Meg Glausser
January 27, 2020
I sliced the tip of my pinky most of the way off around Christmas last year. The first thing I thought, as I started to feel shaky in the knees but before I reached for the paper towels, was, “I cannot — I will not — go to the hospital.” Even with my insurance, a tetanus shot at the ER over the summer had cost $1,000. The prospect of more bills scared me out of even considering stitches: any solution would have to be DIY. Ignoring my horrified boyfriend, I used eight band-aids and a wad of tissues to stanch the bleeding. In the next few days I chewed aspirin compulsively and hoped refusing medical attention wouldn’t prove totally insane.
Four weeks later my finger is fine, if slightly misshapen. What’s not fine is our healthcare system, so dysfunctional and alienating that many Americans try to survive without it in their most vulnerable moments. There are countless examples more serious than mine of people in the US forgoing medical care in order to avoid financial ruin or the sexism, racism, and weight bias they find in the exam room. No one should spend their time deciding whether a symptom or injury is something they can afford to address; or worrying about how to deal with doctors who seem distracted and disdainful; or planning how to do battle with insurance companies. Prioritizing profit over care doesn’t seem to be working for anyone — not the sick, nor the staff trying to help them. Only the pharmaceutical companies are thriving. Change borne from meaningful solidarity between exasperated patients and dissatisfied doctors, nurses, and other workers might be possible. But it’s only getting harder for the two groups to establish empathetic connection: barriers to care are becoming higher, appointments shorter, and paperwork more time-consuming. Could the absolute devastation wrought by the coronavirus pandemic push America to the brink of total system overhaul? It seems unlikely.
When I got the chance to talk to Meg Glausser, a doctor of family medicine in the Bronx, I wanted to know about the specific obstacles she faces as she tries to treat her patients with dignity and what, if any, hope she has for creating better health outcomes in the future. What I learned was that many of the obstacles to quality care are the product of decisions made far from doctor’s offices: in medical schools (where certain specialities are prized), in board rooms (where money rules), and in government (where policy can be shaped by politicians with no medical expertise). We spoke in late December, after Meg had received her first dose of the covid vaccine. Her 2020 had been especially intense — in the spring she gave birth to her second child alone, during the window of time when partners were not allowed into delivery rooms in New York City, and then returned to work in June as the virus limited the in-person services her clinic could offer. Nevertheless, Meg sounded excited at the prospect of mass vaccinations and the new administration’s approach to managing the pandemic.
This interview took place in December 2020. It has been edited and condensed.
Georgia Hilmer: Could you talk a little bit about resilience as it relates to the day-to-day work of being a doctor? Do they teach you resilience in school?
Meg Glausser: The schools definitely select for people who are able to put up with a lot of pressure and who are able to deal with a lot of stress. They don’t tell you exactly how practice is going to be out in the real world but they make you jump through a lot of hoops beforehand.
Do you feel like you had that capacity naturally, before you started down the path towards medicine, or is it something that you learned in the process?
Maybe both. I think being older really helped me. I don’t think I would have been able to handle going straight from college to medical school. I was too interested in hanging out with my friends and riding bikes — I don’t think I could have given up on that decade of my life. I got it out of my system and then when I was in medical school I was able to really focus because I wasn’t worried about dates I was going on and stuff like that.
Where did you go to school and when did you know that you wanted to study medicine?
I didn’t know that I wanted to study medicine until I was probably about 29 years old. First I went to Grenell and studied religion. When I graduated I moved to Maine and got a job cooking in a seafood restaurant. I went and hung out in Mexico for a while and tried to work on a farm and learned to surf. I messed around for a little bit. Then I moved to Austin because my roommate from college lived there and I managed a restaurant for a while.
