I recently had a busy day at the clinic where I see people with cancer. My first two visits were challenging: During the first, I explained to a patient and his wife that his kidney cancer was no longer responding to therapy. Next, I recommended that a patient delay his vacation to undergo treatment for an aggressive malignancy. I was already dreading my last appointment, when I would tell a Vietnam veteran with liver and heart failure that he would not be able to withstand the chemotherapy needed to control his Stage 4 cancer.
It was going to be a long day.
But sandwiched between these appointments, a familiar face showed up in my office. About a year ago, he had undergone surgery to remove a lung tumor. I hadn’t seen him in months. He looked healthy, having regained most of the weight he’d lost. He was happy to get back to fishing and taking long walks. Afterward, I gave him a clean bill of health: “Your labs and scans look great. Why don’t you come back in three months?”
He looked somewhat surprised: “If things look good, do I need to keep seeing you?”
This didn’t mean that he disliked me. (I think.) Rather, he explained that every visit to the oncology clinic was a reminder that he had once had cancer. Besides, he lived more than an hour away and he trusted his primary-care physician to review his scans. And it was very possible that his lung cancer would never return. He would be happy to never have to come back to see me.
I told him that, while I sympathized, most patients in remission should see their oncologist periodically after finishing therapy to monitor their cancer and address possible side effects. He agreed and scheduled an appointment.
What I did not say — or even consciously realize at the time — was that I needed to see him as much as he needed to see me.
Cancer specialists call these appointments “survivorship” visits. They’re where we generally address treatment-related side effects and screen for other cancers and diseases such as diabetes. Survivorship visits are a way for us to stay in touch with patients, and many feel reassured that the doctor who beat back their cancer is continuing to keep a close eye on them. Perhaps that is why women with breast cancer say they prefer their oncologists to stay connected with them even after therapy.
But there is a movement in medicine to push healthy patients out of the doctor’s office, propelled by the 20 million newly insured patients who got increased access to the health-care system after the Affordable Care Act passed in 2010. Recent articles in major consumer and academic venues argue against the annual physical, noting that healthy or asymptomatic patients may not benefit from these visits, which, of course, cost our system money. Telemedicine and home health services also replace in-person care.
Even in cancer care, patients who are cured or in remission often don’t see their doctor regularly. Survivorship becomes the domain of providers such as nurse practitioners and physician assistants. As a result, most of the patients we physicians see have new cancer diagnoses or are receiving treatment.
In other words, nearly every one of them is sick. That’s undoubtedly what any doctor signed up for. And the value of a clinic visit is much higher for a sick patient than for a healthy one.
But as one who treats people on the verge of life and death every day, I am starting to recognize the emotional toll. Between the gut-wrenching conversations about mortality and managing life-threatening complications of a treatment that my team prescribed, a full day of clinic can leave me drained, guilty or, even worse, depressed. That feeling is amplified for patients with diseases such as pancreatic cancer, where the chance of long-term survival is bleak. And I am still in training; imagine how exhausted a seasoned cancer specialist or critical-care physician must feel at the end of their day, after seeing 25 sick patients and answering 10 phone calls from worried family members.
Even among oncologists, who self-select into a profession that is emotionally charged, rates of burnout are high. In a 2014 study published in the Journal of Clinical Oncology, nearly 1,500 oncologists surveyed reported at least some burnout, and it was worse among those who saw more patients. These numbers were higher among critical-care doctors and internists in the most recent Medscape Physician Lifestyle report, which surveyed of more than 15,000 physicians practicing in 29 specialties.
Surviving the tough days
On most of my tough days, I don’t think of seeing a healthy patient as a waste of clinic time. On the contrary, when I saw that my patient who had survived lung cancer was on the schedule, I felt relieved. With patients like him, doctors can afford to spend 15 minutes discussing a child’s graduation or a recent vacation. These interactions remind doctors that treatment can let someone lead a normal life.
These are the patients who prevent me from burning out.
I went into medicine to make sure that sick patients could return to living a normal life. Even if that’s not always the outcome, it is nice to see it happen.
Even in less-critical situations than cancer treatment, “well visits” can be important. Doctors can focus on smoking cessation, exercise counseling and mental health — important topics that are often ignored during a sick visit.
Of course, if a healthy patient does not wish to go to the doctor, that’s their prerogative. And I understand that either patients or their insurers must pay for in-person visits, transportation, medications and lab tests. But I believe those costs can be justified by the improved value of care that refreshed, happier doctors provide.
As more physicians become burned out and apprehensive about practicing medicine, we must realize that there are limits to what chief wellness officers, counseling, and pep talks can accomplish. Only systems-level changes in how doctors treat and see patients will curb the rise in physician burnout. Perhaps healthy patient visits can be therapeutic for everyone.
Parikh is a fellow in hematology and oncology at the University of Pennsylvania and is an adviser at the Coalition to Transform Advanced Care. Twitter: @ravi_b_parikh