Author Archives: admin

Changes

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When I was in medical school an instructor admitted, “Half of what we teach you is wrong. The problem is, we don’t know which half.”  I could say the same about residency. Some of what I learned as an intern fell out of favor by the time I was a chief resident, such as x-ray pelvimetry to determine a woman’s likelihood of delivering vaginally, or the internist’s casual approach to glucose control in diabetic pregnant women.

The pendulum continued to swing over the next thirty some years of my career. We went from “Once a (Cesarean) section, always a section,” to “Every woman should be offered the chance to deliver vaginally after a Cesarean,” to “Let’s put a little thought into who should be doing this!”

I did a rotating internship after medical school because I had no idea which direction I should take. Obstetrics was the last thing on my mind because the physician with whom I had the most contact could be sarcastic and demeaning. That changed during two months of obstetrics in a completely different environment. I ended up taking the second-year position vacated by one of the first-year obstetrical residents who left to fulfill his three-year obligation to the U.S. Air Force. (I heard he went into radiology when he got back.)

Fast forward three decades. I was working as a locum tenens physician for the medical school I’d once attended. My old obstetrical tormentor had retired from practice but continued to be heavily involved in student and resident teaching. The years had mellowed him, or maybe it was because he didn’t have the stress and burden of a private practice.

One afternoon he asked to join me while I was doing an abdominal hysterectomy. I doubt that he remembered me from so long ago, but I was honored that he’d ask and was truly interested in what I was doing. The circle was completing; the student was now the master and the master was now “master emeritus.” Side note: I’ve never been cocky enough to consider myself a “master.”

A few months ago, I met a delightful young medical student doing her obstetrical rotation. She is intelligent, capable, ambitious and learns quickly. She began her first year as an ob/gyn resident in July, which has prompted me to reflect on what has changed since I was the youngster under the gaze of my mentors, some of whom were approaching retirement.

Ultrasound:  Ultrasound has been around since the early 1960s, but the first images looked more like abstract paintings than recognizable body parts. The ultrasound tech would swipe the transducer – a thing about the size of a restaurant salt shaker – that sent and received sound waves – back and forth across a woman’s abdomen. The results looked like this:

I couldn’t tell you what this was, and we suspected neither could most radiologists. More than once we would explore a woman’s abdomen because a radiologist swore “there is definitely an ectopic pregnancy present,” and find nothing.

Ultrasound has evolved. Machines can produce three dimensional images in real time, check on blood flow into and out of organs and measure minute structures in developing fetuses. Emergency departments now have FAST ultrasounds (Focused Assessment with Sonography in Trauma) which can rapidly detect internal bleeding or a pneumothorax (collapsed lung) at the bedside, obviating the need for a CT scan. It’s much better than the old way of diagnosing a ruptured tubal pregnancy, which was sticking an 18-gauge needle through the posterior vagina into the pelvic cavity looking for non-clotting blood.

Gonorrhea testing: Neisseria gonorrhoeae, the bacterium causing gonococcal infections, grows best within an oxygen-poor environment. We used to take a sample from a woman’s cervix, smear it across a culture plate, then stick it in a one-gallon pickle jar with a lit candle and close the lid, burning off the oxygen. By the end of the day we’d have 20 or so culture plates in the jar and the room would smell like burnt wax. Now we look for gonorrhea (and chlamydia) DNA on a cervical swab or in a urine sample.

Fetal monitors and intrauterine pressure catheters: Fetal monitors, which track a baby’s heart rate and a mother’s contractions, were introduced in the late 1960s and early 1970s.  Both were accomplished with devices placed on the mother’s abdomen, but the results often were inaccurate. The scalp electrode, created in 1972 by the venerable Dr. Ed Hon, allows us to monitor the baby’s heart directly.

The modern intrauterine pressure catheter (IUPC) measures contractions through a solid, transducer-tipped catheter threaded into the uterine cavity. The early catheters were fluid-filled tubes connected to a small strain gauge transducer which required a dome of water placed directly on the pickup before the cover was screwed on. The transducer then had to be taped to the bed rail at approximately the same height as the uterus.  Sometimes we’d use a tongue depressor and thick adhesive tape to keep it in place. Then we’d open a stopcock to “zero out” the system, close the stopcock and hoped it all worked.

