Archive for the ‘Professionalism’ Category

If physicians are “muggers” and co-conspirators in “taking money away from the rest of us”, then journalists and economists are pontificating parasites who produce no goods or services of any real value.

I don’t think either is true, but the recent attacks on physicians by economists Anne Case and Angus Deaton, and “media professional” Cynthia Weber Cascio, deserve to be called out. You could make a case for consigning them permanently, along with the anti-vaccination zealots, to a healthcare-free planet supplied with essential oils, mustard poultices, and leeches.

My real quarrel with them — and with the Washington Post, which published their comments — is that they have the courage of the non-combatants: the people who criticize but have no idea what it’s like to do a physician’s work. More about that in a moment.

Ms. Cascio was enraged by the bill from her general surgeon, who wasn’t in her insurance network at the time she needed an emergency appendectomy. She doesn’t care — and why would she? — that insurance companies increasingly won’t negotiate fair contracts, and it isn’t the surgeon’s fault that Maryland hasn’t passed a rational out-of-network payment law like New York’s, which should be the model for national legislation. She doesn’t care that Maryland’s malpractice insurance rates are high compared with other states, averaging more than $50,000 per year for general surgeons. She just wants to portray her surgeon as a villain.

The two economists are indignant that American physicians make more money than our European colleagues, though they don’t share our student loan debt burden or our huge administrative overhead for dealing with insurance companies. They resent that some American physicians are in the enviable “1%” of income earners. But do they have any real idea what physicians do every day?

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“Each man or woman is ill in his or her own way,” Dr. Abraham Verghese told the audience at the opening session of ANESTHESIOLOGY 2019, the annual meeting of the American Society of Anesthesiologists. In his address, titled “Humanistic Care in a Technological Age,” Dr. Verghese said, “What patients want is recognition from us that their illness is at least somewhat unique.”

Though we in anesthesiology have only limited time to see patients before the start of surgery, Dr. Verghese reassured listeners that this time has profound and immense value. He pointed out that there is “heightened drama around each patient” in the preoperative setting. “Everything you do matters so much,” he said. What patients look for are signs of good intentions and competence, and the key elements are simple: “the tone of voice, warmth, putting a hand on the patient.”

Dr. Verghese, a professor of internal medicine at Stanford University and the acclaimed author of novels including the best-selling Cutting for Stone, believes that patient dissatisfaction and physician burnout are the inevitable consequences of today’s data-driven healthcare system, where physicians seldom connect with patients on a personal level or perform a thoughtful, unhurried physical examination. “Our residents average 60 percent of their time on the medical record,” he said.

“It’s the ‘4000 clicks’ problem,” Dr. Verghese said, citing a study in which emergency room physicians averaged 4000 mouse clicks over a 10-hour shift, and spent 43 percent of their time on data entry but only 28 percent in direct patient contact.

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When adjectives obfuscate

A few years ago, at the misguided recommendation of a public relations consultant, many of us in America started referring to ourselves as “physician anesthesiologists”. That was a silly move. The term is cumbersome and does not flow trippingly on the tongue. It is also redundant. You don’t hear our colleagues referring to themselves as “physician cardiologists” or “physician urologists”.

There was never any need of an adjective to modify “anesthesiologist”.

Anesthesiology is a medical specialty, practiced by physicians who have completed residency training in anesthesiology. To become board-certified, we undergo a rigorous examination program conducted by the American Board of Anesthesiology.

In England, comparably trained physicians are called “anaesthetists”. In England, they also refer to their subway system as “the underground”, and to the hood of the car as the “bonnet”. It’s confusing, but we muddle through.

The term “nurse anesthesiologist” is an oxymoron.

I’m all done with the term “physician anesthesiologist”. I am the immediate past president of the California Society of Anesthesiologists, and a 30+ year member of the American Society of Anesthesiologists. I am a physician who is immensely proud to practice anesthesiology. My patients know I am a physician because I make it clear to them when I introduce myself and give them my business card.

Dr. Virginia Apgar was an anesthesiologist. It is an honor to follow in her footsteps, even if most of us will never match her achievements. That is all.

Watching and working in ASA officer election campaigns for the past several years has been a deeply unsettling experience.

The ASA’s officers today are outstanding anesthesiologists, dedicated to their profession and to the organization. But the process of electing them, from my viewpoint, is a dysfunctional endurance test, fraught with barriers to entry and hobbled by tradition.

Imagine a hybrid of ritualized Kabuki theater and a high-school campaign for homecoming queen, and you’d be close. And yet the results have binding effects on a 50,000-member, multimillion-dollar specialty society whose work affects the professional lives of all ASA members.

We need to reevaluate and redesign this system sooner rather than later for the health and long-term future of the organization. Here is a glimpse of some of the fundamental problems.

While in theory offices come open for election every year, in reality it’s taboo to challenge an incumbent officer.

There are no term limits. An incumbent officer can be reelected indefinitely. So anyone thinking about running for office has no certain knowledge of what year an office may become vacant.

People may announce their intention to run for a given office years in advance of when the office is likely to become vacant, with the intentional effect of discouraging anyone else from running in opposition. (Think of dogs marking their territory.)

The campaign process is prohibitively expensive at personal cost to the candidates, often involving travel to multiple state society meetings. The cost alone is a barrier to entry for younger physicians, as is the time away from work and family.

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For several years now, I’ve been the social media curmudgeon in medicine. In a 2011 New York Times op-ed titled “Don’t Quit This Day Job”, I argued that working part-time or leaving medicine goes against our obligation to patients and to the American taxpayers who subsidize graduate medical education to the tune of $15 billion per year.

But today, eight years after the passage of the Affordable Care Act, I’m more sympathetic to the physicians who are giving up on medicine by cutting back on their work hours or leaving the profession altogether. Experts cite all kinds of reasons for the malaise in American medicine:  burnout, user-unfriendly electronic health records, declining pay, loss of autonomy. I think the real root cause lies in our country’s worsening anti-intellectualism.

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