My Blog

One of the newest partners in my medical practice laments how many hours he has to put in to build his practice. Sometimes he must even work until eight or nine o’clock at night, even if he is not on call. I am sorry––but he won’t get any sympathy from me. I recall the days––now too many years ago––of building my now 12-man cardiology group. I was in practice by myself for three years before my first associate joined me. I had cross coverage from another cardiologist on some weekends, but that meant only four days off every month. Meanwhile, I had to make time to interview dozens of candidates and their spouses, including wining and dining, while still taking call and carrying a full office and hospital consulting schedule. It was not unusual for me to complete rounds at midnight, so exhausted I just fell into bed.

Make no mistake, however, about these days of the “iron men.” I believe this type of work schedule was, and still is, extremely unhealthy for a doctor, his family, and potentially dangerous to his or her patients. I do agree that a more humane training schedule for medical students, interns, and residents was long overdue. But as the saying goes, “the devil is in the details.” Newer physicians simply won’t tolerate what we had to put up with our training. As a fourth-year medical student at a large county hospital in Cleveland, Ohio, I recall working up fourteen admissions in one night and being ready to present the cases to the chief medical resident and attending by 7 AM. Had I not taken some histories while I was examining the patient, I would never have been ready at “morning report.” I would have been “toast.”

Medicine is moving inexorably to “shift work.” ER docs have always done this, and now hospitalists have done the same. In the future, more and more specialties will follow similarly as reimbursements decline, and the corporatization of medicine grows. On balance, I think that this is a good thing. If I have a heart attack at 3AM, I would take a rested cardiologist, over one who just finished working a 14-hour day, without equivocation.

If I sound conflicted, it is because I am. I think wistfully of my days off “24 on/24 off” ER rotation during my internship at the University of San Diego in 1975. As I drove home in my yellow VW beetle on Interstate 5, I had to keep the windows down and play “Hotel California” by the Eagles or Jethro Tull at full volume, just to keep from nodding off. Later, my wife would plead with me to “please stay awake.”

These are bittersweet memories. Just as a prisoner-of-war comes to identify with his captors, we too reflect with some admiration at our tormentors. There was the chief surgical resident who said, “The only problem with taking call every other night is that you miss half the cases.” Another resident told the interns that if they enjoyed their sleep, then they should go into something like pathology or dermatology. Unfortunately I enjoyed cardiology too much.

Thinking back, I would likely make the same choices. Yet I can’t help but feel that today’s crop of docs are too soft, and expect too much money for too little work, I also think that their families and patients will reap the benefits as much as they will. And in the end, that’s not a bad thing.

“This is the beginning of the end of the private practice of medicine in America, “ he said. If you guessed that someone famous in March 2010 made this statement, after President Obama signed into law “The Affordable Health Care for America Act”, you would be wrong. An everyday doctor, my father, said this to his family after President Lyndon B. Johnson signed Medicare into law in July 1965. My father was not correct. Far from being the beginning of the end of the private practice of American medicine, this law ushered in what us old-timers now longingly refer to as the “Golden Age” of Medicine. In the beginning, (of Medicare law), doctors could charge whatever they wanted for their services, no matter how absurdly high the price, and as often as they wanted. Not only were they often reimbursed at this level, but the more you charged, the more you would get the following year under an economically illogical system, known as “usual and customary.”

Decades later, as the costs to administer Medicare Part B escalated; the payment system morphed into a more fixed methodology and continues to evolve today. However, as with any monopoly, which Medicare certainly is, costs to consumers are dictated and non-negotiable. However, unlike other monopolies, like a cable company, Medicare pays the providers, (doctors and hospitals), rather than the end user––the patient. Private insurers pay doctors and hospitals largely based upon what Medicare pays, no matter how arbitrary it might be. Cataract and open-heart surgery are reimbursed differently if you live in Miami, than if you live in Fargo.

No matter how many IOU’s Congress writes to cover the burgeoning cost of Medicare Part A,B,D, etc, we all assume that this program is never going to go away. It will be tweaked, like higher deductibles, co-pays for Medicare Advantage programs, raising the eligibility age, and so forth. But the essential facts are that the typical Medicare beneficiary will receive many times in benefits whatever he paid in during his working life. When Medicare was first passed into law, there were about six workers for every person over the age of 65. In 2012 that ratio is now down to 4:1 and falling. People are living longer and demanding ever more sophisticated and costly procedures. The current system is not financially sustainable.