I was not fulfilled so I started taking community college classes and realized I really liked science. I got into UT Austin to do science teaching, to teach middle school, which I thought would be fun. But I hated the pedagogy of that type of education. I really liked the science stuff though. I talked to my advisers and my genetics professor said, “You should be a doctor!” and I was like, “What are you talking about?” But then I started volunteering at a hospital and thought, “Ooh, I love this.” I loved the gore. I loved helping when the nurses were flipping over patients and dressing wounds. So I did my pre-med requisites and I went to UT Southwestern in Dallas for medical school. I did my residency in family medicine at Beth Israel in Manhattan. Now I’m working at a clinic in the Bronx, a community clinic that has primary care and integrated mental health and dental care and a few other things.
What is the point in medical school at which you have to decide about specializing?
It’s in your third year when you’re doing all of your clinical rotations. The first two years are book learning and then you rotate through all the specialties in your third year and decide which one you want.
You ended up choosing family medicine, which is a specialty dedicated to comprehensive primary care for patients with all kinds of needs. You see people with lots of different problems: someone dealing with an STI or a sore throat can come to you. So can someone who is worried about back pain or having trouble sleeping. Sometimes you see a patient once and never again, other times you form a relationship and are their primary care provider for years. Was it clear to you that you wanted to do family medicine? How did you make that decision?
I liked all my rotations so I thought, “I want to be a surgeon! I want to be an OBGYN! This time I want to be a neurologist.” But nothing was quite right. In medical school I was the co-president of the Medical Students for Choice group so I got exposure to the abortion providers and clinics in Dallas. There was this great family medicine doctor who was a provider at one of the abortion clinics and I did a rotation with her. She told me about how great family medicine is because you can do reproductive health and it is very social justice-oriented. That was my first exposure to the new progressive family medicine style that is not your-grandfather’s-GP type of family medicine. But UT Southwestern is a really specialty-focused academic institution that doesn’t value primary care as strongly as other specialties.
Is that emphasis on specialization that you describe at UT something that is symptomatic of the larger medical world? Family medicine is considered less prestigious and sexy?
Yes. That’s exactly the case.
What’s up with that?
There’s a lot more prestige in highly specialized medicine. Many people think that general practitioners can’t know what they’re doing because there’s too much to know in medicine these days. “If you try to know everything, you don’t know anything.” I did a sub-internship as a fourth year in internal medicine and the guy was asking me what I was going into and I said family medicine and he was like, “Oh no, good students don’t usually go into family medicine, you have to do something else.”
What do medical professionals expect will happen to all of the people who just need basic medical care if you discourage students from going into the field that provides that service?
It doesn’t make any sense to me how people are not thinking about and not valuing that role. General primary care is so important and family medicine is so revolutionary. People think of us as the safety net but really the job is about coordinating patients’ care and caring for their whole self. So often if a patient is seeing many highly qualified specialists, each specialist is only thinking about one organ system and not about how the medicines that they prescribe fit into a person’s life or interact with the medicines prescribed by some other specialist. My job is to look at all the aspects of a person’s care.
It seems related to other phenomena in our culture, like devaluing teachers. Unless we overhaul the entire system and somehow don’t need people to do “basic” jobs in education, childcare, and healthcare, we have to continue to support a pipeline of future workers.
It is insane the things we value in this country and don’t. Education and primary care are just two prime examples. Maybe it’s a chicken-or-egg situation: we don’t value it so we don’t pay for it, but also maybe because we don’t pay for it, we don’t value it. Right now surgeons and specialists get paid so much money because they bill for specific procedures that they do or for a specific disease-oriented service that they provide. It is very easy to bill for that type of service but it’s really hard to prove that you’re keeping someone healthy and get paid for not having to do procedures. They’re trying to overhaul the payment systems to value primary care, to reward quality of care and keeping people healthy rather than to pay for service fees. Nobody has figured it out yet though.
