The Financial Burden of Cancer Care

As a board-certified radiation oncologist, I’m trained to know all about cancer and its physical effects on people. Similarly, as a board-certified hospice and palliative care physician, I am well-versed about the psychosocial and spiritual trials patients go through, especially at the end of life. But a recent study I read stopped me in my tracks with a disturbing finding: Cancer is bankrupting an astounding number of patients.

Adrienne Gilligan, PhD, publishing her research in the American Journal of Medicine, found that 42% of cancer patients deplete their life savings within 2 years of diagnosis. This “financial toxicity” –  arguably every bit as serious as the emotional and physical toxicity associated with cancer treatment – risks forcing far too many cancer patients to make an agonizing choice between almost certain death and overwhelming debt.

The Advisory Board Company, a Washington, DC-based organization that researches best practices in healthcare and other industries, highlighted from Gilligan’s article that “the direct medical costs from cancer exceed $80 billion in the United States. [The authors] cited previous research finding that up to 85% of cancer patients leave the workforce during their initial treatment, and more than 50% of cancer patients at some point experience bankruptcy, house repossession, loss of independence, and breakdowns in their relationships.”

One observation from this research that should be even more concerning for those of us in deep East Texas is that in more vulnerable populations with lower socioeconomic status and clinical factors such as smoking and poorer health – this describes Angelina County and surrounding counties – the risk of asset depletion is even greater. Even for those with health insurance, the researchers wrote, deductibles and copayments for treatment, supportive care, and nonmedical or indirect costs (for example, travel, caregiver time, and lost productivity) may be financially devastating.

I see this financial burden all the time. Monthly, I get a report from my billing office on the bills that patients are not paying despite multiple contacts. Most of the time, these are deductibles and copays that patients – who live paycheck to paycheck and who have no savings to start with – never are going to be able to pay. Sometimes it is the entire bill, in the case of uninsured and indigent patients. As a physician, I really only have two options: send them to a collection agency to harass them and try to get whatever proverbial blood out of the turnip they can, or write them off. That my patients should suffer not only with a cancer diagnosis and treatment side effects but also possible bankruptcy is absurd. I am rightfully appalled and angered that our federal healthcare reimbursement system and the private insurance complex have achieved “cost savings” by placing more and more of the financial burden onto patients, who simply are unable to pay. The bankruptcy monster is always at the door.

Doctors are familiar with the Latin phrase primum non nocere – first, do no harm. The idea is really that we should balance the risks of treatment with the benefits. I imagine when that phrase was coined the author did not have financial harm in mind. Today, it has become one of the most important “risks” when weighed against the hoped for gains of treatment. Unfortunately, the provision of healthcare has become a commodity and providers are reduced to revenue-producing cogs on the wheel in a system that has replaced the patients’ needs with productivity metrics. The profession of medicine is less and less in charge of the provision of medicine.

In spite of this new reality, healthcare providers – doctors, hospitals, etc. – must recognize that the mission of any healthcare organization is first and foremost health, not profit. When profit alone drives healthcare decisions, the cart is before the horse. And forcing patients into bankruptcy with draconian billing and collection policies profits no one (except maybe collection agencies). Accounts that have little chance of being paid need to be written off quickly and completely.

In hospital systems, some critical services – for example, social work, patient navigation, discharge planning – may have no direct link to the bottom line in terms of a reimbursable, codable procedure or office visit, but nonetheless have a profound impact on preventing financial losses by impacting readmission rates and avoidable costs associated with inability to comply with prescribed courses of treatment. In addition, finding sources of payment for patients can bring dollars in that otherwise would not be seen. These services must not only continue, but be expanded.

Ultimately, legislators need to change the way healthcare services are valued and reimbursed so that the increasingly unmanageable financial burden that falls on everyone – even the insured, hardworking folk – doesn’t bankrupt us all. This isn’t about patient responsibility; it is about preventing personal financial catastrophe. And now it’s January with high deductibles and never-ending copays to meet. I’m afraid we are in for a bumpy ride. Happy New Year!

There's Something About a Sabbatical

As this column is printed, I will be three weeks into a four week sabbatical. Since I am writing ahead of time, I obviously can’t have predicted how it is going. I can say what I hope it will be, at least to some extent.

I am a Type A personality and part of me – as I write this – wanted to plan out every moment of this break from my daily routine. I even made a list ahead of time of what the sabbatical is and isn’t (for me, mind you). High on that list is that I should not feel guilty if I don’t accomplish certain things that my Type A personality thinks I should. That I should just let it be what it will be. That’s hard for me.

