At least for the moment, the polls seem to be leveling out a bit …
… and I found myself able to think [briefly] about other things. And the other thing on the front burner was a decision I made last week After eight years volunteering at a rural charity clinic, I’ve decided to wind things down and retire for good. If it were for age or health considerations, I wouldn’t be mentioning it. But that’s not the reason.
Our area has a number of retirement communities. At some point, a few retired physicians opened a free clinic for the uninsured, staffed by an army of retired volunteers with a wide variety of medical skills. They raised the money with golf tournaments and donations, and created something I thought was unique – an interface between the retirees [from the "1%" retirement communities] and the patients from the other end of the financial spectrum. But with the coming of the national effort for universal insurance, the powers-that-be decided to change the clinic. We would still see the remaining uninsured, but collect the insurance reimbursement from those who were insured. And so we have a new building replacing our old "trailers." It’s staffed now by employees with far fewer volunteers. We have added Electronic Medical Records [EMR] and a jillion other trappings of a clinic that has been "certified" to receive the insurance "payments."
Working there was a major change from my urban referral psychotherapy practice – more back to basics. The patients often had grown up pillar to post, exposed to abusive situations, substance abuse, and other craziness. At first, I was horrified at the medicine regimens people were on [almost everyone was "on" something]. The focus of this blog arose out of my explorations of these alarming medication practices. So the first order of business was to deal with the medication quagmires. Since I was the only act in town, I was also a social worker, an addiction counselor, a "common sense" psychotherapist, a medication manager, a neurologist, a grief counselor, etc – literally, a jack of many trades. Over time, I got my rhythm and found that I was able to do a lot more for patients in this setting than I might have ever imagined – even with infrequent contact.
I guess I thought I could ignore the changes that came with our new status, but I can’t. Instead of a brief written note and handwritten prescriptions, I have to do it on a computer using a system designed by someone who cut class on the day they taught "user friendly." Apparently the system pays extra if there’s a vital signs recorded with every visit, and a waiting room PHQ-9. There are frequent knocks on the door for some procedural something-or-another. Absolutely everything is just so much harder, and I’m sure that I now spend more than half my time doing these administrative, documentation tasks. The long and short of it is, instead of doing what I know how to do, I spend my time doing things that I don’t know how to do [and see no reason to be doing].
Now imagine how someone who is 55 years old feels, who has 10-15 years left to practice before legitimately accessing retirement, and watching politicians, bureaucrats, and other non clinical intruders dictate the course of care.
Personally, I think colleagues over 75 years old have an obligation to not only speak up more loudly, but get in the faces of your age related opponents and make it as public and personal as one can get to try to implement real, better change.
But, I think that moment of opportunity has passed, and probably too many years earlier. Where were all these seasoned providers who allegedly cared for the profession back in the late 1980s-early 90s when the fight should have been taken to these cretins’ faces who were only out to profit off of health care dollars?
Medicine is really about whores and cowards as a whole. The question really is, how do all these retired doctors who have left in the past 15 years live with themselves, letting this travesty play out?
Medicine lost real mentors and leaders when I finished med school in the late 1980s, believe it with what health care is now!
Joel Hassman, MD
Dr. Mickey, bless you for what you have done pro bono all those years.
The problem in the clinic illustrates why the problems in pharma will not be solved by more oversight. Most oversight is dysfunctional and serves other masters. Central planning doesn’t work. The last federal program I can think of that was an overwhelming success was the GI Bill or maybe the Interstate Highway Bill.
The problem in pharma will be solved by more critical thinking. I think even with MDs, stats fly over people’s head. Maybe philosophy of science needs to be introduced freshman year of medical school so we don’t devolve into Powerpoint absorption robots, because I think that’s what happened. What is a disease? What is an illness? What is essentialism? What is operationalism? What is phenomenology? These are questions I had to learn to answer mostly as an auto-didact. Fortunately, in my first year as a psych resident, a faculty member who was interested in this questions got my interested but it’s not part of medical education and it’s not on the boards.
One more thing about pro bono or Medicaid work. There should be immunity from medical malpractice unless the act involves mens rea, deliberately harming a patient, as opposed to simple negligence or medical error or side effects that were discussed in informed consent. Psychiatrists who do volunteer work should not have to live in constant fear of lengthy and distressing tardive dyskinesia or metabolic syndrome suits, which are popping up with more regularity even when informed consent was clearly established.
