Random Thoughts from a Restless Mind

“Manic depression is touching my soul.”

You’re up;  you’re down. You’re happy; you’re sad. You have the best job in the world; thinking about going to work makes you sick to your stomach. You’re so good at what you do, everybody loves you; everyone is out to get you.

You are an American physician.

Recently I’ve been asked at least a dozen times why I became a doctor, or why I became an eye doctor. I’m not really sure why this has come up now, because most of the people who are asking have known me in some way for many years. Why I became an eye doctor is really rather simple, and I have written about it HERE. The question “why did you become a doctor” is much more complex, much more involved, and frankly I’m beginning to wonder about that myself.

“Why do you want to be a doctor” was at the same time the easiest and most difficult question for me to answer, especially during medical school interviews. I grew up in a small, dying mill town in Massachusetts. The happiest, most fulfilled, most IMPORTANT people in that town were the doctors, of which there were very few. The busiest surgeon in town, Dr. L., could possibly have been the happiest person in the entire town. Beautiful wife, attractive, intelligent, athletic children, really big house. He was even a decent golfer! I don’t think I ever saw him without a smile on his face.

It was Dr. Roy, though, my pediatrician, who really clinched it for me. There must have been another pediatrician in town–heck, there were 24,000 people there. For the life of me, though, I can’t ever recall any of my friends seeing any doctor other than Dr. Roy. He was confident. Secure. Always with a gentle smile whether in the office or on Main Street. My mom later told me that he was perhaps the most influential politician in town as well. Everybody looked up to Dr. Roy, no matter how young or old they might be. His was a happy, contented, full life, largely because he was a respected physician.

Can you name a single pediatrician now living and practicing in the United States whom you would describe like that?

Nevertheless, that’s mostly why I wanted to be a doctor. I want to be Dr. Roy. I wanted people to look up to me because I was good at doing something that was important, something that was meaningful to their lives. All of the doctors in town were like that.

Now? Well, I’m a 51-year-old eye surgeon and I am just like every other physician in the United States. I swing between the euphoria associated with a good outcome or a happy patient, and the bitter black hole that appears when a disease wins. My world is actually pretty good in this regard: for every defeat there are literally hundreds of victories. For every patient who is dissatisfied or unfulfilled there are hundreds who can’t wait to tell everyone in their lives how good their experience was. It’s just that there seems to be a couple more people who are less satisfied. A couple more each year.

Again, the success rate in my particular specialty is incredibly high, and these people who are less than satisfied have actually had an extraordinary good outcome if you look objectively. I think it all tracks back to the creeping consumerism in health care. It’s not good enough to have an outstanding outcome, it’s only truly even good enough if it meets the expectations of the consumer, the patient, no matter how outlandish or inappropriate those expectations might be.

I’m up. I’m down. The downs seem to hurt more because they are so much more, I don’t know, personal now.

I always got the idea that there was pretty much nothing to the business of being a doctor. All the docs seemed to have enough money, although none of them seemed wealthy. There was only one “girl” in the office and she made the appointments, gave you your bill, and took your payment. No back office or billing department. No special personnel responsible for charting, compliance, insurance communications. My “chart” was a couple of 5×7 cards stapled together.

Now? Oh man…the squeeze is coming from all directions. Private practice or big group practice, it doesn’t matter. You either deal with the external forces conspiring to make it more unpleasant to make a living as a doctor (insurance companies, the government, malpractice attorneys) or you deal with your boss (or more likely your boss’ secretary since you’re just another employee, after all). Your chart is now a legal document littered with land mines meant to ensnare even the most pious and dedicated among us.  Most docs do OK financially, maybe not 1%’ers but pretty well. It just seems like so many folks go so far out of their way to make us feel like we don’t deserve our pay. Any of us. Any of it.

I’m comfortable; you don’t deserve it.

Now, if you are not a doc you could sit back and rightly say “quit yer whinin”. I’d get it. I just can’t shake the feeling that Dr. Roy, and all of the Dr. Roy’s of the day, got and gave more out of what medicine could offer than any of us do now, despite the fact that those of us who practice now have so much more at our disposal on the medical side of the equation. It just doesn’t feel as good. There’s just too much that comes between doctors and that sense of service, of satisfaction in those bygone days. It just seems so much like work now. I don’t think Dr. Roy ever went to work. I believe he would have practiced pretty much the same way if he’d inherited a million dollars.

You’re up; you’re down. You have the best job in the world; you can barely make yourself open the office door. Everybody loves you;  you don’t deserve it.

“Manic depression is a frustrating mess.”

