Short-selling private practice

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Today is a remarkable day for me. I’m officially leaving private practice after almost 18 years, to return to academic medicine with a faculty position in a highly regarded California department of anesthesiology.

Why would I do that?

There are many positive reasons. I believe in the teaching mission of academic medicine:  to train the anesthesiologists of the future, and the scientists who will advance medical care. I enjoy teaching. The years I’ve spent at the head of the operating room table, anesthetizing patients every day, have given me a great deal of hands-on experience (and at least some wisdom) that I’m happy to pass along to the next generation.

But the other, more pragmatic reason is this. I’ve lost confidence in the ability of private-practice anesthesiology in California to survive in its prevalent form — physician-only, personally provided anesthesiology care.

MD-only:  A viable model?

California is an outlier among all other states in its ratio of physicians to non-physicians in the practice of clinical anesthesia. Nationally, there are slightly more non-physicians — including nurse anesthetists (about 47,000) and anesthesiologist assistants (about 1,700) — than physician anesthesiologists (about 46,000) in the workforce, according to 2015 National Provider Identifier (NPI) data.

But in California, there are about 5,500 physician anesthesiologists and only 1,500 nurse anesthetists in the workforce, while anesthesiologist assistants can’t yet be licensed here at all. Though some other states, chiefly in the western half of the U.S., also have more physicians than nurses in the anesthesia workforce, none tops California’s ratio of more than 3.5 to 1.

It’s hard to see how such a physician-skewed model of anesthesia care can continue to be financially viable, no matter how much affection I have for it. I genuinely love safeguarding my patients through anesthesia for complex surgical procedures, from beginning to end. But there’s no way that it makes sense for many of the tasks involved to be performed directly by a physician. If the Institute of Medicine advocates for nurses to practice “to the full extent of their education and training” in order to provide cost-effective care, it stands to reason that physicians ought to work at the top of their licenses too.

Many of the daily tasks involved in MD-only, personally-provided anesthesia care could and should be delegated to nurses, pharmacists, and technicians. Easy examples include starting IVs, drawing up medications, labeling syringes, and monitoring a patient’s blood pressure. Surgeons don’t perform these tasks during surgery, intensive care physicians don’t perform them in ICUs, and hospitalists don’t perform them on the inpatient wards. And we haven’t even mentioned other routine tasks such as changing the suction tubing on the anesthesia machine between cases — a duty that is well within the skill set of the OR clean-up crew. It makes no fiscal sense, in our cost-conscious time, for physicians to be performing these tasks personally.

Logically, it’s an appropriate use of physician anesthesiologist skills to decide, for example, if a patient’s heart condition has been adequately optimized prior to proceeding with surgery. If there’s a problem during anesthesia with a sudden change in blood pressure, an abnormal heart rhythm, or any other severe medical problem, a physician is the logical person to diagnose the problem and prescribe treatment. The duty of the nurse or any other non-physician practitioner is to monitor the patient, administer prescribed care, and alert the physician to any new problems.

The new multidisciplinary world

The best solution to cost-effective medical care is the use of teams. The American Society of Anesthesiologists (ASA) endorses the concept of the anesthesia care team, a model in which a physician anesthesiologist supervises anesthesiologist assistants, residents, and/or nurse anesthetists in the delivery of anesthesia care, just as an intensive care physician supervises a clinical team in the care of multiple patients.

A January 6, 2016, editorial in JAMA, written by two anesthesiologists and a surgeon, describes how the concept of  “captain of the ship” has become antiquated in an era of complex perioperative care requiring multiple specialists. “When done properly,” the authors believe, “multidisciplinary team-based care is the key to good health care delivery.” That care is likely to involve “intensivists, fellows, residents, midlevel professionals, nurses, pharmacists, physical therapists, nutritionists, and others.” All right, fine; that statement seems inarguable, and may even qualify as old news.

The real surprise in the JAMA article, though, is this. The authors advocate changing the administrative structure in which the teams work. They favor “institutes, centers, or other consolidations that focus on a specific disease process, e.g., a heart institute that houses cardiac surgery, cardiology, cardiac anesthesiology, and cardiac ICU.” In other words, a traditional department structure — such as a private, MD-only anesthesiology practice — would have no place in this brave new multidisciplinary world. The remarkable fact to me is that two out of three of the authors of this editorial (Michael Nurok, MBChB, PhD, and Bruce Gewertz, MD) hail from Cedars-Sinai Medical Center, where I worked up until today.

