More and more, I read about physicians who are ready to give it up. I hear similar views in the physicians lounge and in hospital hallways. These conversations are a modern phenomenon; they did not occur when I entered the profession 20 years ago.
They have germinated as a result of rising forces that have demoralized many practitioners. Some of them include:
• Loss of autonomy
• Loss of income
• Loss of stature and prestige
• Required ‘Quality’ initiatives
• Health care ‘reform’
• Infighting within the medical profession
• Medical liability system
• Insurance company hurdles to get paid
• General gerbil wheel existance
Luckily for me, I am still happy on the job. Of course, I am not immune to the above realities, and would readily accept a vaccine to protect against them, if one existed. I try to focus on the core purpose of being a physician, and work to sequester the noise and static, at least while a patient is seated before me. Since I am a member of the human species, I do not always succeed. Sometimes, stuff creeps out of a compartment at the wrong time, and I try to stuff it back in its place. It’s a struggle, but I usually prevail. So, with regard to being a practicing physician, I am not ready to give up. I keep my 'white flag' in the closet.
There is a part of the profession, however, that I have given up with zeal and enthusiasm. For me the decision was easy, but for some colleagues it is agonizing. A few years ago, I gave up performing a procedure that is essential for many gastroenterologists. It is called ERCP, which stands for a term that is so long, that I wonder if its practitioners thought they would be ‘paid by the letter’. To save you googlers a key stroke, here’s the term in full.
Endoscopic Retrograde CholangioPancreatography!
This is a fancy endoscopic event when the gastroenterologist passes one of our flexible black serpents down your throat and snakes it around corners to reach the small intestine. Then, tiny tubes can be inserted through the scope into the liver and pancreas to accomplish tasks that previously required surgery. This invention is a towering milestone in the practice of gastroenterology.
How important is this skill in my trade? Peruse the ads at the back of any medical journal under the gastroenterology section and you will read phrases, ERCP required or ERCP preferred.
Why would I give up performing a test that distinguished me in my specialty and made me a more marketable gastroenterologist? Would we expect a professional basketball player to eliminate 3 point shots from his game? Would we expect a concert pianist to declare a moratorium on playing any piece in the key of A flat? Would we expect a congressman to vote on legislation that he hasn’t read? (Yes, you may snicker now.)
It seems odd to voluntarily surrender skills that allows one to occupy a higher orbit in his profession; yet this is exactly what I have done. I gave up ERCP because I simply wasn’t good enough at it. I never killed anyone, and my complication rate was within the expected range for this procedure. It certainly was exhilirating when I was successful, and quite demoralizing when I couldn't get the job done. More and more, I realized that the ERCP field was advancing, but I wasn’t. My skills were acceptable, but stagnant. Why didn’t I simply incorporate the evolving technology and gadgetry into my practice? This response is a blog post in itself, but the summary statement is that it is extremely difficult for a practicing community gastroenterologist to stay current with evolving technical procedures.
So, I gave it up, not the professsion, but an important aspect of my practice. It was liberating as I now knew that any of my patients who needed ERCP skills would be referred to someone who did it much better than I could. The quality of a physician – or any occupation – is determined by the weakest element of his practice. I hope that pruning my practice has made it sturdier.
These are vexing issues. When does someone give up an essential element of his occupation? Sometimes, the answer is obvious. We don’t want cardiac surgeons with flapping tremors to perform delicate heart surgery. We don’t want airline pilots who suffer from sudden blackouts to be at the controls. However, sometimes the deficits are more subtle, and it is not clear that the practitioner is impaired to the extent that a professional change is required. Where is the boundary line and who should set it?
Quality measurers from the government, insurance companies and professional medical societies will soon be unleashed on a mission that they can't succeed at. They will fan out across the countryside claiming they can measure the unmeasurable. Those of us who understand the guts of medical care realize that what really counts, in medicine can’t be counted. For example, these qualitycrats might have deemed my ERCP skills to be acceptable, using their check-off boxes and quality rubrics. Indeed, I was granted privileges to perform this procedure in my local hospitals every 2 years through the perfunctory recredentialing process. The reasons that impelled me to set the ERCP scope aside are real and legitimate. But, they can’t be weighed and measured.
I hope that the quality buzzards who will suffocate the medical profession give up before we physicians do. I can loan them my white flag.