Determining ruptured membranes: Back in the old days we determined if a woman had “broken her water” by inspecting the vagina with a speculum for amniotic fluid, testing any visible fluid with nitrazine paper, and then slapping some fluid on a slide, letting it dry and look through the microscope for “ferning.” If there was any question, we’d have the woman wear a pad and check for fluid an hour or so later, or, in rare cases, inject indigo carmine dye into the uterine cavity and look for blue fluid in the vagina.  When ultrasound came into widespread use, we looked at fluid levels around the baby.

Then a company created an expensive test to check for an amniotic fluid protein to determine whether membranes had ruptured. Their ad campaign preyed on all our fears by asking, “Are you really, really, absolutely, positively sure?” Hospital administrators took away our nitrazine paper and microscopes because now they had a test for which they could bill. Doctors liked it because it meant they didn’t have to stagger out of bed in the middle of the night to do an exam, or so they thought.

Then in August 2018 the FDA issued an alert reminding physicians “that the labeling for these tests specifies that they should not be used on their own to independently diagnose…ROM (rupture of membranes) in pregnant women.”

A Korean study found a positive test in a third of women in labor with intact membranes. A review of ROM testing published in The Journal of Obstetrics and Gynaecology of Canada was cautiously optimistic about protein assays although they cautioned “Further studies are needed to assess the reliability of the test according to the time from membrane rupture.” So what would make the critics happy?

We do our best, but nothing is perfect.

Hysterectomy: Vaginal hysterectomy has been compared to rebuilding an engine through the tailpipe. The Grand Old Man of vaginal hysterectomies attached to my residency program retired during my second year, so I learned to take out uteri through an abdominal incision. Not that I couldn’t do a vaginal hysterectomy, but I liked being able to see what I was doing. Few things are worse than fishing for a bleeding artery through a vagina.

Laparoscopic-assisted vaginal hysterectomy (LAVH) started to become popular in the 1990s, but the learning curve was steep. I knew physicians who spent seven hours on their first few LAVHs after going to a weekend course, which is no substitution for extensive residency training.

The alleged advantage of LAVH was being able to detach the tubes and ovaries under direct visualization, but one still had to finish the procedure vaginally. Most of the required equipment was disposable and expensive, making it 40% more expensive than a traditional vaginal hysterectomy. Some of us thought LAVH made up for a lack of skill.

Robotic surgery started becoming popular in the early 2000s, but robots were used more for marketing than for patient benefit, and they weren’t cheap. A robot cost $1-$2.5 million up front and came with a $100,000 to $170,000 annual service contract , enough to give any hospital bean counter palpitations.

But, after years of experience and refinement, doing a hysterectomy exclusively with laparoscopic equipment made total laparoscopic hysterectomy (TLH) a truly “minimally invasive surgery.” One surgical assistant told me taking the detached uterus out at the end was like uncorking a bottle. More than one study found there was no advantage to using robotics over TLH. I suspect many of those machines will be gathering dust in closets, sitting next to $100,000 carbon dioxide lasers used to treat precancerous cervical lesions before LEEP (wire-loop cautery used to whack out a chunk of cervix) became popular.

Employment: Physicians were masters of their domains for most of the twentieth century. In the early days, you graduated from medical school, did a year internship to get a license and hung out a shingle as a general practitioner.  Specialties (and specialty boards) started appearing during the 1950s, along with residency programs lasting three to seven years, and the old GP would become extinct. Physician practices were still largely independent even into the 1990s. Being employed by a hospital or, worse yet, a “goddam HMO” made you a substandard physician who couldn’t get a job anywhere else in the eyes of the Great White Fathers who still ran things.

But, as I’ve previously discussed, things have changed. By 2017 less than half of American physicians owned their own practices, especially in metropolitan areas. I live in the Chicago suburbs where a large majority of private practices have been absorbed by large medical groups and/or hospitals. New physicians expect to be employed rather than deal with the headaches inherent in independent practices: personnel, equipment, rent, taxes and liability insurance, which can run $150,000 a year for an ob/gyn. We gave up autonomy for financial security and lost both in the process.