People often ask me – when they find out I am a cancer and hospice physician – how I can do what I do without staying depressed. “Isn’t it hard?” they ask. My pat answer is that I love what I do, so how could it be hard? When I am doing what I believe God has gifted me to do, it is the easiest job in the world!

But that simple answer obscures that fact that burnout is a real possibility, even for me. Even though I love my job, frustrations arise. Not every patient is pleasant or easy to work with. Stress happens. We all need a break sometimes.

There are different ways to get away, and how we go about it may depend on where we are in life. During the routine work year, breaks can come in all shapes and sizes, from the afternoon off to a three day weekend or a more substantial week or more off for a vacation. These standard breaks rejuvenate us and help us stay focused when we are back at work.

A sabbatical is something altogether different.

The word sabbatical has at its root what we recognize as Sabbath – rest – which has a deeply spiritual meaning of both rest and worship in Judeo-Christian theology. The idea of an extended rest from work has a long history in the academic setting, where professors are given time off from teaching to travel, write a book, or study. But I never hear of doctors taking a sabbatical.

Doctors need it. Physician burnout is, according to some, is at epidemic levels. Others call it a crisis. Whatever. Let’s just say, burnout among physicians is far too common. The specialty of emergency medicine reportedly has rates of burnout at nearly 60% with many other specialties at 50% or higher. Burnout is basically severe, chronic stress characterized by emotional exhaustion and lack of empathy for patients along with a cynical or negative attitude and a sense that you are spinning your wheels in your career and not getting anywhere. Does that describe any physician(s) you know? I guarantee it does. I don’t want it to describe me.

Why physician burnout exists (and is increasing) is not the subject of this essay. But if you talk to doctors, government bureaucracy, electronic health records, insurance companies, and declining reimbursement despite longer work hours are almost always going to come up.
Doctors need a break. More than just a scheduled afternoon off or periodic vacation. I would argue that at some point in a physician’s career – if they want to stay the course for the long haul – they need to take a sabbatical.

What does a sabbatical look like? It depends on the person. My advice for those considering a sabbatical is to keep in mind three key components: time, distance, and purpose.

Time is important in order to distinguish a sabbatical from a vacation. Two weeks, for example, is not long enough to truly get away from work. You spend the first week just beginning to unwind and the second week worrying about the hell you are going to pay when you get back to the office. Four weeks is a minimum for a true sabbatical.

Distance is important as well – certainly physical distance, in that you want to avoid the temptation to check in on work. Get out of town. Out of the country, even. In this digital age, electronic distance is also important. Are you still going to be tied to Facebook? Instagram? Twitter? Or worse, to your electronic health record? Emotional distance is key as well. Let go of the thought that only you can do what you do.

Finally, consider if there are things you’ve always wanted to do – books to read (or write), goals to accomplish – but you’ve never had the time to do them. Be creative; think outside the box.

Avoid the temptation simply to travel, where you feel obligated to visit every cathedral and museum from A to Z. That’s a vacation. A sabbatical is about you. Be careful, though, that you don’t set unrealistic goals for your sabbatical, and that you don’t come back feeling guilty that you didn’t accomplish all that you set out to do. Remember, the definition of sabbatical is rest. Be still. Listen. Be open. Don’t just “do”! Find out more about who you are apart from medicine.

Personally, I’m taking my cue from two Biblical imperatives that guide my thinking about life in general. The first, Romans 12:2 (NIV), states, “Do not conform to the pattern of this world, but be transformed by the renewing of your mind. Then you will be able to test and approve what God’s will is—his good, pleasing and perfect will.” And the second is from Philippians 4:8 (NIV): “Finally, brothers and sisters, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable—if anything is excellent or praiseworthy—think about such things.” I will be reading German theologian Dietrich Bonhoeffer’s profound book, The Cost of Discipleship. But I am not going to feel guilty if I don’t finish it. I’m resting, after all.

The Grass is Greener in Lufkin!

Sometimes our medical community gets a bad rap. In any community, there can be a tendency to think the grass is always greener somewhere else. This is true whether we talk about education, retail, quality of life, or in my case, medical care.

I have been accused of being critical of our local healthcare community. Perhaps my commentaries on healthcare in general, and the very real problems we all face, have been taken by some to mean I am not supportive of our local healthcare. Nothing could be further from the truth! 