It’s the jobs, Stupid. That’s what should be on the office wall of every legislator at every level of government across America. Say what you will about Bill Clinton, but did anyone ever get it more than that first Clinton presidential campaign? A simple sign in their campaign war room reminded everyone of the central message: “It’s the economy, Stupid!”

It’s more than that, of course. Now, you could say, “It’s the jobs, Stupid!” What can you do to stimulate the creation of jobs now? Sure, you can take a page out of Rahm “Never Waste a Crisis” Emmanuel’s book and combat our crushing unemployment by pumping money into grand public works. Who doesn’t agree that our bridges, roads, sewers and subways are in dire need of repair? But everyone was enticed by President Obama’s promise of “shovel ready” public projects into which stimulus funds could be pumped, followed instantaneously by the hiring of willing hands to man those shovels. Stimulus I didn’t really turn out that way, so why would we embark on Stimulus II? Or III? Return on this investment was pretty much zero.

Nothing will get our economy moving faster and restore our national spirit than employing more people, and at a higher wage. Let’s take a quick look at the kind of job sector that would be most desirable.

Any industry into which we might pump money should have the ability to ramp up employment at the first dollar of public investment, or the first loosening of a needless regulation. OR BOTH.

Any sector targeted should be able to create and fill jobs across a broad range of salary, experience, and skill levels, and it should be relatively gender-neutral. It should reward achievement and educational advancement. Any jobs created should be domestic, although any hard products created must be attractive for export. It should be an American business sector that is expanding now, and poised for additional growth.

Pretty ambitious list of criteria, huh? Where will we ever find an industry or economic sector that could fulfill all of these criteria without some new genius discovery or mega-bureaucratic mischief?

Easy. Healthcare.

Think about it. Right now our country is fixated on cutting the money flowing into healthcare businesses such as hospitals, nursing homes, and doctors’ practices. Government regulations make it more and more difficult to make a profit while providing healthcare. Perhaps more frightening is the fact that similar regulatory agencies make it nearly impossible to bring new medical products to the market or build the sales of existing products.

Despite that, healthcare and related industries (pharmaceutical manufacturing, medical device manufacturing, health insurance administration and sales) continue to grow in all ways that we can measure, except the most important one: jobs.

I know your reaction. “We’re gonna go broke paying for healthcare as it is; how could we possibly pump MORE money into that?”

Hear me out before you dismiss my theory out of hand.

Every new regulation, every new requirement, every cut in payment for an office visit or a medicine or a hospital stay results in a net LOSS of jobs. And worse, pretty much no one in the entire healthcare and medical sector is hiring now, partly because of declining pay for services and products, and partly by the gloom caused by an assumption that the future holds nothing but more of the same.

We should try to identify regulations to remove. Start with removing the prohibition on drug companies marketing so-called “off-label” use of prescription drugs when it is clear they are beneficial. More sales of existing drugs means more jobs. More sales of existing drugs — along with fewer barriers to approving new drugs — means even more jobs.

People in healthcare and related businesses make a good wage, and there are jobs available across a broad wage scale. These folks buy houses, employ skilled trades, go out to eat and the like. As they advance, they earn higher salaries, and then they do the American thing: they spend it!

Pump more money into healthcare rather than less. Stop all of this talk of cutting payments to hospitals and doctors and instead index fee increases to inflation. Stop reducing Medicaid rolls and give doctors and hospitals an incentive to care for these people by increasing Medicaid payment to the levels of Medicare. That would create more jobs.

Education matters in all things medical, whether you are a doctor or someone working in a pharmaceutical factory. Generally, the more education you have, the better you fare economically. There is no systemic gender or race discrimination in healthcare. With doctors, nurses, hospital administrators, academicians, the only requirement is to be good at what you do. Same thing in related industries like medical device manufacturing; ambitious people of all types, men and women, young and old, can advance in their careers. Advancement means more job openings.

And guess what? More jobs means generating more income that can be taxed! More jobs create more spending and more sales that can be taxed! You could even encourage more of this by decreasing income taxes on those people most likely to spend that money, which would then create…wait for it…more jobs!

Oops. Sorry. Politicians are involved. Decrease taxes? That’s just crazy talk.

The next thing you know someone will propose some really crazy thing, like increasing the money we spend on healthcare.

*Credit for the idea to William J. Petraiuolo, M.D.

“I’m sorry, Doctor, but we can’t have you give that talk; you have a conflict of interest since you’ve been paid to do research on that medicine.”

“Well, Senator, it’s a conflict of interest for a doctor to sell those crutches in his office.”

“It is the opinion of this newspaper that physicians should declare to each patient any ownership interest they might have in a surgery center so that the patient is aware of any conflict of interest.”

