Jeff Forster

That rather depressing perception is shared not only by a hefty majority of the survey's 7,700 respondents but also by a number of high-profile physicians: "We all worry that American medicine may no longer be the magnet it has been for America's best and brightest," AMA Past President Yank D. Coble Jr. said last year in sizing up the profession.  

National Institutes of Health Director Elias A. Zerhouni has also fretted that many promising students may be shying away from careers in medicine and medical research. 

Some of the more vocal among today's practicing physicians have lamented the transformation of their beloved profession into what they view as a trade. In short, maybe prospective doctors-if they're listening to those elders-are reluctant to 

 for the same reasons doctors at midcareer are trying to 

. As one young doctor groused, "MBA graduates with six years of post-high school education may start for nearly the same compensation as physician residents with 12 years of post-high school education. This does not even begin to assess other factors such as lifestyle, indebtedness, and liability." 

The uneasiness is not exclusive to medicine. "Science as a profession isn't particularly honored," said Cornell University physicist and Nobel Laureate Robert C. Richardson in an interview with 

 in July. Richardson was talking primarily about PhD careers in the sciences and engineering. 

In 1975, the US ranked No. 3 in the world in the percentage of 18-24-year-olds who earned degrees in the natural sciences and engineering. Today our country has dropped to No. 17, and half of the engineers graduating from US schools were born in other countries. "The glamorous degree these days," Richardson concluded, "is the MBA." 			

Putting the grumbles in perspective        Just how legitimate is the "best and brightest" gripe? How much reality is in the perception? Any concerns about the Doctors of the Future must be put in context. Consider that average MCAT scores for both medical school applicants and matriculants have steadily 

 over the past decade. Applicants' mean MCAT verbal reasoning score rose from 8.3 in 1992 to 8.8 in 2003. Mean scores in the physical sciences portion jumped from 8.1 to 9.0, and in biological sciences from 8.2 to 9.3. We're not sending schlubs to med school these days. 

Articles

A loaded question, and everyone has an opinion. Among the intriguing thoughts: Maybe it's the wrong question.

Are the best and brightest going into medicine?

 "Like most family doctors, I've spent years undercoding. Now that I'm learning   to do it right, level 3 and 4 visits are going to be a lot more common, and   should boost my productivity by 15 to 20 percent. 

 Medicare, meanwhile, is starting to get tough about services. I know when   I need to do an ECG, but it's hard to find the right code to convince Medicare   that when I put a patient on a particular medication I need to monitor his conducting   system. I'm getting a lot of denial lettersat least one a week. My partners   are, too. But we appeal every one, and so far we've won them all." 

 	Charles M. Davant III, FP, Blowing Rock, NC 

 "No matter what name is given to itprofession, job, vocation, callingmedicine   is a wonderfully rich field of endeavor. My bias is that nothing will ever change   this. My own goal is to make headway in practicing evidence-based medicine that   is scientific and substantive, and is also sensitive to the individual needs   of individual people. 

 I've always loved the 'game plan' capsulized by Stephen Grellet (1773-1855):   'I expect to pass through this world but once. Any good thing, therefore, that   I can do, or any kindness I can show to any fellow human being, let me do it   now. Let me not defer nor neglect it, for I shall not pass this way again.'   " 

 	William Roger Davis, FP, Claremont, CA 

 "My relationship with my father has been the biggest influence on how I live   and think. Not having gone to college himself while six siblings were college   graduates, he saw to it that all seven of his children got a college degree.   He was proficient in three languages, read extensively, and discussed world   affairs with us routinely. He taught me tolerance and acceptance of those who   are socioeconomically lower and different in caste and religion. I carry that   beacon." 

 	Rahma Mustapha, physiatrist, Valatie, NY 

 Physician's travel diary: "Aspen on steroids" 

 "Japan gives new meaning to the phrase 'in your face.' It is one of the most   densely populated countries in the world. Much of its extreme public politeness   and elaborate manners, I suspect, evolved from having to live amiably in small   homes and crowded public places. 

 Contemporary Japan is one of the most expensive places to visit. It makes   Aspen look like K-Mart; I think of it as Aspen on steroids. Our room at the   beautiful Park Hyatt in Tokyo was $390 a night, not including a 15 percent consumption   and hotel tax. The sticker shock continued: $5 for an apple at the market, $9   for a cup of coffee at a luxury restaurant, $110 for a piece of fresh tuna,   $150 per person for a meat entrée cooked at your table. I did come across   one book that recommended staying at "love hotels," which are clean and cheap.   We have now been to every continent; our two-week excursion through Japan was   by far the most expensive. (The least expensive, for the record, was South America.) 

