Consider the following scenarios
1. Dr. Sam is an Orthopedic Surgeon. He enjoys an excellent reputation and is known for his surgical expertise. Like most orthopedic surgeons he is very confident in his profession which is sometimes mistaken for arrogance. In reality, he is very demanding of himself as well as those who assist him. He is very detailed oriented in his performance accounting for a strong surgical success rate and minimal complication rate. The demands of this career, however, have taken a toll on his personal life. He is married to Laura, a strong woman in her own right. They met when he was in his surgical residency at a major teaching hospital on the east coast where she worked as a counselor having her degree in social work. Having delivered two children, she still occupies a part time position at a local counseling center. Sam is a loving father and husband and the marriage is strong but an early strain is developing. They have a daughter and a son, Megan and Mark. Although basically “good kids” there is a lack of supervision and participation in family life by Sam who is having trouble fitting them into his hugely busy schedule. Megan is a straight A student who excels at all she attempts. She is close to her mom but, like her brother, her relationship with her dad is plagued by his unavailability. Laura tries mightily to compensate with the kids, scheduling her work around their activities but recognizes that Mark needs his dad to mentor him. There are arguments regarding this from time to time but Sam can’t seem to budget the time into his schedule. When Sam is at home, he spends most of his time napping, reading medical literature, or catching up on paper work. It isn’t that he doesn’t support and love his son but simply is unable to make him a priority. He encourages Mark to excel as a student and as an athlete but is often absent from his children’s events. Mark is 17 years old and in his senior year of high school. Due to his father’s significant income, he is able to attend a private school where his grades are quite acceptable. He participates on the swimming team and generally does well although not a star. He generally avoids trouble and is thought by most people to be a “straight up” kid. However, he has recently been hanging with a group of the “Jocks” who have been experimenting with drugs. At first, Mark refused to participate but it was becoming clear that if he did not participate, he would not be considered a member of the group. So, with some trepidation, he trialed some “weed.” Over time, he moved on to cocaine. Mark eventually got caught up in a drug bust and Sam received a call to retrieve his son at the police station. The police station has the typical ambience of a government agency office with cream colored walls and tile floors surrounding a plethora of counters and desks only a few of which are occupied. Sam is greeted by a rather severe appearing officer manifesting boredom with his job mixed with a somewhat condescending and judgmental expression on his face. He invited Sam and Laura to come around the counter and join him at his desk. It was covered with scattered papers, a computer screen and a phone completing the picture of a very busy officer. He appeared to be 40 to 45years old, had a full head of dark black hair with just a touch of premature grey at the temples. He was of medium height and had a sturdy look to him although not athletic.
Having been through this routine hundreds of times, he launched into his usual speech. Your son was found in possession of illegal substances. He is not thought to be selling them. It is his first offense. We will release him in your custody. He will need to appear in court the day after tomorrow. The clerk will give you the time and location. “You need to keep a close eye on your son. He seems like a good kid. Keep him out of trouble. We don’t want to see him here again.” And with that, the meeting was over with Sam and Laura hardly saying a word.
Sam did not sleep well during the night. He was facing a family crisis of significant importance for the first time since he and Laura were married. Laura was angry. Although not saying so, she was concerned that Sam had fallen down as a Dad. Her anger was directed at everything but the main issue on her mind. Doors were slammed, dishes banged on the table, conversation was short and curt. Difficult thoughts flew through Sam’s mind and, for the first time, he began to seriously question his life. Is Mark in trouble because he failed to supervise and mentor him? Was his profession so all-encompassing that he had spiritually abandoned his family? Was the wealth engendered by his work the driving force in his life? And at what cost? His family was the most important part of his life but he was failing to see this. Sam has a major surgery scheduled for 9:30 AM. Is he an impaired physician with such intense personal pain and feelings of failure as a parent? His disappointment in Mark and himself was consuming. He also was uncertain as to what would ensue in the courtroom. On the other hand, cancelling the procedure would have consequences as well. The patient was fearful regarding the surgery and putting it off would add to anticipation and anxiety. It would be difficult, in so short a period of time, to find a substitute surgeon, family members of the patient would need an explanation, hospital resources would be wasted. Sam also knew that his response to stress had always been to get busy. He also has an abundance of self-confidence. It seemed that he was capable of proceeding which was very likely because Sam is the man he is. However he advises his surgical assistant, a fellow talented surgeon to monitor the procedure closely as a safeguard. (It is hospital policy that for more complicated surgeries there be two qualified surgeons at the table. And in fact, Sam has asked his colleague to be primary surgeon on the case and Sam will assist.)