And on and on the drums beat, droning incessantly and insistently about the dreaded “conflict of interest”.

In a world now run by the terminally attention deficited, with multi-tasking and synergy-seeking all the rage, we apparently have one domain in which nothing but the purest, most antiseptic, monastic and single-minded devotion to a single task and goal is acceptable: the provision of health care in America. Think about it…the simple existence of OTHER interests is de facto evidence of some nefarious CONFLICT of interest. The underlying assumption appears to be that it is impossible to have any additional interest–ownership of a business, a consulting agreement, stock or stock options–without the ability to devote your primary attention to the best interests of your patient. Any other interest is automatically bad, and every physician is guilty and can’t be proven innocent. How did we come to this?

There are issues and examples both substantial and trivial, and yet each of them is addressed as if they are one and the same. I bought pens last month for the first time in my professional career (I graduated from med school in 1986). It was weird. Who knew that there was a place called Office Max and that this huge store had not one but TWO aisles of pens to peruse?! I think it was Bics in a KMart the last time I bought a pen. Somehow this fact means that I have been making decisions for my patients based on all those pens I DIDN’T buy all these years. There’s only one problem with that: I don’t remember a single thing about even one of those pens.

And yet somehow accepting those pens is a “conflict of interest”. Seriously.

Why is it that if I somehow get something from someone, big or small, even if I perform some service or even buy something from them, that it’s a “conflict of interest” if some company or other might make money from what I do for my patient? Why is every peripheral interest that exists around the little silo in which I practice medicine–a space occupied by me, my staff, and my patient–why is that automatically a “conflict of interest” with some sort of negative connotation? That I must be doing something bad? Why not just “another interest”? Why can’t these things be a “convergence of interests” between what is best for my patient and any of the other stuff that might be going on around us?

Listen, I get it. There have been instances where docs have pushed inferior products on their patients because they had a significant financial incentive to do so. I’m reviewing a med-mal case right now where the plaintiff had an eye problem which resulted in cataract surgery. The cataract surgeons are not being sued, but I looked over the surgical record and saw that they put an inferior POS lens implant in this guy’s eye, and I KNOW they did that because they own the surgery center and that lens is dirt cheap. THAT’S a conflict of interest. But for every surgery center owner like this putz I know 50 who put in state-of-the-art implants because that’s what’s best for their patients. Those docs still make a profit, but it’s smaller because they are putting the patient first. Why is THAT a conflict of interest?

It’s not.

Three different companies make 3 versions of the same kind of medicine, all of which have identical efficacy and safety, and all of which sell within pennies of each other. How does one choose among them if one needs to be prescribed? Is it such a heinous insult to humanity to choose to prescribe the product from the company that pays the doc to consult on some other project? Or the company that brought in lunch? Or (GASP!) the one that left a couple pen lights in the office? Tell me, how and why is this a “conflict of interest”?

This trivialization of the concept of “conflict of interest” is actually weakening the protections that we should have against REAL conflicts that cause real harm. Pushing unproven technology (artificial spinal discs, anyone?) on unsuspecting patients prior to definitive proof in return for obscene “consulting” agreements, for example. Applying the same degree of moral outrage to a ham sandwich as we do to conflicts which truly pit the best interests of our patients against some profound interest on the part of the physician that prevents him/her from centralizing the patient is farcical moral equivalence. I think it is actually harming our patients.

Our most renowned medical editors, innovators, inventors, and teachers are withdrawing from public positions that require a monk-like aversion to these “conflicts of interest”. Who will replace them? Will the ascete cocooned in the conflict-free zone and unaware of what developments are on the way contribute? How about the teachers? Will we be taught by “specialists” who put together the purest power-points from the latest scrubbed articles, priests who are not stained by the sins of the those who are touched by the commerce of medicine by actually touching, you know, patients?

Here’s my bid: a true “conflict of interest” is one in which there is an essential tension between what is best for a patient, and some other ancillary benefit that might accrue to the physician. Something that makes the doc think about that other benefit first, before the patient. Everything else is an “additional” benefit. We should stop this silliness; stop trivializing the concept of “conflict of interest” through the dumping together of all other interests in the same gutter. We should all be allowed to ignore all but the truest of conflicts as we continue to put our patients’ interests first.

We should be allowed to seek a “convergence of interests.”

Uncle. I give up. Full surrender. Total capitulation. I cannot beat the takers.

It’s funny because my first three drafts of this missive started out “stop the madness”, but I can’t. It won’t stop. The “Do-Gooders” and “We Shoulders” who make the decisions because “they think” or “we feel” have beaten me. Beaten everyone like me. The white flag is up. Turns out the windmill is really a dragon, and contrary to what it says in all the fairy tales the dragon always wins.