Those who work with me know that I strive for excellence in all I do, and I expect the same from those who work with me. I have considered it an honor and a privilege to be part of this medical community for almost 25 years now, and had I not found this community to be welcoming, supportive, and high quality, I would not have stayed.

Think about it. We are a town of barely 35,000 people, and we have access to everything from neonatal intensive care to neurosurgery and open heart surgery. (Oh, and excellent cancer treatment as well!) These services are rarely seen in a town our size, and it happened for a number of reasons.

First of all, we are a destination for healthcare for patients coming from many surrounding counties. That give us an effective population of several hundred thousand - enough to support sophisticated specialties. Second, we have had visionary leadership from key physicians over the years. I won't try to mention all who have made a difference - there are many - but I do want to highlight just a few for what I see as having provided a significant and long lasting contribution to local healthcare.

Anyone's list would include Dr. Ravinder Bachireddy, a world-class cardiologist whose incessant focus on quality brought credibility and excellence to local cardiac care at a time when everyone in the state (indeed, the nation and the world) was headed to Houston. Along the same lines, Dr. Bill Shelton and Dr. Kavitha Pinnamaneni, in their respective radiation and medical oncology fields, made it possible for cancer patients to stay at home for outstanding cancer care, unifying many different physicians and surgeons involved in cancer treatment into a nationally accredited cancer program.

Dr. George Fidone's energy, intensity, vision, and incredible skill has brought pediatric care to virtually every child in the area. Our kids are healthier for it. Neurosurgery, neurology and stroke care are as good here as can be found in big cities, thanks not only to local medical leadership but also to philanthropic support. Robotic surgery has been embraced and mastered by our local surgeons and gynecologists to a far greater extent than our neighbor to the north or, frankly, most communities.

An early family practice pioneer, Dr. Anna Beth Connell led the way early on for women physicians to be not only allowed into the good ole boy network but also respected as colleagues. Women now make up the majority of medical school graduates and are coming to Lufkin in record numbers and in all specialties.

Finally, I cannot even begin to talk about healthcare without considering the incredible support of local foundations, especially the TLL Temple Foundation and the Kurth Foundation. Their contributions can hardly be totaled or their impact measured. We struggle at a national level to figure out how to care for all people, but that burden has been significantly lowered at the local level by the incredible generosity of our foundations. For that, I am eternally grateful.

Sometimes we all need a reminder of how green the grass is right here in Lufkin and Angelina County, and what a privilege it is to have the healthcare community and resources we have. Next time you see a local doctor, nurse, or other healthcare professional, thank them for living and working here!

What I Would Like to See in Healthcare Reform (Part 1)

I often tell people that if all I had to do was take care of patients, life would be grand. It is the countless hours of dealing with the administrative aspects of healthcare that have practically ruined the practice of medicine for many physicians. You should care; it takes away from our time with you.

TheHill.com, noted that physicians and their staff spent over 15 hours per week complying with quality reporting requirements and that for every hour a physician spends with patients, an additional two hours are consumed completing administrative tasks related to the visit. This meaningless (to physicians, anyway) work has costs in both time and money, leads to burnout, and is increasingly mentioned as the reason for early retirement. I, for one, found myself daydreaming in a committee meeting the other day and I calculated that it was 3361 days until my 65th birthday. That's 9 years, 2 months, and 15 days. No, am not planning to retire early, but sometimes I sure wish I could. Healthcare needs reform.

The average person thought Obamacare WAS healthcare reform. In reality, Obamacare did nothing to actually improve the healthcare system; it simply added more people to the rolls. Don't get me wrong. Having more people insured is not a bad thing. But we need more than just additional enrollees in a broken system.

After Trump was elected, there was an initial, overly optimistic assumption that Obamacare was on its last leg. Recent infighting among policy makers suggests Obamacare may be more like the proverbial cat with nine lives. I only hope true reform is part of whatever "replacement" or "repair" Congress and the President come up with.

In particular, let's hope some of that reform will significantly scale back a bloated, paranoid bureaucracy that sucks hundreds of billions of dollars out of healthcare that could go to those who actually care for patients. And, perhaps, some could go back into the taxpayers' pockets.