This scenario demonstrates that doctors are human with all the same personal and domestic issues that we all have. However, the professional life of a physician competes. Is this because of the need to be perfect in our work? (Physicians and airline pilots can least afford to make mistakes). Is it an “ego” thing? Is it an obsessive need to generate income? The good news here is that for Sam it was a wake-up call. After reevaluating his behavior, he scheduled family time with the same importance as his professional time, cut back a bit on his practice, and reestablished his relationship with Laura. They are a fortunate family. These problems frequently end up in divorce court. And, oh yes, Marc received community service with no criminal record.
2. Dr. Paul was up during most of the night in the intensive care unit. The patient was a new admission having been involved in a serious automobile accident requiring multiple intravenous lines, tubes, and procedures. The situation was critical and Paul remained at the bedside for 4 hours finally rolling into bed at 4 AM. He has a full schedule of office visits today. He wends his weary way to see his patients almost falling asleep behind the wheel. He heads to the hospital first where he looks in on his patient from the previous night. His vital signs are stable and he has improved considerably. He then visits his eight other hospital patients doing a quick evaluation and getting a progress note on the chart. He then heads for his office anticipating a full schedule. The stimulation of working with his patients keeps him awake and alert throughout the day. At the end of his hours he completes a few dictations, makes a few calls, and signs off a few forms. Feeling totally exhausted he climbs into his car and heads for home. Meanwhile, a patient of his arrives at the emergency room with a complaint of chest pain and trouble breathing. The possibility of a heart attack must be seriously considered. This patient is one he has cared for over the last several years and has grown very close to. Dr. Paul at first attempts to divert the care to the ER physician. However, he doesn’t feel comfortable with that decision and turns his car around back toward the hospital although he was looking forward to dinner and a relaxing evening with his family. Duty calls even when it is personally painful. Would it be ethical to leave this patient’s care to the ER physician, even appropriate to leave the care to a rested physician? Is Dr. P being too hard on himself? Is this unfair to his family? Would he really be able to rest knowing his patient is in the ER? When does a physician reach his limit?
Paul is 44 years old. He has always felt a deep commitment to his patients and has been known to give them the best care he can.
During his training, due to his diligence and work ethic, he had been offered an assistant clinical professorship at the hospital where he had trained. However, he turned this down because he wanted to be a frontline internist taking care of patients. He also realized that he would be required to do research and publish articles in an academic setting. He simply had no interest in that type of medical career. As he was driving back to the emergency room, he pondered how he will be able to do this when he reached age 60 or 65. He made a mental note to be certain that he continued his exercise program throughout his life. Mental and physical fatigue can be a challenge to physicians especially in primary care. Today there is much less of a problem as systems of cross coverage and off-hours coverage have been established in many hospitals. However, physician judgement re both treatment options and physician ability to make decisions, ego, hero complex, and misguided loyalty to the patient can create dangerous situations for the patient and the physician.
