The appointment was for his annual physical, and to review his well controlled hypertension and gout. After we had addressed these issues, I asked if there was anything else he was concerned about.

I have a serious problem with the ubiquitous use of 'due' when talking with patients about what their medical options are. This came up recently when I was given a list of my patients who were ‘due’ for certain services, required if my institution is to receive a financial quality incentive. Typically, ‘due’ shows up in EHR alerts (the diabetic patient is 'due' for their A1c or microalbumin) and quality programs (patients are 'due' for a mammogram every 2 years, a DXA at 65, a pneumovax at 65, even well child visits at set intervals).

Treating patients with chronic pain is one of the more challenging tasks in primary care:

Ordering periodic urine drug screens (UDS) on patients being treated with opiates for chronic pain has become so common it is now the de facto standard of care. That doesn’t mean it benefits patients. 

Every year when I brought my chain saw in to be serviced and have the blade sharpened, Reggie tried to get me to buy a set of chaps. They weren’t cheap, and, while I was not the least bit sanguine about the destructive power of the saw, I used it infrequently, only in good conditions, and with care. The chaps were a garish orange, and I always declined.  Reggie always shrugged, looked disgusted, and rang up my bill.

A few years ago, when he made his usual offer and I declined, he looked at me for a very long moment, and then said:

I love taking care of patients and have enjoyed my 37 years (and counting) as a primary care physician.  When I stop, it won’t be because I am rich, bored, or have lost interest. It won’t be because I am tired (though I am). It will be because of friction.

The 15 minute appointment slot is dead.  To borrow from Monty Python, it is not resting, stunned or pining for the fjords, but definitely deceased, stone dead, is no more, has ceased to be, expired and gone to meet 'is maker, a stiff, bereft of life, run down the curtain and joined the bleedin' choir invisible.

As medical institutions roll out one new broken quality protocol after another, I have struggled for a way to point out the irrationality of this approach.

When this happens, I never know whether I should be frightened or enraged.

Ask any primary care clinician for a list of pet peeves and one of the top three will be: “Doing my consultant’s work.”

Just to be clear, the overwhelming majority of specialist consultants DON’T do this. But some do it occasionally and a few do it as a matter of routine. Every time it happens, it rankles.

A few examples: