The Ages of a Physician   3/96

A professional life in the past was quite simple. One would make the decision to become a doctor, get the training, hang out a shingle and practice for the rest of one's life. Practice frequently was the doctor's entire life to the detriment of family and friends. Doctor's wives have told me they wished they were as lucky as their husband's patients. The patients saw them during the week, on weekends, holidays, day or night. Even though they sacrificed family time, many physicians could never see themselves in any other arena. They practiced until they no longer could and sometimes even longer. None of the physicians in my home town retired before death. In Sacramento, some of our colleagues have tried to retire only to reopen their offices and rehire their staff.

Life never remains simple. And a doctor's life has become very complicated in the last decade or so. We have added several other stages or ages to our medical careers. Some are not by choice. But they need not be negative.

Many physicians still in the private practice of medicine have had to reassess their practice situation and reflect on their professional life in general. The changes in practice reimbursement has caused this reassessment stage for many of us. We thought that we would go on practicing for many decades. We thought we could go on being professionals and let our staffs work out the details of payment for our services. Now with changes all related to finances, we have been totally de-professionalized. We are unable to think of being the true professional where service is primary and payment is secondary. In fact, recently a patient I had been seeing was sitting in my waiting room and I was prevented from calling him in for an evaluation. I was told I could be in serious jeopardy for rendering service without authorization. I made sure that he was not in danger, allowed the superstructure to work out the details, and saw him a few weeks later. A far cry from the first 15 years of my practice when we never asked a patient for his insurance until after arrival for professional care. We are not leading but following. We are allowing others to force us into unprofessional conduct that not only frustrates us but is to the detriment of the patients we serve.

The young physician building-a-practice years has essentially disappeared. About 15 years ago a pulmonologist from the East Bay came to Sacramento to pick my brain about how to set up a practice. He felt that he had an opportunity to set up a pulmonary practice and create his own pulmonary function lab as the last such opportunity in any metropolitan area in California. Few currently hang out shingles to build a practice from the ground up with a $100,000 bank loan. Many join groups with a ready made flow of patients. This has changed as we become more like employees even though theoretically hospitals and other organizations cannot practice medicine. This can easily be bypassed now with foundations which the physicians don't really control. Any practice not controlled by physicians, the professional with the highest training and ability to assess the clinical problem, is someone other than the licensee practicing medicine. That normally would be grounds for rather severe punitive penalties.

For many the daily practice challenges have become a grind where our productivity is measured rather than our diagnostic acumen. Instead of working several hours after the staff goes home, putting the final touches on our expert renderings of the day, employed physicians go home at the same time as the staff. And they seem equally bored. One administrator was actually overheard stating, "There is no one lazier than a previously self employed physician who now works on salary."

This redirection has caused a dislocation of many physicians into arrangements they have or soon may regret. As the organizations to which they have prostituted their lives are being bought and sold like sports franchises, they are not only dislocated, but in total disharmony with their inner souls that made the decision, did the planning, got the education and training, practiced their ideal type of medicine and surgery, and planned an active retirement. Will we be seeing many dysfunctional physicians in the future?

As we reflect on our lives, we may have occasion to re-chart our course for a second career or a new age in our medical lives. Many have told me they have taken this course of action in order keep their mortgage paid and obtain health and retirement plans. Some of us have found new horizons which give us fresh challenges with a type of medical practice which brings fulfillment. Others have to consider proceeding into the retirement years. Many don't have the means to do so. For some physicians as employers in corporate practice, retirement became possible especially as financial planners became involved. For others the realities of their practice never allowed this. Doctors are known to have difficulty with investments and retirement plans. The old security for retirement, selling one's practice, is no longer possible. Instead of being assured of perhaps one-half of an income for 5 or 10 years while the new owner paid for the practice while doing the work, all the equity has disappeared with non-physician ownership of our practice. As a result many doctors are settling for less in their golden years or are practicing into their eighth and ninth decades. Several have told me they are unable to consider retirement until they are 72 to 75 years of age since their pension plan is inadequate and their mortgages are still unpaid. Some have reduced their hours from 80 to 40 a week and feel this is as close to retirement as they will ever get. Is there any other group that considers a 40 hour week hardly working? It is unfortunate that so many of us feel so helpless and hopeless as we exit from this once noble profession. Why are we lost at sea? Can we get on course again?

We need articulate spokesmen who can focus on common goals and elucidate causes worth fighting for. The written word is a powerful tool, a shared voice which can create debate, illuminate, and perhaps bring about understanding, change, and unity. We're please that the letter/opinion pages are becoming more active -- four pages in January. These editorial pages now also show up on the internet (A well intentioned friend posted them on the world wide web at http// We now have the opportunity to communicate to the world without media prejudice. If only one-half of physicians put their personal thoughts and concerns "on the WEB," and if only 1000 visits occurred to each of our pages over a year, we could send a personal message to the equivalent of the entire population of the United States. Can we get on line and get our web home pages out there for the world to see? How about a goal for each of us to make it happen during 1996? That would a formidable strike to return our professional stature, one that our patients will be proud to support, and no politician could destroy.