3. Dr. L is married with three children, all under the age of ten. He is officially off for the weekend and he and his family are heading for the door having planned a family outing to the city zoo. The children are excited and anticipating the activity. There are few family activities due to Dad’s profession, making it all the more important. His youngest son at the age of six is particularly on a high, having talked incessantly about it for several days. Before they can get to the car, Dad’s cell phone rings. His partner, who is on call for the weekend, needs help. He is at hospital A in ICU in the middle of a procedure. There is a second patient at hospital B going into shock and, although on call, he cannot get there for at least another hour. Dr. L determines a need to return to the hospital. His 6 year old son becomes angry and accuses his dad of never being able to do stuff with them. The beleaguered father foolishly attempts to educate a six year old about the moral obligations that go with being a doctor. There is a tug and a ton of stress for the good doctor but duty calls. With a sense of duty to his patient, and with a sense of guilt towards his family, he heads for the hospital. One of the most difficult challenges for physicians is striking a balance between profession and family. It is thought that there is a higher divorce rate for physicians than for the general population. When a physician arises in the morning, he/she has no idea what this day will hold. Patients don’t schedule their illnesses. Not only is there an occasional serious emergency but there are also “call-ins”, patients who need to be seen today for a variety of reasons prolonging office hours. There may be an unexpected new admission to the hospital along with a discussion with family members seeking the doctor‘s opinion. Some or all of these issues occur during the course of most days
4. Dr. W is in his late 60’s and was hoping to retire at 70. However, his spendable income has been falling over the last 20 years and he has underfunded his retirement plan. He is tired and has lost his passion for clinical medicine. It appears that he will need to continue in practice into his 70’s to maintain his lifestyle. The stress may lead to health problems complicating his already difficult position. The financial piece for physicians is likely to continue to worsen as reimbursements decrease and physicians become accountable to various health care organizations. There is also the concern regarding his continued competency as he ages. For now, he is quite astute and keeps up on the medical literature. Will he maintain this as he ages? Should older physicians be required to undergo physical and mental testing if they remain in practice? This has the potential to create a personal financial crisis for Dr. W. and his family.
5. Dr. Q is in the middle of a bitter divorce. There are two children involved with whom he has been very close. His mind is fretful, sad, angry, and distracted. In the midst of this he is seeing 20 people a day in his office and doing hospital rounds on another 15. He is worried about making mistakes and remaining professional on the job. How does he make this work? Severe emotional distress, especially on a prolonged basis can interfere with most people’s lives. Some throw themselves into their work. Others are incapacitated. For the physician with patients depending on him/her for their health and welfare, not to mention their very lives, this is a most serious issue. The decision to take time off depends upon an “honest” decision by the physician as to his ability to focus totally on his patient when in the professional realm. Most physicians choose to continue their work without danger nor damage but remain acutely aware of their vulnerability.
6. Dr. F. has been competitive throughout his life. He was a successful athlete throughout high school and college. He ranked in the top five in his medical school graduating class. Unfortunately, his ego has also run in high gear. He ultimately became a cardiovascular surgeon with a strong track record. His reputation was exquisite. However, in the course of a heart bypass operation performed one evening when he was unusually fatigued, he made a fatal error leading to a cardiac arrest and the death of the patient. It was clearly a mistake on his part and there was no one else to blame. When he talked to the family, however, he described the death as due to an intrinsic abnormality of the heart leading to complications and death. The family, although in shock, accepts this explanation. Dr. F has been noted to display an arrogant attitude about him and, while working well with staff for the most part, does have a “Ben Casey” kind of personality. (For the youngsters in the group, he was a somewhat surely neurosurgeon character in the early years of TV). It appears that this doctor’s EGO is interfering with an otherwise excellent physician and surgeon. Is this a fatal flaw? What if the family requests the medical records? What if someone else in the operating room feels a need to report? What if the medical staff launches a peer review of the case? Humbly admitting the truth, and his human frailty would probably be much less likely to create a threat to Dr. F than being caught in a falsehood.
In 2014 there are major changes occurring in the health care system. These changes are causing uncertainty for all parties involved directly and indirectly with health care. Traditionally, physicians have been generally autonomous running solo, small group, and clinics (small and large). For the most part they have been financially independent operating as small businesses. Their income has been based upon their ability to produce. Now changes in the paradigm are forcing physicians to seek “umbrellas” as regulation and financial controls are demanding larger case loads and less income to them. More importantly, many physicians are feeling a loss of control as team medicine is becoming a new paradigm. Hospitals and their administrations and staff are participating in decision making although physicians still define the care. Some physicians consider this intrusive and resent the “interference” with what they believe is solely the domain of the physician.
This changing paradigm has significantly increased stress for these men and women leading to increased personal strife. In order to understand this issue, let us first look at the whole issue of becoming and being a doctor. From approximately the age of 18 the total focus in life becomes the attainment of that MD degree. Tunnel vision is established. All relationships begin to change and will continue to do so throughout the rest of life. Social relationships break down as life is committed to study. Marriage is deferred or relegated to second tier during this time If the student has children, they will see little of him/her during these years.
