It's All in the Family
Asking a Family Medicine doctor
I say this in the interview, but when I think about family medicine, I think about someone who’s doing a little bit of everything. That means seeing patients from childhood to adulthood, seeing all sorts of ailments and issues, and directing people to specialists if need be. I can’t remember the name of my family medicine doctor I had as a child now, but I remember her as always being in my corner, and caring for me when I was going through tough health stuff.
So when I talked to Dr. Francesca, I brought this notion up. Mostly because I’m so curious about how a doctor manages that kind of pressure. To know what you know and then when you don’t know, have the wherewithal to say so and be direct about your not knowing.
Dr. Francesca asked that I not use her full name, so I’ve honored that here. She is a family medicine provider in a city I won’t name either. She is also super funny, and charismatic, and you can clearly see she cares about the work she does. We talk about, unsurprisingly, health insurance, being a lesbian in hostile environments, meeting her wife and working together, and being an immigrant to the US.
Also, side note: the sound quality was not great during this interview so I won’t be uploading it as a podcast, but will do so with the next interview. I hope you enjoy this second installment!
Dani Janae:
When did you first realize you wanted to get into medicine?
Dr. Francesca:
Oh, I think I was five or six or something like that. I've always wanted to be, well, I wanted to be a doctor, but I also wanted to be an artist. It's a stereotype, but if you come from an Asian household, going to art school is like a hobby, it is not a profession. But the interesting thing is my parents actually wanted me to go into finance, because that's what they do, my entire family is in finance and business and all that stuff, but I didn't want to do that, because that would mean if I... Well, I think they would be fine with me going to art school as long as I became an architect because then I could work for them, or in finance so again, I could work for them. I did not want to do that, so my form of rebellion was going to medical school, which I think I was doing rebellion wrong, but it was a good way to get away.
Dr. Francesca:
That's one thing too, though, in an Asian household, you can't really be gay, so I had to figure out a way that I could make a living and support myself. I guess I was just planning on that, if I got disinherited or whatever, I could at least do what I do and not have to worry about that. But I also did like medicine, so it kind of worked out.
Dani Janae:
Totally. Can we talk a little bit more about wanting to go to art school? I know it's not the crux of the interview, but I'm just curious about that.
Dr. Francesca:
Well, I went to art classes and all that, I always wanted to do art. I think I wanted to be an animator for Disney at one point.
Dani Janae:
Oh yeah?
Dr. Francesca:
But again, we get told that it's a hobby, not a profession, so that never panned out. I still kind of do that when I have free time, which is not a whole lot these days, but it's been turned into a hobby, and it's still nice. I think at some point, too, in medical school, I ended up doing medical illustration, which is kind of a mix of both.
Dani Janae:
Yeah, totally. That's really cool.
Dr. Francesca:
I guess I got some of that art to apply to medicine, which was very helpful.
Dani Janae:
That's really cool. Was family medicine your first choice or was it a journey to get there?
Dr. Francesca:
No, it was actually a journey. After I finished medical school, I actually went into an OB-GYN residency because I really actually liked surgery and I liked delivering babies and all that stuff, but I think I did a year of it and then just realized it was not for me. It was super stressful and I was turning into this person I didn't like because it was very stressful. I just realized I didn't want to do that for the rest of my life, so I went to family medicine, which actually worked out really well, because actually in family medicine, you could actually choose to do prenatal care with the little babies and all that stuff, which I did train for, as well, and then I think it just didn't work out. It works really well, say, if you worked in more of a rural area where there's not a lot of providers, but then there's not a lot of support is the problem there. If I would do prenatal care, I would have to be on-call all the time until that baby gets delivered because you were the only person in the area to do that.
In the cities, obviously, they would go to OB-GYN, so I ended up not doing that anymore, but I guess it's fine. I did that for a few years and then just left because I actually did like rural medicine, I worked in this small town in Wisconsin for four years.
Dani Janae:
Oh wow. How was that?