Patient care and ownership: The generation of physicians before me cringed when administrators used terms like “customer service,” but in their hearts they knew what it meant. They took good care of their patients because those patients were their livelihood. In a group practice the patients were all OUR patients, rather than MY patients and YOUR patients.

Primary care developed “concierge care” as a backlash to corporate medicine. Concierge care promises same day or next day appointments, access to one’s physician 24/7, unhurried visits and “personalized care,” or what I used to know as “doing my damn job!”  I’ve called patients with test results, talked to them at all hours of the night and I made at least one house call to check on a patient’s Cesarean section incision that had opened up.

This “white-glove customer service” comes with annual fees ranging from $1000  to a whopping $25,000! And that is just for the privilege. Actual care still costs money. You can’t use Flexible Savings Account (FSA) or Health Savings Account (HSA) money for the fee, so this isn’t an option practical for the masses.

I’d like to think there’s a new generation of physicians willing to fix what’s broken for everyone, but I’m not holding my breath.

An Epidemic of Stupidity

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I’ve declared the third week of July as National Health Care Stupidity Week, for I’ve never encountered such high levels before.

I saw an ophthalmologist for a problem with my left upper eyelid at the beginning of July and scheduled surgery for three weeks later. We asked the scheduler how much the procedure would cost but she said, “It depends.” That’s not much of an answer to a physician who understands the vagaries of CPT coding and insurance reimbursement. You give the insurance company the codes and your charges. The insurance company laughs their asses off and then tell you “No fucking way. THIS is what we’ll reimburse you.”

The scheduler said, “I’ll ask the doctor what he plans on doing and I’ll call you in two days with the charges.”

I can understand if the physician wasn’t quite sure what he was going to be doing right after seeing me, so we let it go.

The week’s aggravation started at Drugs ‘R’ Us, a national chain, which the threat of litigation prevents me from identifying. I’ve used a maintenance inhaler for life-long asthma, for which there is NO generic. The price has climbed from a $150 insurance copay for a three-month supply from a parasitic mail-order pharmacy benefit manager to $400 for one and NO insurance coverage until (my very high) deductible is met. I brought this up to my pulmonologist last month and asked for a little-known generic equivalent (different medications but should have the same therapeutic benefit).

He said, “Well, Thieving Bastards Pharmaceuticals have this discount card that will give it to you for free if you have insurance. It’s good until December 2018.”

I learned a long time ago there ain’t no free lunch, but if they are willing to part with it for free, I’m in. I took it to Drugs ‘R’ Us and, after 20 minutes or so of fighting with the computer, I got my inhaler. ONE inhaler. I have to go back every month for this charade.

The pharmacy’s robot phone said I could pick up this month’s inhaler. However, the pharmacy tech brought me a bag with three inhalers and a bill for $935 “because you haven’t met your deductible.” No shit, Sherlock. I have insurance with a high deductible and a health savings account (HSA) which is great at a certain income level but completely useless if you’re making minimum wage (in which case you probably don’t have any insurance and you’re a drain on society, at least according to the bastards who’ve been trying to undo the ACA for the past 8 years).

“Last time I got one and it was free! Here’s the card and I’m NOT going to pay almost a thousand bucks for this. I’d rather die a quick and painless death.” (I’m using that phrase more often these days.)

“Well, let me change it but I have to run it through the system again. It’s going to take some time.”

Fine. I sat in one of the uncomfortable chairs in the pharmacy waiting area and perused the local paper, which didn’t help my mood any.

Then my phone rang.

“Hi, this is Brunhilda from the Pretentious Suburban Surgery Center. Your insurance is going to pay 80% of the procedure after you’ve met your deductible, but you haven’t met your deductible, so we want your left testicle ($1305) as a down payment.”

“First of all, why? Second, what is this going to cost me in total?”

“Well, we ask everyone for a down payment.”

No, you said it was because I hadn’t met my deductible but, please, proceed.

“Why? This isn’t a cosmetic procedure and I’ve already signed the boilerplate insurance assignment form that says I’m responsible for the remainder.  So, again, what is this going to cost me?”

“We can’t tell you what we charge, and the insurance company won’t let us tell you what they will pay us.”

“Why not?”

