When a reader responded to Dr. Zoe Kiren Deol’s column in Monday’s First Cuts e-newsletter it sparked her to write another column in response.

I think you did a great job explaining your thoughts on medicine today.  I am a general surgeon in my 35th yr of practice and trying to decide when to retire.  I was never someone to point to retirement and it isn’t an easy decision for me.  When I started, I never thought of giving up practice until I could do it no more.  Things have changed so much and your place in society is certainly not the same.  Isn’t it interesting that we pay $70,000 a year for malpractice insurance and are told by the lawyers that it only adds 1% to the cost of medical care and our new president takes reform off the table when ostensibly trying to cut down medical costs?  No one seems to care what Dr’s think anymore, even about medicine.  There is a Dr shortage now and I worry who in the world will do medicine in the future?  I wish that we had a voice that would be heard.  Keep trying to tell our side of things and maybe eventually some will hear and understand.   -John

Dear John

By Zoe Kiren Deol, MD, FACS

January 27, 2010

Thank you for your heartfelt comments about my article on doctors who are leaving medicine. I think there is a clear delineation between those doctors who are willing to "stick it out" and those who are fleeing for greener pastures. That line is drawn between those who can remember the good ol' days, and those who never personally experienced those days. 

Thank you for your heartfelt comments about my article on doctors who are leaving medicine.  I think there is a clear delineation between those doctors who are willing to "stick it out" and those who are fleeing for greener pastures. That line is drawn between those who can remember the good ol' days, and those who never personally experienced those days. 

My father underwent open-heart surgery at the age of 70 for the sole purpose of keeping his surgical practice.  His malpractice insurance refused to insure him unless he had the surgery.  My father had already had three major heart attacks during his career, the first one at the age of 45. Two of the three heart attacks occurred while he was operating; however, both times he finished his procedure before he walked down to the ER for treatment.  Now that is dedication.  That kind of devotion can only come from memories of a rewarding career that made it worth dying for. Unfortunately, my generation never personally experienced that type of gratification.  We only saw the spark of immeasurable joy in our fathers' eyes that made us want to work hard to achieve the same in our adult lives.  

I was the only one of four children who knew this side of my father. I started going with him to the hospital and the OR when I was 10 years old (something that would never happen in today’s world of hospital restrictions).  It was like watching a total transformation as his foot crossed over the threshold of the hospital.  You could see the light enter his toes, travel up his body, and force those perpetually down-turned corners of his mouth in an upward direction.  He was in his element, and oddly enough, so was I.  I had the same joy and excitement all the way from my medical school days through my surgical residency.  In fact, my happiest days were my residency days.  Despite the grueling hours and immense work load (my residency occurred before the RRC created work hour limitations), I laughed so hard every day that I cried.  My residency made the TV show "Scrubs" look way too serious.  

Ever since I started writing this column, I have had so many of my friends from those days contact me and ask me to reminisce with them.  They all want to grasp at memories of the days when we had no responsibilities other than helping people and saving lives. Some were even angry that no one told us during our training of what lay ahead.  No one told us that we wouldn't have time to care for people.  No one told us that we would spend all of our time filling out forms, arguing with insurance companies, and trying to keep our overhead down so we could pay the bills and still have something left over for ourselves.  One of my friends just told me that he left his general surgery practice and started an oncology fellowship as a last ditch effort to stay in medicine.  He figured that specializing might offer him some semblance of control in his life that he lost the day we graduated from our residency.  It sounds odd to say that we long for the days of a residency that had us working in excess of 100 hrs per/week for pay that could barely support a single life in a studio apartment.  However, when the trade off for going into private practice is losing everything that was gratifying about a career in surgery, it makes you search for those days in the form of a fellowship.

You are right about this phenomenon ultimately resulting in a doctor shortage.  Unfortunately, the current health care system has caused a Darwinian "survival of the fittest" society where the definition of "fittest" means those doctors who know how to play the system rather than those doctors who know how to treat a patient.  I don't blame the doctors for this, and I know that there are plenty of good doctors still out there.  However, when most come out of residency with: 250,000 in debt, a new family to support, and malpractice premiums in the range of 70,000 a year, the ones who value compassion over cash tend to be weeded out.  The ones with street smarts soon learn to hone those business skills and push the thoughts of “what is in the best interest of the patient” to the back of their minds (not by choice, but out of necessity).  That is the only way to survive in the world of medicine today (at least in this country).  I, unfortunately, am the "weakest link".  I have my father's genetics, which prohibit me from collecting on a patient who ignores their bills.  I always see the good in people and assume that they would have paid me if they could afford to. So, despite the protests of my office staff, I would shuffle those unpaid bills into the shredder at the end of the month and just go home without a paycheck of my own instead.  In this world of "had-or-be-had", I was definitely had.

So, what does the current health care reform proposal do to address this disconnect between doctor and patient? One “bright idea” is to create a reimbursement system for physicians based on patient outcomes.  After spending years in a practice where none of my patients followed doctors orders, and most tended to blame someone else for their failures, this proposal seems to perpetuate the sense of detachment from responsibility, which has ended this country in the current economic mess.  No one wants to take responsibility for his or her own actions.  They want to buy a house they can't afford without having to pay their mortgage.  They want a job that pays them big bonuses without having to carry out the duties of the job description.  They want to spend whatever they want without having to pay the credit card bills at the end of the month.  They want to eat whatever they want without taking responsibility for the weight they gain.  And, they want to see their doctors for treatment of conditions that they take no responsibility for having despite years of: smoking, overeating, drinking, and forgoing exercise. 

There is nothing more frustrating than identifying a medical problem, explaining it in great detail to your patient, outlining a course of action, and losing sleep over their welfare, only to later learn that this very same patient left your office and ignored all of your advice in favor of a lifestyle they felt they had earned the right to live without facing consequences.  We have all been lulled into this sense of privilege by the visions we saw through the rose colored glasses that were passed out as our country shifted from prosperity based on hard work to prosperity based on illusion. We now have a country full of people who make a career out of suing people for various wrongs they have suffered rather than a country full of inventors and creators.  So the thought of taking the downtrodden physician and adding the burden of responsibility for the health of these same people who already shirk their responsibility of living a healthy lifestyle seems ludicrous.  But maybe that’s just me …

What's your take? E-mail

Dr. Deol is a self-employed, board-certified general surgeon.