Back in 2012, Berkshire Hathaway CEO Warren Buffett called healthcare "the tapeworm of the American economy". To be more accurate, the federal government is healthcare's tapeworm. In an online article in Medical Economics last year, Ryan Gamlin, who studies what drives inefficiency, waste, and harm in U.S. healthcare, found that "as countries spend a larger percentage of their healthcare dollars on administration (as opposed to public health, or providing patient care, for example), things get worse for patients and healthcare providers. High administrative expenditures seem to be associated with negative experiences of providing and receiving healthcare." That is a nice way of saying there's a ton of money wasted going to paper pushers.

Helen Adamopoulos, writing in Becker's Hospital Review in 2014, noted that US hospital administrative costs account for more than 25% of hospital spending, more than double that of Canada, for example, where hospitals receive global, lump-sum budgets. In contrast, US hospitals must bill per patient or DRG (diagnosis-related group), requiring additional clerical and management workers and specialized IT systems. They also have to negotiate payment rates with multiple payers with differing billing procedures and documentation requirements, driving up administrative spending. Not to mention all the personnel, time, and IT required to satisfy CMS’s (the Centers for Medicare & Medicaid Services) monstrous appetite for "quality" and "safety" data, with the ever-present threat of fraud and abuse hanging over every unintentional misstep.

What should be a simple process of billing for services provided is a minefield. And anyone who has ever tried to understand a hospital bill knows it is an impossible task. Aliya Jiwani, writing in BMC Health Services Research, notes that billing and insurance-related (BIR) administrative costs in 2012 were estimated to be $471 billion and that fully 80% of this spending, which provides little to no added value to the healthcare system, could be saved with a simplified financing system. Jiwani predicted that greater use of deductibles under Obamacare will likely further increase administrative costs, stating, "Empirical evidence from similar reform in Massachusetts is not encouraging: exchanges added 4% to health plan costs, and the reform sharply increased administrative staffing compared with other states."

A CNBC report of a Health Affairs study tagged the extra administrative costs of Obamacare at more than a quarter of a trillion dollars, an average of $1,375 per newly insured person, per year, from 2012 through 2022. The Health Affairs blog authors reported, " The overhead cost equals a whopping 22.5 percent of the total estimated $2.76 trillion in all federal government spending for the Affordable Care Act programs during that time."

What do I wish we could be different in our healthcare system? In March, I will discuss some specific changes that would reduce the administrative burden on healthcare providers and, in many ways, return us to a simpler, more direct, and frankly better transaction of healthcare.

History and Medicine in Angelina County

I recently came into possession of Angelina County Medical Society meeting minutes dating back 80 years, from 1936 to 1954. These archives were kept by Dr. W. D. Thames. A walk down medical memory lane with these records is remarkable. Some facts are simply mundane. For example, dues in 1936 were $10.50 per member - $488 in today’s dollar. That makes our current County Medical Society dues of $100 seem like a bargain.

More fascinating to me is that even though the practice of medicine has changed profoundly over the last 80 years, little of the economics and politics of being a physician has changed. For example, charity care issues were documented back in 1937. We struggle with that today. The physician-patient relationship – what today would be assessed by patient satisfaction scores – was the topic of lectures in 1938.

The broad legislative issues on the table today are hardly different than those in 1938 when a Legislative Committee was appointed. Scope of practice issues with optometrists and chiropractors were discussed way back in 1941. In 1953, Dr. Arnett “encouraged members of our society to join the American Association of Physicians and surgeons, which is a political organization of doctors. Its purpose is to stop socialized medicine.” (What would they say now?)

Some issues from the past seem frankly quaint today. In 1952, Dr. Arnett was to appoint a committee to investigate a physician who took out an ad in the Lufkin Daily News, apparently quite the no-no at the time. The next month’s minutes document how that physician “apologized and said it wouldn’t happen again”. The Society even had a secret ballot to vote whether he was guilty or not guilty of advertising. He was acquitted on a 9 to 2 vote.

Admirably, the Angelina County Medical Society minutes also contain notable evidence of community involvement and civic leadership. In January, 1940, the Society was holding joint meetings with city and county officials and the Chamber of Commerce directors to discuss a federal aid program for the building of a county hospital. It was these very discussions that spurred local industry leaders to join together to build a new hospital. The legend we pass down is that in 1941, Arthur Temple, Sr., President of Southern Pine Lumber Company, W.C. Trout, President of Lufkin Foundry & Machine Company, E.L. Kurth, President of Southland Paper Mills, and Col. Cal C. Chambers, President of Texas Foundries, along with ten other businesses and industries, joined resources, refused federal funds, and raised one million dollars to build the non-profit Memorial Hospital (now CHI St. Luke’s Health Memorial). But we have forgotten the groundwork was laid the previous year by the healthcare community, the city and county leaders, and the Chamber of Commerce, all working together. Such cooperation and leadership can still take place today.