“It’s in our contract.”

“You’d tell me if I was paying for all of this out of pocket, wouldn’t you?”

Silence

“Well, my financial adviser has told me that’s not a great idea. I’ve got an HSA funded with pretax dollars and if I overpay you and you then reimburse me directly, I might run afoul of the IRS, which is not known for being gracious.  Would you be willing to talk with her as I have to leave town in a few minutes?” (Translation: “If I acquiesce to this extortion, Peg is going to ream me a new one. We’re going to play good cop/bad cop and I’ll let her ream you a new one. You really don’t want to poke this bear, but you’re gonna have to learn the hard way.”)

She says, “I’d be happy to!” and I hung up, snickering.

An older woman came to the pharmacy while I was waiting. She was bent over a wheeled walker, wheezing audibly as she shuffled up to the counter. I suspect she had long-standing COPD and it made my lungs hurt just to hear her breathe.

“They called me and told me my prescriptions were ready.”

“What’s the name?”

She wheezed her name.

“Your prescriptions have expired, and we put a call into your doctor’s office to get authorization for refills.”

“But someone called me and asked if I wanted all my prescriptions refilled. She even listed all of them and I said ‘yes!’ Then I got a phone call from you!”

“That is an automated system and we don’t have any control over it.”

This went on for several minutes with the poor woman protesting that she’d done everything she’d been told but slowly realized this trip had been for naught.

Finally, she sighed, said, “Well, what are you gonna do,” turned around and shuffled out. She was far more resigned than I ever would have been. ( is one of my all-time favorite revenge movies. Just sayin’.)

The pharmacist came out, handed my drug card back to me and said, “We put in a phone call to the company and we’re waiting to hear back. It shouldn’t be too long.”

Twenty minutes later I was still waiting. Finally, I got up and said, “I have to leave town. Can my wife pick this up?”

“That’s no problem. We’ll let her know when it’s ready.”

Then I asked her. “Is there a generic for this because the card expires in December and I can’t afford $400 a month for this.” I gave her the generic medication names.

“It looks like the only one is ‘Yerstillscrewed’ but insurance doesn’t cover it.”

“I KNOW that, but I can get a three-month supply using GoodRx for less than half of what one of the brand-name inhalers costs.”

It’s turns out that Thieving Bastards Pharmaceuticals changed the program so that it only covers that drug up to $200/month. You know, the drug for which they set the price at $400.

I left and started my drive to Springfield. I was just about at Joliet when the phone rang.

“This is Vinnie, the enforcer, uh, business manager from the doctor’s office. I wanted to let you know that your insurance is going to pay 80% of the procedure after your deductible is met, but you haven’t met your deductible, so we want your right testicle as a down payment.” (It’s been two weeks since the initial visit and less than a week before surgery.)

“Why?”

“It’s our policy.”

“I’ve had other procedures and visits, and no one has EVER asked for money up front. You just told me what my deductible is, and you know how much I’ve met, which means you also know I’ve been paying towards it. The surgeon’s fee and the surgery center charges are likely to eat up the rest of my deductible. Again, how much is this going to cost?”

“It depends.”

“What do you mean, ’it depends?’ That’s bullshit. There’s a CPT code for the procedure, and you have a charge for it. I know that because I’m a physician and I’ve had my own charge list. You’re going to give the insurance company a bill with a CPT code. They are going to send me an EOB (Explanation of Benefits) which will tell me what YOU charged, what they allow, what they’ve paid and what my obligation is. So, to pretend this is a deep, dark secret is disingenuous. The only thing that “depends” is how much the insurance company is going to pay you and your contract with them defines their reimbursement. So, to ask me for money up front is insulting. You’re making me sound like a deadbeat.”

“No, no, we do this with everyone.” (Where have I heard that before?)

“Yeah, well no one else has ever asked me for a deposit! No one asked for a deposit before my colonoscopy, or when I went to the ER for a doppler scan for lower leg pain. Look, at this point I’m ready to cancel the whole goddam surgery and find someone else!”

“No, no, no! I’ll talk to the doctor and let him know how you feel and you can discuss it with him.”

