Medicine: The Calling Becomes a Job

The Phantom recently decided he needed to change jobs. 
Again.
For nearly three decades the Phantom had practiced medicine as a solo practitioner, with all the risks of a small business owner:  signing a lease which was essentially a mortgage without the benefits of ownership, for half a million dollars, meeting a payroll, keeping track of all the licenses and government regulations for disposal of medical wastes, keeping up a computer system to electronically bill Medicare and other insurance companies--a requirement, not an option--managing the upkeep of office equipment, making decisions about whether or not to buy a sonogram for the office--the cost of a new car which had to be paid off over time, calculating the reimbursement vs the monthly cost of upkeep and payment. Finally, when the man from the office building in which he rented space showed up in his office, wearing a leather jacket, looking like a thug with his gold necklace and diamond stud earring, and uttering the words, "And now we have to talk about your new lease. You know, this part of Chevy Chase has become Rodeo Drive East," the Phantom knew it was time to close shop.

Luckily, there was a job opening for his specialty in a town which was  gorgeous and alluring along the New Hampshire seacoast, and the office was brand new, a block from the hospital, a twelve minute commute from the new house the Phantom found just three miles from the ocean. The Phantom and his wife packed up, sold the house in which they had raised their kids, bid good-bye to their bewildered friends and neighbors and moved up to New Hampshire. 

Symbolically, the day they were to start out, their 13 year old dog died. So, the final remnant of the life they had known in Maryland, running the dog along the Potomac river towpath, was put to rest and off they went, like so many other economic refugees before them, pilgrims to the Promised Land of New Hampshire.

And New Hampshire did not disappoint. Within walking distance of their home was everything they needed, hardware store, dry cleaners, pharmacies, restaurants, gas stations, auto repair shop, all the convenience of a New York City neighborhood in a small New England town. And of course, there was the ocean.

Bidding good bye to two thousand patients and to two hundred colleagues was not easy--it was like breaking up with 2000 girlfriends--"It's not you. It's me." But soon enough there were new patients and new colleagues and the people were fun and wonderful.

But all good things must come to an end: The job was with a for profit, corporate medical system and after five years, the emphasis became, most emphatically, on the profit and the medical system part was almost forgotten. The corporate offices were far away, in Virginia.  

And in a sequence which is being played out across the country, the typical pattern is: You are hired at the highest salary you will ever get from the new employer, and eventually, the screws are tightened, the salary gets converted to an "eat what you kill" design, so you are left with the prospect of either racing past patients or substantially reducing your income. Every minute you spend with a patient is a dollar less for you to pay your bills.

What to do? What doctors are doing now with regularity: look for another new job, get the two year salary and when that term ends, look again. Hope you don't have to move your home. Hope you can simply move among the various employers.

In New Hampshire, that prospect is limited by "non compete" clauses which forbid the doctor from practicing within 15 to 20 miles of his former office, but a 20 mile commute can be managed.

When the Phantom took his new job, his wife was sullen and uncharacteristically quiet. She finally fessed up to the problem: The Phantom was leaving the biggest hospital in the seacoast, a gleaming, newly renovated edifice. She had been the wife of a doctor who everyone in town seemed to know. The women who sing in her chorus had, in surprising numbers, consulted him or knew someone who had. She felt, as she had in Maryland, she and he were part of a community, valued and respected.  His new job was in a town across the border in Massachusetts, twenty miles away, where they would never be known. The hospital there was shabby compared to the New Hampshire digs, although the doctors' office building was new. But the local esteem of friends and neighbors would not be there. They would know nobody in that community. 

It would just be a job now. You commute in, drive home and nobody would even know who you are. You could be working for Liberty Mutual or Sig Sauer or Westinghouse or any of a range of corporations which have no emotional resonance in the community in which you live. 

Medicine had been converted from a way of life, from a calling which enobles,  to just another job. Her status in our new community would change.  Her husband would no longer be locally famous and respected. He's just a salary man now.

Of course she had had a stellar career of her own, commuting back and forth to Washington, DC, flying around the country. She did not need her husband's status for the sake of her own sense of self worth.  She had plenty of success and satisfaction from her career before she retired. But now, watching her husband, move from an upscale practice in an upscale area to a town which looked shabby and a little desperate, it felt like a slide toward decline, even if she stayed in her beloved New Hampshire home.

For the Phantom, things did not look that way. He could see the new reality of medical practice. It wasn't just old doctors crawling off to economically deprived areas to die. The idea of a "glamour practice" had long ago lost its allure. The Park Avenue practices he and his wife had seen in New York City in the 1970's had all vanished into institutions--over 90% of doctors are now employees, working for big groups, institutions, hospitals, corporations. They do not build up practices by attracting the rich and famous and watching the hoi polloi follow into the waiting rooms. They do not revel in being named a "best doctor" by the local magazines, and buying a framed copy of the article to post in the waiting room. They go to work, see the patients caught up in the corporate net, referred by other doctors who refer not because they value the talents or the glamour of the consultant but because their corporate bosses command: Use this guy. He's our employee. The money comes back to us.

This is actually a system which can result in great efficiencies and even in better quality. When the Phantom became an employee, he got his ultrasound machine and all sorts of other equipment which he could never afford as a solo practitioner and he was able to improve the quality of care for his patients, while seeing more of them.  He was able to go to two medical conventions a year, and these are not boondogles. These conventions are where vital information gets exchanged, critically evaluated and digested. They are exhausting, but since the government required doctors to keep up continuing medical education, it's been worth going to these events.

So what it means to be a doctor has changed.  And maybe that's not so bad. It means well trained doctors are willing to go to humble towns where medical care is needed because that's where the need and the dollars are. It strips ego away from the practice of medicine. That old idea of a glamour practice was, in its own ways a corruption. It was about the ego of the doctor. If a doctor says to himself, or to others, " I went to Harvard Medical School, trained at Columbia and Hopkins. I treat the rich and famous and I am rich and famous.And this is success in medicine,"   is that such a good mindset we need to mourn its passing? Doctor to the stars. What ever happened to the humble country doctor?

And the fact is, for the most part, the doctor was never really admitted to the society of the fast set. As in the world of Downton Abbey, the doctor was admitted to the mansion as a workman, not as an equal. He simply did not have enough money or class to be "one of us."

American doctors now  are more like the assembly line workers in Detroit. We are part of a big, efficient system which puts out a product people want and we get our salaries and benefits and we punch the clock and we go home. We are no longer defined by our jobs. We may have prestige because we command relatively large pay checks (although these have diminished substantially, $100-200,000 is still enough to keep you in the upper middle class.) But we do not have esteem. Esteem is what attaches to the individual. Prestige attaches to the group. But it's no longer, "Good ol' doc Phantom. He delivered every one of us into the world, and he eased our passing out of it." 

Norman Rockwell is dead.

Long live Henry Ford.