The way that you prove that you’re keeping people healthy is just through a lot of mindless documentation that doesn’t really actually help the patient. The more documentation and administrative burden that you put on the provider, the less time I actually have to interact with patents and make an impact in their life. The system asks me to do all of this stuff on the computer to prove that I’m giving good care but it only gives me 15 minutes to do that. Either I can spend twelve minutes documenting and three minutes talking to the patient or I actually make a difference for the patient — but I don’t get the “credit” through the documentation. It’s sort of a can’t-win situation. You end up documenting in your off-time or poorly.
Do you think that the fact that most medical students (besides you) are typically very young when they’re in school factors into that specialization frenzy that you described?
I do think that a lot of people don’t have any real world experience when they start medical school. A lot of people have a background where they haven’t had jobs and have had a pretty sheltered life. You go to medical school and you get wooed by the specialties and you also have these gigantic loans, $400,000 sometimes, and have to think about paying those off. When you look at the specialist compensation, it’s like four times as much for an ophthalmologist as for a primary care provider. So there’s that. Also, interestingly, the people who go into family medicine are much more likely to be from diverse backgrounds: diverse socioeconomic backgrounds but also just like … people who did weird stuff before they went to medical school, like me.
That’s something that statistically bears out or is that just a feeling you get?
I haven’t seen the statistics but I really would put money on it because I think that it is true. I think it’s primarily people who are older, people who are more well-rounded, who go into family medicine.
Is it a predominantly female specialty?
Yes. Including the medical assistants and the nurses, 95% of the people at my clinic are women. There are two male providers; they’re both gay. We just recently hired a male nurse. But literally everyone else is female. In my residency class, one out of nine of us was male. The class before mine was all female.
Do you have a theory about that?
I think that women do the work that is undervalued. We are teachers, we take care of kids. We spend more time with patients and thus get reimbursed less. We go into specialties that are more forgiving of certain lifestyle choices. There’s a perception that it’s easier to have a family if you go into primary care rather than surgery or another high-intensity specialty. Neurosurgery, for instance, you have to be on call seven days a week and get up at 4 o’clock in the morning. A lot of people who make those decisions think of it as sacrificing having a family or a social life for your career. I think a lot of women choose careers where they can have more of a life.
Was that trade-off something that was talked about openly with your classmates or your colleagues or was it something you intuited from seeing who did what job?
It was definitely talked about openly. The neurosurgeons were proud that they worked all the time. Surgeons see themselves as badasses. I love hands-on stuff, which is why I do procedures, and I definitely considered going into surgery, but I didn’t want to get up at 4 o’clock in the morning for the rest of my life. It’s exciting for a while but if you think about just taking out gallbladders one after the other for the rest of your life, I didn’t want to do that. Family medicine is so much more interesting: every day you get to do so many different things, like see a prenatal patient and then the next week you get to become her baby’s doctor for years and then you go into a grandparent’s room and then you get to drain the abscess on the butt of some dude. All different things.
Could you tell me more about the Medical Students for Choice you described at UT and how abortion rights fit into your political consciousness as a doctor when you were starting out?
I had always volunteered for Planned Parenthood and existed in a bubble of people who thought like me. I couldn’t imagine how anybody would not support a woman’s right to control her bodily functions. Then I got to medical school and there was an organization fair my first year where these two bright-eyed people were sitting at the Medical Students for Choice table and no one was talking to them at all. All of these twenty year-olds were scared to engage with them or felt anti-choice by default from their upbringings. I realized that even in a prestigious academic institution there was a lot of prejudice and anti-choice sentiment around. That made me think about the issues more and clarify my values. I decided that it was important for me to put myself out there a little bit. You start to be connected to abortion, like you’re a pro-abortion person. People know you as that. You have to decide that you’re okay with the association. When I realized that it was an important thing to put my neck out for, I decided that I needed that to be part of my career.
Did you feel that there was a cost to that stance or that you faced repercussions for being vocal about your values?
There were people who I felt the side eye from but I don’t think I actually ever directly experienced any discrimination, which is not the case for everyone. I came to New York because I wanted to train in a family medicine program that would teach me to be an abortion provider as well. There are very few family medicine programs that do; it is mostly OB-GYNs who learn to provide that care.