I called Peg, who spent the next three days dealing with the office, getting nowhere. Finally, she got a call from the new office manager, a far more reasonable person. They talked for a couple of hours about what appears to the patient to be a hostile approach to payment. It was both illuminating and infuriating.

High deductible health plans are sometimes several hundred dollars a month less expensive than plans with lower deductibles. Some high-deductible plans come with Health Savings Accounts (HSAs), a Republican wet dream Paul Ryan drags out as an alternative to the ACA. HSAs are funded with pre-tax dollars – a maximum of $3450 a year for singles and $6900 for families in 2018 – which can only be used for health care expenses, at least until the account holder reaches 65. Old goats like me (over 55) get to put away an extra $1000 per year in our HSAs. The plans still come with  out-of-pocket maximums of $7,350 for singles and $14,400 for families.

This is a great idea if your income level allows you to part with a few hundred bucks a paycheck and you’ve got a tidy sum in your bank account. It sucks if you don’t have the income, the savings, or if you anticipate ongoing medical expenses.

Here’s the problem. Lower income people get high-deductible plans because the premiums are affordable, but they are at greater financial risk because they don’t have the savings to cover the deductible. They may avoid preventive care if they are unaware that most high-deductible plans cover it with no out-of-pocket costs, opting to take a chance they won’t develop a more serious (and costly) illness later. Because they often can’t afford the deductible, they are more likely to default on outstanding medical bills. Hospitals and physicians have caught on and now demand money up front.

Asking for a down payment would be far more palatable if it applied to everyone. It’s no different than a contractor asking for money up front for a pricey remodeling job. Pay some now, pay the rest when the job’s done. But framing it as something required only of people who haven’t met their deductible implies they are deadbeats and is insulting. Further, waiting until a few days before surgery to extort money is infuriating. It should all be explained up front when scheduling the surgery.

The logical solution is universal coverage, but Congress lacks the political will and there are too many people making waaaaay too much money off the current system.

Hang on, because it’s only going to get worse.

 

Atonement

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Music has always been part of my life: a blessing; a balm; sometimes a curse. A local radio station pretentiously calls Baby Boomer classics “the soundtrack of our lives.”  The pieces that have augmented my existence are less well-known: the B sides; the obscure tunes once heard only on late night radio, nurturing our ears and caressing our souls.

One of those songs is “Triad”, from Jefferson Airplane’s album Crown of Creation. It begins with two acoustic guitar chords, inevitably triggering this memory. Cue up the track here before you read further.

Summer 1975. I see my 12th floor dorm room at the University of Illinois. There is no one else around—they’ve left for the summer—and even I’m not there. The lamp on my desk provides warm but incomplete illumination. Out of the window, in the west, I see the street lights along Florida Avenue and the silhouette of the Assembly Hall, a giant, concrete flying saucer just south of Memorial Stadium.  Beyond that, in the darkness, a slowly pulsating red light on a distant transmission tower.

The second guitar comes in with a haunting melody and the scene fades to midday along a long, straight stretch of two-lane blacktop. A lonely FINA gas station sits on south side, along the edge of the cornfields. A railroad track runs parallel to the highway on the north side. The road disappears into the heat waves rising in the distance. It could be any two-lane anywhere on the prairie, but this is U.S. 36 between Decatur and Springfield. I’m going to meet my girlfriend’s parents with a mix of anticipation and fear.

You want to know how it will be
Me and her, or you and me.

Her family lives in a tired, Depression-era house with Frank Lloyd Wright moldings on the upper window panes that have been painted over several times.. Her father is an alcoholic whose mind is now that of a prize fighter punched in the head one time too many. He greets me with a grunt, trying to be cordial, but won’t look me in the eye. Her mother is a woman with black hair whom I could imagine in years past wearing one of those frilly 1950s aprons with an old, heavy stainless-steel iron with the black plastic handle and the braided cord with the round plug, smiling while ironing the laundry, a regular Suzy Homemaker. But her face is taut, having been hardened by a life she would not have deliberately chosen. It was her lot and she stayed with it. That’s what you did back then.

