Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

Cape Cod

Posts Tagged ‘insurance’

Epilogue to “Mommy-Track” post on “Equal Pay Day”

In 2011 I wrote an essay in response to an article I read in the WSJ on the coming physician shortage. In short I agreed with a letter that pointed out the effect of physicians working fewer hours than they had traditionally worked. In that letter the effect of the changing demographics in medicine (more women physicians, generational shifts) was pointed out. My essay agreed with the points in the letter. My thesis is that you can’t “have it all”, in medicine or anywhere. Someone, somehow, always pays.

While reading about “Equal Pay Day”, the day on which the “average female wage earner” achieves the same amount of pay as the “average male wage earner” acquired in the previous 12 months, a couple of things strike me. First, the general thesis of my essay continues to be accurate, at least in medicine. Income is determined by the choice of specialty, as always, but beyond that it is driven much more so by the number of hours a physician works and how productive that physician is during those work hours. Work more hours, get paid more money. Perform more of your doctorly duties in each one of those hours, get paid more money. There are fewer and fewer physician jobs in which seniority on its own drives income, thereby negating any lack of seniority which may be caused by a career “pause” to have or care for children. Physician income is largely gender-blind. As an aside, the dirty little secret of physician pay is that production-based compensation is the norm everywhere, even at those institutions that claim otherwise.

The second thing that strikes me is the malignantly erosive effect of ineffectual, unnecessary external regulation on the practice of all medicine on effective physician work hours. In 2014, whether you are a man or a woman, the bureaucratic load associated with practicing medicine is oppressive, and hours that just 5 years ago may have been spent caring for patients is now spent caring for charts, bills, and other paperwork. These hours generate no real health benefits for patients, and do not produce any revenue that pays the doctors for working them. In a particularly cruel example of Murphy’s Law, or at least the Law of Unintended Consequences, the specialties that are hardest hit by this relentless onslaught of the unnecessary are those that tend to pay physicians the least. Fields like Family Practice and Pediatrics. On “Equal Pay Day”  it is particularly ironic to note that those hardest hit specialties tend to be staffed by the highest percentage of female doctors.

A final note as I read this post 3+ years after the initial writing: the choice of “Mommy-Track” to describe those women who graduate from medical school and work fewer hours than their male peers because of their choice to prioritize their families seems needlessly pejorative and provocative. I’ve left it in for this Epilogue because to edit it today seems dishonest in a way. Besides, I’m a little bit better at writing in 2014 than I was in 2011. I can be plenty provocative now without resorting to the pejorative.

Slip-Sliding Away

The announcement came in the mail, by email, and proclamation at a dinner. My good friend (and personal physician) would be retiring from the practice of medicine at age 55 to take a position as a very senior hospital administrator. This news was delivered by another physician friend, a 55 year old orthopedic surgeon who put my wife back together after a Humpty Dumpty fall off a horse, during a dinner at which he described his intent to drastically reduce his call schedule and ER coverage. That morning in the OR I was chatting with an industry rep who was telling the story of an extraordinarily talented 45ish year old cataract surgeon who has limited his daily volume to 6 cases (that’s what he’s contracted for with Kaiser) despite the fact that he is able to complete this schedule by 9:30 AM. I thought of all of this while I, a 52 year old eye surgeon somewhat famous for my ability to handle a crushing workload without sacrificing either outcomes or a pleasant patient experience, was mapping out my 2014 office and OR schedule with a reduced work week and additional vacation days.

Have you noticed? There are fewer of us out there doing our jobs. Fewer doctors, that is. We’re slipping away, young and old. The last vestiges of the physicians who lived through the Golden Age of medicine are hanging up their spurs, taking down their shingles, and riding off into the sunset. They are being replaced by an almost equal number of youngsters just out of training, young bucks saddling up yearlings and slowly joining the rodeo. Those of us in the middle, mid-career docs of all sorts, we’re still there. Sorta.

