Fixing the system and prioritizing patient care [PODCAST]

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Join us for a thought-provoking episode as we sit down with Cindy Rubin, a pediatrician and breastfeeding medicine specialist. Cindy opens up about the challenges faced by physicians in the current health care system, particularly the constraints of 15-minute appointments and the impact on patient care. She shares her personal journey of transitioning from being on time to running behind in order to provide comprehensive care and build meaningful relationships with her patients and their families. We discuss the added strain caused by the COVID-19 pandemic and the need for systemic changes in scheduling, staffing, and compensation models to prioritize quality care. Don’t miss this candid conversation as we explore the need for a reimagined health care system that values the well-being of patients and physicians alike.

Cindy Rubin is a pediatrician and breastfeeding medicine specialist.

She shares her story and discusses her KevinMD article, “We need to stop blaming the doctors.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Cindy Rubin. She’s a pediatrician and a breastfeeding medicine specialist. Her KevinMD article is titled “We need to stop blaming the doctors.” Cindy, welcome to the show.

Cindy Rubin: Thank you so much for having me. It’s an honor.

Kevin Pho: We’ll get to the article in a little bit. First off, briefly share your story and journey to where you are today.

Cindy Rubin: Well, it’s all kind of related to this article, actually. So I am in the Chicagoland area, and I went into medicine kind of later. I did not know what I wanted to do when I grew up, and I was a little bit of an older medical student. I came back to Chicago for residency in pediatrics, and I was an outpatient general pediatrician for 13 years. During that time, I was becoming increasingly burnt out, essentially, and disillusioned by the system. And I also, in that time, was kind of finding my niche in breastfeeding medicine and lactation, and that just added fuel to the fire, because one of the big problems right now, I think, is that people don’t have enough time to spend with their patients. And the more I got to know my patients, and the more I was doing breastfeeding medicine, which required a lot of time, the harder it got to be where I was.

And that leads into the article, which I literally think I wrote in about 15 minutes when I got home this particular day, after a student asked, “Why do you have 15 minutes for all your appointments?” as if I had chosen that. And it’s interesting that she, as a med student, didn’t realize that that was how things were set up, and I’m sure that I didn’t realize that as a med student either. It’s kind of like a bait and switch. You know, we go into medicine with these big dreams and things that we want to do, and maybe we’re a little overly idealistic, but then we end up where we end up and find that we are hamsters on a hamster wheel and can’t do what we want. And not only that, but we kind of lose ourselves in the process.

Kevin Pho: Now, you mentioned that you were burned out in that traditional pediatric practice. We talk to a lot of physicians, and burnout means different things to different doctors. So tell us, during that time of burnout, what exactly were you feeling? Give us a story, an example, an illustration of what it meant for you to be burnt out.

Cindy Rubin: Yeah, for me, I think I was depressed, I think I was depressed. I was absolutely physically exhausted. I was running behind, hours behind sometimes, in clinic, and therefore feeling like I was being a bad colleague to my fellow physicians and my support staff, because I was always running behind. I was not doing a good job as a doctor, because I was feeling all this pressure. And then I wasn’t feeling like a good mom either, because I was staying at work late and exhausted and felt like I didn’t have the time with my family either. So I think it was all those things on top of me, and I was dreading going to work. I was doing it, and I was loving the moments when I was in with my patients, but I was really, really dreading it all day, every day, like that drive to work. And that’s not how you should feel.

And I don’t think I realized that there were other options, or I kept kind of searching for other options but felt very stuck. And yeah, I talk about this actually in an upcoming article, that there was a night that I just really remember vividly, of coming home from work. The kids were already in bed, done with dinner, bedtime. I’d missed all of that. And I remember walking in, and my husband was standing there, right in front of where I am now, at the sink, and I put down my bag. I think I was expecting it to be, you know, “Hi,” whatever, and I just broke down in tears, because it was just like, “What am I going to do? How can I get out of this?”

Kevin Pho: So tell us about what kind of changes you made from a practice standpoint, and what your practice is like now.

Cindy Rubin: So, 180 degrees. Shortly, actually, after that article, I did quit my job, and I decided to open a direct primary care pediatrics practice that provides general pediatrics. But then I also, as I said, had become more and more involved in breastfeeding medicine, and so I also provide breastfeeding medicine care, consults, and these awesome fourth-trimester packages that I offer as well. This whole model, but specifically this fourth-trimester care, really, really allows me to provide kind of intense one-on-one support, not just medical care but support for people who are going through really, really challenging times. And it’s just incredibly fulfilling and rewarding, and hard. And now I’m a business owner, so that’s this whole other aspect, that I’m learning this brand-new profession, essentially, of being an entrepreneur. But yeah, I had to get out of the system, I think, to find myself and who I wanted to be within medicine again.