Her father doesn’t like me because I’m the wrong color. “Why couldn’t you have found a nice white boy?” he asked her after I left. Her mother doesn’t like me because we’re sleeping together. “I don’t like how you live,” is how she framed it. It doesn’t matter that I’m planning on going to medical school. I declare my love and devotion to her daughter but she seems to know better. Later I will contemplate awkward holiday family gatherings and realize she is right. Despite that, she sincerely thanked me when I called a few years later to let her know her daughter’s tonsillectomy went well.

Your mother’s ghost stands at your shoulder
Face like ice — a little bit colder
Saying to you — “you cannot do that, it breaks
All the rules you learned in school.”

I ask her to marry me during my first year in medical school and give her my mother’s old engagement ring, the one my father, long deceased, gave her. She picks out a wedding dress and models it for me. It truly is a fairy tale, but I am totally incapable of keeping the promise I’ve made. I’ve not yet confronted my own demons and will betray her. Through tears of anger and unspeakable pain she will rage, “You had yourself a virgin!”

Did we love each other? Or were we just looking for the love and affirmation missing from both our lives?

Four decades later, in the shadow of my eventual mortality, the guilt surprises me and I try to atone for the sins of my youth. I am not alone. Others have confessed their own transgressions to me – relationships condemned by immaturity, selfishness or fate. We all seek absolution but there are no do-overs in life, no path to penance. We can only acknowledge our trespasses against others and move on.

I’ve thought of apologizing to her, but would I be doing it for her or for me? I will never know. for some things are best left undisturbed.

Commencement

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June is the month for graduations and commencement speeches. I accomplished the former in 1979 and it’s unlikely I’ll ever be asked to do the latter. I wrote this in 1998 in response to a long-forgotten question my sister-in-law asked and revised it for this blog post.

To all graduates, family members and faculty, welcome. It’s my honor to be here today. I might not be if it was not for persistence, determination, and the fear of being stuck with loans I couldn’t repay if I was unemployed.

First, to the esteemed faculty:

When I applied to medical school, admissions committees wanted applicants who looked good on paper: science degrees, high test scores, ambitious undergraduate years, and largely male. They frequently weeded out those with the characteristics patients wanted in their own doctors, replacing them with what they were most familiar – future Great White Fathers.  If those anomalies survived medical school and residency, they were often ostracized and driven out once in practice because they refused to follow the herd and questioned what we did. The heretics among you kept you honest; you needed them to grow. And you have made progress.

Medical school classes have become more diverse. Women made up slightly more than half of applicants and new students in 2017. The FlexMed program at Mt. Sinai’s Icahn School of Medicine in New York has admitted nontraditional students for thirty years. There are fewer white and more Asian-American students admitted, but the percentage of African-American and Hispanic students remains low.  A lot of work remains.

There are many different ways to teach and to learn.  The creation of medical schools was done, in part, to standardize what was taught and to ensure some semblance of consistency in medical training.  But much has been lost confining students to classrooms and expecting them to read volumes of medical literature taken out of context.  The old guys used to say, “Look at the patient, not just at the lab tests!”  Teaching at the bedside still has a place and cannot be replaced by expensive computer-controlled models or simulations.  It can be done with integrity and respect for the patient — and for the student.

Be careful what you say, for the damage might be permanent.

I did a month rotation with a faculty urologist during my junior year of medical school. At the end he wrote “He does not have what it takes to be a physician,” on my evaluation. I should not have been surprised; his over-achieving son, a year ahead of me, had highlighted the entirety of Harrison’s Principles of Internal Medicine – a 1200-page tome – in four colors, and he had purchased his own indirect ophthalmoscope. I was stunned, humiliated, and spent the next six months wondering if he was right, if I should drop out and career for which I was better suited.

Remember the golden rule.  Do not “teach” medical students with sarcasm, derision or humiliation. Bitter, cynical students and residents become bitter and cynical physicians. We all suffer for it – patient and physician.  If you can’t say something nice, don’t say anything.  But it is not that hard to find something good in someone.

Always teach the art along with the science.  Teach students and residents to laugh and cry with their patients, to rejoice in the little accomplishments and grieve for the losses.

Above all, teach them the grave responsibility that comes with the profession. This is not shift work; a job to endure until retirement. It should still be viewed as a calling.

