Sunday, April 24, 2022

Employed versus Independent Physicians - Which is Better?

In my illustrious (or at least long) career, I have had 3 jobs.  After I finished all of my training, I was an employed physician for nearly 10 years.  Afterwards, I joined a small private practice group where I remained for 20 years.  Over time, as partners in the practice left or retired, I became the practice’s president by default.  I don’t really have an authority persona, which my staff was well aware and hopefully appreciated.  In nearly all cases when a decision could either favor the interests of our employees or the practice, I favored our staff. This earned a huge measure of staff loyalty, but no achievement award from the Chamber of Commerce. I am more than content to be regarded as a caring boss than a shrewd businessman.  Three years ago, I joined a rather large Cleveland medical enterprise where I now serve as a physician employee.

Employed versus Independent Physicians

Employment                         Independent

I know the advantages and drawbacks intimately of both models – employment vs business owner.  Indeed, an entire blog could be devoted to comparing and contrasting the two models.  It’s a complex issue.  It is self-evident that each option has its own advantages.  But the analysis likely changes depending upon the phase of the physician’s career.  For example, now in the autumn of my career, do you think I miss worrying over making payroll, erosion of patient referrals to the practice, declining reimbursement, grinding paperwork fighting insurance company denials, rising overhead expenses, compliance with state and government agencies, endoscope repair and replacement and physician recruitment?  Sound like fun?  Not at this stage of my career.  Presently, all of the above cited tasks are now in my employer’s in box – not mine.  I am now fully and enthusiastically devoted solely to the practice of medicine, which has been a joy.

But at earlier phases of a physician’s career, he or she may willingly take on the burdens of managing a private business in return for the autonomy and independence that this model affords.  Indeed, that was me for 20 years.  But no longer.

Of course, I miss the freedom that I enjoyed when I was the decision maker.  It is no longer effortless for me to take days off.  I do not hire my own staff.  No one, save the patients, asks my advice on anything.  But I am using a different set of weights and measures now.  And for me at this stage of my professional life, my scale tilts markedly in the employed direction.



Sunday, April 17, 2022

What is Causing My Stomach Pain?

One of the most vexing issues for patients and their doctors is dealing with unexplained abdominal pain.  Indeed, over the course of my career, I have treated thousands of these patients.  Every day, one or two of them are on my office schedule.

Many of them have had abdominal distress for decades.  Many have had several visits to emergency rooms and have seen multiple gastroenterologists and other doctors over the years.  Diagnostic tests are done and often repeated in the ongoing quest to find an explanation.  When I review a patient’s entire medical record, I am often astonished to learn how many CAT scans have been repeated to evaluate the same pain.

These patients understandably are operating under the notion that the medical profession should be able to explain the cause of their pain. This is the primary reason that these individuals seek care.  This is, after all, the job of a doctor.  In addition, they also want decent pain control so that they can live a more normal life.

Sometimes, it's best to choose another route.

If a patient has chronic and unexplained pain, there are two possibilities.  The first is that the physicians and medical professionals who have evaluated the patient over months and years have missed a lurking diagnosis.  Perhaps, no one considered a rare illness. Or a common condition was the culprit but was behaving in an uncommon manner making it difficult to recognize.  No physician can ever be 100% certain that every conceivable diagnosis had been excluded.  Here are samples of patient inquiries that I am unable to categorically reject.  “Could this be a parasite?”  “Are you sure this couldn’t be cancer?” “My aunt had the same symptoms and it took years until they knew it was her gallbladder.”  While these possibilities may be unlikely, I can never absolutely dismiss them

The second possibility is that the unexplained pain is also unexplainable.  Readers may be surprised to learn that this group of patients is the largest category in our abdominal pain patients.  Most of the abdominal pain we see won’t light up on an imaging study or a lab test.  Many of these patients may be assigned a diagnosis of irritable bowel syndrome, which may include an array of digestive symptoms which are difficult to explain even though a ‘diagnosis’ has been made.

Can folks with unexplainable abdominal pain be helped?  Absolutely.  But for many of them, gastroenterologists may not be the most skilled specialists for these cases, even though we are ‘stomach doctors’.  For example, if a patient sees me for a 3rd or 4th gastro opinion, it is likely that the patient is not on a healing pathway.  If the same approach in medicine, or in life, is failing, then it’s time to change direction.  And this is often the advice I offer these patients.  I tell them that I do not know which particular path they should pursue, but they need to make a left or a right turn rather than continue along on the same road.  They should be open to alternative approaches including functional medicine, integrative medicine, acupuncture, naturopathy, meditation and even hypnotism, among others.  This is not time for physician arrogance.  Many times, I have looked these patients in the eye and pointed out that since the prior strategy has brought no relief that a new approach must be considered.  In nearly every case they immediately get it since it just makes sense.  For many of them, it’s a why didn’t I think of that’ moment. 