And now entering the scene is “The Affordable Health Care for America Act.” Passed under Presidential duress, this massive overhaul of the American health care system, is yet to be fully functional. It is still unknown if the very linchpin of the law, the personal mandate, will survive a constitutional challenge by the US Supreme Court this year. However, I will argue that this ruling may be irrelevant. Much like a poison or virus is injected into the blood stream, the long-term effects of Obamacare will continue to ripple through our society for years to come.

From the moment I heard the President say, “If you like your insurance and doctor, then you can keep it,” I knew his intent was opposite of this statement. The end game here is a single payer system based upon a Canadian or British Health System. Rules, regulations, and costs to private insurers will become prohibitively high to the point that they will simple stop doing the medical insurance business.

I plan to retire in two years, so this latest scheme to “reform” American healthcare, won’t directly affect me. However, I fear for the effects on patients and future doctors. I support true competition as the way to drive down health care costs, not less. For example, in 2000 when I had Lasik surgery, it cost $2500 per eye. In 2005, when I had to have an idea redone, it was only $1200. And that is because insurance did not cover it. The cost of the procedure was simply responding to the supply of Lasik surgeons, (increasing) to the demand, which became level.

I do not profess to know if the next few years will birth the “beginning of the end” of medicine, as we know it. I am however, certain that the more centralized the payment and delivery of healthcare becomes, and the less competitive, the more the costs will be and the less access to it we will all have. I hope that I am wrong.

MEDICAL OFFICES FACE A NEW HOLIDAY SEASON

Gone are the large tins of popcorn and the nuts. Ditto for the cookies and fruitcake. My practice administrator and I reflected last week about what our staff kitchen used to look like the week before Christmas ten years ago. The counters were overflowing with gift baskets, fruits, and all kind of holiday treats. The doctors’ desks had bottles of wine gifted by referring doctors and grateful patients. Now these areas are empty. Save for the few Christmas cards taped to the cabinet wall in the patient check out area, it would be easy to miss the traditional signs of the holiday season. Not even the hospitals are sending us gifts anymore. Why should they? They now seem to spend money buying up medical practices instead.

It is a fitting sign of our medical and economic times that the simple act of giving to one another to say “thank you for your loyalty and business,” is going the way of the “Walkman” cassette radio player. Perhaps it is our fear of government regulations and anti-kickback rules. Or maybe that we stand yet again on the precipice of the annual new century 25-30% Medicare pay cut due to SGR (Sustainable Growth Rate). As has become our yearly new tradition, we will write, call and email senators and congressmen pleading with them not to cut our Medicare rates….again. If the carrot doesn’t work, then we try the stick––if this passes, we will post signs stating that we can no longer afford to see new Medicare patients after January 1. If history repeats itself, there will be an eleventh hour repeal form the legislative executioner, as politicians suck up to seniors, cook the numbers and books, and miraculously put off the SGR cut for another year, adding another few billion dollars to our federal debt.

When medical doctors graduate they all recite the Hippocratic oath. Here is the second line: “To consider dear to me, as my parents, him who taught me this art, to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art, without charging a fee.” Many of us have interpreted this last line that we should also not charge our colleagues or families for our medical care, i.e. professional courtesy. Thanks to Congress, and in particular Representative Pete Starke of California, it is now illegal not to charge a colleague for medical care.

We used to give boxes of chocolates to nurses at the hospitals. This year we took the money we would have spent on that and gave our office employees a bonus instead.
Everyone it seems is cutting back––be it for legal or pure economic reasons. And yet something profound has been lost here. No I, and my waistline, do not miss the plethora of sweets and calories. What I believe is missing is simpler than that. It is gratitude. Thankfulness for our referring doctors, and from home health care agencies, patients, and oxygen supply companies. I cannot be bribed to send business to someone simply because they gave my office staff and me a large tin of popcorn.

What has been lost in this entire minefield of government regulations and compliance worries, is the death of giving to one another to show our appreciation. And that more than anything is what is missing from this holiday season.

A MIRACLE

Having practiced cardiology now for over thirty years, I have seen more than a few patients recover from open-heart surgery. However, until recently I had no direct experience with a child who had to endure similar trauma. Last December my granddaughter, in Atlanta, was born with a complex congenital heart malformation. She had a temporary procedure in February to keep her from being “blue”, or having low oxygen levels.  Although any “minor heart surgery” procedure is a bit of an oxymoron, she did well and was able to gain critical weight until a more extensive and corrective procedure could be done.

That procedure was done successfully on Friday, August 26, at Emory Children’s’ Hospital in Atlanta, and the parents were told to expect a one to two week hospital stay. The baby did so well that she was moved out of the intensive care unit after two days and sent home on only her third post-operative day. This is on the short end of the expected stay even for an adult undergoing coronary bypass and or valve surgery. To everyone’s surprise, this was nothing short of a miracle.