 But the trip itself was fascinating, and everything we hoped it would be.   My wife Becky is a better gardener and potter, I a better World War II historian.   Beautiful ceramics, fans, hand-painted parasols, gold-plated lacquerware, woodblock   prints, and stunning photographs will continue to remind us of this fabulous   trip. So will our Visa card balance." 

 	John C. Hagan III, ophthalmologist, Kansas City, MO 

 "Managed care contracts are written in legal jargon precisely so they will   be difficult to understand and will require legal advice before signing. However,   many physicians just sign the contract and cry later. Every check for every   reimbursement must be scrutinized, because insurers often don't even pay what   they say they will pay. 

 I negotiated one contract to pay me 120 percent of the Medicare fee schedule.   When I received the first check, I discovered that it was based on a Medicare   fee schedule that was 2 years old. I would not accept the company's lame explanation,   and they are now using a current fee schedule." 

 	Deborah L. Moritz, dermatologist, Mansfield, OH 

 "Every day, in addition to running my practice in orthopedic surgery, I review   three to 10 requests for preauthorization or reimbursement for a health plan.   I pore through other doctors' charts, trying to determine if patients I have   never seen are getting quality care. I am not an insurance company prostitute,   and my motto is not 'Just say No.' I am simply a physician trying to do my small   part to help my peers. 

If it isn't written in the chart, it didn't happen

. Our training programs   drilled that thought into our heads. Documentation has always been essential   for communication between professionals, but now it has become one of the strongest   incentives to get paid for our work. I am here to tell you that you can get   approval for almost anything you wantif your documentation is complete. 

 Twenty years ago, or even just 10, a patient and doctor could arrive at a   treatment decision and have confidence that most third parties would pay the   bill. Today, almost any procedure must be preauthorized, and even then, payment   is not assured. Computerized auditing programs, all-pervasive, have made it   very difficult for a physician to get paid unless the documentation is complete. 

 I regularly get requests for diagnostic studies or treatment without the basic   requirements to meet a standard of care for orthopedic patients. Many times   I've seen an MRI followed by a myelogram-CT followed by a discogram, with no   intervening objective clinical findings that would justify either the expense   or the invasive nature of the procedure. In today's extremely busy offices,   physicians are using the tools of modern technology to make a diagnosis instead   of talking to the patient and putting their hands on the patient. The intellectual   powers that got us through medical school are being left behind in the pressure   to see more patients in order to meet the overhead of an office stuffed with   staff to deal with the insurance companies! 

 The request for a diagnostic arthroscopy, accompanied by one page of illegible   scratches, is not going to be approved. The request for a total knee on a 49-year-old   man, accompanied by one page of medical informationwith no X-rays, no CT,   no follow-up, and no early historyis not going to be approved. In a back injury,   further intervention requires documenting a reason in the medical recordsuch   as the failure of routine conservative care, accompanied by increasing radicular   pain, or some other change in an objective finding. 

 You wouldn't want your children to have surgery based on some of the charts   I see. 

 I truly believe that most of us perform a complete history and physical. What   we don't do very well is put it on paper. I don't believe that my colleagues   perform surgery and other procedures just for the money. Sometimes, however,   I can see how an uninformed lay reviewer might conclude that the doctor's house   payment was due, or the tuition just went up at his daughter's college. 

 The rules have changednot necessarily for the better, but they have changed.   We all know how to document our reasons for recommending a particular course   of treatment, but we have allowed others to come in and pick the bones of our   charts. Make sure the chart is complete when your staff forwards its preauthorization   requests. Make sure the information is legible and that it says what you intended. 

 Automatic chart-writing programs are great and getting better. But you need   to take responsibility for making the record concise and complete. Send copies   of X-ray reports, CTs, other specialist consults, and anything else that reinforces   your diagnosis and proposed treatment. 

 Most of the requests I see are probably indicated. Unfortunately, unless 

   the paperwork is complete, the job is not complete. Document what you want to   do, and I'll bet your approval rate goes up." 

 	George M. Cole, orthopedic surgeon, Amarillo, TX 

Doctors share their thoughts on practicing medicine today                           Your voices                                                                Compiled by Jeff Forster, Editor

Your voices

"Your call is important to us" and other lies 

 	I pick up the phone to call Cablevision and question a mysterious charge   on my monthly bill. 

"Thank you for calling Cablevision. Your call may be monitored to ensure the quality of our service. To continue in English, press 1."

I dutifully press 1 again, but instead of getting a friendly customer service representative, I get this automated drivel: 

"Are you ready for some new blood? The new warriors of WCW [World Championship Wrestling] ignite in WCW's 'New Blood Rising.' Sunday, Aug. 13, live at 8 pm. If you would like to order 'New Blood Rising' for $29.95, press 1 now."

There's new blood rising, all right, but it's my own.