The fact that I can provide abortions in the context of a whole, full-spectrum family medicine practice is very special and really unique. So many states have these crazy laws that don’t allow abortion providers to practice any other type of medicine or are micro-managing of the ways abortion providers get paid. It basically stops anyone from practicing primary care if they also want to provide abortions, which doesn’t make any sense because abortion is such an integral part of the reproductive life of a woman. We know that one in four women get abortions in their reproductive life cycle. A woman can come to me and trust me because I’m her primary care provider; I can get her birth control or provide an abortion. And if a woman changes her mind and wants to continue her pregnancy, I am there to provide prenatal care right away. That is seamless and safe. It just doesn’t make much sense any other way.
When I think about my own anxieties about healthcare and how difficult it can be to feel empowered in the system, the idea that you have to go begin an entirely new relationship in order to get abortion care just seems like the obstacle it is obviously intended to be. I can imagine that it would be incredibly intimidating for someone in an already vulnerable state to think, “In order to get an abortion, I can’t go see the person I already have a relationship with, I have to start from scratch.” It doesn’t seem very patient-centered.
Could you tell me about what a typical work week is like for you now? And about what your clinic is like?
It’s a safety net clinic so the vast majority of our patients are Medicaid recipients or are uninsured — though a lot fewer people are uninsured lately, hopefully it stays that way. There is a significant undocumented population that is ineligible for Obamacare plans. We serve mostly people from the neighborhood and most people in the area have a lower socioeconomic status.
I work Monday to Friday most of the time. I have a mix of responsibilities, which I love. I’ve tried to have a lot of different things that I do so that I don’t get too burnt out just seeing patients all day everyday because that’s really exhausting. I see my own patients all day Monday. Tuesday I see patients half the day and I do procedures in the afternoons, which can be abortions or inserting IUDs or implants, or draining abscesses and putting in stitches, injections of joints, ultrasounds, hands-on stuff. Half of the day on Wednesday and Friday I supervise the residents who are seeing patients. They are medical doctors who are credentialed but still are in training and need supervision. We also have a nurse practitioner residency. On Thursday I get a little bit of administrative time and the rest is seeing patients. I have a medical student with me here and there. One Saturday a month I supervise the medical student free clinic that is run out of our clinic. It’s fun to work with residents and students and trainees.
You said that seeing patients is exhausting. Is the exhaustion from being “on” and constantly social or is it the intellectual exhaustion of figuring out what is ailing someone?
That’s a good question. It’s mainly the computer. The computer is exhausting. You have to pay such careful attention and are just typing constantly. Also, speaking Spanish. A majority of the patients that I see in the Bronx speak Spanish; often people speak a mix of Spanish and English. My Spanish is improving but it’s not effortless and it takes a lot more brain power to do that.
Some people have a lot of complex problems. I think maybe if you caught me on a different day, I would be less overwhelmed by this but today, this afternoon, I really felt it: people have a lot of sickness and a lot of mental health problems that really compound their illness. As an individual, it is hard to coordinate your own care. Just picking up the medicines that you need to take can be difficult. When you have three specialists that you need to go see and don’t totally get why you have to see them, it’s tough. So I have to pull information from people who don’t really understand what they’re doing or what kind of medical care they’ve got, pull all of that information out of them and make decisions based on that. It’s hard.
Is there a clock running down? Do you have a set amount of time you’re supposed to spend with each patient?
Yes. There’s not enough time. You’re allotted twenty minutes per patient.
Regardless of what they present with?
Regardless of complexity, whether you’ve ever met them before, whether they have a UTI or they have diabetes, heart failure, and a COPD exacerbation. All of that gets twenty minutes.
Who sets that standard?
That’s the organization. They have calculated, based on reimbursement, that the way we stay afloat is for everyone to see the equivalent of three patients an hour all day every day.
Wow.