At the same time there is the beginning of a dichotomy between personal and professional roles. During medical school and postgraduate training, there is a split in worlds. Within the world of training there is a constant downward flow of criticism from the fellow onto the residents onto the interns onto the medical students. In addition to the long hours, verbal abuse from some of the senior physicians may generate a response of self-protectiveness masked as growing arrogance. Meanwhile, in his/her personal life, the pedestal is already being constructed. The mother is already bragging about “my son the doctor”. High school and college friends may grow away due to lack of availability to socialize and a new perception of the student being on a different social level now. People in general perceive him/her as being on some mythical superior level.
As time goes on, physicians may connect to a position of aloneness along with an elevated sense of importance manifested by an inflated ego. To some extent this may be necessary for them to do what they do. For example, neurosurgeons seem to be more detached from patients (I know some exceptions) and more technical. If he were to allow himself to emotionally attach to what he does, could he actually operate on the human brain knowing the possible (probable) incidental damage being done?
Ultimately, both the physician and the world build the pedestal. To his colleagues he is a competitor within his field. Some conversations in the doctor’s lounge are dedicated to how much more knowledgeable each physician is than his colleagues are no matter the topic. To his patient, he is required to be “godlike”. He is required to have a smile and a reassuring manner. He must be up to date with his scientific knowledge. He cannot appear distracted. At the same time his personal life, no matter how difficult, cannot in any way manifest itself in front of the patient. The hospital staff may also tend to be very judgmental regarding the physician’s practice and will complain among themselves if the care is inconsistent with what they believe is appropriate. Some staff members are very good at conversing with the doctor. Some are afraid. Some physicians are receptive to staff input, others are very resistant.
What frequently happens is that, due to the above attitudes, the physician, the staff, and the patients all contribute to construction of the pedestal. But now, many physicians are fearful of losing the pedestal due to shifting paradigms. Physician autonomy is severely threatened as doctors are forced out of private practice and into employment or large organizations. They will find themselves forced into working for a hospital(s), or hospitalist group, joining bundled groups, associating with Accountable Care Organizations etc. As a result they will become accountable to various bosses in ways never previously imagined. Financial demands may control the medical marketplace driving down physician reimbursement placing volume requirements on their practices and dictating the amount of time off. Many physicians are willing to make this tradeoff allowing for freedom from business aspects of running a practice.
So “what’s up doc?”
• Traditional training and practice have created an aloneness
• The physician has been placed on a pedestal by patients, staff, and himself
• The physician’s personal life while being impacted by his/her profession frequently cannot be shared causing internalization of stress
• The family may feel left out of his/her life accompanied by his/her sense of guilt.
• This has caused ongoing construction of the pedestal protecting him/her from all these forces
• There are major changing paradigms in health care
• How will these changes affect physician attitudes and behaviors?
• Are patients already experiencing changes in the physician-patient relationship?
• Is high tech turning some doctors to impersonal medical engineers?
• There are those who would argue that nobody forced him/her into the profession. I would argue that many young people entered training not realizing the downside of this vocation (which is true of many careers) and doesn’t change the current challenges.
So here’s what’s up (one physician’s opinion)
• Physicians are far less autonomous than previously and becoming less so
• Solo physicians and small groups are becoming obsolete
• Health care is becoming “BIG BUSINESS”
o Hospitals are consolidating into large networks
o Physicians are increasingly seeking employment positions and are treated as employees with benefits, malpractice coverage, specified hours, defined time off, and mandated off hours coverage
o Health care administrators are increasingly business executives
o Successful independent physician groups are those with large numbers of physicians
• Government and Insurance companies are driving changes in the reimbursement arena
o Salaried physicians
o Medicare changing focus from service payment process to quality of care and cost containment. Double edged sword. Involves more policing (RACS/MACS/OIG) but does incentivize better care.
A word to the wise
• Be aware of the changes described above
• Be involved with your car
o Use the internet to investigate your illness
o Become a partner to your physician re your care
o Be prepared to have different physicians in the hospital than in the office
o Never allow yourself to be intimidated by a physician
o Always feel free to seek second opinions
o If your physician appears to be threatened by your doing any of the above, reassess your choices
I wish you well with your health care