I recently heard from a physician whom I knew well in an
earlier stage of her training—I’ll call her Pauline. She completed her training
at one of the top children’s hospitals in the US, and served in several
capacities in academic medical centers before her most recent job with a
physician-owned for-profit practice. She called me to express her frustrations
and to ask if the right course for her was to quit doing clinical medicine.
Pauline had become skilled in her earlier jobs in providing
primary care for children with severe chronic conditions. Her reputation was
such that when she was settled in her current post, pediatric subspecialists
started to refer their difficult cases to her for follow-up. This patient mix
did not suit her current employer for two reasons. First, these children were
hard to take care of and even though they could have their visits “up-coded” to
reflect their complexity, the practice much preferred to see healthy children
with colds and earaches that could be moved through quickly and who did not
demand much staff time and attention. Second, most of these children with
special needs were on state insurance, which did not pay as well (even after
up-coding) as the private insurance the practice coveted.
Pauline found herself constantly struggling with her
co-workers and superiors in order to deliver all of her patients—not just the
special-needs kids—the quality of care she had been trained to demand. As far
as the practice was concerned, it was Pauline, and the medically complex kids
she was attracting into the practice, who were the problem.
One recent incident had especially concerned Pauline. She
had set up a visit to see a new medically complex patient and had blocked off 40
minutes, the amount of time she felt she needed to do a good job. The child had
a complex genetic disorder, cerebral palsy, and heart, lung, and kidney
problems. Both the cardiologist and the
nephrologist had called asking her to take this patient. She agreed.
After she had scheduled the visit, a manager called her and told her
that she was being allowed only 15 minutes to see that patient. After some
fruitless discussion with him, Pauline finally said, “Okay, I guess that means
that you’ll be seeing the patient instead of me, right?” The shocked voice at
the other end of the phone line replied, “What do you mean? I don’t know how to
take care of patients.” “That’s exactly my point,” Pauline put in.
Pauline explained that this manager assigned to her office
is not even a college graduate. Physicians cannot access the schedule
electronically and have no control over scheduling. These functions are
controlled by the office manager and (amazingly) by some of the medical
assistants who have received some “leadership” training. These medical
assistants are even allowed to evaluate the clinical competency and skills of
Now, at this stage, I can imagine a response from a
management-trained person. Pauline is obviously one of those starry-eyed
idealist physicians who believe that money grows on trees and that costs should
never be a factor in caring for patients. Somebody who actually knows what it
means to make a payroll and keep the lights on has to step in and rein in these
physicians. There has to be somebody in the system someplace with a head for
business, who can recognize the stark realities of what today’s practice
demands from all parties. Physicians should get off their high horses and stop
imagining that they can give orders to everyone else.
So let me add a further nugget about Pauline’s background.
In one of her previous jobs, she was made the manager of a pediatric outpatient
center within a county hospital caring for a largely indigent population. This
center had been running in the red for a good while. Pauline took over and within
28 months she’d streamlined the place and had them running well in the black,
while still administering a quality of care that Pauline and her colleagues
could be proud of. In short, Pauline could probably tell the managers of her
current practice a thing or two about how to optimize patient scheduling without
compromising care or cost —if they’d listen.
Pauline probably has a nearly-unique skill set in her
community and has put in a lot of years of training and experience to get
there. Due to the present state of American medicine, and those who want to run
it as if it were an industrial operation to make a profit, Pauline is thinking
about leaving clinical practice altogether despite her relatively young age –
and she has several colleagues, who trained in the same way that she did, who are
considering this option.
Fortunately, Pauline has at least for now postponed any
final decision about leaving clinical medicine entirely. Here’s what she last
am leaving the organization – I cannot remain in an organization where profit
comes ahead of quality – and as a former medical director who had financial
accountability/responsibilities, I know it does not HAVE to be a choice.
I do not know what my next steps will be from here. For me, working
with integrity, compassion and a desire for excellence is not negotiable.
MUST become better advocates for our profession. For too long, we
have been asleep at the wheel while insurance companies and corporations shaped
the environment in which we practice. We cannot allow this to continue.
We are professionals, not vocationally educated
medical automatons who need every
moment of work day micromanaged by ‘leadership-trained’ management
extenders who have no idea what it means to take responsibility for patients.
Dr Howard Brody