val­i­date his emo­tional expe­ri­ence, pro­vide edu­ca­tion about his con­di­tion and non-pharmacological ways to man­age it (e.g., behav­ioral activation, sleep hygiene, etc.), and have a dis­cus­sion about med­ica­tions, which should always include risks, ben­e­fits, and alter­na­tives, in 12 minutes.

It is much eas­ier to write a script and ask some­one to return in a month. (This inspired my post about the Auto­mated Psy­chi­a­trist Machine.)

Fur­ther­more, this clinic was in a med­ical cen­ter with a group of pri­mary care physi­cians. Pri­mary care doc­tors referred their patients with diag­noses of schiz­o­phre­nia and bipo­lar dis­or­der to the psy­chi­a­try clinic (as they should). These indi­vid­u­als, how­ever, were “too sick”. Never mind that, unlike the pri­mary care physi­cians, we psy­chi­a­trists had the train­ing to diag­nose, treat, and man­age these indi­vid­u­als with sig­nif­i­cant psy­chi­atric conditions.

Thus, these patients often returned to their poor pri­mary care physi­cians, who tried to care for them the best they could… which often entailed med­ica­tion reg­i­mens that were unnec­es­sary. (Pri­mary care physi­cians deserve no blame for this: How are they sup­posed to know?)

This clinic also “rewarded” psy­chi­a­trists for “pro­duc­tiv­ity”. The more patients a psy­chi­a­trist saw, the more money the psy­chi­a­trist would earn. This led to “cherry-picking” patients. Psy­chi­a­trists would keep patients who either had minor con­di­tions or symp­toms that had resolved, because those are the patients you can ade­quately see in 12 min­utes. As a con­se­quence, patients with more debil­i­tat­ing symp­toms could not access the clinic. The psy­chi­a­trists had no incen­tives in either time or money to send these “cherry-picked” patients back to their pri­mary care doctors.

My frus­tra­tion and dis­il­lu­sion­ment com­pelled me to leave the job. I returned to posi­tions at the “fringe” to work with patients who often are also not part of the sys­tem or patients that the sys­tem had failed. Con­sider the man who has been home­less for the past ten years and is too para­noid to access any health care ser­vice. Or the woman who was beaten and molested as a child, sent to fos­ter care and group homes, never com­pleted high school, “aged out” of youth care, and now has no resources or support.

I couldn’t wait for the sys­tem to change, so I sought out set­tings where both my skills would be use­ful and I could be the kind of doc­tor I want to be. There may not be many physi­cian jobs at the “fringe” and cer­tainly not all physi­cians want to work there. When we physi­cians vote with our feet, though, we show what we value, the kind of care patients deserve, and how the sys­tem must change.


  1. Really, though, all of med­i­cine could be “psy­cho­so­matic med­i­cine” or “pub­lic psy­chi­a­try”; the divi­sions between mind, body, and envi­ron­ment are arbi­trary.
  2. I don’t like typ­ing my note while I am see­ing a patient. I’m not fully attend­ing to either one when I do that.