Out of Patients: A Novel

Kirsten Winnie, MD

Fam Med. 2023;55(4):275-276.

DOI: 10.22454/FamMed.2023.940115

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Book Title: Out of Patients: A Novel

Author: Sandra Cavallo Miller

Publication Details: University of Nevada Press, 2022, 253 pp., $21.00, paperback

Out of Patients is a fictional account of family physician and community preceptor Norah Waters. The book chronicles Dr Waters’ day-to-day as the newest partner in a small private practice in Scottsdale. Many of us will recognize the hectic practice, juggling patient demands, covering for colleagues, and juggling two medical students with very different struggles. At one point, Dr Waters notes something we have all thought: “I couldn’t make [the admissions committee meeting] because no one could figure out how to cram thirty hours into one day” (p. 135). She navigates all these challenges along with a mysterious harasser plaguing the practice—but this review is without spoilers! This story, like Sandra Cavallo Miller’s previously reviewed work,1,2 weaves together romance, mystery, and a love of animals with a genuine portrayal of academic family medicine.

The work centers on burnout, and the emotional depiction of it in this novel feels spot-on—pervasive, exasperating, miserable. Though Dr Waters blames financial challenges, inept partners, difficult patients, and the electronic health record (EHR), a key driver of burnout is missing. Many newer physicians, myself included, grew up with EHRs. Further, more and more physicians are working as employed physicians in larger groups. While EHRs have their challenges, physicians may be less frustrated with them than with the omnipresent nonclinical administrator, demanding more work with less support, despite having no inkling of what contributes to excellent patient care. Adding battles with insurance companies, prior authorizations, and other bureaucratic hurdles, the resultant discrepancy between the care we wish we could deliver and the care we actually are able to render is a big driver of many physicians’ burnout.3, 4 Because Dr Waters works in a small private practice, some of the drivers of burnout are different; while many readers may recognize the feeling, they may not see themselves in that setting. While expanding the aperture on burnout would have been nice, the story works, given the setting and personality of the character. It works so well that the romance subplots were unnecessary components.

Family medicine educators could use this work among themselves or with learners because a multitude of touchpoints in the story could serve as excellent discussion fodder for everyday challenges in practice and education. Aside from the mystery subplots, Dr Miller’s work explores important themes in teaching, such as how to connect with and inspire reticent learners, how to manage breaches in professionalism with learners, how to navigate social media and clinical care, and how various perspectives are brought to the admissions committee table. In addition to the valuable perspective on educational themes, the book also highlights clinical and personal development challenges, such as managing a partner’s differing practice, coping with challenging patient interactions, coming to grips with our reactions and emotions after a less-than-optimal patient outcome, and contending with employee relations.

Perhaps most importantly, Out of Patients offers perspective on physician burnout. The author masterfully and realistically shows rather than describes burnout, including the way it waxes and wanes, and the way good comes with guilt and stress. By the end, Dr Waters authentically seems to have found a ray of hope but still has a path to walk. She morphs from perennially miserable to glimpsing evidence of good in practice, her learners, and her colleagues. The transformation happens organically as she makes new connections with colleagues, reflects on the good in family medicine with her learners, tries new things to improve the practice, and fills her own cup at the animal shelter. She relates how, slowly, things change: “I felt adrift, out of my element. For so long, my element consisted of bitterness and depression. And those pieces still swam around inside me, but now better flotsam floated in there too” (p. 245).


  1. Cavallo Miller S. Where No One Should Live. University of Nevada Press; 2021.

  2. Winnie K. Where no one should live. Fam Med. 2022;54(8):653-654. doi:10.22454/FamMed.2022.751025

  3. Berg S. Generational divide: 4 ways physician burnout differs by age. American Medical Association; October 7, 2020.

  4. Leiter MP, Frank E, Matheson TJ. Demands, values, and burnout: Relevance for physicians. Can Fam Physician. 2009;55(12):1,224-1,225, 1225.e1-6.

Lead Author

Kirsten Winnie, MD

Affiliations: Kaiser Permanente Santa Rosa Family Medicine Residency, Santa Rosa, CA

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