hospital, OB GYN, physician

Working the Holidays: The Invisible Heroes of Healthcare

No one wants to be sick around the holidays, or go into labor during Christmas Eve Service.  We are constantly reminded that we have no control over these things as emergencies arise 365 days a year and thankfully, there is always a place to seek help and someone who is ready to be of assistance.

The holidays are what remind us of what is important in life.  They are a time for gathering with family and friends when the otherwise hurried pace of life doesn’t usually leave time for a home cooked meal with Mom, chatting with cousins, or playing in the snow with kids.

Unfortunately, some people have to miss these precious moments- their jobs require it.

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If you walk through a hospital during Christmas, you will notice it to be eerily quiet.  Only patients with true emergencies will be there, and health care workers will be ready.

You will see a phlebotomist with a Santa hat on striking up a conversation with a patient while skillfully drawing their blood.  You will see a nurse comforting a woman in labor and a surgeon closing the incision from an appendectomy.  You will see a cafeteria worker flipping burgers and humming a song while he works, providing the sustenance to keep the rest of the team going through their 12-24 hour holiday shifts.

They are all happy to have their jobs, but they are missing their families immensely during this time.  Few professions require the dedication to work during a time when everyone else is tending to the people that make their lives meaningful.

Alternatively, some health care workers may have volunteered to work.  Perhaps the holidays are a particularly difficult time as they are acutely reminded of the loss of a loved one and the memories forged on these holidays in the past.  Working may provide a necessary and welcome distraction.

Regardless of the reason these people are working over the holiday, they are providing a desperately needed service- a service to others at the expense of their own families.  These actions are what remind us all of the need to take care of each other.

Thank you to all of the janitorial staff, medical assistants, nurses, phlebotomists, ultrasound techs, and doctors (to name just a few) who keep America’s hospitals running and care for our patients over the holidays.

Merry Christmas and Happy Holidays!

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physician, Uncategorized

Do Patients Pay Less for Cheaper Care? Why the CVS/Aetna Deal Matters

On a recent trip to urgent care for my child, I began to more clearly see how the changes in medicine are affecting our patients and who is benefiting from the bottom line of what is occurring in the US health care system.

A minor injury to my 2 year old son had me waiting patiently to be seen at a local urgent care center.  Eventually, a nurse practitioner evaluated, correctly diagnosed, and successfully treated my son.  (I make it a habit not to treat my own children as I feel it more appropriate to be “mom” instead of “Dr. Jones” to my children in these types of situations).  I appreciate nurse practitioners and feel they provide a great service and are filling in gaps in areas of need, especially in this time of physician shortage.

My concern arose as I considered how this medical care visit was truly playing out financially.  I paid a copay with my insurance- no big deal, it was $30.  My insurance would be covering the majority of the visit.  However, ultimately the company running the urgent care facility would be charging the same rate to my insurance, and same copay to me, for my care regardless of whether I saw a physician or a nurse practitioner.  I even went as far as calling a billing specialist in membership services at my insurance company to ask if this was the case.  She indeed confirmed that there is not a separate charge for urgent care visits depending on the level of provider seen.

My question to anyone who has seen a nurse practitioner or other qualified individual, is your co-pay lower for the service? Do you receive a discount for not seeing the higher paid/more trained physician?  In my situation, there was no reduction of copay.  So, if they are collecting the same amount for the service provided despite a disparity in income level of the provider, who benefits from this profit?

The company running the urgent care center reaps all of the benefits of employing a health care provider with a lower salary than that of a physician.  Their smaller salary likely means more profit for the company.

Again, I am in no way against using mid-level providers, nurse practitioners, midwives, etc.  They are here to stay and provide an important role in healthcare moving forward.  However, my argument is that if a company is benefitting financially from hiring “cheaper” people to provide care to their patients they should at least be passing the savings on to the patients who are receiving the care.  Often, these companies are looking for the financial bottom line and what they can get away with to reap the most profit.  It is a primary responsibility of top administrators to make money for the company, and we can hardly blame them for successfully completing the role they were hired to fulfill.

Transparency is required in these situations.  The patient must know they are not seeing a physician- when they could be- for the same cost to themselves and their insurance company.   They should have the ability to demand physician care if desired.

