William M. Gilkison, MD

After 40 years of practicing family medicine, I had had enough. Years of progressively increasing obstacles in the path of good medical care that stalled my economic livelihood led me to decide to retire. They won! They beat me down!

Who’s “they”? Well, they are Medicare, commercial insurers, HMOs, Medicaid, HIPAA, Clinical Laboratory Improvement Amendments (CLIAs), nurse practitioners (NPs), physician assistants (PAs), prior authorizations, pre-certifications, retail clinics, healthcare economists, and the assassin-in-chief, Meaningful Use (MU); that’s who! They all did their part to emasculate physicians and make the business of medicine nearly impossible. If I were paranoid, I would think there was a concerted effort to devalue physician importance, control and reduce our financial well-being, and relegate us (at least those in primary care) to employee status.

Every day was met with new challenges, new policies, or denial of payment. When they did pay, it was pennies on the dollar. The threat of fines and disenrollment in payer contracts by these entities scared me into submission. I was tired. Becoming an employee of a large multi-specialty group for my last seven years eased the burden some, but then MU came along, and I was done. It was the final insult. My productivity plummeted. My frustration and anger grew, and there was no solution other than backing away from clinical practice.

Being a physician used to command respect and prestige, but now that only exists in the hearts of loyal, long-term patients. It is healthcare economists, hospital administrators, insurance company executives, CMS, et al., who now call the shots.

I got tired of taking an annual pay cut when I should be at the peak of my earning years, interrupting patient visits to talk to an unknown person on the phone to justify a test I ordered, and attesting to the multiple stages of Meaningful Use so I didn’t get docked another 5 percent. How many ways could they make it more unpleasant? I never had to deal with a Medicare audit, CLIA inspection, or HIPAA violation, but they succeeded in making me fear it could happen. In a large group practice, one could have a lot of staff members to help with the busy work, but I was still responsible for the final say.

When I went from seeing 35 to 28 patients a day (due to EHR and MU), when I realized these policies and programs were disguised as good for patient-care outcomes, and when I saw the focus of a visit shift from the patient to the medical record, I gave up and retired. It was a decision I needed to make, because I felt my importance was waning.

I feel bad for those doctors new to medicine and those who aren’t financially able to retire, because the nightmare continues daily. Young doctors will know a different medical profession than I knew. Primary care will be managed by NPs and PAs; physicians will be salaried depending on specialty, tenure, and maintenance of certification; and some PhD at Harvard or MIT will decide what’s best for patients. It will be a sad day I hope to never see.

I’m afraid the AAFP, AMA, and ACP haven’t been the influential force they needed to be. The government and insurance companies control the purse strings, so they are in charge. We physicians must do as their policies dictate.

I’m very glad I practiced when I did and was able to make a comfortable exit at the right time, but I could have practiced longer if things hadn’t changed so drastically. My advice for young physicians is do the best job you can for your patients because they are your real concern.

William Gilkison, MD, is a 1969 graduate of Indiana University School of Medicine and completed his residency at the University of Colorado School of Medicine in 1974. He practiced family medicine in Indianapolis for 40 years; 23 of those years as a solo practitioner. His practice experience includes adult and pediatric outpatient and inpatient care, nursing home care, and for the first part of his career, obstetrics. He retired Dec. 31, 2013, and now resides outside Phoenix.

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Every day was met with new challenges, new policies, or denial of payment.

Physician burnout led to my retirement

William M. Gilkison, MDThe United States Preventive Services Task Force (USPSTF) was established in 1984 as an independent panel of experts whose goal was to establish guidelines for preventive services for use by the medical profession and patients. The panel is comprised of 16 individuals, many of whom are practicing clinicians and all of whom have expertise in certain preventive disciplines. 

	In so doing it provides the medical profession and the public with specific guidelines for offering such services. But in my opinion, some of its recommendations cause confusion among patients and physicians and lull them into a complacent attitude toward preventive care.

	The USPSTF lists 96 different conditions for which it has published recommendations. But nowhere is there any recommendation on how often to have a general checkup, or even whether to have one. The task force doesn’t touch that subject, because despite its denial that recommendations are made without concern for cost-effectiveness, the “annual physical” is usually not covered by insurance or considered cost-effective. But every patient who, as a result of a checkup, has been found to have some abnormality for which they were asymptomatic feels it was money well spent. 

	In the early 1970s, clinical staff and faculty professors in my family medicine residency were vigorously promoting the annual checkup as an effective, logical means for patients to become part of the “medical system” and have their health needs addressed. We residents found that to be a great idea and a meaningful change from the episodic care delivered for decades. 

	It was an uphill battle, but one that physicians were winning. In my practice of 40 years, I did two to four adult complete physicals, and numerous Pap smears, pelvics and breast exams, four days each week, to provide my patients with the best preventive care I could offer. It seemed to be very effective, and patients were appreciative and compliant in scheduling each year.  

	Then along came the USPSTF, and the preventive care paradigm shifted.
	Suddenly, mammograms were more harmful than helpful because they led to unnecessary additional mammogram views and biopsies. Prostate-specific antigens (PSAs) were taboo, too, because they led to “unnecessary” prostate biopsies. Pap smears were no longer helpful for finding cervical cancer and were done too frequently to be cost-effective.

	In short, just when the medical profession was influencing the preventive medicine attitudes of Americans, the USPSTF recommended against services that had become commonplace and widely accepted. 

	The USPSTF has earned the respect of healthcare providers in all clinical disciplines, and provides helpful guidelines for performing preventive services. Certainly, the vast majority of the USPSTF’s recommendations are sensible and noncontroversial, because they are well-proven and time-tested. For years, however, many people also accepted as truth the benefits of mammography, PSA testing Pap smears, and the annual exam. As a result, patients have become confused about what is right for their care. 

	As guidelines change, the time between essential procedures lengthens, increasing the risk of missing changes in a patient’s health. 

	I think these time lapses are a disservice to patients, because they begin to adopt a “if I don’t feel bad, I must be OK” approach to health screenings. It is the duty of every healthcare professional to know the health history and lifestyle of all patients and advocate on their behalf for appropriate screenings based on that knowledge, in spite of USPSTF guidelines, because they are just that, guidelines. The public is better served with this attitude. 

some of The United States Preventive Services Task Force (USPSTF) recommendations cause confusion among patients and physicians and lull them into a complacent attitude toward preventive care.

Author | William M. Gilkison, MD

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Physician burnout led to my retirement

USPSTF doing a disservice to physicians and patients