Private Practice Column

Episode 24:  Moving Forward
Nothing in the world is more dangerous than sincere ignorance and conscientious stupidity.”
-Martin Luther King Jr.

As I approach the half-century mark some things have come into focus, while paradoxically my need for reading glasses has grown.  When you are in practice for 12 or more years, many things have come and gone.  Practices come, go, merge, dissolve, reform, and join the ever-growing Borg-like mass of acquisitions and private equity.  It’s a little but like standing in my front yard, growing up as a kid in the Chicago suburbs, where our house was next to the expressway (we don’t use the word “highway” where I am from).  Cars whizzed by at seemingly breakneck speed, where I just stood there, watching them go by.  Wondering where they were going – if they were rushing to get home to see a loved one, get to work, go on vacation, or leaving for the last time. 

I have seen some things (so far).

The current crises in healthcare did not happen in a vacuum, nor overnight.  I was chatting with colleagues over text, when one mentioned that he was old enough to remember when pain was “the fifth vital sign.”  As an intern, we were made to feel terrified by nurse managers and shift supervisors that we were bad doctors if patients did not have complete pain control.  I recall some patients saying their pain was “10/10” even when they were falling asleep in their beds.  The Affordable Care Act passed and we all knew things were going to change, some for the better, but mostly not.  We also saw doctors outsourcing more and more tasks to midlevel practitioners in order to see more patients and do more stuff, to try to stay at the same speed on the hamster wheel.  We have seen the effects of politics and prejudice creep into our daily lives as doctors, to the point where we cannot agree on the most basic of things, nor tolerate each other talking about one another’s opinions and labelling has become the de facto way to talk to each other.  The cancellers have been cancelled and so on and so on.

We are in the midst of a not-unpredictable upheaval that may or may not require some change or even the resistance to it.  As we watch the UK NHS going through a major upheaval with the rubber stamping of nondoctors to do cardiac catheterizations and even surgery (not dermatologic procedures, but full on, if that gets cut, someone dies type stuff), it is obvious we are not seeing the movie playing right in front of us.  The shortage of physicians in the US has been fostered by decades of inaction by Congress.  The advocacy wing of most if not all the medical societies, imperfect as they are, have been calling repeatedly for increasing the number of residency slots.  There have been some meager increases, but not enough to meet demand.  Physician reimbursement from the Medicare Trust has also been decreasing, while all the while policy wonks have been screaming the doctors STILL make too much, while insurance CEOS make 7-8 figure salaries, not including benefits. 

So, everything seems pretty screwed right now.

I am heartened to know that as a doctor, my training has taught me healthy skepticism.  It was skepticism that led me to question the utility of the benchmarks set by the ACA along with the voluminous number of reports and datapoints CMS asked us to report on.  Surely, these would help patients.  So far, despite over a decade in place, not a single paper has been put out to demonstrate the benefits to patient safety nor outcome based on the benchmarks (ANY of the benchmarks, really) set for us by the overlords at Centers for Medicare.  Rather, it has become obvious that we get the stick, and not the carrot. 

But didn’t we kind of know this was coming?  I mean, right?  We are all smart folks in medicine and have things like critical thinking skills, above average intellects, and a very hard work ethic.  And surely, there had been study groups or white papers put out showing all the stuff we will be doing or have done have some benefit to the overall health of our community and country?  Actually, no.

There was and is a certain number of physicians and administrators, and recently physician administrators that have risen through the ranks, kissing the ring and essentially feeding physicians into the furnace of the bloated, ineffective and inefficient monstrosity of the United State Healthcare System.  We have all seen them.  Former chair people who have given up their scalpel for “Quality Officers” or “(insert buzz term here) Officers.”  They basically sit in offices, not touching patients, and sit in meetings or put out social media posts designed to do anything but what an actual physician does.  We need doctors who do stuff besides talk about stuff.

Some would say we need them.  I would agree in some cases.  There are those in this class that truly understand what it is to be a physician in charge of other physicians and demonstrate not only the ability to empathize with their colleagues, but also to make hard decisions that will tick people off but will also pass muster and scrutiny.  The job is not easy.  These are unfortunately rare.  One in particular is a former ENT colleague who is now in charge of my former residency’s parent system.  His job is massive, and I am sure he is well-compensated.  I am truly heartened to know he is at the helm.  Because you need not only a smart doctor, who not only knows why things break down, but also is part accountant, politician, and therapist. 

Most physician administrators do not and cannot fill the role as it needs to be.  Some might be stuck in a system that has them simply there as a showpiece: “See!? We got a doctor in charge too and they agree with us!”  Some are simply there to collect a paycheck.  They go to meetings, have someone write a report, they sign off, go to a fancy retreat at a beachside resort, the Holiday part, rinse and repeat.  These are the nonchange makers, and frankly we might want bad change makers versus the incredible institutional inertia these physician administrators bring.  At least they are doing something. 

Then there are ones that have ascended through skullduggery and other lascivious means.  These are by far the most pervasive and invasive of the species.  They often flit from place to place, punctuated by 3-5 years of chaos, and somehow the disorganization and rote destruction they bring is erased by a simple administrative blip and they fall into the next position, collecting “bennies” and golden parachutes like baseball cards.  They are by far the worst to work with, and you know it – so do they.  Some will try to get you to divulge your deepest insecurities about your business and practice and weaponize it against you, while playing your coffee chum or even cycling bud.

The truth of the matter is most doctors do have an altruistic streak.  They want to see the rising tide lift all our boats. 

When the lure of a five-day work week, a clipboard instead of a scalpel, and no more calls from sick patients or urgent care needs becomes too strong, some will answer the siren’s call.  It’s hard to argue with a good night’s sleep, food not from the hospital cafeteria, and coffee that doesn’t taste like mop water.  I get it. 

What we need to focus on, and saying this who does not train anyone other than my now-departed doggo to use her pee pad, is how to strengthen the internal compass of every physician.  Because in a way, we WANT more physician administrators.  We need them.  But to focus on patient and physician facing issues.  Things like, making sure we are getting fair compensation, that patients are not getting half-assed care or crappy bandages to save 3 cents apiece and so on.  How can this be done along with the mounds of other stuff they have to cram in their brains?  I for one would be happy to visit programs and talk about my experiences as a private practice doc and how if I could play Dr. Frankenstein and cobble together the ideal physician admin, what I would want.  That is not to say I can fix the whole thing, and no one doctor can, but certainly it is a beginning.  Cross-pollination from private practice, to group, to academia, we need to converse on how we can supply better and smarter people to run this circus.

Certainly, the clowns in charge right now are unsuitable – and we need change.