When physicians’ and patients’ minds are open, there is much greater chance to find healing and relief. 


Sunday, April 10, 2022

Fake News - Why are We So Gullible?

It’s certain that you have heard the phrase ‘Fake News’ bandied about these past few years.  It seems there is no consensus defining this term.  Here are a few differing interpretations.
  • Inaccurate reporting where minor, immaterial errors appear, but the essence of the story remains true.  For example, if an article wrongly names a restaurant where a meeting is held, the article should not crumble.
  • Deliberately slanted reporting to serve a political agenda.  I do believe that this happens daily.  Reporters and editors are charged to compartmentalize their own views, similar to judges, but they are human like the rest of us.  The next time you open a newspaper, read the headlines carefully and you will find examples of wording that is less than fair and balanced
  • News reports that are completely on the level, but are attacked by those whom are threatened by the reporting.  I don’t feel that I need to give examples here.
Fake or On the Level?

A close cousin of Fake News is gullibility.  Folks today tend to believe what they read and hear, even if the position is untested or even disproven.  Remember how many diehards maintain that certain vaccines caused autism even though this linkage was thoroughly and repeated debunked by the scientific community?

Several times each week I have to reassure my heartburn patients that their medicines will not corrode their bones or lead them to kidney dialysis.  A screaming headline, Nexium Linked to Hip Fractures, may gain clicks, but it is misleading and not based on scientific facts. 

Our gullibility is exploited when malicious foreigners and those among us load Facebook and other social media sites with false and provocative information to divide and confuse us.   And, it works.   We are all too ready to accept as fact what is truly fake news hiding under camouflage.  

I am not excusing the purveyors of Fake News or those who falsely assign this label to truthful reporting.  But, don’t we – the consumers of news – have an obligation to perform some measure of due diligence?

Sunday, April 3, 2022

Will Smith Gets Slap Happy at the Oscars!

In my own life, I do my best to use one set of weights and measures.  By that I mean applying the same standard always when judging individuals, businesses, politicians and even nations.  There is not a day that passes that we do not see exasperating evidence of double and triple standards being applied.  We saw Republican senators recently excoriating a nominee under consideration for Associate Justice of the Supreme Court by senators who previously voted to confirm her!  No gloating here, Democrats.  Your treatment of Justice Brett Kavanaugh during his Senate Judiciary hearings was not your finest hour either. 

The Cleveland Browns recently acquired a superb quarterback, Deshawn Watson whose 5 year contract will provide him with a miserly $230,000,000. Presumably, after taxes, he should still have enough to live comfortably.  As everyone in Cleveland who is breathing knows, Watson is facing 22 civil lawsuits accusing the athlete of sexual abuse.  In fairness, two grand juries declined to indict him for a criminal offense and Watson has of yet not been convicted of anything. He denies the allegations.  However, the NFL was sufficiently persuaded of his misconduct that it is expected that he will be sanctioned by them.  I’ll ask readers to consider how their employers or prospective employers might react if they faced nearly 2 dozen civil lawsuits for sexual abuse.  Let me be the first to respond.  In my case, I would expect that my employer would arrange for a pair of security guards to escort me to my car.

A week before this posting, during the (yawn) Academy Awards ceremony, actor Will Smith charged the stage and slapped comedian Chris Rock hard across the face.  This wasn’t merely a demonstration of unrestrained rage and horrible judgement.  It was a crime witnessed by millions of people.  Smith returned to his seat and avoided any consequence either from Academy security personnel or law enforcement.  Later on in the ceremony, Smith received his Oscar award and was seen celebrating later that night.  Of course, the Academy promises a ‘full investigation’, but I think we all know where that will land.  A day after he committed assault and battery, Smith issued a lawyerly apology that was obviously crafted by others. 

What would have happened if an ordinary person in the Oscar audience -or anywhere else- stood up and approached another person and slapped him silly without warning?  (Here’s a hint.  If you’re thinking ejection from the auditorium followed by arrest, then you’re on the right track here.)  Suppose one of my patients arrived 20 minutes late and I seethe over this disrespect and opt to let my hands do the talking.  Do you think that I would be permitted, if not encouraged, to continue seeing patients later that day or ever?  More accurately, that would be the day that my retirement would begin.

Using one set of weights and measures would restore so much faith in the system and in each other,  Many folk prefer to have multiple sets at their disposal.  I guess this depends if your mission is fairness or to win.