You see I, Dr. Quixote as it turns out, thought that being right made a difference. I thought that data, precedent, FACTS would rule the day. Silly me. Silly, sorry sad little me. I thought it was about patients, patient outcomes, statistics, but all along it’s been about the system and protecting the system, protecting it from the very possibility of theoretic risk, protecting it from…patients.

Here I was looking at yet another cost being added to the experience of my surgical patients and asking why a change was being made. Why were we opening a new bottle of $13.00 eye drops for each laser patient, when each bottle held enough medicine for 100 patients? Why were we using a new vial of antibiotic to be injected into the infusion bottle of each case, when each vial held enough medicine for 5 cases? Why, indeed, when there had never…not once…been a reported case of acquired infection, ever, from using one bottle or one vial. Ever. When eye doctors in their offices use and have used, bottles of eyedrops until they can’t squeeze our a single extra molecule. Why?

I blanched at the waste. Plastic baggies of bottles full of drops carted to the trash. Vials of man’s best antibiotics less the microliters used for one surgery crowding the sharps buckets. It was unconscionable, an insult to Puritan and non-adherent alike. The amount of waste nothing short of vulgar.Did no one else see this? I mean, here we are in the supposed throes of a healthcare crisis born of excess and waste, and yet I, Dr. Quixote, flailed alone?

Data…surely data would prevail. Look at the cost, I cried. Never mind the insult to the Puritan ethic, simply look at the cost! You can’t bill the patient, though Lord knows you’ve “mistakenly” done so innumerable times. It’s a cost. It decreases “revenue in excess of expenses” (you’re a non-profit…I get it…we can’t call it profit). I even understand why you’ve spurned my entreaties about Pre-Admission Testing even though there was an article in the New England Journal of Medicine that said PAT is unnecessary. The NEJM is the only medical journal that God reads, and even SHE knew I wouldn’t win THAT one because you can get PAID for PAT. I get that one.

You’ve beaten me. Today I see it. You sent in the REAL decision maker, one of the people who make the decisions in this new age of medicine. I was still under the illusion that maybe I, a doctor, was a decision maker. That I, a doctor who looked at and liked real data, had a vote, some skin in the game. No, today you sent in The One From Pharmacy. I have seen the One With Power and now I know that I am beaten.

The One From Pharmacy has all the words. He has all the weapons. “It’s only fair that each patient receive the same freshly opened bottle/vial.” “What if we have an infection and we re-used a bottle? How could we ever face that patient?” “Here’s an article by a pharmacist that says you could possible have contamination of an open bottle.” “Should we ignore this article that discusses the theoretic possibility of infection?” I also know from prior conversations with The Hospital Administrator that The One From Pharmacy cannot abide not knowing the destination of each drop, cannot abide not having the option of charging each individual patient (if only he could) for each medicine, and that a new bottle must be opened and assigned to each patient for this purpose. This I know.

Oh, I tried. I really did. I tried to point out that each of the articles the The One From Pharmacy shared with me were nothing more than opinion pieces, essays that were little more than editorials sharing one author’s thoughts. His or her feelings. “I think,” therefore it must be. But…but…but…there’s no DATA. No evidence. Nothing to refute decades of experience in the operating room. No results or reviews showing that the status quo is dangerous, only some somebody who managed to get what “they think” into some non-peer reviewed journal.

“Doctor, are you saying that we should just IGNORE these articles? You would have us simply continue with business as usual? The governing bodies ALL say this COULD happen. Are you saying that we should ignore what they THINK?” I confess, I had no answer. I was paralyzed, caught between my horror at the thought that decades of success, as well as common sense so obvious it made stomach hurt, were to be tossed aside because of some someone’s feelings, and my fascination at the sheer revulsion registering on the face of The One From Pharmacy. Funny, he wasn’t anything at all like what I thought the dragon would look like.

I stood there for a moment, bleeding, as the realization slowly came to me that I was defeated. Vanquished. It’s a shame, really, because doctors of my generation are the last, best hope for all of us. We bridge the divide between the ancients who lived through the Golden Age of Medicine–the Giants who cured polio, discovered antibiotics, replaced joints–and the moderns, the nextgen who will live through the silicon age of medicine–Dwarfs who will serve a system, cure the economics, replace care.

I felt small, diminished, inconsequential, a failure, a disappointment. It was hard, frankly, to haul my carcass to the operating room to begin my work day. Yet that’s exactly what I did. I mounted my steed and raised my lance; slowly, ever so slowly, we rode alone to the operating theater.

A white flag, attached to my lance, waving in the breeze.