It sucks. You try to shave off time when it’s a simple patient — but a patient is never simple. Even if they’re coming in just as a young woman with a UTI, if she hasn’t been seen in a year and has questions about her contraception, you can’t just say, “Oh, come back to talk about that,” because now is the time and she’s not going to talk about contraception in a month because we’re going to make her wait in the waiting room another hour. And she needs it now. There’s no easy answer though. I understand that the reimbursements are small so they need us to see this many patients to stay afloat to be a safety net.
How has going to the office every day and providing care for a community that really needs it shaped your thinking about politics?
I feel really lucky that I have a job where my whole working day I feel like I can actually make a positive impact for people who need it and make an impact on things that I care about on a larger scale. It is really hard for me to read the news and think about other difficult political or social issues outside of work because my whole brain is consumed by intense stuff all day. Nathan [my husband] wants to talk about news from his political podcasts when I come home and I’m like, “ I can’t!” I just want to watch cartoons. Sometimes even listening to NPR in the morning is too much.
That makes sense. I was listening to an interview with Ed Yong at The Atlantic who has written a lot of big stories about the pandemic and he was talking about the value of camaraderie for essential workers, how having people in the trenches with you helps you stay resilient. Is there a look you can give your coworkers that says, “Oh my god, I can’t believe I have to do this,” or, “This is so hard,” or, “Help me!”
Yes. All of that and more. It is absolutely priceless. I could not do my job without my coworkers. For a while when we were all so freaked out about covid we were spaced out so that we didn’t all work in the same room. Usually the medical providers have a work room with desks and we sit in there and tell each other about cases or make jokes or give each other candy. The idea of not being able to work and talk to each other together was horrifying. We know we are all still at risk because we sit and eat lunch in the same room but it’s worth it because we just couldn’t survive our jobs without that way of blowing off steam. And also you have twenty or thirty patients in a day and if you have a really hard patient to wrap your mind around, you can come and bounce it off another person and you’re way less likely to miss something. Or they’ll reinforce your idea or tell you something you forgot. I think it makes care better too.
I know people who are at these small clinics where they never see anyone else and I just couldn’t work like that. The staff that works at our clinic, the medical assistants and nurses, a lot of them live in the neighborhood and have worked there for years. It just feels like a family and everybody knows each other’s personal business — maybe too much sometimes — but it is such a supportive environment. One of the best nurses, she and her whole family got covid over Thanksgiving, and her husband has been in the hospital and she’s been out of the office and it’s just been devastating. But we’ve all been sending meals and giving medical advice to her and the whole staff has been supporting her. I feel like that’s exemplary of our clinic: we are a family.
What do the next six months to a year look like, in your mind (if you can even think that far ahead), for you as far as how your job is affected by the pandemic?
Hopefully, since New York is more sensible with masking and stuff than the rest of the country, we won’t have such a surge after the holidays. But it is certainly possible that we could go back to a telehealth situation, where I would see patients over video. I’m so excited about the vaccine. That feels like such a ray of hope. I am lucky enough to be at a site where we’re giving injections. I was one of the first people in our organization to get it. We’re working really hard to vaccinate everyone who wants it in our organization in the coming weeks. We have a big enough supply to do that, which is so exciting. Hopefully, it won’t be as devastating in the spring and we will be able to get people vaccinated and start to turn a corner.
Is your goal to work in family medicine as long as possible or are there other ideas you have about what you would like to spend your time doing?
I think it is possible that I will try to learn about medical administration and systems more. I would like to potentially, at some point, be in a role where I could also work on making healthcare delivery systems better because I’m interested in that and I think there’s so much room for improvement. There are graduate programs where you can do three years while you’re still working so that you can learn about healthcare administration. A big movement in primary care is improving quality of care through the patient-centered medical home, which means essentially centralizing care and being accountable for the healthcare of your population of patients. I also think that as I get older I will have less energy to see so many patients all the time, so maybe I could have a job where I work part-time with patients and part-time in an administrative role.