>Absolutely everything is just so much harder, and I’m sure that I now spend more than half my time doing these administrative, documentation tasks. The long and short of it is, instead of doing what I know how to do, I spend my time doing things that I don’t know how to do [and see no reason to be doing].
From a patient’s perspective… Most office visits involve some sort of computer hardware or software problems. The office wi-fi isn’t working properly-data can’t be entered or retrieved from the iPad. The doctor is too busy typing and entering data on a terminal to look at me. The receptionist is having issues with setting up a followup appointment. The pre-admission clerk at the hospital is the newbie and the software guru is on vacation, sorry for the delay getting you in to get your EKG and x-rays. Wow, I can see why you guys are so pissed off all the time. Weren’t computers and technology supposed to *increase* productivity and reduce mistakes? Hmm, I’m not so sure.
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No they were designed to collect large amounts of data for central planners. They were sold and promoted on a false premise.
It’s been 55+ years since we first met. So I can’t help thinking what a loss your leaving the clinic will be to your patients. It’s sad that all those to come will now never get to know your big heart, your good sense. It seems to signify a real change in things, like starting a new life, or the end of a century. Although I cannot by rights speak for everyone you’ve ever known, I nevertheless believe it’s true for all of us when I tell you: Thank you for all your good work — I’m so glad to know you.
This is so sad on so many levels. The government has forced generous physicians who just want to practice medicine into the role of outlaw, because they can’t handle the paperwork. Brazil and Idiocracy are no longer dark comedies, they are prescient documentaries.
https://www.youtube.com/watch?v=5_00bbE9oxQ
https://www.youtube.com/watch?v=hmUVo0xVAqE
“I just can’t find a way not to be constantly pissed off……”
This happens to any reasonable physician. You can’t take bright highly motivated people who are basically trained to be independent thinkers and practitioners and crush them under the weight of gross mismanagement and political self interest. The idea that every huckster out there has their own plan for medical “reform” when they don’t know a thing about medicine or taking care of patients is infuriating. If they did, they would not have us wasting half of out time on nonsensical clerical work.
I agree with the opinion that senior physicians have an obligation to speak out about how the field has been stolen by politicians and business managers and hope for the pendulum to swing in a favorable direction. But so far it seems that the younger generations seem quite content under business managers rather than clinicians.
I started out in a public health service clinic that sounds very similar to yours and the problems sound like they never change. Thanks for all of the hard work in that setting. The people running the place seem to missed the point like most places who generally find out that when a knowledgeable psychiatrist walks out – it may be a long time before they find another.
And I know that sense of relief…..
When I got interested in the commercialization of psychopharmacology, I knew absolutely nothing about the processes of drug development and approval, or for that matter, clinical trials and how they worked. And a number of biological psychiatrists have tirelessly fielded my often naive questions – tutored me along – much as I’ve been “tutored along” from medical school forward. Most people don’t realize that medical education continues to be an apprentice system, mainly staffed by volunteers [the clinical faculty]. Medical School teaches medical science, but much of doctoring comes from the volunteers freely available all along the way.
My point being that volunteering [teaching and/or pro bono work] is an integral part of medicine, and I hate seeing the micromanagement of medical care in the current era interfering that [necessary] tradition…
Just out of curiosity, what EHR were they using. A small clinic wouldn’t be using Epic, but let me tell you, my hospital system is, and it is driving me nuts.
or Medicaid work. There should be immunity from medical malpractice unless the act involves mens rea,
Wow. Just wow.
What is so shocking, EC?
People with high levels of training should work for next to nothing or free but leave themselves wide open for huge lawsuits and loss of reputation? That’s right out of the school of “no good deed shall go unpunished”.
Only in America is medi-mal such a huge cottage industry.
Someone is kind enough to volunteer, give them a break.
http://articles.courant.com/2014-08-14/news/hc-ed-florida-doctors-malpractice-20140814_1_health-care-act-volunteer-doctors-connecticut
You don’t think that a Medicaid patient deserves the standard of care?, i.e. “the level and type of care that a reasonably competent and skilled health care professional, with a similar background and in the same medical community, would have provided”
I believe that Medicaid patients do deserve that even if they are poor.
