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Am Fam Physician. 2001;64(3):517-518

Case Scenario

I see my regular patients three and one third days a week; on Monday mornings, I see patients for urgent problems on a walk-in basis. Early one Monday morning as I entered my office, I noticed that the waiting room was unusually full. “We're in for a busy day!” I said to the nurse. “They're all signed in to see you,” the nurse said. I could see she wasn't joking, so I urged the staff to move the patients into examination rooms as quickly as possible to improve patient flow. The first patient I saw started right in: “For several days, my right arm has been numb. All my joints hurt, I can't move my fingers and my arm aches to my elbow.” I asked if the patient had sustained any recent injury. “No,” was the reply. “Actually I've had arm pain for two months, but since Friday I've had this different pain, added to the other pain I've been having.” As I thought about the roomful of waiting patients and the probable difficulty of sorting out the cause of this particular patient's troubles, the patient added, “Fix this now, doctor, I'm in a lot of pain.”

I can't help the surge of frustration I suddenly feel. I am wondering why the patient waited until the last minute to take responsibility for this complex problem? Can't patients see how busy I am? I remember a conversation with a colleague who is seriously thinking of opting out of clinical practice. Am I headed in this direction, too?


Monday morning. A waiting room full of walk-in patients. A patient in pain who says, “Fix this now.” And a physician who wonders if he is going to have to leave clinical practice, defeated by the stress and the hassles.

How many things can we find wrong in this everyday picture? More importantly, how can they be made right?

The following suggestions may help this practitioner and others avoid burnout.

Take charge of your own schedule. Who says you have to face your walk-ins on Monday morning? Is that the best time for you and for them? Instead, consider starting your workweek with a half day of familiar patients. Or by catching up on paperwork or CME. It is your schedule, and you are in charge of it. Take control, analyze your workweek for “pumped” and “slumped” times and rearrange your workload so you work flexibly and in your natural rhythms.1

Eventually, of course, all physicians have to see walk-ins and face unpredictable interruptions. Get all the help you can. Start with the office nurse who lets you know “They're all signed in to see you.” Cross-train your staff to triage walk-ins so the least complex cases to treat are presented first. Train the nurse to obtain a thorough history about the condition the patient is presenting for so when you see that patient, you will have a capsule summary, which will save you time and effort.

Most physicians make use of only about 10 percent of the potential skills and strengths of their staff. Every member of the staff can become a “physician extender.” Slow down long enough to cross-train your personal office staff, then listen to what they can tell you.

As for that full waiting room, forget about it—literally. No physician ever treats a full waiting room. Whether there are three or 30 patients waiting, we treat only one patient at a time. If you can concentrate fully on the patient in the examination room and forget the roomful of waiting walk-ins, you'll work faster, more effectively and more relaxed. In addition, your patients will perceive you as having taken more time with each of them (even if you've actually taken less time). Why? Because physicians judge the length of an office visit quantitatively, by minutes on the clock, while patients experience the office visit qualitatively—did we really pay attention to and concentrate on them? So, learn to concentrate, concentrate, concentrate.2 If other patients, interruptions, family matters, etc., distract us, then even a long office visit will seem hurried to our patients.

Do one thing at a time. Physicians' brains don't do parallel processing well. When at work, be fully at work. When at home, be fully at home. Both your patients and your family will love you for it.

Keep in mind that patients hate interruptions during the clinical encounter, and you should, too. Research shows that physicians are interrupted every six minutes, but it takes four minutes to recover our concentration and work rhythms.3 If you allow interruptions to patient visits, you waste about 20 hours each week.

Anything done rhythmically is done faster and more smoothly, with less effort and wasted motion. So train your office staff to minimize interruptions to emergencies. You can set an example by not interrupting the staff unless what you need is more important than what they are doing.

To enhance the rhythmic nature of your work, do a walk-through of your personal workspace with your staff to see if you can make it more efficient and ergonomic. Make sure the arrangements suit you—other users will have to adjust. When everything is designed for your needs, you should be able to dance through your day's work.

Now, back to the patient with the arm pain. The complex patient with many complaints can usually be helped by focusing on one complaint at a time. Ask, “What worries you most today?” or “We can work best on just one thing at a time, so which of your symptoms should we start with?” And notice the “we”—it's for real. “Doctor, fix this now,” is not an acceptable contract in the modern doctor-patient relationship.4 “This is selfcare” should be the physician's motto, especially with any chronic problem, since the patient is going to have to make some changes in lifestyle in all such cases.

In the end, you need to take care of yourself first, or you won't be able to take care of anyone else. A stressed-out, run-down physician, or one sidelined with a myocardial infarction or a cerebrovascular accident, is of no use at all to that roomful of patients. Stress can kill, and it has. If you must, downsize your operation, retrain yourself for a less demanding specialty, relocate to a state with a friendlier professional climate or get professional help to handle the stress—then do it. Many physicians have done so and done well. Work that “fits” you is more enjoyable and goes quickly, easily and much more productively. Finally, honor yourself. You will have to insist on doing what you want, your way and on your schedule.

No one else can do that for you.

Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, associate deputy editor.

A collection of Curbside Consultation published in AFP is available at

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