A prime example how this business scenario is becoming the future of medicine can be seen in the recent proposed merger of CVS and Aetna. The companies involved are in a massive media campaign to make patients think this is to their benefit.  Please remember, these are businesses at the end of the day and their ultimate goal is to increase financial return to investors.  The basic facts are still at play- a drug store is buying an insurance company.

On Wall Street, the widely held belief behind this merger is that by teaming up, CVS and Aetna can have a fighting chance against the behemoth that is “Amazon”, as this online giant attempts to get into prescription drug sales.

Often, the patient is the one to suffer in situations such as this merger, as they will actually pay more and receive less choice.  It’s a monopoly and if your insurance is owned by a drug store company, guess which prescription you will likely receive?  The one on formulary at CVS of course!  So, if the prescription chosen to treat your condition is on formulary at CVS, there most certainly is less overall cost in the health care transaction.  So, does the patient pay less since their prescription costs less or a lower copay for seeing a mid-level provider in a “clinic” that is now part of the plan to have in CVS stores?

You guessed it, the company will profit each time a prescription is written for a drug under their formulary instead of one that isn’t.  The company will also profit each time a midlevel provider sees a patient instead of a physician.  Again, is this in the best interest of the patient?

One last piece of information to consider, the Aetna CEO will walk away with $500 million in cash and stock if this deal goes through.  This executive, who is not a physician, has much to gain from this merger.  I don’t begrudge anyone good fortune, but I also don’t believe the media should portray that the patients are the primary ones to benefit in a deal such as this.

Patients and physicians are no longer accepting the status quo and what everyone outside of health care is telling us is “in our best interest”.  We see and understand what is going on.  We are speaking up and demanding better.

OB GYN, Physician Training, retirement

Is it Ethical to Retire Early from a Career in Medicine?

Eight weeks after I delivered my 3rd child, I was diagnosed with a 4 cm lung mass.  Yes, you heard that right. For those in medicine, this is terrifying to hear as the first thing that comes to mind is lung cancer.  Lung cancer is notoriously hard to treat, typically fatal with a short life expectancy after diagnosis, and extremely unfair to a lifelong nonsmoker who has spent 12 years in the prime of her life dedicated to training to become a physician.

Luckily, I soon found out my situation was not as grave as first expected.  A PET scan leaned toward benign diagnosis (or at least consolidated disease).  I could temporarily push aside the paralyzing fear of leaving my 3 young children with no mother and focus on getting rid of this mass that was causing pneumonia, difficulty breathing, coughing for 2+ years, and go ahead with scheduling the thoracotomy.  After resection of the mass which was densely adherent to my pericardial sac and phrenic nerve, I lost about a 1/3 of my left lung.  To my amazement, after my ICU stay I left breathing better than I had been in years.  Benign diagnosis was confirmed.

This experience made me reevaluate my life and it stopped my “hamster wheel” of life I had been running on at a dizzying speed.  I viewed this health scare as a second chance at life.  I didn’t take this lightly as it almost seemed unfair that I got this chance to live while others who have a lung mass often have it turn out to be one of the most fatal of cancers.  Having to face the prospect of this potentially devastating diagnosis changed the course of my life. I was able to view my career for what it was and had become.

 

I had planned to work in my medical career as a physician indefinitely, or at least well into my 60’s.  It had always been my passion to work in obstetrics and I love my patients and the bonds I build with their families. It was never my intention to leave early, and it didn’t factor into choices along the way for my career.  But here I was, ready to retire in my late 30’s after several years of increasing disillusionment with the health care environment.  Apparently, I just needed this wake-up call for a chance to realign my priorities.

Loss of physician autonomy, pressure to increase productivity as opposed to quality care, and placing cost effectiveness ahead of best medical practice were weighing heavy on me.  In addition, the litigious environment in the US has become out of control and encourages frivolous lawsuits without any repercussions for those seeking damages without merit or basis for the claim.

I could no longer honestly tell myself that I was working so hard for the good of my patients, and I became cynical that my efforts were to the benefit of the financial bottom line of a health care system with its priorities out of sync with my own.  This is not specific to any health care employer, physician group, or hospital.  It is emblematic of the US healthcare system in general.  It is the reason I left medicine entirely and did not merely seek to work elsewhere. The problem is pervasive.