Dr. Francesca:
It was interesting. It was interesting for a while and then when you're only the only brown person in a small town, it gets really scary after a while. I got called a colored doctor from Hawaii. I'm sure they didn't mean bad by it, but these are nine-year-olds who probably have never left their town, that's just how they were, but that happens. It's a small town where over the years, the opioid crisis got worse, I guess, so you'd get patients who want you to give them opioids and you would say no and then they'd threaten to kill you. These are people who can have weapons and firearms and all that stuff, and if you call the police, they take 30 minutes before they get to you, so that just made things stressful.
This was before the ACA was a law and the people would not have insurance. That's also the problem with medicine over the past couple of years, it has just become increasingly more corporate, and that's kind of still happening right now. The healthcare system I was working for just wanted the bottom line like, "You'd have to see this many patients," but it's a small town, there's only so many people who are going to go see you. I'm not going to stand by the side of the road and beg people to come into the clinic. And then I think in Wisconsin around that time, they didn't want, because I think Scott Walker was the governor, it was a Republican governor at some point and they wouldn't expand Medicaid and all that stuff, so it just made it increasingly hard to practice there, so I ended up moving back to the city, which is a little safer.
Dani Janae:
Yeah, definitely. When did you make that move?
Dr. Francesca:
A couple of years ago. I think, how long have I been here, for 10 years now?
Dani Janae:
The way that I've always understood family medicine is that you are a jack of all trades, do a little bit of everything type of doctor. Is that a fair assumption or is there more to it?
Dr. Francesca:
Yeah, that's a fair assumption. A general practitioner is basically someone directly out of med school, who just decided to hang a shingle on the door and then practice medicine. In family medicine, it's still a residency program, but basically, you train for three years in various different areas, so you can focus on outpatient care, like ambulatory medicine, you can focus on emergency care, urgent care, you can also be more of an inpatient hospitalist person, you can be an OB. They basically train you in everything and then you get to choose where you want to focus.
My wife did sports medicine, that's what she's doing right now, and Ortho. I have classmates from residency that do more inpatient hospitalist care. In small hospitals that don't have hospitalists, you are the hospitalist, basically. In the cities, it's more internal medicine that tends to go into the hospital to do inpatient care, which you could also do, actually, but I'm just doing more outpatient now, just because it's a lot less stressful, so that's where my practice is right now. It's supposed to be an 8:00 to 5:00 kind of job, but it's not really, but it's as close to an 8:00 to 5:00 job as you can get, family medicine, at least.
Dr. Francesca:
After a while, you can't... I used to do hospital work when I was in Wisconsin. We worked in a small clinic, but you also worked in the small local hospital there. But after a while, being on-call for 24 hours every three days gets old.
Dani Janae:
I can imagine.
Dr. Francesca:
So now, I'm just doing more outpatient, which is still not an 8:00 to 5:00 job, but it's close enough.
Dani Janae:
That's another thing that you hear a lot about doctors, but I think especially doctors that don't have that very narrow specialty, is that you work a lot of hours and being on-call, all of that stuff, is a part of the experience. Can you talk a little bit about that?
Dr. Francesca:
Yeah. When you're straight off the residency, most people are kind of idealistic, you kind of want to do everything, so I used to do everything, really, literally did everything, because you didn't really have a choice. You were the only person there in a 30-mile radius, you were it. We basically learned as you go and figured things out, I don't know, like how to take a fish hook out of somebody's lip, the things you don't plan on in medical school, you figure it out, you find a YouTube video. But over the years, I think it just wears you down, and then you figure out where you want to be. Most of my friends, they have families, they have kids, and that changes your priorities after a while.
The problem, too, though, is not a lot of people do primary care, which is a problem, and even before the pandemic, that was a problem, there was a shortage. Because most people, when you graduate from medical school, you're in a lot of debt, so people will go to specialties or fields where they can earn more so they can pay off that debt. Primary care doesn't pay that well in medicine, so I think that's why there's a shortage in primary care, which got worse with the pandemic, obviously. In my clinic alone, we lost nine doctors. Nine people retired or just left medicine in the past two-and-a-half years or so, so that's not good right now. People are complaining they can't find doctors, and there's only so many of us, so you would probably hear from a lot more people that it's kind of hard to find a doctor or takes weeks to see somebody, which is unfortunate.