Is there any hope for physician-only anesthesia groups?

It may be that the MD-only anesthesiology practice is about to become an endangered species. In the last few years, we have witnessed numerous examples of formerly successful practices succumbing to market forces they didn’t expect. In 2011, for instance, New York-based Somnia Anesthesia Services won the contract to provide anesthesiology services at Kaweah Delta Medical Center in Visalia, California, displacing the physician-only group that had held the contract for 16 years. Somnia brought in a new chief of anesthesiology from outside, and proceeded to recruit nurse anesthetists to complete the switchover to a more cost-effective care team model.

The Kaiser Permanente system, California’s largest nonprofit health plan, for decades has staffed its operating rooms and procedure locations according to an anesthesia care team model. The major academic medical centers in California, including the University of California hospitals, Loma Linda University, Stanford University, and the University of Southern California, all utilize the care team model with physician anesthesiologists supervising residents and nurse anesthetists. Without fanfare, these programs are all teaching their residents how to practice anesthesiology in a team-based environment.

Yet it’s too early to ring the death knell for California’s private anesthesiology groups. The smart ones are already making changes to increase the likelihood of their survival. They are getting more involved outside the operating room, in the overall management and financial success of their hospitals.

In the San Francisco Bay area, Keith Chamberlin, MD, MBA, a physician anesthesiologist, has led the formation of an Accountable Care Organization (ACO) at Marin General Hospital, and is currently the President of the ACO’s Board of Directors.

In Pasadena, anesthesiologist Rick Bushnell, MD, MBA, is leading Huntington Memorial Hospital in a Perioperative Surgical Home project designed to improve the patient experience and outcome. As Dr. Bushnell explained recently in the Anesthesia Business Consultants Communique, the physician anesthesiologists will focus their attention “on the most complicated 20 percent of patients,” seeing them both preoperatively and after discharge in order to prevent costly readmissions.

“If our specialty is to maintain its relevance,” Dr. Bushnell said, “as anesthesiologists we must assume more responsibility. We must extend and improve our management to include the complete perioperative process, a continuum from the moment of decision to operate to the completion of recovery.” The anesthesiologists work with “intervention teams” of nurses, physician assistants, nurse practitioners, and nurse anesthetists, as he explained in his article, to improve post-op and post-discharge surveillance and intervention on the hospital floor, in the home setting, in the emergency department, and in the post-discharge clinic.

Would care be even cheaper without physicians?

Certainly health care would be cheaper if we didn’t utilize physicians at all, and simply allowed non-physician practitioners — nurse practitioners, nurse anesthetists, physician assistants — to practice independently. But that idea carries its own risks. Perhaps it has some merit for primary care in underserved areas. The acute-care environment of the operating room, however, is different and much more hazardous.

In my opinion, the answer to rising health-care costs is not to give non-physicians such as nurse anesthetists the regulatory authority to practice medicine without a license, and to administer anesthesia without consulting with or accepting advice from a physician anesthesiologist. Patients want a fully licensed physician in charge of their care, just as they want a lawyer — not a paralegal — managing their legal affairs, and an experienced, fully qualified pilot flying the jet plane.

I’m placing my bet on the likelihood that California’s anesthesia practices will continue to move away from physician-only, one-to-one anesthesia care, and more in the direction of the anesthesia care team model. The CSA’s efforts to gain the right for anesthesiologist assistants to work in California, it seems to me, will give us an excellent additional option for expanding the anesthesia care team. It will be fascinating, and possibly alarming, to watch how the anesthesia marketplace in California continues to evolve.

2 COMMENTS

karen

Dear Dr. Tse, Advice? Read everything you can find about the business of anesthesia. One excellent common-sense online source is Tony Mira's Anesthesia Business Consultants' quarterly communique. Go to meetings such as the ASA's Practice Management, and get familiar with the concepts of the Perioperative Surgical Home. If a private practice you're looking at doesn't seem to be keeping up with the times, be wary. Smart practices are working closely with their hospitals and extending their footprint outside the OR. Since this website is strictly ...Read More

Brian

Congratulations on this transition in your career and for sharing your forecast on the climate of California's anesthesia marketplace. What advice would you have for a current resident who plans to stay and practice in California to prepare for this? We will spend years in the role of being supervised, but upon graduating will likely be in a role of having to supervise others. Also, which institution will you be joining? Thanks!