The stands are full. All sorts of spectators and commentators are there to see the healthcare rodeo. The reporters and the pundits, the bloggers, those who dwell in the halls of academe and the basements of the bureaucracy fill the bleachers, prepared for much back-slapping and self-congratulation as the fruits of their intellectual labors, the young buck docs, take over for the much-maligned Marcus Welby generation. The kids’ll be OK, better than OK, because the audience has successfully changed everything about how doctors are trained and made it the way they, the audience, think it SHOULD be. No need to worry about the newbies and all of the non-doctor “healthcare providers” and how slow they are in general, or how they work fewer hours, or take more time to handle a visit–those docs in the “sweet-spot” in mid-career are there to take up the slack until the audience’s brilliance is born out. Sorta.

Everything seems to be a bit chaotic at the healthcare rodeo. There are so many more things that need to get done. It’s not enough to rope and tie that diabetic, there seem to be too many diabetics now. Those young docs spend an awful lot of time just outside the ring doing non-doctor stuff. Where are the grooms, the seconds, the helpers? Why aren’t they doing all that stuff outside the ring so the doctors can get in there and ride? It looks like there are a bunch of those mid-career guys and gals over there outside the ring too, doing non-doctor stuff. It sure seems to take a lot of time. The young bucks seem to take that all in stride. Maybe a stray shrug of a shoulder, but not much more. It’s all they’ve ever known. The mid-career docs seem to be making do. Sorta.

Something’s just not quite right, though. The numbers just aren’t quite working. Matching the number of docs retiring with the number of newly-trained docs seems to be coming up short. All of those newly empowered other “healthcare providers” don’t seem to be making much of a difference, either. There seem to be too many patients, too many people who need both sick and well-care, and too few doctors to provide it. The pundits and the professors say the solution is not more doctors but more other “healthcare providers” and new technology. Help is on the way they say. Preparing the path to this end seems to involve a PR campaign that not only minimizes the contribution of doctors in general, it denigrates the efforts of the one group of docs that is keeping it all afloat: the mid-career physicians who are neither old enough to retire nor young enough to not know any better.

The whole house of cards depends on these men and women going to work and doing just what they’ve been doing for 20+ years. Seeing lots of patients in any given time slot. Performing lots of surgeries efficiently and well. Showing up in the ER for a consult or answering the phone at 3 AM. All for lower pay and less respect. The whole thing rests upon the presumption that they will continue to do this regardless of the non-medical impositions of the new “way it should be”, regardless of the continual battering of their self-worth. Thus far that’s how it’s playing out. Sorta.

There’s something afoot, though. Quietly and without much fanfare, the mid-career doc is slipping away. She’s sliding out the side door and taking a job in administration. He’s slipping in a 4-day weekend every month, on top of the 4-day week he started working a couple years ago. While nobody noticed she started to limit the number of surgeries she would do in a day, ducking out at noon on OR day instead of 2 or 3, the backlog of cases now building up to months rather than weeks. Oh sure, they are still counted as a full-time doc on everyone’s ledger, it’s just that they aren’t as full-time as they used to be, as full time as the system is counting on them to be. The net effect is that with the same number of doctors counted we actually have FEWER docs available to see more patients.

You see, the mid-career physician is also listening to what the editorialists and the bloggers and the academics and the bureaucratic minions are saying, about the “way it should be” and how they really feel about worth of doctor work, and in response they are slip sliding away.

Told to do more for less some of those mid-career warhorses are just doing less. All those men and women who are the equivalent of “innings eaters” on a Major League pitching staff are no longer as available, effectively reducing the number of physicians available to take care of patients. If the new “way it should be” is correct this should pose no problem, right? Just have all those folks who used to be seen by a physician seen by a “healthcare provider.” Got a sore throat? CVS or Walmart is just around the corner and they do the same quicky Strep test your doctor would have done. Surely the AP nurse will notice that tender spleen, or that especially swollen tonsil encroaching on the midline like your 55 year old doc with 25 years of experience would have. No worries. You can follow up with that nice new doctor in the big clinic, that ACO thing you’ve read about. There’s an opening in 12 weeks. Your old doctor who would have stayed late in the office to see you in follow-up in a day or two is no longer available.

He started a new career selling veterinary supplements at rodeos. Slip sliding away…

 

 

Does “MD” = Manic Depression?

“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.”