Medicaid pays extremely low fees, but the doctors who take them are not volunteers. I think that latter fact, is part of why MIckey decided to retire from his current gig. He liked volunteering.
Medicaid barely keeps the doors open and covers the overhead. When all is said and done, it’s pretty close to volunteering. Especially for psych and internal. And I never said anything about lowering the lowering the standard of care. Lawsuits address mistakes or maloccurances after the fact and do not increase the standard of care. A frivolous lawsuit can kill an older doctor or wreck their health and obviously all the incentives are to retire and stop being society’s punching bag. European societies aren’t sue-happy and do not have quality of care issues as your post would imply.
Dear Mickey
I am sorry for your patients that you are leaving but I understand.Many if my peers in both medical and no medical professions have either walked or want to walk very badly away.
My concern is for the young folks.
How can they be mentored or guided into the history of their profession and the
philosophical ethos that guide the shining lights of our country
The professionals that due care and due give a damn.
Medical students and others in field placements or practicing need to hear about TB,Polio wards.
They need to know about home visits.
Many need to learn about when and why some state institutions or religious
institutions worked and also why so very many went so terribly wrong.
I hope your voice and words can be heard by all of them.
There has to be ways to break the cycle we all are in and restore memory and compassion to all service relationships.
Ah the typos again
Please ignore.
“There has to be ways to break the cycle we all are in and restore memory and compassion to all service relationships.”
Not as long as population health, data collection and cost containment are the primary drivers of the system. I see no evidence that this will change.
The politicians who claimed to be the most compassionate turned doctors into groveling data entry clerks and patients into a dot on a scatter chart.
For someone who has been providing care most of my career at clinics that are Medicaid dependent, and that is a fair and accurate description, dependent, I think there are two questions for readers who are health care providers need to answer, and not just reflexively but really ponder first:
1. Are health care resources finite or infinite? I still meet people to this day who invariably make statements that health care is an infinite service. Really! If that was true, would we be in the position that health care is in today?!
2. Do you as a provider really think bureaucracy has any honest and concerned interest in the care of patients? Just look at formularies and the way electronic records are utilized.
Also at the end of the day, it is hideous how many patients genuinely think we should have taken a vow of poverty to be a physician. But, it is even more pathetic and disgusting how many health care providers think that we should just accept whatever income stream we are offered or could access in providing care for Medicaid and Medicare.
Here’s my prediction, and yes, cynical and jaded, nothing has changed: By the end of this decade, the majority of students who enter medical school, over 80% at least, are either scarily clueless to what they are accepting in their career goals, or, are callously complicit with the agenda of politics and business and are just covertly planning how to game the system for profit mongering.
Not that those two presentations aren’t already in play these past 10 or more years, but, they will become predictable for the sizeable majority of medical students.
What did George Dawson say above here? “But so far it seems that the younger generations seem quite content under business managers rather than clinicians.”
Again, and the older senior colleagues think they are insulated from this?! Or maybe too many of them have sold it and have terminally compromised the medical profession. Advocacy is not an option, but an expectation when one took the Hippocratic Oath at graduation.
This is not directed to Dr Nardo in any way, but, I am ashamed of the behaviors and choices by my older colleagues in psychiatry these past 20 years. They have as a whole, even if just 50.1%, shown me nothing less than pathological paternalism and incomprehensible indifference to the chronically mentally ill.
And again, I left the APA 21 years ago because in 1995, almost 50% of members per their vote were more than accepting of what managed care was doing to the profession.
Sorry Dr Nardo, it really is about working with whores and cowards, again not at you, but, can’t you have a moment of transparency and note what you have seen in your travels these past 15-20 years with colleagues you once respected but might revile now???
Joel Hassman, MD
It’s hard to feel too sorry for people who entered medical school after 2010. They knew this was happening and signed up anyway. The group that’s really getting hit hard is the 30-55 year old group who are now doing something way different from they signed up for, encumbered by student debt like chattel. The combination of maximum responsibility and minimal control is psychologically toxic in any work environment which is why soldiers don’t stay infantry privates for forty years.
It’s sad for me as a patient, because I trust older physicians more and they are retiring in droves because the paperwork is overwhelming. I’d rather just pay cash and have some eye contact and individual attention during the clinic visit.