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Is it always wrong for a surgeon to book cases that will be done in two operating rooms during the same timeframe?

If you’ve paid much attention to the overheated commentary on social media since the Boston Globe published its investigative report, “Clash in the name of care“, you might easily conclude that the surgeon who runs two rooms ought to be drawn and quartered, or at least stripped of his or her medical license.

John Mandrola, MD, a Kentucky cardiologist who I’ll bet doesn’t spend a lot of time in operating rooms, weighed in on Medscape with a post called “The Wrongness of a Doctor Being in Two Places at Once“, accusing surgeons of hubris and greed.

Respectfully, I disagree.

The Globe’s story tells the dramatic tale of how a prominent surgeon at Massachusetts General Hospital often scheduled two difficult spine operations at the same time. According to the Globe’s reporters, the surgeon typically moved back and forth between two operating rooms, performing key parts of each procedure but delegating some of the work to residents or fellows in training.

On one particular day, a complex case ended with a tragic outcome. The patient, a 41-year-old man, sustained spinal cord injury at the level of his neck, leaving him permanently unable to move his arms or legs. Another prominent MGH surgeon leaked details of the case to the press, and was summarily fired.

Of course, I have no special access to information about what goes on at the MGH, and can’t comment on the specific cases highlighted in the Globe’s report. But I’ve been giving anesthesia for a long time in first-class hospitals. On countless occasions, I’ve seen surgeons run two rooms, and have administered anesthesia to a patient in one of them.

Have I ever seen a patient come to harm because the surgeon scheduled concurrent cases?  No.

Have I ever been annoyed because a surgeon delayed the start of my patient’s case because of the demands of the case in the other room? Yes, but I always agreed with the decision to delay, and the wisdom behind it. If the surgeon is at a critical portion of the first case, we have no business starting the second case until the surgeon gives the go-ahead.

Have I ever been thankful that the surgeon had two rooms? Yes indeed. Here’s why.

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5 COMMENTS

Karen: see you tomorrow at 11 am on the show. This is excellent stuff!

Bob Ruxin

Karen-- I shared this post with a good friend and her adult daughter who recently had complex surgery at MGH and is scheduled for another one in March. We had just discussed the article and I tried to argue there might be good reason for double booking. Your inside perspective makes the case much more persuasively. I suspect not only your medical, but your journalistic credentials trump those of the Globe reporters and editors.

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SOS

I admit, I was taken aback at the headline in the Houston Press:

GOING UNDER:  WHAT CAN HAPPEN IF YOUR ANESTHESIOLOGIST LEAVES THE ROOM DURING AN OPERATION

The curious reader is bound to wonder why the anesthesiologist would leave the operating room in the first place.

Of course, reporter Dianna Wray explains that in many hospitals, one physician anesthesiologist often supervises multiple cases staffed by nurse anesthetists. This model of care is called the “anesthesia care team“, and has a very long record of safe practice in nearly all major hospitals in the United States. Typically, the anesthesiologist makes rounds from one operating room to the next, checking on each case frequently, just as an internal medicine physician would round on patients in the hospital who are being monitored by their nurses.

Ms. Wray’s article narrates in detail what happened in several anesthesia cases where things went horribly wrong. She points out that the patients and families were not aware that the anesthesiologist would not be present during the entire case.

Complications can develop with patients on the ward, in the intensive care unit, or in the OR. In any medical setting, the nurse’s job is to recognize the problem in time to call for help, so that the physician can respond and the patient can be treated successfully. Sometimes, the call for help may not come in time for successful resuscitation. The results can be tragic — cardiac arrest, brain damage, even death. Hospitals track “Failure to Rescue” events that cause adverse patient outcomes as a Joint Commission and CMS standard for measuring quality in nursing care.