The decision to leave became a question of “why am I doing this, and for whom”?  I decided to retire early.

I have since learned that many feel this is not an appropriate thing to do in your late 30’s.  There is the argument that I owe a debt to society now that I have the skills acquired from all of those years of training. Or that the government paid for my residency salary and that I am indebted due to that.  Or that it is selfish to stop working to spend more time with my family.  There is the argument that it is not fair to leave my patients that I have been caring for over the years.
My response to the ethics of my decision to retire early: If you pay for the privilege of a medical degree and work hard to pay off this debt, should it be your decision if you want to continue to practice?  The government did pay my salary as a resident, which amounted to a little more than minimum wage for 4 years of 80 hour work weeks.  Do I owe something because of this?

As for leaving my patients, I actually do feel a little guilty about his one.  I love my patients.  I also struggle with no longer using my degree for clinical practice, something I worked so hard for.  We are already feeling the strain of physician shortages and this another thing that gives me pause.

In the end, the burden of practicing medicine in today’s environment no longer outweighed the positives for me.

Ironically, it’s my patients who hugged me and told me how happy they were for me to live the life I felt I needed to.  It’s my patients that spoke up (without me saying a word) about how the medical field has changed and that we are losing good doctors as the control of medicine is being handed to hospital administrators and politicians who are making choices about health care without a medical degree. It’s my patients that brought presents on my last days and thanked me for the care I did provide throughout my career instead of lament about what I “could” have done if I stayed longer.

It was a very personal and difficult decision for me to leave medicine and luckily, my colleagues who know me have been incredibly supportive.  On the other hand, one thing that has surprised me is the number of physicians contacting me who want out of healthcare but don’t know how, or can’t, get out.

How do we retain physicians? It is not by increasing salaries. Doctors aren’t in it for the money, we chose this profession to help people and save lives.  We do it by reforming the current health care environment and making this a profession that is sustainable.

Give medical decision making back to physicians.  Decrease the cost of health care by cutting out costly administrators and through tort reform.  This is the way to keep our best physicians and improve health care in our country for our patients.

Ultimately, is it ethical to retire early from a career in medicine? Or is it a bigger picture issue of how do physicians take back control of medicine so that we aren’t leaving at a time of shortage? This is a major concern for our country moving forward.

 

hpv, OB GYN, Parenting, vaccine

This Mom (and OB/GYN Doctor) Sounds Off on Whether Your Daughter Should Get the HPV Vaccine

My young daughter will be entering middle school in another year. However, she still likes coloring books. If she watches a scary movie, I have to lay with her in bed until she falls asleep.

She is still just a kid. Should I really be worried about HPV? Is this something you should consider for your daughter?

Most people know that the HPV virus is sexually transmitted. However, most people don’t think it could happen to their daughter. Unfortunately, more than 80% of the population has been exposed to the HPV virus during their lifetime. How is that possible?

Well, let’s assume your daughter has 1 lifetime sexual partner. Let’s pretend her future husband only had 1 girlfriend prior to meeting your daughter. However, maybe his previous girlfriend had 5 partners- and who knows how many exposures those 5 partners had.

Now it’s easy to see that you don’t have to be sexually promiscuous to be exposed to HPV. It could happen to anyone and often does. HPV is silent (there are often NO symptoms), and people don’t know they have it and therefore pass it on to others unknowingly.

As an ob-gyn doctor, I know about the HPV virus and have seen so many patients affected by this virus that can cause cervical cancer if left untreated. I have seen women die from cervical cancer caused by this virus. I have seen pregnant women who are newly diagnosed with cervical cancer have to decide whether to delay treatment or potentially risk their pregnancy by treating the disease.

Luckily, most of the time we can monitor the HPV virus through pap smears/hpv testing and never have to intervene as the body will often clear the virus on its own. Occasionally, treatment in the form of excisional procedures on the cervix are necessary to prevent progression to cervical cancer. If you have never seen a LEEP procedure done in the office, trust me, you want to spare your daughter from this if at all possible.