Another more poignant event occurred in February, 1954. Then President Dr. Gail Medford “read a letter from the Negro Chamber of Commerce wanting help from the Angelina County Medical Society in their plan to improve sanitary conditions in the colored community. Drs. Taylor and Spivey, City and County health officers, were appointed to work with the colored organization.” We cringe now, thinking about Jim Crow segregation and disparities in neighborhood services and conditions. But do we recognize similar disparities in healthcare today? Are we addressing the needs of the indigent, uninsured and underserved populations among us? Is the medical community as approachable today as it apparently was in the segregated 1950s?

Technology has revolutionized healthcare over the last eighty years. But technology cannot replace the heart. Let us not forget our calling, our oath, and our love for the patient. The practice of medicine should never be just a job. It is a profession.

I invite everyone to the Salute to Healthcare banquet on Thursday, November 10, 2016. Help us recognize and honor those in our community who set the standard in healthcare and who are true to the calling – the profession – of medicine. Call the Chamber at 634-6644 for ticket information.

The Significance of an Ethical Foundation

Last month, I wrote about the role of the hospital Ethics Committee and commented that open and honest communication between healthcare professionals, patients and family solves most ethical dilemmas. That assumes we are speaking the same ethical language and have a common ethical foundation, both in medicine and in society at large. In our increasingly pluralistic society, that is no longer a safe assumption. The recent Orlando attack on a gay nightclub showed us that people can do terrible things when ostensibly motivated by a perverse ethic or belief system.

Ethics, at its core, is simply a set of moral principles or values which guide an individual’s – or a religion’s or a government’s – actions. In the United States, that governing set of principles has been rooted, sometimes more and, regretfully, sometimes less, in a Judeo-Christian ethic based on the inherent (and, according to the Declaration of Independence, Creator-endowed) equal value of every individual. In medical ethics, the two related guiding principles date much further back, to Hippocrates around 400 BC: the sanctity of human life and the concept of “first do no harm”.

Modern medical ethics rests on four major pillars: Autonomy (the patient decides), Beneficence (does it help), Non-maleficence (don’t harm), and Justice (is it fair or impartial). In other words, do our medical recommendations and interventions respect the rights of the individual patient, are they helpful, do they not do harm, and are they fairly and equally available. It is a tall order to keep these broad principles in mind, especially when trying to balance competing interests with limited resources.

American history in general – and medicine in particular – has tended to elevate Autonomy over and above her sister principles. We are a pioneering, individualistic “I did it my way” society. The winds appear to be changing, both in healthcare (with the move toward universal healthcare) and in political discourse. The traditional emphasis on the individual’s responsibility in his or her own pursuit of happiness is taking a back seat to the notion that it is the government’s role somehow to guarantee equal outcomes, seemingly regardless of effort, for all. For example, we just completed a groundbreaking primary season where an avowed socialist garnered significant support on a platform of income redistribution.

Amidst this sea change of process, of roles and responsibilities, can we agree on a common ethic to guide us?

I firmly believe that regardless of who we elect and within whatever system of healthcare delivery we end up with, a Judeo-Christian emphasis on the inherent, God-given value of each and every individual (whether black or white, gay or straight, handicapped or not, born or unborn) is uniquely protective of both the individual and society as a whole. Mass shootings and terrorist acts demonstrate that our moral ethic (or lack thereof) determines our behavior. To paraphrase a Dostoevsky character in The Brothers Karamazov: If God does not exist, all things are permissible. A disturbing corollary appears to be: If my moral ethic condones and encourages killing lots of people, why not do it?

Motivational speaker Zig Ziglar once said, “Since belief determines behavior, doesn't it make sense that we should be teaching ethical, moral values in every home and in every school in America?” Whose values? All belief systems are not equal. Governments and terrorist organizations which do not value the individual, inherent worth and equality of “all Men” – to again reference the Declaration of Independence – are not going to treat their (or our!) citizens equally. In fact, they may kill them (and us).

If I had to choose one word to describe the ethical principle I pursue in life and in healthcare, it is love. Not hate, not selfishness. Not religious dogmatism. And not a “love” of government, cult or fanaticism that discriminates or (God forbid!) kills others in the name of some god or political whim. It is the pure Christian commandment to “Love your neighbor as yourself.”