The fact is — anesthesia is dangerous. We have made huge strides in developing safer drugs and better monitoring techniques. But going under anesthesia — losing consciousness from the drugs we give — is really the same thing as inducing coma. Most anesthesia drugs have the potential to depress breathing, lower blood pressure, and decrease the function of the heart. Even regional anesthesia, using proven techniques such as spinal and epidural blocks, can cause major complications.

I can verify that even the most routine procedure — under sedation, regional block, or general anesthesia — has the potential to evolve into a crisis. Some days are completely routine, and some days I find I need every scrap of medical knowledge and experience I can bring to the problems my patients face.

No one should read Ms. Wray’s article and conclude that a physician anesthesiologist needs to be in the OR with every patient 100% of the time. Nurse anesthetists are highly qualified members of the anesthesia care team.

However, patients and families have a right to be informed about the plan of care. Will a physician anesthesiologist be present for the entire case, or supervising more than one case? Will a physician anesthesiologist be involved at all?  Many people would be surprised to learn that in a number of states, including California, there is no requirement for nurse anesthetists to be supervised by physicians, or even to consult with a physician about patient care.

Ms. Wray’s article explains that many nurse anesthetists feel that they should be able to practice in complete independence, without a physician anesthesiologist even on site. This is part of a concerted effort nationwide to grant independent practice to all advanced practice registered nurses (APRNs) — nurse practitioners, midwives, and anesthetists — in the name of cost-cutting.

Proposed changes to the VA Nursing Handbook would mandate that APRNs must practice in VA hospitals without physician supervision of any kind, whether or not the mandate conflicts with state law, and whether or not the nurse would prefer to have physician backup. Given how desperately ill and injured many of our veterans are, this seems like poor policy indeed.

The cases that Ms. Wray outlines in her article are tragic, and they prove how quickly a situation can deteriorate in the operating room. They highlight the folly of attempting to cut costs in our healthcare system by reducing the presence and availability of physicians. Once a patient has encountered a life-threatening complication, even the best attempts at resuscitation may fail. That’s why the key to success is having a high-functioning healthcare team that can avoid the complication in the first place.

To clarify one point in Ms. Wray’s article — certified anesthesiologist assistants, or CAAs, are qualified anesthesia practitioners on a par with nurse anesthetists. In the states where CAAs are licensed, they perform exactly the same functions in the operating room that nurse anesthetists do. The only major difference is that CAAs prefer to work under anesthesiologist supervision. Both CAAs and nurse anesthetists are certified healthcare practitioners who take direct care of patients, as distinct from anesthesia technicians who assist with anesthesia equipment and technical procedures.

I’ve written before about what a shame it is that animosity ever exists among healthcare professionals in any field, especially my own. Medicine is, or should be, a team sport. I rely on an entire surgical team of physicians, nurses, and technicians taking care of my patients every day. I’ll always value the wisdom, skill, and friendship of the many experienced nurse anesthetists I worked with at Duke University Medical Center when I was a young physician fresh out of residency.

My husband, a cardiac anesthesiologist, often gives his residents a favorite piece of advice:  “In anesthesia, it’s not necessarily what you know, it’s what you can think of in time.” Sometimes what you need to think of is to call for help. I’ve certainly done that on any number of occasions, when I needed someone with a different set of specialized anesthesia skills from my own, when I wanted to run an unusual problem by an experienced colleague, or when I just needed an extra pair of hands.

That’s the real advantage of the anesthesia care team. Help is around when you need it. You just need to think of it in time.

6 COMMENTS

Johnsnow

Dr. Sibert has a marvelous talent for translating "Medicaleeze" into "Everydaypeopleeze". Again herein proven. I hope she is planning to collect her writings into a book for "The Public". For the record: The status of CRNAs in the U. S. Armed Forces was accomplished by a series of command decisions by non-medical line officers. It was based on apparent cost, shortage of anesthesia physicians, and an inherent conflict between line officers and physicians of any specialty. There was never any consideration of the wisdom or a ...Read More

Ben

Dr. Silbert: Good post. But I disagree with some of the points made. 1) CAAs are not on par with CRNAs. With experience, a CAA, CRNA and anesthesiologists will all be on equal footing as stated by several anesthesiologists. But to state it as one surgeon placed its that someone with ZERO prior medical training/education can learn and understand all the complexities of physiology, pharmacology, and anesthesia in only 2years of training and are on the same footing as CRNAs is dishonest and hard to ...Read More

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Compression fx PNG

It’s amazing how quickly my role switched from physician to patient, thanks to a silent assailant: osteoporosis.