Kevin Pho: All right, let’s talk about your KevinMD article titled “We need to stop blaming the doctors.” Tell us, how did your article come together?

Cindy Rubin: And, like, it was really, I mean, I start out by saying that it was a med student who asked me, “Why do you have 15-minute appointments?” And I literally, it just made me realize, “This is crazy,” and I came home and just, you know, had diarrhea on the paper, I think. Just everything that was building up. And, you know, I think what I must have been feeling, looking back, and why that title came about, I think, was that I was always running behind, and I was getting blamed for that. And it was by my staff, and often patients. I mean, I had patients who would leave without being seen, and were very frustrated, understandably so. But I felt like I was becoming the office problem because I was actually taking time with patients that they needed. And that is not, it’s just not the right way to practice medicine.

Kevin Pho: Who was blaming you? What exactly did they do?

Cindy Rubin: So one of the things I point out, I had a wonderful MA, who I loved dearly, and she was looking out for my own good, but she was coming up with ways to get me out of the rooms as quickly as possible. And though I appreciated that, and I know where she was coming from, it was making me feel like something had to be done to change the way I was doing things. And she was right, but nothing was going to be able to be done within that system and model, because what I needed was more time to be able to do the things that I needed to do. I could not just walk out of the room when I was in the middle of taking care of something that needed to be addressed. So, yeah.

Kevin Pho: Now, if you had to adhere to the every 15 minutes per patient, or every 20 minutes per patient, or whatever time it was for you to stay on time, tell us, how would that detract from your relationship with patients?

Cindy Rubin: I felt like I was always thinking about how long I had. Like, that was in the back of my head, instead of just focusing on what I was doing in the room, but, “How can I get this done as quickly as possible?” And I was just talking to somebody about this, and I remember feeling like I couldn’t. I had started out my career always asking, you know, “Is there anything else I can do for you? Any other questions that you have?” And by the end, I didn’t ask that anymore, because I didn’t want there to be an answer. I couldn’t spend any more time, and I didn’t want to open up that can of worms. And that doesn’t help people feel like they’re really being listened to, and their problems aren’t being addressed.

Kevin Pho: So I think what you describe is certainly pervasive in primary care, in internal medicine primary care too, and what you describe is exactly the same situation as what I face as well. So you talk about some solutions in your piece, and potential fixes. So what are some of your ideas?

Cindy Rubin: So I mean, I do think that changing people’s mindset is a big thing. Like, right now, one of the challenges in a direct primary care model is that we are so used to using our insurance. And part of what is forcing us to have these quick appointments is how little we’re getting reimbursed, and therefore, for us or hospitals to make any money, we need to see more patients. Plus there are, you know, so many administrators needed to deal with the billing and the coding and this, that, and the other thing, that if we made this a more straightforward, transparent system, we could probably cut a lot of that out and ultimately give more to the patients.

But it is really, really ingrained in our heads, this insurance system, and how we need it and we need to use it. And I am stuck in the same thing, where, you know, even though I have this high-deductible plan where I’m never going to reach my deductible, I feel like I need to use my insurance and go in network, even though it’s not going to help me at all. And instead, I could have just picked a doctor who was going to spend more time, or who I had gotten a referral to because they were a really good doctor, but instead I chose this other doctor that was in network. And so, yeah, I think cutting out a lot of that admin. But in order to do that, we have to revamp the entire insurance system, and I have no idea how to do that, really.

Kevin Pho: So short of going to a direct primary care practice to practice medicine the way it should be, is there any way, within a traditional system that still employs the vast majority of physicians, is there any way to fix the current system? Or would you say the only solution is to leave that system and open your own direct primary care practice?

Cindy Rubin: Yeah, I think, I believe, I did not have the patience or the wherewithal at the time to figure that out. But I think there has to be a way to spend additional time, and maybe it’s not all going to be in person in the room with a patient. But there’s a lot of back-office stuff that can be done, and preparation for appointments, and things that support staff can do to make that appointment run more smoothly, so that the doctor can really be in there and address what needs to be addressed. I mean, one of the big things with EMR now is that we’re clicking all these, you know, check boxes that have nothing to do with good medical care, or very little, and that sometimes even force us to do things that might be against a patient’s best interests. So cutting that sort of stuff out, and letting doctors be doctors, but still use insurance. I mean, it’s just that the insurance should not be able to make all of those rules.