Is this idealistic? Absolutely. Is it achievable? No, to be honest. But that doesn’t mean I stop working tirelessly, incessantly toward that goal. Our country should do the same.

Doing the Right Thing, One Day at a Time

As I write this column, it is Saturday morning of Memorial Day weekend. I have been at my office several hours working on patient charts and mapping out cancer treatment plans. This type of work cannot be done in the midst of a busy clinic day. Once I am done today, my radiation physicist will compute these patient plans. Then I will come back out later today or tomorrow to review and approve them so treatment can start next week.

Such is a typical Saturday morning for me. This is the tedious, mental work that requires me to be alert, focused, and very careful. Modern radiation treatment is highly precise, and the treatment is only as good as the planning process. If I don’t accurately target the cancer, it doesn’t get treated. And if I don’t carefully protect surrounding normal tissues, side effects can be worse. All of this takes dedicated, uninterrupted time. So, I am here at my office this lovely Saturday morning because, well, it is the right thing to do.

What does it mean to “do the right thing”?

A number of guiding principles come to mind. For me, the most important one is to take my time. Doing the tedious work on a Saturday morning or weekday evening. Spending adequate time with my patients. When I rush or get careless, I make mistakes. And by the way, we should acknowledge our mistakes and learn from them.

A second principle is: don’t do either more or less than required. Medically speaking. What I mean is physicians shouldn’t do procedures that are unnecessary just to pad their pocketbook. The flip side is also true: physicians should provide needed care even if they do not expect to be paid for it. Yes, there are times when this is not possible, but the concept and practice of providing charity care is part of who we are and what we profess to be as physicians.

Third, don’t be afraid to ask for help. I can provide most radiation-related cancer treatment in Lufkin, Texas, thanks to the fantastic equipment and personnel at CHI St. Luke’s Health Memorial. But there are rare or unusual cases where I don’t mind asking colleagues for assistance. It’s OK to pick up the phone and call my Houston colleagues if needed. In a similar vein, I tell my patients that I am not offended if they decide to seek treatment elsewhere. Patients need to be comfortable getting their care from me, and almost all are. Some physicians get all bent out of shape and act offended when someone wants to go elsewhere for care. They need to get over it and realize it is not about them. We are to serve our patients, not the other way around.

Fourth, treat everyone the same. What I mean by that is, each person has value, and that value is not based on their insurance plan. We shouldn’t let money dominate our decision-making.

Reimbursement for one’s work is important, but physician compensation comes with an obligation that an ever growing, younger crop of physicians seems unwilling to meet. We “old school” physicians often lament that younger doctors don’t view medicine as a profession. New medical school graduates view medicine as a job, with an employee, get-in-and-get-out, do-the-minimum mentality. Yet, they expect high salaries off the bat. What a shame! Sometimes the best payment is the heartfelt gratitude of a needy patient.

Each of us should strive to do the right thing, one day at a time, no matter what our profession or job.

A Spoonful of Sugar

I don't think I'm unique in having a family that discusses medical issues at the dinner table. But in a family with a doctor, sometimes discussions – to the dismay of my children – are more colorful than they would like. I have learned (mostly) to keep discussions from veering off track. For my family’s part, they know there is a cardinal rule that must be obeyed: you are not allowed to mention Google or Reader’s Digest when discussing medical facts. That rule was recently broken by my wife, Catherine, but in an interesting and forgivable way. Here's the story.

My wife takes a potassium pill – a common supplement – once a day. As anyone who takes this pill knows, it is a big tablet. A horse pill, some would say. And because of that, she wasn't taking it reliably. Some days she could swallow it without too much difficulty, and other days she just couldn't get it down. If she tried a couple of times without success, she just let it go. That’s where Google comes in. In a worthy attempt to educate herself, she went online, researched the medicine, and found out why she needed it. Now, she is much more compliant... to a point. She won't take it if she is alone, because she doesn't want to choke on it.

When she told this story at the dinner table, she concluded, "Isn't that interesting?" To which I replied, "What is interesting is that you didn't trust that because the doctor prescribed it for you, you needed to take it." My daughter then remarked, "That's because a lot of doctors are quacks." So much for respecting the medical profession these days.

