* * Anonymous Doc

Wednesday, September 16, 2009

I never really thought about this, but, in the outpatient setting, people with insurance don't see residents. You have insurance, you make an appointment with a doctor, you go to his office, he sees you. You don't have insurance, you go to a clinic, and you're seen by someone like me. Or at least that's what I've seen so far. There are a couple of different outpatient settings I've been rotating through over the past couple of weeks. When I'm at the public hospital, I'm the only doctor the patient sees. I go in, I take a history, I do an exam, and then I consult with a more senior resident, or an attending-- but that all happens behind the scenes. As far as the patient is concerned, I'm the doctor. The only doctor. And yet I'm three months out of medical school. At the private clinic, I shadow an attending, he sees the patients, and I watch. I look but don't touch.

Is the care any different? Probably not-- in the public hospital, I'm consulting with other residents, there's an attending there overseeing everything, and all decisions have to be explained and justified. Even if I were to make a mistake, in this setting it probably gets caught and corrected (I wouldn't say the same thing about the inpatient rotations, at least not all the time). If anything, the care is probably better in the public clinic, because everything is being looked at multiple times and talked about. In the private clinic, if the doctor says something, I have to be pretty convinced he's wrong to feel bold enough to question it. And even if I question it, there's no reason he would listen. So there's not the same process of review. I mean, an attending who deals with these same problems every day for years is probably not making a ton of mistakes--

I guess the continuity of care is different-- in the private clinic you have your own doctor, he sees you every time, but in the public clinic you're just getting whichever resident is working that day and picks up your file. So you're constantly having to explain your situation to someone new, you're having to trust the resident has read the file and knows what's going on.... So that's a difference....

I don't know if there's a point here. I don't actually think the public clinic is providing worse care than the private clinic. It's just interesting that the customer-facing end of it is probably the biggest difference-- you see a doctor versus you see a resident-- as an outpatient, someone with insurance is never, ever going to see a resident. Perhaps that's obvious, and I just never thought about it before. The bigger question, I guess, is whether this is the smartest allocation of doctor resources, but I'm not sure I've thought about it enough to have an answer.

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