Dani Janae:
Yeah, definitely. Along those lines, I'm wondering what an average day looks like for you. How do you start your day and then move through that?
Dr. Francesca:
Let's see, my average day starts at about 8:00 most days. I do have a day where I start later, but that's because I also finish later, I think it's a 10:00 to 6:00 day because some people who work, obviously they can't see their doctors during office hours without taking off work, so lots of patients appreciate that. Occasionally, I work weekends, but pretty much 8:00 to 5:00 on most days, and you just start seeing patients until you see all of them. That's the thing too, nowadays with technology, people can send you messages and questions and there are phone calls, and it's a lot to do in between the actual seeing the patients. It's interesting, sometimes people are like, "I want my doctor to call me," and I'm like, "I would like to do that, but I just don't have the time." Some people are just like, "I want you to drop everything and call me right now." I'm like, "No, I can't do that." But that's where support staff helps, we have RNs, we have LPNs, and things like that to call them and figure that out.
That's pretty much it. I used to see about patients every 20 minutes, so that would be 18 patients a day or so, sometimes, sometimes 40 minutes if they were more complicated patients. But I think recently, I just moved to more 30-minute visits, just because patients are just a lot more complicated. I ended up being behind most of the time and patients didn't like waiting, but they also wanted their doctor to spend more time with them. If you do that, then you're just going to be late the entire day, so I just increased the patient visits, which means fewer people to see. With medicine, you get paid, and this is the icky side of the business side of medicine, which I don't like, you basically get paid by work units, so it's not by patients, it's basically how complicated a patient is and how much you do and that's worth a dollar amount, but obviously, the more patients you see, the more you can make.
If you work for a health system, you're employed and they have an expectation that you're supposed to see this number of patients or earn these number of work units, so if you take more time with the patient, that's fewer patients you see and that's less money. I like spending time with my patients because I think you can't really do a whole lot in 20 minutes, or they come in, they haven't seen a doctor in 10 years, they have a list a mile long and they expect you to fix everything in 20 minutes, I'm like, "That just doesn't happen," or like, "I wish I could make that happen, but I'm a doctor, I'm not a magician," but that's the thing. But I figured I'd rather spend more time with the patient and give them the care they need, so that's where I'm at right now.
Plus, I've been super burned out, so I figured I'd probably just do that, or else I probably won't last another couple more years in this job, but we'll see. We'll see. I'm sure they'll want me to see more people because there's not enough doctors to see the number of patients we have.
Dani Janae:
One thing that you said that led me to this question is that this idea of getting paid by the work unit was the term you phrased. I think that's not something that a lot of people know about medicine, that that's how you get paid, because everyone just assumes that you work 8, 9, 10 hours a day and you get paid by the hour, or like a fixed salary. I'm wondering, are there any other things like that, like misconceptions or surprising things about your field, that people would be surprised to hear?
Dr. Francesca:
Let's see. Oh, recently, I had a patient get really mad because their insurance wouldn't cover this particular medication they were on that they had been on forever. But what happens typically with insurance is they have what we call formularies, there is a set of group of medications that they have, I don't know, made deals with the drug manufacturers that they can get, say, this particular brand of medication cheaper, these insurance companies negotiate with the pharmacy companies. You could be on one medication one year and be on the same insurance and on January 1st, your insurance company changes their formulary and something you were on just is not covered anymore.
I had a patient who used to be on this medication and now it's not covered and I told them that. There's this process called a prior authorization where basically, you answer questions, you try to justify why you are giving this particular medication to the patient or why they are on this medication, what purpose, and then you hope somebody in the insurance company understands and says, "Okay, fine, we'll pay for that medication." Sometimes it works, sometimes it doesn't. I could tell them all the information about why I think this patient needs it, but they can still say no. I did that with this patient and insurance said, "No, we're not paying for it. You have to try this medication that we are covering," and he got so mad. I'm like, "I don't know what you want me to say." I think patients think we are all-powerful. I would have patients say, "Why don't you write a letter to my insurance so they cover it?" I'm like, "I could write 100 letters, if they're not covering it, they're not covering it."