Of course, as a doctor's wife, Catherine very much respects the profession of medicine, and I had a twinkle in my eye when I "accused" her otherwise. My daughter's sarcastic analysis, however, did sting a little. Long gone is the era of paternalistic medicine, where TV doctor Marcus Welby, MD simply told his patients what was best and they complied without question. Now patients come to our offices telling us what is best and expecting us to comply. And front line primary care doctors are so strapped for time and paid so little for each office visit that sometimes it is easier just to acquiesce. 

Physicians must resist that temptation. Historically, perhaps it was appropriate for the family doctor to be paternalistic when he knew his patient so well – both inside and outside the office – and when he took care of the medical needs of the entire family. Too often today, the primary care physician is seen simply as the source of a referral to a specialist. The gatekeeper moniker was a kind way of referring to the physician whose true role was (as far as the insurance companies were concerned) to prevent specialist referrals rather than facilitate them. That is a far cry from the position of a genuine coordinator of care who manages the various specialists’ recommendations and knows all the medications that have been prescribed. Such coordination takes a great deal of communication not only among healthcare professionals but between the primary physician and the patient as well.

All physicians – not just primary care physicians – must work harder to earn the respect and trust of their patients. We must take the time to explain the interventions we recommend and the medicines we prescribe. Those horse pills will go down a lot easier with a little sweet talk and education along the way. And our patients will be happier and healthier as a result. Now, that's good medicine!

The Profession of Medicine

Physicians today rarely encourage students to consider becoming a doctor. There are quicker ways to start earning a good living. (Petroleum Engineering and Investment Banking come to mind.) But beyond the financial aspect, being a doctor just isn’t the same as it once was. Increasingly, patients don’t trust doctors, much less respect them or care whether or not they are happy.

A recent online Daily Beast article suggests the public should have more empathy for doctors. The author notes that 300 physicians will commit suicide this year, making it #2 on the list of the 19 jobs where you are most likely to kill yourself, according to Business Insider.

Why? She believes well-intentioned people working to solve the healthcare crisis have come up with answers that are “driving up costs and driving out doctors.” A simple example: “Just processing the insurance forms costs $58 for every patient encounter.” She also quotes noted writer Malcolm Gladwell, “You don’t train someone for all of those years in [medicine]… and then have them run a claims processing operation for insurance companies.”

Insurance claims, bureaucratic red tape, “quality” metrics (that are often more about trying to successfully report than actual quality) – all of these take away from face time with patients and chip away at the joy of what is increasingly becoming an unrewarding profession, not only monetarily, but emotionally.

In other words, practicing medicine has become a demeaning, demoralizing, punitive, bureaucratic nightmare for many physicians.

Don’t get me wrong. Most physicians make a good (or even great) living. I do, and I am not ashamed of it. As an honor graduate from Rice University with a medical degree from Baylor College of Medicine, followed by an additional four year residency, I am proud of my training and feel I have worked hard to get where I am. But with position comes responsibility.

Unfortunately, physicians have, for decades now, not paid attention to the cost of prescribing the latest and greatest drug when an older, cheaper generic is just as effective. Likewise, we put expensive imaging and treatment equipment in our offices and refused to acknowledge that there may be a conflict of interest, when studies show we order more tests and do more procedures as a result.

On top of that, I fear there is a growing contingency of younger physicians who see the practice of medicine as a job only, with a corresponding (and alarming) callousness toward the poor and uninsured.

There is hope. We have many physicians in Lufkin who have earned our respect, and I am honored to call them colleagues. Since 2008, Drs. Ravinder Bachireddy, George Fidone, and Kay Carter (and Mrs. Demetress Harrell) have each been recognized as Healthcare Professional of the Year at the Lufkin/Angelina County Chamber of Commerce Salute to Healthcare banquet. The Chamber has also honored Drs. WD Thames, Anna Beth Connell, George Thannisch, Dan Spivey, and Jacob Thomas with Lifetime Achievement Awards. Young physicians, who may not have gone into medicine for the “right’ reasons – indeed, all of us – would do well to follow their example.

Emily Shelton, the wife of my long-time partner, Dr. Bill Shelton, gave me sage, simple advice when I first moved to Lufkin in 1992: “Just do what’s right.” A sense of duty, compassion for the poor, cooperation with the healthcare team, communication with patients and families, collegiality with fellow physicians, and, of course, excellence of care are hallmarks of a great physician. That’s what being a doctor is all about. It can still be a rewarding, respected profession if we “just do what’s right.”