To the new graduates:

Even though William Hurt’s movie The Doctor is dated, all beginning medical students should be required to watch.  Your patients will be people with weaknesses and vulnerabilities hidden behind their strengths. You share those same weaknesses and vulnerabilities although you are loath to admit that to yourselves, your colleagues and your families.  Walk many miles in your patients’ shoes; you will be a better physician for it.  Accept that you are not perfect and never will be; your patients already have.

Long gone are the days when a physician hung out a shingle and practiced the way he wanted in an office he owned, before he retired after forty years. I say “he” because back then women physicians were few (and resented). Many, if not all, of you will be employed by a corporation.  Be careful and realistic.  The perceived security of a steady salary, liberal vacation and “avoiding the business hassles” comes with a hefty price tag.  When we trade autonomy for financial security, we end up with neither.  Some of my colleagues regretted selling their souls.  You will be judged on how much you cost the company, not on how compassionately you treat patients, which may adversely affect the care you provide your patients.  You will also be judged on your loyalty to those who sign your paycheck. They expect you to be a “team player,” even when the team bus is headed for a cliff. Or, as one of my former partners asked me, “Why can’t you just take the money and shut up?” Don’t leave your conscience at home.

Managed care is not intrinsically evil, but its implementation has been fouled by greed, callousness and stupidity.  It is an imperfect response to the rising cost of health care, an event which has largely been ignored by the medical profession.  My predecessors robbed the candy store and left all of us with the aftermath.

People do not trust the health care system; you can help restore that trust.  But don’t make promises you can’t keep.  Properly managed, there will be care for all.  But health care dollars are not infinite. You must choose between want and need; what is desirable and what is necessary.  As the Rolling Stones sang, “You can’t always get what you want, but if you try sometime, you just might find, you get what you need.”

Beware of the Golden Handcuffs. Avoid conspicuous consumption and remember money cannot buy happiness.  You can’t spend it if you are 6 by 6 in the dirt, and you can’t take it with you.  He who dies with the most toys still dies.  Keep in mind you will still be making more than 99% of the population.  Also remember you told the admissions committee some ridiculous story about going into medicine to help people, not to make a lot of money.  If you tell a lie long enough, it becomes the truth, so make it true.

Be kind to nurses, because they can make your life easy or a living hell. They also have your back and may one day prevent you from doing something completely stupid.  You owe them far more than those in the administrative suite who often have no idea what you really do.

Be grateful and acknowledge the other people that help you do your job: unit secretaries, housekeeping, maintenance, phlebotomists, transporters, techs. It won’t kill you to smile and say hi. Trust me, they will notice.

Find other things to do with your life.  Medicine cannot be your entire universe; you need to strike a balance in your personal life.  If not, your spouse may leave you, your kids may hate you or, worse yet, not know you.  You will be tempted to ease the pain with drugs and alcohol.  Some of you may be driven to suicide–a waste of a good doctor and the taxpayers’ money.  You won’t be much good to your patients–and yourself.

Don’t be afraid to pick up a colleague who has fallen.  Someday, the favor may be returned.  Don’t compete, keep score, or ostracize each other.  There isn’t any point.

If you find yourself wondering why you go to work in the morning, it is time to pick another profession.  If you never question why you go to work, you made the right choice.  This has been an honorable profession.  Let’s keep it that way.

Thank you and good luck.

Stop Whining

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I came across the plaintive tale of a young OB/GYN physician, Dr. W, who decided to bail out of practice after less than a decade. She gave several reasons: falling asleep while driving home and wrecking her car; missing out on birthdays and weddings; sticking herself with a needle while drawing blood from the umbilical cord of an HIV positive patient and felling like crap while taking prophylactic antiretroviral drugs. Worst of all, she discovered health care wasn’t what she thought it was when she started residency, and that physicians are “only pawn in game of life,” albeit very well-paid pawns.

I can hear the ghosts of the old timers saying, “See, we told you women had no place in medicine!” I can also hear the voices of the women with whom I went through medical school four decades ago yelling, “Shut the fuck up! Do you have any idea what we had to endure so that no one now thinks twice about women in health care?”