I went to the gym in the morning before work 12 days ago, as I often do now that my children are all grown up and out of the house. First, a couple of light sets of leg exercises served as a warm-up, and then I started a set with a barbell on my shoulders. I’ve been doing weight training for years, since my mother suffered badly from osteoporosis and I knew I was at risk. Weight training, along with calcium and Vitamin D, can help maintain bone density.

The weight was average for me, and I was halfway through my second set of 12 repetitions when suddenly there was a loud noise, like a sharp crack or pop, that people in the gym heard 10 feet away. I felt my mid-spine collapse downward what seemed like an inch, accompanied by sharp pain. The trainer grabbed the weight, helped me lie down, and called my husband.

I did a quick self-assessment.

Can I move everything? Check.

Is anything numb? No.

Can I do a straight leg raise without more pain? Yes.

This confirmed that I didn’t have any spinal cord injury and probably didn’t have a herniated disk. The most likely diagnosis was a spinal compression fracture, which turned out to be exactly what happened.

Off to the emergency room

My husband insisted on driving immediately to the emergency room, which gave me a little time to reflect.

By coincidence, September is “Pain Awareness Month”, and I had been wanting to write a piece in support of the American Chronic Pain Association and the American Society of Anesthesiologists‘ recognition of pain as an endemic problem. Chronic pain ruins lives, and inappropriate treatment of pain with narcotics too often leads to addiction, overdose, and death.

But what to write?? I treat acute pain in my daily work as a physician anesthesiologist looking after patients in the immediate recovery timeframe, right after surgery. Sometimes I take Aleve for a headache, but that’s about it. Now, of course, it seemed much likelier that I would have a story to tell.

Luckily for me, the Cedars-Sinai Medical Center emergency room was relatively quiet at 6 a.m. The staff whisked me off to X-ray, and the technician quickly took supine and lateral films. He said, kindly, “Ma’am, I’m not a doctor, but it looks to me like you have a compression fracture.” He printed out the films for me to see, and of course he was right. A nurse gave me some morphine, which eased the pain considerably, and then it was time to consider next steps.

Conservative treatment or intervention?

My fracture was at the level of the 12th thoracic vertebra or “T12”, the commonest site for compression fractures. This is hardly a rare problem. One in four American women will have a vertebral compression fracture during her lifetime, and men can suffer them too. The most common cause is osteoporosis, a condition in which bone loss over time results in weak, brittle bones.

The emergency room physician ordered a CT scan to see the extent of the fracture in more precise detail, and to see whether or not any bone fragments were endangering the spinal cord. Then he called a neurosurgeon, Dr. Khawar Siddique, to see me.

The neurosurgeon outlined treatment options. Basically, there were three:

Conservative treatment: a back brace, pain medications, and 6-8 weeks of rest, with gradual mobilization;

Surgery: thoracic fusion;

Kyphoplasty: a less invasive procedure to stabilize the fractured vertebra.

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13 COMMENTS

karen

Dear Diana, Again, I think treatment choices are many, and should be decided by each individual in concert with your physician. As far as I am aware, estrogen therapy alone isn't enough to stop postmenopausal bone loss, but of course it may have multiple other symptomatic benefits. All best wishes, and thank you for writing-- Karen Sibert

DF

Dear Dr. Sibert, What about estrogen therapy? And maybe even some testosterone therapy. btw, This is my first post ever on a blog. I feel so strongly about the benefits of estradiol therapy, in the form of brand Vivelle Dot patch, I had to respond to your story. Estrogen therapy may help prevent future fractures. I use Brand Vivelle Dot myself, for osteopenia. All the best to you during your recovery.

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Walden

Did it ever occur to some of today’s physicians that many people work awfully hard and complain a lot less than they do about “burnout” and “work-life balance”?

Did it ever occur to them that “work-life balance” is the very definition of a first-world problem, unique to a very privileged class of highly educated people, most of whom are white?

