Tag Archives: physicians

Angels in Scrubs

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Physicians taught me how to treat diseases. Nurses taught me how to care for people.

It’s no secret that I feel more of a kinship to nurses than I ever felt to physicians. I was an orderly working eight-hour shifts with nurses long before I went to medical school. I saw what the nurses did, how hard they worked, and how the orders physicians gave, with little thought to implementation, affected them directly. They also treated me as part of a team, not as cheap labor to be abused and berated.

During my internship I quickly learned that nurses can make a physician’s life easy or a living hell. I threw myself on the mercy of the head nurse at the beginning of my ICU rotation and she guided me, suggesting drug dosages, ventilator settings and letting me know when to call for help.

Obstetric nurses taught me about the natural progression of labor: when a woman entered active labor, when she was in transition, when to intervene, and when to leave well enough alone. (Thanks, Marj B!). One threatened to teach me about labor: “We’ll shove a bowling ball up your butt and then tell you not to push.”

Clinic nurses taught me to treat Medicaid patients with kindness, respect and a little tough love. They also taught me I could not solve everyone’s problems.

Once in practice I realized I couldn’t do my job without nurses. They spent an eight or twelve hour shift with a labor patient while I was in the office or tending to someone else. Sometimes they would stay past shift change if the woman was close to delivery. They started IVs, ran Pitocin, magnesium sulfate, antibiotics, and blood. They comforted a woman while she got a spinal or an epidural anesthetic. And they were the first to resuscitate a baby in trouble.

Nurses watched over my patients after surgery, while they recovered from serious illnesses, and while they slept. One seasoned med/surg nurse told me what drug to order for a little old lady whose daily cocktail was a lot more than “mostly ice;” she went into “D.T.s (acute alcohol withdrawal, the night after her surgery.

Nurses are not afraid of anyone, including physicians, who sometimes do really stupid things. Chocolate and contrition goes a long way towards appeasing them. Not pissing them off in the first place goes even further.

Physicians live by “every man for himself,” with, until fairly recently, an emphasis on “man.” Nurses support each other, and physicians who stand up for them. They don’t have massive egos (for the most part); they just have to deal with those egos every day.

Nurses will cry with you after you’ve delivered a dead baby, or when someone with a terminal illness finally loses the battle. They’re eternally grateful when you have the foresight to buy everyone lunch because the day is going to hell and they will never make it to the cafeteria.

So Happy Nurses’ Week to all the nurses of various species I’ve known: registered nurses, licensed practical nurses, advanced practice nurses, nurse practitioners, certified registered nurse anesthetists, and my favorite, certified nurse midwives and L&D nurses.

 

Jurassic Doc

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I don’t recall the exact moment I realized I was sliding towards obsolescence, but by that time it didn’t matter because I didn’t care.

I did my residency during the early days of ultrasound; images looked more like a Rorschach inkblot than pelvic organs or babies. We all believed radiologists made shit up when they read ultrasounds. Few things were more irritating that having one emphatically identify a non-existent tubal pregnancy, committing us and the patient to an unnecessary exploration.

We used one of the first TV cameras adapted for a laparoscope, a rather bulky attachment whose picture was as atrocious as it was fascinating. The attending physician watching the monitor while the residents tied a patient’s tubes laparoscopically said, “Maybe I DON’T want to see what you are doing.”

The hospital where I did my internship bought a Computerized Axial Tomography (CAT) scanner, a great advance over simple x-rays and a fortuitous event. One of the radiology interns volunteered for the initial scan and discovered he had a brain tumor. Word got around only after people began questioning the sudden onset of baldness.

Technology’s transition from medical advance to hospital marketing tool started in the 1990s. Physicians touted “minimally invasive surgery,” which some patients interpreted as “painless and risk-free.” Magnetic Resonance Imaging (MRI) replaced CT scans and generated new revenue as outpatients sites opened. (One small town boasted five MRI machines.)

Administrators became enamored with robotic surgery in the early 2000s, buying a toy that cost $2 million and came with a $150,000 annual service contract. Initially acquired by large private and university healthcare systems, robots found their way into small community hospitals looking to attract more customers to augment declining revenues.