For my daughter who suffers with OCD, (Obsessive Compulsive Disorder), the hospital stay was a nightmare and she actually pushed for the early discharge. To her a hospital is a veritable house of horrors where mistakes are the rule, and every interaction with a healthcare person is fraught with errors in judgment and miscommunications. The blood must be drawn at 4 a.m.­­

“Why can’t they do it later?” she would ask.

“Because the doctors need this information early on to adjust medications before they enter surgery for another six to eight hours,” I answered.

The pre-operative echocardiogram took one and one-half hours.

“Why does it take this long?” she asked.

And I said, “You are in a teaching hospital, and everyone needs to learn. Complex congenital heart disease surgery is not done in community hospitals where things go faster.”

“Why do they have to awaken her for vital signs?”

“Because those are the rules,” I would say again, trying to be patient. Her baby was poked and prodded for 84 hours, and my daughter couldn’t escape this perceived medical jail soon enough.

Yet, what is easily over-looked here is the true miracle of rearranging the veins, arteries, holes, and valves of a sixteen-pound child in under three hours, and then discharged home in three and one-half days.

As a physician and cardiologist, it is not easy to be on the flip side of the doctor patient relationship. Nurses and doctors often dread taking care of a physician or his family, so I tried to be as unobtrusive as possible. However, the temptation often got the better of me as I asked the critical care unit nurse, “Is that right bundle branch block on her EKG new?” I think being on the receiving care of medicine, and or surgery, offers a wonderful opportunity to make us more compassionate and empathic caregivers.

The wonders of modern medicine, and the awesome skills of a pediatric cardiac surgeon are nothing short of miraculous. And oh by the way, the prayers of a multitude of friends and family members didn’t hurt either.

MAKING DOCTORS MORE HUMAN

Recently at lunch I sat with a general surgeon who I have known for many years. Like many of our peers, he is hard working and puts in many more than 40 hours of work each week. Before I decided to “slow down” a few years ago, my typical workweek was 60-80 hours. Dr. N, the surgeon, was lamenting about how things had changed and how new physicians did not share our same work ethic. He should know––his son is in training now to become a surgeon too.

“They don’t want to work as hard as we did,” he said. They realize they will make less money, but they want more time off for themselves and their family.”

“How can they do that and still practice good medicine?” I asked.

His response was simple and obvious––“Shift work.”

In the years since the two of us completed our training, the medical establishment has finally realized that putting in such grueling and long hours is not good for either the patient or the doctor. As an intern in the emergency room, I recall doing a two-month rotation of “24 on/24 off, meaning working non-stop for 24 hours, and then off for 24 hours. This pace was purportedly to prepare us for the rigors of private practice. It also weeded out those docs who would later enter a specialty with more humane hours like dermatology or pathology.

What it also accomplished was to wreck havoc on our personal lives and our marriages. Graduate medical educators finally realized there must be a better way to train doctors, and mandated maximum hours per week for interns and residents.

One of my lay friends asked why we cardiologists for example had to work such long hours. Being my patient as well as my friend, I tried to explain by example.

“Let’s say,” I told him, “that some night––like 3 AM, you have severe chest pain and go the ER––maybe you’re even having a heart attack. Who would you want to come in and see you?”

Without hesitation he said, “You, of course.”

“Well there you go, “ I said. “How good a decision maker do you think I’d be if I had just worked a 12 or 14 hour day?”

He of course had no answer.

I do believe that tired physicians make more errors, and in the end, these changes are probably for the better. It will however take some re-educating of patients to no longer expect their doctor to be there for them 24 hours a day, seven days a week.
A personal touch may be lost, but in the final analysis, this re-humanization of medicine will benefit everyone.

HYPERBOLE

Noun: An obvious and intentional exaggeration, or an extravagant statement or figure of speech not intended to be taken literally.

There are so many things vying for our attention these days that it is challenging to separate an urgent message from the ordinary or mundane. In our 24/7-news world with instant information delivered via texting, I Pads, and smart phones, we have become a community afflicted by collective ADD, (or attention deficit disorder). We can’t seem to get our fill of information, accurate or otherwise, which occurred only minutes ago, or in the case of Twitter, as it is even happening. If there is a natural disaster our first instinct is not to run to someone’s aid, but to record a video of it on our phones and then upload it to YouTube.

Consequently there is little, or no time, to evaluate the veracity of all this information. The same syndrome of over-hyping and glorification has similarly afflicted new medical information. Clinical trials of new treatments, medications, and procedural approaches to diseases, are released on-line before we have a chance to read them, let alone critically review the results.

