You Can Find My Office Next to the Restroom

bathroom break

Warning: this is one of those fluffy entries, not much substances, lots of musings…

A few weeks ago, I ushered a new patient to my office for her initial history and physical. Once in my office, she looked around and said, “Wow, they don’t think much of you, do they?” At first I was puzzled, but then figured out she meant that my office is small and undesirably positioned right next to the patients’ restroom. It’s not furnished lavishly, only with the essentials: desk, exam table, and two chairs. I also have a file cabinet containing some species of records.

Perhaps in the business world, one’s value to a company is reflected in the lavishness of one’s office. It is not like that in the doctor world, or at least not in the doctor world I inhabit. I don’t think about the size of my office, the location, or the furnishings. As long as I have everything I need to do my job, I don’t care or even notice other amenities. But some of the patients notice.

I’ve had some patients ask how I can stand the smell. On intake days, with eight or so new patients in varying stages of opioid withdrawal, my office can sometimes take on a certain redolence from the restroom next door.

It doesn’t bother me. I became immune to bad odors in 1985, roughly when I started my clinical rotations in medical school. By the time I got to my residency program, any sense of smell I still had was burnt out during my two-month rotation through the emergency department. I’ve been exposed to massive burdens of every type of stench emitted from the human body. As a result, I reflexively start mouth-breathing in the presence of unpleasant smells. It’s automatic.

I’ve worked for five opioid treatment program companies, in fifteen separate facilities. In many of them, the doctor’s office was next to the restroom, but I’m sure that’s just coincidence.

The worst was in an old building shaped like a “U”, with the pharmacy in the center. My office was at one end of the “u” and directly across from…you guessed it…the patient bathroom. That wasn’t the worst thing, though. Unfortunately my office had an inch and a half gap between the floor and the wall, and it appeared to be a major thoroughfare for bug travel. It was not uncommon for a roach to emerge from the gap, waving antennae like he was a pageant queen.

I usually had my back to this area, so the patients would be the first to see the invader. Almost without exception, the male patients would jump to their feet and stomp the intruder into bug heaven. I would smile and say, “Thank you, my dragon slayer.” We would share a laugh and get back to business.

Why are the physicians’ offices less luxurious in the opioid treatment programs than the rest of the doctor world? I think for the same reason some OTPs are in run-down buildings in the worst part of town. The stigma against medication-assisted treatment makes it more difficult to get regular medical office space. For all I know, maybe only the buggiest places were rentable. It’s also possible that some opioid treatment programs don’t think it’s worth spending money for a nice facility.

Doctors’ offices at OTPs may tend to be shabby because doctors aren’t in the opioid treatment program every day. Obviously, the counselors who are there every day should get the nicest offices because they will be using them more hours per week. Often when the facilities are cramped for space, the program doctor has to share an office with one or more other people. I know where I work now, two or three other people work in my office when they need space. As a result, a variety of detritus comes and goes.

One day a patient asked, “Are those your shoes under the exam table?” I didn’t have to look up. I knew he meant the pair of espadrilles that appeared one day without any explanation. I said “No, I don’t know whose those are.” He looked at me oddly, as if that were a strange answer, so I told him, “That’s nothing; there are other random things. I just don’t ask anymore.” One day my office was filled with balloons, and on another day, with hot dog buns.

The shoes were gone a month or so later, as quietly as they had appeared.

At my other program, my office is so small that literally we have to ask the patient to leave the room so that we can wheel in the EKG machine, then come back in. It is very cramped, but what I really mind is the heat. This OTP is in the mountains, but as cold as it may be outside, it’s always summer in my office.

This office has no vents and no overhead lights. When I complained about the lack of proper lighting, the program manager brought in floor lamps. One gives a puny little light, and the other throws enough heat to keep French fries warm. I have to remember to dress for summer even in the middle of winter.

It would be easy to take shabby offices personally, but I don’t think that’s generally what is behind it. OTPs take a more utilitarian approach towards facilities than other branches of medicine. I think OTPs get so used to being the red-headed stepchild that they forget to take pride in their surroundings.

Having nice facilities may not feel like a high priority, but it should be. We need to provide space as nice as other medical offices. We provide an intensely important service, with literally decades of data to support what we do for patients. Maybe our surroundings should reflect the importance of what we do, and the significance of what we do.

5 responses to this post.

  1. Posted by William Taylor, MD on March 31, 2016 at 2:11 am

    There are two models of paying for medical care, the Adam Smith and the Karl Marx. Under the Adam Smith model, patients are paying their own hard-earned money for essential services. The last thing they want is to see their money being wasted on palatial facilities. Methadone clinics and suboxone practices are definite adherents.

    Many medical offices follow the Karl Marx model, spending someone else’s money, usually the insurance company’s. Here, cost is no object, only the best will do. Check out the cardiologist’s or the orthopedist’s office, exceeded in grandiosity only by hospital atria.

    Oh wait, there’s a third model: the ER, where NOBODY pays for medical care. Here the typical doc is lucky to find a chair and two feet of counter space to do paperwork.

    Thanks for posting an enjoyable, if lighthearted commentary.


  2. Posted by Rebecca on March 31, 2016 at 4:21 pm

    Hi Dr. Burson, Here, here re your comment about how OTPs are looked upon. I want to bring this care right out to the light. No more stigma – no more words & terms like ‘addicts, being clean, being ‘good’ if you are not using’ and more demeaning and judgmental language – no more even applying the term “using.” No more misguided morality. No more shame. Even no more “cool” drug language by those affected or those who think there is even a smidgen of coolness to all this which sugarcoats this illness and appeals to the young and impressionable. Just evidence based and compassionate care. Research and understanding. Advancements. What any patient deserves. As usual, it took an epidemic that is hitting the white and wealthy to get things rolling. It took too many deaths. Sheesh. Thanks for all you do.


  3. Posted by Thomas Salmon on March 31, 2016 at 6:09 pm

    Patient and clinician space should be clean, respectful and calming. None of these are very expensive. Let’s care enough for ourselves to receive and maintain such space.


  4. Posted by Kevin on April 1, 2016 at 9:08 pm

    Now that I think back, you are right, most of all OTP facilities are older and not as updated, u would think as much as they charge (not complaining) they would update some facilities, spruce up the place and make it more comfortable.


  5. I do have to give Community Substance Abuse Centers of Mass, NH, and ME of having very nice and clean facilities that make you feel like you are in a medical practice. Bonus points too for not placing the MD and NP next to the restroom!


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