By the time a girl visits her ob-gyn’s office she may have already been exposed to HPV and we potentially missed an important opportunity to give the vaccine. This is due to the fact that we typically don’t see teens in the office unless they are having a problem, and we don’t start pap smear screening until age 21 (appropriately so).

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Pediatricians (and family practitioners) do a fantastic job of making sure our young girls are getting the vaccine when indicated. Currently, the vaccine can be given to girls between the ages of 9-26 years old. Most girls are vaccinated with the series at age 11 or 12. Remember, the point is to vaccinate far PRIOR to sexual activity. We don’t expect your 11 year old daughter to be sexually active.

On the other hand, I have had to do numerous procedures on patients in their 20’s who have precancerous lesions from the HPV virus. Most are shocked and terrified and don’t understand how this could have happened to them.

As a mother, I am just like any other parent who would do anything to prevent my child from suffering. I worry about risks and benefits of treatments (even preventative) and how they will affect my daughter. I feel lucky to have had the opportunity to truly understand the research and risks behind this vaccine through extensive training in obstetrics and gynecology.

It is empowering to have access to a vaccine that can actually prevent cancer.

So, while the physician in me appreciates and understands the research and clinical implications this vaccine portends, when I counsel patients I find the mother in me also weighing in.

Since I do have a young daughter who I would do anything to protect, I can assuredly say that she will be getting her HPV vaccine when she turns 11. I want to know that I did my job as her mother to protect her when she can’t yet understand how this may impact her life down the road.

 

retirement

The FINANCES behind retiring from medicine at 37

I originally wrote this article as a guest blog for the site http://www.physicianonfire.com/ last month.  The physician author of this blog specifically requested I write on this topic as his site deals with financial independence and retiring early (FIRE).  I am now posting here since I have had requests from readers to share the financial decisions that allowed me to retire early from a medical career. Please let me know if you have suggestions/thoughts, or what has worked for you in the comments below.

Usually, when I tell people I retired from my physician career at age 37 they respond with shock.  Some look at me like I am the most foolish person they have ever seen.  Some with disdain (“all that medical education wasted”).  Some doubt that my future will be secure without having a steady paycheck.  However, as it is only my close friends/family I discuss this with, they mostly respond with sincere happiness as they understand this is a life choice I made after much deliberation and know that it is the right decision for me and my family in pursuit of the life I want to lead.  There are many factors that led to this decision and I have written about some of it in previous articles Retired at 37: Breaking Up With a Career in Medicine.  However, this article focuses on the financial aspect.

Finances can be a tough subject for physicians.  We are notorious for being poor money managers.  Most of us don’t have the time or desire to commit to understanding personal finances in detail. Who has time to learn about 401K’s, the stock market, and budgets while learning about anatomy, pharmacology, and immunology while in medical school?  Or while working 80+ hours per week in residency?  Besides, we won’t be earning an attending physician paycheck for years.  By the time we earn a real paycheck we are so exhausted by the delayed gratification of our 20’s that we want to splurge a little, right?

I don’t proclaim to be an expert by any stretch.  However, I found the freedom that comes with financial independence to be life changing and something that should be attainable for all physicians. I am not here to encourage everyone to retire in their 30’s from medicine, but to gain financial freedom.  I hope you can continue practicing medicine into your 60’s (if this is what you want), but to not feel trapped in a situation when encountering unsustainable job structure, illness, divorce, etc.  Of course, finances did factor into my decision to retire.  I have 3 kids and wouldn’t stop working if I needed a steady paycheck to support them. Luckily, some decisions along the way helped me not to rely on this paycheck moving forward.  There are many different paths to financial independence.  Here are some steps that led me down my path to financial freedom and ability to retire early:

  1. Kept medical school loans to a minimum. Yes, you do have control over this. Most people outside of medicine are shocked to find out that medical students are essentially able to get loans for as much as they want.  You can determine your own “living expenses” and someone will be ready and willing to give you this loan as medical students are typically good about ultimately paying it back (although years down the road and with a ton of interest).  I was lucky my parents paid for my undergraduate studies but medical school was on my own.  I probably started my “frugal” mentality at this time.  My husband, who I was dating at the start of medical school, would often make fun of me for my bare cabinets with canned green beans and ramen noodles as my main staples.  Of note, he also had loans from undergraduate school that we had to factor in as well. Don’t worry, we didn’t eat like that forever!
  1. Started paying off loans immediately after forbearance ended at the maximum amount we could, not the minimum required.
  1. Lived well below my means. We continued living in my residency townhouse for a while, even after accepting an attending job.
  2. Looked for job with high earning guaranteed right from the start. Many positions I was offered entailed low salary the first few years and then potential for partnership and jump in salary but not until 4-6 years down the road. This was downright scary to me.  What if I didn’t like the job? What if they never actually promote to partner?  The writing was on the wall for private practice in ob-gyn with soaring malpractice premiums and it seemed unsustainable to me for most of these private practices.  I wasn’t willing to take the chance. I had also heard that many people may leave their first job after 2 years.  So, I figured why not at least get a large salary those first two years while I get a better feel for the landscape? Luckily, my job did not have a non-compete agreement, so I knew I would have options if I decided to leave (I actually stayed with my first job as I was initially very happy with my choice out of residency- this lasted for about 7 years).
  1. Maxed out yearly contributions to retirement vehicles. 403B during residency, 401K with new job (which also had a pension that vested after 5 years), and started a Roth IRA. I had to devote some time to learn about what all of these things are and why they are important! Investing is key.finance
  1. 529. My first child was born in residency, but I did not start a 529 at that time as wanted to maximize retirement account yearly contributions first. Once those were being maxed out, I started 529 for oldest child and then when subsequent children were born funded those too.
  1. Lived off one income. I feel this one factor made the absolute most difference!! Certainly not all, but most of my colleagues are in a dual income household.  We always lived off one income (mine) and paid off loans with the other.  This always forced us to live within our means. This may be hard to accept initially as many physicians feel that the delayed gratification never ends, but trust me it’s worth it! I do have to admit, our one splurge was a nice vacation every year.  “Work hard, play hard” is my motto and I probably wouldn’t have made it without those necessary times of respite to recharge. Travel is one of my passions.
  1. Got Creative. For those who have a partner who does not have a career in medicine, there may be options opened for them since a physician job is very secure.  You will always be able to find work as a physician and it is quite unlikely you would lose your job. In addition, health benefits are common with employed physician jobs and therefore you can take a big burden off your partner to worry about this.

–          This can free up some room for ingenuity with your partner if their job allows for different payment structures. Commission based jobs with a low salary and no health benefits may be unsustainable for someone supporting a family. However, if you use the idea of living off one person’s salary (your physician salary) and allow your partner to get creative it can really pay off.  Employers may jump at the opportunity for this type of pay structure which would have very little risk for them but could have huge potential upswing for the partner.   We chose to take this risk. We couldn’t have done it without the stable physician salary/benefits component.  It was possible my husband would make barely anything certain years or alternatively, make large sums depending on the work flow.  Nothing was guaranteed to last and so any windfall that came from his work was immediately placed into debt repayment or kid’s college funds.

When starting out of residency at my first attending job, I planned to continue to practice medicine until my 60’s, cutting back on hours if needed, but I assumed my love for medicine would keep me wanting to work indefinitely. Several things changed my mindset, including financial independence.  Once I knew I didn’t “have” to work, I started to view my career a little differently.  Maybe I wasn’t honest with myself previously with how the stresses of on call nights, sleep deprivation and increasing administrative workload was negatively impacting my life and health. It sometimes feels like you are on this treadmill that keeps going and you don’t have the time or energy to ever stop and think about what you are doing and if you are leading the life you envisioned for yourself.

time

Once financially independent, it became my choice whether or not to work.  The frustrations of salaried work in ob-gyn, the negatively changing healthcare climate, and missing time with my young children was weighing on my mind.  I wanted (needed) out for myself and my family.   However, I needed a push to get off that treadmill and realize what was going on.  “Luckily” for me I had a major health scare that also occurred at the same time that I reached financial independence.   Decision made.

Now, the choice can be mine if I decide to ever return to medicine.  I’ll never close that door completely, although I don’t see it in my future if you ask me now.  There is so much out there I am still excited to explore.