Coffee is bad for you––no, wait––that’s old news. Now it is good for your heart and may prevent cancers. Vitamins and anti-oxidants were the darlings of the 1990’s, but now medical experts “know” they are worthless and just give us expensive “urine.”

Beer is bad for your weight and waistline. But news flash––it prevents osteoporosis, so drink up. Spicy foods make GERD (gatroesophogeal reflux disease) worse. Really?
Not according to most recent research. Now one of the culprits for this affliction is––(oh no, please tell me this isn’t true)––chocolate!

Finally, if I had a dollar for every time a newscaster, movie star, sports figure, or interviewee (of anything) says someone or something is “amazing” I could retire as a multi-millionaire tomorrow. If everything is so “amazing”, then nothing is left to be ordinary.

I suppose I should just get use to living in this age of exaggeration, embellishment and flash; but just for a while I’d like to turn back the clock, and watch a slow moving and boring world.

Seeing Clearly

Upon awakening this morning, I was able to see the clock on the wall, the neighbor across the street, and the television. It has been years since I was able to do this––at least without glasses. You see, on Thursday May 12, I had a cataract removed from my right eye, and a new corrective, or refractive lens, placed in the now empty eye capsule behind my cornea. The removal of the cataract, and placement of the lens was done under local anesthesia in about five minutes––nothing short of miraculous. It’s kind of like having a permanent contact lens inside your eye. My left eye, which I use for reading and intermediate distance––like looking at the computer screen as I am writing this, will be done in about two weeks.

For many people, this everyday ability of good vision is taken for granted. For me, it has been a life-long battle. When I was in second grade my mom figured I needed glasses when I was sitting about six inches from the TV screen. I wasn’t just a little nearsighted––I was half way towards legal blindness.

My eyeglasses looked like the bottom of Coke bottles, and I was constantly being teased as “four eyes.” When I graduated college, I celebrated the invention of contact lenses, even though they were the hard non-oxygen permeable type. I didn’t care––for eyeglasses-free living I would endure a lot.

As science advanced to more flexible, soft, and oxygen permeable lenses, my life too became easier––even as my near sightedness progressed. Upon hitting the age of forty, I could not read clearly without reading glasses, so it was back to frames and lenses for the new curse of farsightedness which comes with middle age.

I was able to buy a few years however with “mono-vision.” This is where your dominant eye, (in my case the right) is corrected for distance, and the non-dominant is under-corrected so you can still read and see the computer screen without glasses. However, by the time I was in my early fifties that stopped working too.

So next came LASIK, where your cornea is sculpted with a laser, so you purportedly don’t need glasses or contact lenses. Again, I went with the mono-vision, and again it worked-––at least for a few years. In 2005, my right eye suffered a plastic shrapnel injury when I stupidly tried to pry open a dresser draw, behind which my daughter’s cat was hiding. My right eye immediately went from 20/30 to 20/100 vision, and it was back to glasses––again.

I tired an enhancement of the LASIK in 2007 with an old procedure called PRK––forget what is stands for––it didn’t work. By 2010 my previously diagnosed cataracts had gotten so bad that I was afraid to drive a night.

Thus, the new chapter in my quest for near perfect vision continues. I will let you know how it turns out.

THE DARKER SIDE OF PROGRESS

I am not easily impressed with emails forward to me anymore.  However a recent one  called “The Truth” struck a cord with me, and is well worth repeating. There is a personal and societal price to pay for our faster and technologically advanced world. Yes, I can look up the price, dosage, and side effects of any medicine on my smart phone in less than one minute, whereas in years past I would have to search the voluminous pages of the PDR (Physicians’ Desk Reference).  Forgotten names and facts can be “googled” instantly, and we can scan bar codes in stores and check flights in progress on our phones or IPads. Yet, as technology has added so much to our “apparent” living, it also has distracted us from what is really important.

To quote from “The Truth”:

We have more conveniences, but less time.

We have more medicines, but less wellness.

We have learned how to make a living, but not live a life.

We’ve added years to our lives, but not life to our years.

We buy more but enjoy it all less.

We’ve learned to rush, but not to wait.

We have more kinds of food, but less nutrition.

We have more leisure time but less fun.

Spend more time with your family, friends, and loved ones. Life is a chain of moments to enjoy. Enjoy everyday, every hour, and every minute, for it may be your last and we never know when the end will come.

Sometimes we should stop waiting for that special day. Drink that special wine, or enjoy that special perfume now. Play hooky once in a while.

Yesterday is gone and tomorrow is only a dream––today is the only reality.

Think about it.