Being a physician isn’t a nine to five job unless you’re a dermatologist. Obstetrics is a grueling, physically demanding profession and four years of residency should have made that intuitively obvious. Babies arrive at all hours. So do emergencies like ectopic pregnancies and twisted ovaries. Someone has to take care of those patients and sometimes we must go above and beyond the call of duty in the name of patient care.  Good labor nurses frequently stay past the end of their shifts to follow through on pending deliveries.

My first post-residency job was in rural Michigan with a former fellow resident. We did every other night call which turned into solo call when one of us took vacation. Two years later I joined three ob/gyns at a staff-model HMO, doing call every fourth night and every fourth weekend. I did 250 deliveries a year, four years in a row. Sometimes it was so exhausting – I didn’t know my own name after doing thirteen deliveries one weekend – but it was nowhere near as bad as residency.

Those of us who’ve been in this biz for a while aren’t oblivious to the dangers of sleep deprivation. The Institutes of Medicine, the Joint Commission, and even The American College of Obstetricians and Gynecologists (ACOG) recognize the problem. But you made one choice when you entered residency and another choice when you started practice. There’s a middle ground between working yourself into an early grave and quitting altogether. You just have to find it.

I’m a hospitalist in a town with about forty OB/GYN physicians, mostly women, in groups of six to ten. Most of them are mothers; one of them has six kids! They take call a few times a month. Yeah, sometimes staying up all night gets old, but they are making far more money than I could ever fathom and it’s hard to walk away from those golden handcuffs. Working part-time is one possibility but you can’t expect a full-time salary.

Dr. W. said, “no one wants to hear a doctor complaining about their job.” No shit, Sherlock. What makes you think physicians are the only people who work odd hours, miss out on family events and suffer from sleep deprivation? Municipal workers where I live (the Midwest) stay out all night plowing and salting snow-covered roads in the winter. Many sales reps spend a lot of time driving or flying to clients and living out of suitcases. Store managers are the first to get called in if there’s trouble – a fire, a water main break, a burglary – and they fill in on the floor when someone doesn’t show up for work. My brother-in-law calls his Asian-Pacific vendors in the dead of night because that is when they are doing business. Many of those people make a lot less money than you, but it’s part of the job and they don’t whine about it.

I had joint custody of three kids and worked full time. I picked them up from daycare and/or school, cooked dinner, bathed them and read them stories before tucking them in. I made them breakfast the next morning before getting them dressed and dropping them off. I did laundry, housekeeping and grocery shopping with no help. I missed some things, but my life was far easier than someone on active duty spending fifteen months in a war zone, just hoping to come home alive.

(c) Can Stock Photo / zabelin

I’ve never worried about acquiring HIV from a needlestick because the chances are about 3 in 1000. I don’t double-glove when I do surgery because I can stick a needle through two pairs of gloves just as easily as one. I worried more about acquiring influenza from women who came to my OB Emergency Department hawking up hairballs this past flu season.

Health care started changing in the 1970s, not the mid-aughts of the 21st century. I came of age between the Great White Fathers who could do no wrong (and who had easy access to amphetamines, so they could function like superhuman gods), and the employed physicians of today who ceded autonomy for financial security and lost both. Administrators, insurance companies and the government started telling us what to do in the mid-1980s when the money got tight. Capitation, diagnosis-related groups (DRGs), relative value units (RVUs), and the overly complicated ICD-9 coding system (now the hilariously overly complicated ICD-10 system) made unending paperwork an integral part of practice. Medical coding and billing is a multibillion-dollar industry.

I left the rat race over twenty years ago, largely because I got tired of the people who signed my paycheck lying to me. I became a locum tenens physician and traveled around the country. I made a quarter of what I could have made in private practice, but I could just do my job, get paid and go home. No meetings. No hospital politics. No turf wars. If the situation became untenable, I could give thirty days’ notice and walk, something I did only twice. And, I didn’t have to pay a $150,000 tail for liability insurance.

What troubles me now is seeing a generation of physicians for whom practice appears to be just a job to endure until they make enough money to retire. I can honestly say that for me medicine was a calling (I was thirteen when I decided to go to medical school). Now I’m just praying for a quick and painless death in lieu of spending my golden years beholden to some baby doctor who doesn’t listen, can’t think and is just going through the motions.

Crying Girl: (c) Can Stock Photo / jirousova