I think that's maybe a misconception that patients will have, that they somehow think we actually run things. We do not run things, your insurance actually runs things. We can tell you what to do, we can tell you what we want to do, but that doesn't mean your insurance will pay for it. Patients hate insurance, we hate insurance more, because you have people in their offices not with patients, that are not in the clinical setting, and they make these decisions, and it's all business and money, which is kind of sad where our healthcare system is. It shouldn't be for profit, but it is. That's probably one big misconception that patients have, that their doctor can just write a letter or say something, and magically, the problem will be fixed. Unfortunately, it doesn't work that way.
Dani Janae:
What do people assume about you when they hear what you do?
Dr. Francesca:
I don't know. Mostly, they just start asking me questions, which is funny. If I meet new people, it always happens that they start asking me medical questions, which for the most part, I don't mind.
Dani Janae:
Personal medical questions?
Dr. Francesca:
Yeah. Sometimes they'll ask me about things and I'm just like, "Okay." I'd rather answer their questions rather than have them Googling things. Oh, I always hear this from patients like, "You probably hate that I Googled this." I'm sure there are doctors that hate the people who Google, I don't mind. I don't mind that patients research their own conditions and things like that. The problem, though, is not everybody is good at filtering out information on the internet, or there's just a lot of misinformation. I don't mind if patients come in with information and questions about their condition or things that they feel that they have, because sometimes actually when you research things, then you're able to communicate exactly what's going on with you.
Because that's a problem, sometimes patients have something going on and it's hard to figure out because they don't have the language to basically tell you what's going on, so I have to tease this out, asking them specific questions to figure things out. So sometimes it actually is helpful when people research what's going on with them because then they can narrow things down, and they have a better way to describe what's going on with them. But then the problem becomes when they already diagnose themselves based on the internet, which it doesn't always work that way, or they think they have this weird condition and you have to tell them, "Yeah, it kind of fits, but this only happens in this situation, so it's very much not something that's going on with you, I'm pretty sure," but that kind of helps sometimes.
But most of the time, I only have a problem with it when patients come in and they demand certain tests be done, because sometimes it's not the right test to do and then they get mad, but I'm like, "Some of it, yes, it's probably a reasonable thing, but some of these tests, you can't really get until you go through certain steps." Some people will have back pain, maybe they just pulled something, but they come into the clinic demanding an MRI, that's not going to happen, or you could probably get it, but your insurance is not going to pay for it. I have to go through certain steps to get there for you. Maybe at some point, it is needed, say, but it's not the first thing you do when somebody has back pain. I think some people get mad at that, they think their doctor doesn't want to do something for them, but there are some tests that we do have to order and there are some tests that you order if you suspect something else. I try to explain that, but I don't think everybody does.
Some doctors will just say, "No, I can't do that." I try to explain to people why I'm not doing something or why I'm doing something first, and for the most part, it works. Iit doesn't always. I'm sure I know some doctors who would just say no, and that doesn't always work with patients. Not everybody really takes that time to explain things to patients, I think, which then becomes a problem. Things like that, I think, would be some of the common things that patients probably should know. There are so many threads sometimes I run by on Twitter and they're talking about their doctors and I'm thinking, why didn't their doctor do this and this, that seems to be pretty routine. And they don't. I think patients really should advocate for themselves, as well, especially people of color, because oftentimes, and I think we just had an unconscious bias training yesterday so this is really new to me, because some people will not advocate for themselves, or they don't know or they are afraid to.
Certain doctors will certainly just minimize symptoms, especially women, they will say it's anxiety or they will blame everything on the fact that the patient's overweight or obese, which yes, may contribute to things, but it's not the only reason for everything. People will minimize people in pain, that's a problem, though. I admit that's still a problem for me, because we went from one end of the spectrum where it's like, "Let's fix everybody's pain and give everybody pain medication," then you get an opioid crisis and now, it's swung over to the other side where "I'm not going to give anything." It's finding that middle that's been more difficult. But there's definitely a lot of bias, unfortunately, that's still a big problem right now and there's no easy way to fix it, unfortunately.