Kevin Pho: I think the title of your article is “We need to stop blaming the doctors.” Now, do you feel patients have insight in terms of some of the difficulties and struggles that you just articulated in a traditional medical practice?

Cindy Rubin: I think people are getting more vocal about it, because people are becoming more aware, but I think, for the most part, no. And I think that that’s what was so frustrating: I just felt like I was in a kind of trap, where nobody realized that this wasn’t something I had created. So I don’t think that people have any concept of what doctors are really going through. But there are more and more people speaking out. There are a lot of articles on KevinMD of people talking about the same sort of thing. So I think the word is getting out, but I still haven’t really seen any overriding solutions for the system as a whole.

Kevin Pho: Now, I’m sure that your colleagues in that traditional pediatric practice probably had similar stories to what you’re describing now, right? But you made the move to go to a direct primary care practice, which is a fairly bold move, because there are a lot of physicians who would kind of stay in the traditional medical practice for whatever reason. So what made you make that move, in contrast to other doctors who might have stayed?

Cindy Rubin: Yeah, I mean, I had been introduced to direct primary care initially at a conference that I was at, and I was like, “There’s no way I’m ever going to do that.” I didn’t want to be a business person. I’m still not really sure if I wanted to be a business person. But everywhere I looked for other solutions, I felt like I was going to end up right back where I started, and those problems were still going to be there in one way or another. And I think I just got to a breaking point. Maybe there’s something about my personality, or just the things I had been exposed to, that got me to feel confident enough to do what I did. But I knew that I was drowning, and I needed a life raft, and I got one by, thankfully, meeting other doctors, and the communities of doctors who are now trying to help people see that there are other options out there. And I want to be one of those people for the other people who are still kind of stuck in the system and looking for a way out.

Kevin Pho: How difficult was that transition from traditional care?

Cindy Rubin: Hard. And it has only been about a year and a half now, and it really is a new career. I mean, I didn’t know anything about business. I didn’t know anything about getting myself out there. I didn’t know anything about it, and I still feel very uncomfortable trying to sell my services, because, again, that’s something that we just don’t do in the medical system, and people are not used to directly exchanging money for medical care. And so that is very, very uncomfortable for me. I’m trying to learn more and more that the only way for me to continue providing this good care is that I need to get paid to do it, to be able to serve more people, and I need to remind myself of that. But it’s hard. It’s a whole mindset shift.

And, you know, I did this partially for my own professional fulfillment, but also to be able to be there more for my family. And I did not realize how much having a new business was really like having a newborn, and I’m not quite as present for my family as I had hoped to be. I hope that once I get, you know, kind of further in and get more systems in place, that will get better. But there’s definitely things that I did not realize I was jumping into. But maybe that helps me to make the jump, right? It was a little naive.

Kevin Pho: If you had any opportunity to make that jump again, would you do it again?

Cindy Rubin: Yes. A thousand times yes. Yes.

Kevin Pho: We’re talking to Cindy Rubin. She’s a pediatrician and breastfeeding medicine specialist. Her KevinMD article is titled “We need to stop blaming the doctors.” Cindy, tell us some of your take-home messages that you want to leave with the KevinMD audience.

Cindy Rubin: Oh, you’re never stuck. You’re never stuck, even in medicine, where we typically kind of follow a straight line. There are other options, and there are, I’m sure, ways of making it work within the system too, so it doesn’t have to be as drastic as, you know, quitting your job and becoming a DPC doctor. There’s also direct specialty care, by the way. But yes, reach out to other people that you see who have done something differently, and just learn from them. And just know that you are not stuck, and there are other ways of doing things. You know, I’m sure that there are a million other ways that haven’t even been done yet. But you’re not alone in feeling the way you feel if you feel stuck. And kudos to you if you don’t feel stuck and you’ve found a really good situation for yourself. Spread that word too. If you’re in a good situation, get more people to be in that situation, so that the bad kind of stuff, you know, so that they will learn how to do things in a better way.

Kevin Pho: Cindy, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Cindy Rubin: Thank you so much for having me.

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