Understand your reasons for retiring and pain Dr. Mickey. I am 15 years younger than you and am still in the Sturm and Drang of inpatient and outpatient work at the medical center I toil (and troll) for. Like you my private practice allows me peace of mind to practice in the “old” ways I was taught. And this gives me a source of income independent from the medical center that employs me, so that I can send my kids to college. Whatever. The thing that strikes me most these days is that when I arrive at the inpatient unit conference room, where docs, residents, medical students, and social workers convene to deliver “care” (and I use that word loosely), EVERYONE is interacting with a computer screen and NO ONE is talking to one another about cases! Backs are turned to all– it is the screen that is the audience! It is remarkable! It’s a room full of residents in psychiatry and medical students being taught about psychiatry– and all they are doing is TYPING on a computer and NO ONE is interacting with a PATIENT! It is a Kafkaesque nightmare! I hope you can enjoy your retirement and find well deserved satisfaction in the memories of all you have helped.
As an FYI, I switched to a PCP at the beginning of this year who actually looks at you when you initially go in to discuss the reason for the visit. Not once does he look at the computer. For what it is worth, he seemed to be in his late 50s.
Mickey, I thank you for taking the time to work as a physician volunteer with all those patients who obviously needed your services. I definitely understand why you no longer will be doing this but am greatly saddened at the circumstances that drove you to this decision.
I wish I could post this illustration of my run-in with EHR.
http://pasteboard.co/qj55h0Aps.png
That blasted nurse was so computer-occupied during my intake interview in an emergency room at around 1:00 a.m. that my report of being near fainting was just an annoyance to her. Barely looking over her shoulder at the pale, sweating, and mightily upper-abdominal-pained customer who complained of vision going dark and being about to faint, and asked if she might lie down, Big Nurse issued her opinions in a hateful tone. I should “get a grip,” and I wasn’t going to faint. Her un-healing hand pushed me upright when I finally remembered that I should lower my head to prevent loss of consciousness. I ended up with a convulsive syncope episode for the record books, and my neck will never recover. I don’t see that happening if the nurse been focused on me. Any idiot would get a blood pressure reading under the circumstances, but that idiot was serving her digital masters.
Worse, I found out later that the injurious episode was not mentioned in the records of my visit. Yet worse, I found out recently, when I went in two days later to have my neck looked at, the NP who took down my account recorded it as “according to the patient, she was seen for […] and was sitting in a chair in the hallway when she suddenly felt weak and dizzy […]. She states that she did fall out of the chair and was knocked unconscious for less than a minute.”
Maybe the very worst part of this sordid anecdote is that the ER doc who saw me and signed off on the falsified records is an “Expert Medical Reviewer” for the Medical Board in my populous, economically important state. He’s also an examiner for the American Board of Emergency Medicine. But, knowing about the C.S. episode, he felt the back of my head for a lump, and found nothing. There was an egg all right, and good doctor would know where to find it, based on the bizarre contortions of convulsive syncope. It’s higher up, neither the back or the top of the head. The impact of my head on the concrete floor was so great that I was aware of it –think of a bowling ball dropped onto concrete from a height of three feet– despite not regaining conscious per se. The sound of it was what drew the feet that surrounded me when I finally opened my eyes.
Moral: the formalities of record keeping can harm patients, and there is no guarantee that the information recorded at such great expense is accurate; it can be harmful, too.
(About the illus.: the hamburger is a fabrication, and I am not a corgi, which makes it about equal in accuracy to what the local charlatans wrote about the occasion.)
[Dr. N, please forgive my submitting a ranty personal anecdote if it’s out of place. I’ll understand if you choose not to shunt it onto your blog.]
After Tuesday they might still need you as a volunteer…
is it me or are the former candidates’ trendlines mirror images of eachother/
literally draw an x axis to separate the two and flip the blue, and i’m pretty sure it’s the red line.
Gagan,
since there’s no third party picking off more than a small fraction, that’s necessarily going to be the case.
i see. thanks dr o’brien.
still kinda weird. you ought to think they have some sort of third option, but nope.
reminds me of the stock market 😉
This is also a cautionary tale about demands for “oversight”. The oversight you want is not going to be the oversight you get. Be careful what you wish for, it may come back to haunt you.