Every day, I go to work and see the example of the nurses and technicians who work right alongside me in tough thoracic surgery cases. Zanetta, for instance, is the single mother of five children. She leaves her 12-hour shift at 7 p.m. and then faces a 60-mile commute to get home. She never complains, and unfailingly takes the extra moment to get a warm blanket for a patient or cheerfully help out a colleague. When I leave work, I see the gardeners who arrive in battered pickup trucks and mow lawns in the Los Angeles summer heat for slim pay and no benefits. I can’t imagine these people wasting time worrying about work-life balance. They’re too busy working.

Or look at what it’s like to work in one of the world’s top restaurants. Edward Frame, now a graduate student in social research, described his first job in a Michelin-starred kitchen for an article in the New York Times.

“I worked in a small alcove, connected to the dishwasher,” he wrote. “Glass racks came out, I wiped away any watermarks or smudges, and then, just as I finished one rack, another appeared. This went on for hours, like some kind of Sisyphean fable revised for the hospitality industry. By hour two my fingers hurt and my back ached. But I couldn’t stop. The racks kept coming. Slowing down never occurred to me. There wasn’t time. I needed to make it nice. I wanted to make it nice.”

Let’s face it—a lot of people have jobs much worse than being a physician. Apparently, they don’t expect to be coddled or to receive much sympathy about their rate of burnout, or their lack of “work-life balance”. Nor do they expect that workplace expectations will be altered just to suit them.

I can’t imagine having the gall to complain about how tough it is to be a physician when all you have to do is open your eyes and see what’s all around us:  people working incredibly hard, making far less money than we do, and then returning home to face the responsibilities of family life, child care, housework, home maintenance, and everything else.

We—physicians—thankfully can afford help with these tasks. The Medscape Physician Compensation Report for 2015 reported that the average compensation for a primary care physician was $195,000 and for a specialist $284,000.

When I was a new faculty member making an instructor’s salary right after residency, it’s true that I didn’t have a lot of take-home pay left after I made monthly payments for student loans, private pre-school for two children, housecleaning help, and a full-time nanny to provide transportation and after-school care. The full-time nanny was essential because a child with a bad cold or an upset stomach needs to stay home, and a physician can’t drop everything to stay home too. These were investments that my husband and I made because we felt that being a physician is important work.

But in medicine, the prevailing wisdom today is that the rigorous culture of the past needs to change—along with the expectation of dedication to duty, long work hours, and stoicism—because it’s all just too difficult and we risk getting burned out.

Now Stanford University has started a new “time-banking” program designed to ease pressure on faculty physicians and basic science professors. As admiringly described by reporter Brigid Schulte in the Washington Post, the program allows faculty members to “bank” hours that they spend on uncompensated activities such as committee work and earn credits to use for support services at home or work.

Dr. Gregory Gilbert, an emergency physician who was the poster child for the Post article, used his credits for delivery of meals to his home, housecleaning services, and employing a “life coach” to help him “find better balance in his life”.

Wait just a minute. I’m sure that Dr. Gilbert is a good person—a divorced father trying to be a conscientious physician and spend time with his children. He must be a smart guy if he’s on the faculty at Stanford. Do you mean to tell me that Dr. Gilbert couldn’t figure out how to order food delivery and arrange for housecleaning before Stanford came up with this program?

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13 COMMENTS

karen

Dear Dr. Vercammen, "Burnout" is a colloquial and imprecise term which means different things to different people. Major depression is a clinical diagnosis, a very serious illness, and a threat to life; that is not and has never been my subject. I'm sure you know the difference. Confounding the two, as you do in your comment, is sensationalism. To imply that my opinions make me either responsible for or indifferent to physician suicide is not only unjustified, it skirts close to the edge of libel. Please--and I ...Read More

Chris Vercammen, MD

Dr. Sibert- As a current senior resident looking forward to my chief resident next year, I was profoundly disturbed by your article, in particular that it found its way into wider circulation via KevinMD. I would hate for any current resident, in any field, who is experiencing burnout to have read your piece. It represents a particular type of fantasy, retrograde approach to how physicians work and live. 1) Burnout is a real phenomenon. Having experienced it myself during my training, it is a profoundly troubling ...Read More

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