 Phone rage is building everywhere, and not all of it is aimed at telemarketers   and obnoxious cell phone users. Some of this anger may also be heading your   way. As our 

 points out, patients are tired of hearing the all-too-familiar   refrain, "Doctor's office, can you hold?" Frankly, no, they can'tor won't. 

Feeding this frustration is the realization that what we want from a phonethe ability to talk with another human beingso often isn't what we get. Instead, we get to 

 The mechanical voice tells us that our call is important, but in the meantime,   it banishes us to Muzak Purgatory or Sales Pitch Hell. Some machines now tell   us how long we must wait to talk to a live person. (My colleague, Jeff Burger,   once waited patiently for 20 minutes, only to be told by the machine that the   offices had just closed for the day.) And the ever-so-helpful machines prod   us when we don't enter the needed information fast enough. 

We've come such a long way since the very first phone call (1876): "Mr. Watson, come here, I want you." Isn't it ironic that the first words uttered over the telephonea device designed to facilitate communication over distanceswere a request to drop the phone and meet face to face?

We're moving stealthily away from face to face and into a world in which Bell invariably reaches Watson's voice mail. And Watson replies by e-mail. As my daughter Hilary asks "Don't people talk to each other anymore?" 

Call me quaint, but nothing will ever quite replace a real person with a real voice on the other end of the line, someone with a real brain and a real heart, who deals effectively and pleasantly with people who need information or help.

 "We place a strong emphasis on customer service," says Alan J. Beason, CEO   and administrator of a cardiology group in Shreveport, LA. "We spend a lot of   time trying to find genuinely nice, service-oriented people who have a strong   work ethic. We want people whose concern and compassion for patients and co-workers   are sincere." Beason sums up his staff's mission in nine words: "Serve the patients,   serve the doctors, help one another." 

 says that a patient's perception of the service he gets in a   doctor's office will help shape his perception of the quality of care. "Just   as all patients share a clinical diagnosis requiring technical expertise," the   authors wrote, "they also have a customer service diagnosis requiring caring,   competence, compassion, and service excellence skills. To treat one aspect while   ignoring the other understandably results either in poor clinical outcomes or   less than optimal patient satisfaction."

 That's   a message worth heeding. And this is not a recording. 

The   Way I See It: We need to get better at customer service

 Mayer T, Cates RJ: Service   excellence in health care (commentary). JAMA 1999; 282:1281-1282. 

 We're happy to add two new experts to our masthead, though they are by no   means new to these pages. They've been working with our staff for many years   and sharing with you their unique insights and experiences in practice management   and personal finance. 

 is President of Rocky Mountain Professional Consultants,   Inc. in Lakewood, CO. He's been with the firm for more than 20 years and its   president since 1997. His dual designations of CHBC and CPCM stand for two widely   respected credentials: Certified Healthcare Business Consultant and Certified   Professional Consultant to Management. Gary is a founding member of the National   Association of Healthcare Consultants. 

, has his own fee-only financial advisory firm,   IFC Personal Money Managers, with offices in Albany, NY, and New York City.   He's on the 

 list of "The 150 best financial advisers   for doctors" (see our Aug. 7 

) and lectures nationally on such topics as personal finance, investment   strategy, tax planning, and estate planning. Gary is Chairman of the National   Association of Personal Financial Advisors. And he has a nifty Web site called   

, a junior at Trinity College in Hartford, CT, spent a whirlwind   summer at Medical Economics Company, working as an intern for this magazine   and our clinical counterpart, 

. She wrote articles, edited   articles, pitched in on Reader Service requests, helped staff writers do research,   and appeared in my door regularly with the announcement that she had finished   the task at hand and was ready for another. 

 We were fortunate to have Talia among us, and I predict she will go farthe   safest prediction I've made in some time. 

  

Jeff Forster. Memo From the Editor: "Your call is important to us" and other lies. 

"Your call is important to us" and other lies

Memo From the Editor: "Your call is important to us" and other lies

 "'Physician, heal thyself' is a terrible piece of advice. . . . Physicians   are no better than regular patients at taking care of themselves. 

 Each of you out there look to your right and left and to the rows of brightly   robed physicians on this stage, many of the most distinguished in the world.   At least one out of every four of us in the course of our lifetime will experience   a clinical depression. Will you recognize it in yourself? Guess again. 

 Remember Osler: 'The physician needs a clear head and a kind heart.' Your   generation is fitter and healthier than mine. Listen to your family, continue   to exercise, pursue the arts; music in particular has helped me. 

 When symptoms of burnout, depression, substance or alcohol overuse appear,   be in the care of your internist. Superwoman or Superman you are not." 