Dani Janae:
Speaking of bias, I'm wondering, and this is kind of a personal question, you can answer it or not answer it, but are you out at work, and if so, how did that process go for you?
Dr. Francesca:
I wasn't originally, because actually, what happened is my wife actually went to this health system first, I was still in Wisconsin, and then a job opened up and I applied, and she didn't say that I was her wife so that it wouldn't influence anything, things like that, so we weren't out initially. I think my wife started to talk about me to one of our colleagues, and then it was just fine, they're just like, "Oh, I really realize that." Initially, we weren't out because you never know with people, but over time... This happened a few years into us working in the clinic, so that kind of worked out fine, so now I'm mostly out to most people. But patients, though, sometimes I don't say, because you never know. But when patients are, say, LGBT and they will talk about that, then I know I'm a little bit freer to talk to them about that, but obviously, I don't volunteer at the first thing, because you never know with people. But I found over the years, I've seen more LGBT people, I guess people talk and then they just find you.
Dani Janae:
Definitely. Does your sexuality or queerness ever become relevant or intersect with the work that you do?
Dr. Francesca:
I think so, because now I have a lot more LGBT patients, especially young people, and they're a little more open to talking about it. I'm having more non-binary teenagers, more people are realizing they're transgender, so we're doing a lot of transgender care, so that's helpful, I think. I think there's a lot of people, too, who are LGBT, they don't necessarily want to be open with their doctors about that because they may not feel safe, as well, there are certain doctors that do not know what to do in that case. That's been helpful in certain cases, but there's still a bit of a minefield that you have to navigate every day, but I think it's helpful. I think there's a lot more resources now. I know, I can't recall the name, but there was actually a database or a network where you could sign up if you were LGBT or you were open to seeing LGBT patients or doing LGBT care, which I think is helpful when you're looking for a doctor. Hopefully, that gets more common, but it's not yet.
Dani Janae:
Along those lines, are there other queer doctors, besides your wife, that you get to work with or interact with on a daily basis?
Dr. Francesca:
Let's see. Do I? Not in my clinic. Oh, wait, no, our clinic director is a queer man, I just completely forgot about that. He's a pediatrician, he's pretty cool, so that's one. Oh, and there's another doctor who actually did work for us, he was also a gay man, but he's retired now. So there are some people, at least in our clinic, and I'm sure there are more people out there places and whatnot. My previous primary, she was a lesbian, which was helpful, but now it's super hard to get in to see her, so I had to see another doctor. I couldn't see my doctor. I think she did transgender care because we actually have a gender clinic in my health system, which is really nice. I don't think every health system has that. They're like the one blue state in the sea of red.
Especially nowadays with all these laws that they're putting in, it's certainly a strain on a lot of our patients, for sure.
Dani Janae:
How do you manage that with your patients who are feeling a bit scared or uncertain about the care that they're receiving, not from you, but the future of the care that they'll receive?
Dr. Francesca:
I try to find them, especially over time as you practice, you get to know some of the specialists and who is a good doctor and who's maybe not so good with patients and things like that, so I usually try to direct them to those people. Even in our gender clinic, there was one doctor that most people didn't like, so I tried to steer them away from that one. That's how I do it, I guess, I try to get them to the people that will likely work well with them. The problem is access, though, because I certainly have a lot of people who want to see, say, a therapist, and therapists of color are hard to find, but my Black patients would rather see a Black therapist. I get why, it's just a different experience, and that's super hard to find nowadays. I think it's a four-month wait to see a therapist, just any therapist is a four-month wait and it's difficult. But that's how, I try to direct them to the right people as much as I can, which gets increasingly harder because there's not a lot of people to send them to.
Follow Dr. Francesca on Twitter at docwhatever
Dani Janae, this was such an informative interview! Dr.Francesca talking about getting paid by the unit and then explaining insurance coverage — that absolutely baffled me! Really excited to read and listen to more of your interviews in the future.