On Burnout; On gatekeepers and "medkeepers"; On rebellion; On phone service; On the value of medicine; Today's paperwork.
"'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."
Whitney W. Addington, internist, Chicago
(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?"
Andre S. Chen, FP, Austin, TX
"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)."
R.A. Major, FP, San Francisco
"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."
Kenneth N. Shannon, FP, Southside, AL
"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 my 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."
Alan J. Scharrer, FP, Holden, MO
Jeff Forster. Your voices. Medical Economics Jul. 24, 2000;77:104.