 (President's Address, Convocation Ceremony, American College of Physicians-American   Society of Internal Medicine, Philadelphia, April 13, 2000. Addington is immediate   past president of ACP-ASIM.) 

 "The derogatory term 'gatekeeper' is waning a bit lately. Good riddance! It   has done tremendous damage to the trust that had always been the norm between   patients and their primary care physicians. 

 With the recent onslaught of direct-to-consumer advertising of prescription   medications and increased patient demand for these products, I feel that a new   term, 'medkeeper,' may accurately describe how people view their primary care   docs these days. The medkeeper is the one who keeps people from getting access   to the medications they see advertised on TV. Once again, we get to be the bad   guys as we protect our patients from inappropriate therapies. First we insist   on evaluating our patients in the office rather than just calling in an Rx.   Then we may have the gall not to recommend the particular therapies that patients   came in for. As they walk out of our offices, I'm sure they mostly remember   that their doctor didn't give them what they wanted. 

 Managed care wants gatekeepers. Patients want medkeepers. Anyone want a doctor?" 

"What would happen if we 'providers' had the courage to write the insurance   companies and tell them we no longer will be managed care contract providers?   I'm for it, if my colleagues will join me!" 

Gary M. Gorlick, pediatrician, Los Angeles

 "Why can't doctors answer their phones? I am always frustrated when calling   a colleague. After five to eight rings, I hear 'Doctor's office: Can you hold?'   No one in my office is allowed to answer the phone that way, and it seems to   save us time. There are some physicians I simply don't refer to because of their   phone service (or lack of it)." 

"Medicine is not a product that can be put on a shelf and sold. It involves   human emotions and feelings, and it takes years of experience to learn the art   of medicine. To prove this point, ask any CEO, lawyer, or insurance executive   what is the first thing they think of when they have a suspicious mass, lump,   or spot. They want the best of health care, not the 'lowest bidder.' Yes, health   care requires a team approach, but an experienced pilot needs to fly the plane   during a storm." 

 "Today, like many other days, I am asked to sign a death certificate. The   patient had become a friend in the many years I provided his care. To see him   now in front of me as a black and white form and a list of illnesses misses   entirely the humanness . . . the kindness . . . the actual life and loves of   this dear, gentle man. Nowhere can I write that he taught children how to paint.   Nowhere can I say that he cared for his mother until she was 98. Nowhere can   I talk about his devotion to his church, his wife of nearly 50 years, his many   loving children and grandchildren. I would like to list all his accomplishments   side by side with his "final diagnosis." The world is cheated not knowing these   things. 

 Today, like many other days, I am asked to sign a contract to join a new insurance   venture. I read it carefully and find a clause that makes me uncomfortable,   a clause that asks me to support the concept of managed care. In the past, when   I signed contracts with HMOs, I agreed to work with them, but I was never asked   to embrace their philosophy. Should I write into this contract that they must   also embrace 

 beliefs about medical care? The contract sits unsigned   in a far corner of my desk. 

 Today, like many other days, I am asked to complete and sign a workers' compensation   evaluation for a patient seeking disability benefits. I do not know this woman   well; she's seen me twice for pain she relates to an injury she sustained four   years ago. She apparently has seen many doctors, yet somehow it has become my   responsibility to render the final decision on her disability. I have many of   the records, but I don't have the firsthand experience that can help me decide   what is appropriate. I'm not able to extract this, clearly, from the patient.   Did she come to see me because she's heard I might be an easy mark? (I hope   not.) Did she see me because she respects my opinion and will follow my recommendations?   (I hope so.) I push this form from one corner of my desk to the other, hoping   to ignore it, yet it finds its way in front of me again. I place a call to the   initial examining physician, whom she left after two months of care. I hope   he will give me some insight into her condition. I await his reply. 

 Today, like many other days, I am asked to sign a school physical form. It   will medically clear my young patient to play baseball. On this very short form,   I have nowhere to list what a miracle this is! He has had a radical, lifesaving   procedure, correcting a severe congenital heart disorder. He has also overcome   a very distressing social situation that resulted in the separation of his family.   He now lives with his father, is getting wonderful grades, and has adjusted   marvelously. His desire to participate in team athletics is like a successful   leap over the Grand Canyon! I sign my name as clearly and proudly as I can,   acknowledging my small part in this dramatic accomplishment for this inspiring   patient. 

 Every day, I'm inundated with a blizzard of forms that elicit many emotions.   As I sit and look at the paperwork, I realize that I'm already late for my first   patient." 

On Burnout; On gatekeepers and "medkeepers"; On rebellion; On phone service; On the value of medicine; Today's paperwork.

Author | Jeff Forster

Articles

Are the best and brightest going into medicine?

Your voices

Memo From the Editor: "Your call is important to us" and other lies

Your voices