I’ve always been cautious; I was never the first to embrace that which was new and heaped with promise. My choices were often met with incredulity. “What? You DON’T treat warts and cervical dysplasia with a laser?” No, but thirty years ago I saw physicians willing to plunk down fifty grand for an office model, even though they had no idea how to use it. Those contraptions are likely catching dust in a closet, having been supplanted by the far simpler wire-loop cautery known as LEEP.

I never cared for doing surgery exclusively with a laparoscope. I could take out a tubal pregnancy through a small incision and be finished in the time it took to set up all the laparoscopy equipment. I didn’t get on the Laparoscopic Assisted Vaginal Hysterectomy (LAVH) bandwagon, having watched my colleagues turn a 45-minute procedure into a seven-hour ordeal. I learned “new” wasn’t necessarily “better” but was always much more expensive.

I preferred delivering babies to gynecologic surgery, and most of my subsequent jobs were for obstetric coverage. I stopped doing major gynecologic surgeries in 2007, relieved. Then earlier this year an office nurse said, “Any woman who has a big scar on her belly from an abdominal hysterectomy should sue her physician for malpractice.” I’d passed the point of no return and was on the way out.

I don’t mind being a dinosaur, partly due to the direction my profession has taken. We spend far more money than twenty years ago for very little tangible benefit. Younger physicians rely too much on lab tests and scans and too little on actually listening to and examining their patients. I don’t want to talk with a patient while typing notes into a laptop—the health care version of texting during dinner. And I don’t want to take ten minutes to generate a prescription from an electronic medical record (EMR) when I could do it with a pen in 30 seconds.

I’m looking forward to retirement and I’m happy to pass the baton onto a younger generation. My only regret is that I probably won’t be around in thirty years to witness the same realization cross their once-eager faces.

The Sky Is Falling! Obamacare is Coming!

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A physician shortage is one of the many catastrophes conservatives claim will befall the country if Obamacare isn’t repealed.  Alyene Senger, in a Heritage Foundation Issue Brief, thinks declining Medicare and Medicaid reimbursement rates combined with obnoxious bureaucratic oversight will cause already dissatisfied physicians to retire in droves and dissuade younger people from becoming doctors. Jeff Tangney, CEO of the physician social media site Doximity, Inc., predicts we’ll be short 90,000 to 150,000 physicians by 2025 as 30 million people obtain health insurance.  The unstated implication is “You’re screwed because some undeserving, lazy moocher is getting the health care you worked so hard for, and YOU’RE paying for it.”

This is wrong on so many levels I’m not sure where to start.

 Overwhelming the system?

The uninsured have always been there but now they will have health insurance. Barring an unexpected pandemic, thirty million people aren’t going to become sick on October 1, 2014. People won’t be trampling each other in a Black Friday-like rush to the doctor’s office. More may now seek preventative care, but not necessarily.  My well-insured sister-in-law hasn’t had a Pap smear in 24 years.

 The scourge of Medicare and Medicaid?

Physicians were predicting disaster before Medicare was enacted in 1965. Ronald Reagan railed against “socialized medicine” in 1961. Now, they love it because it pays them for taking care of old people. My late father-in-law’s internist got a hundred bucks for each five minute visit.

More people on insurance means more revenue for physicians and hospitals instead of bad debt write-offs.  The same holds for Medicaid. Many physicians refuse to see Medicaid patients; those that do accept those patients out of necessity or a sense of moral obligation. More people will be eligible for Medicaid but the Feds will be throwing more money into the pot, so what’s not to like?

 Doctors leaving in droves?  I don’t think so.

The independent, solo practitioner is almost extinct. More than half of all physicians are employed by a hospital or a healthcare system and don’t have to worry about the bureaucratic headaches of private practice. Younger physicians find this attractive because they want a life outside of practice.  Employers like them because their young minds can be molded into the corporate way. Established physicians like the idea of a guaranteed salary and potential productivity bonuses.  And many, if not most, physicians will shut up and endure for the right price. Those of us nearing retirement may get out early because we’re tired, but Obamacare provides a convenient excuse for the complainers.

For the past thirty years I’ve heard physicians complain that “the practice of medicine isn’t fun anymore.” But they are also bound by the golden handcuffs. The average physician income is $259,000/year and even primary care physicians average a healthy $189,000/year.  It’s hard to walk away from all that money. Trust me; I still see a lot of luxury cars in doctors’ parking lots, including one Tesla Model S.

You will still get the medical care you need.  Everyone should.