Sunday, July 4, 2010

Should Physicians Give Up and Surrender?

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More and more, I read about physicians who are ready to give it up. I hear similar views in the physicians lounge and in hospital hallways. These conversations are a modern phenomenon; they did not occur when I entered the profession 20 years ago.

They have germinated as a result of rising forces that have demoralized many practitioners. Some of them include:

• Loss of autonomy
• Loss of income
• Loss of stature and prestige
• Required ‘Quality’ initiatives
• Health care ‘reform’
• Infighting within the medical profession
• Medical liability system
• Insurance company hurdles to get paid
• General gerbil wheel existance

Luckily for me, I am still happy on the job. Of course, I am not immune to the above realities, and would readily accept a vaccine to protect against them, if one existed. I try to focus on the core purpose of being a physician, and work to sequester the noise and static, at least while a patient is seated before me. Since I am a member of the human species, I do not always succeed. Sometimes, stuff creeps out of a compartment at the wrong time, and I try to stuff it back in its place. It’s a struggle, but I usually prevail. So, with regard to being a practicing physician, I am not ready to give up.  I keep my 'white flag' in the closet.

There is a part of the profession, however, that I have given up with zeal and enthusiasm. For me the decision was easy, but for some colleagues it is agonizing. A few years ago, I gave up performing a procedure that is essential for many gastroenterologists. It is called ERCP, which stands for a term that is so long, that I wonder if its practitioners thought they would be ‘paid by the letter’. To save you googlers a key stroke, here’s the term in full.

Endoscopic Retrograde CholangioPancreatography!

This is a fancy endoscopic event when the gastroenterologist passes one of our flexible black serpents down your throat and snakes it around corners to reach the small intestine. Then, tiny tubes can be inserted through the scope into the liver and pancreas to accomplish tasks that previously required surgery. This invention is a towering milestone in the practice of gastroenterology.

How important is this skill in my trade? Peruse the ads at the back of any medical journal under the gastroenterology section and you will read phrases, ERCP required or ERCP preferred.

Why would I give up performing a test that distinguished me in my specialty and made me a more marketable gastroenterologist? Would we expect a professional basketball player to eliminate 3 point shots from his game? Would we expect a concert pianist to declare a moratorium on playing any piece in the key of A flat? Would we expect a congressman to vote on legislation that he hasn’t read? (Yes, you may snicker now.)

It seems odd to voluntarily surrender skills that allows one to occupy a higher orbit in his profession; yet this is exactly what I have done. I gave up ERCP because I simply wasn’t good enough at it. I never killed anyone, and my complication rate was within the expected range for this procedure. It certainly was exhilirating when I was successful, and quite demoralizing when I couldn't get the job done.  More and more, I realized that the ERCP field was advancing, but I wasn’t. My skills were acceptable, but stagnant. Why didn’t I simply incorporate the evolving technology and gadgetry into my practice?  This response is a blog post in itself, but the summary statement is that it is extremely difficult for a practicing community gastroenterologist to stay current with evolving technical procedures.

So, I gave it up, not the professsion, but an important aspect of my practice. It was liberating as I now knew that any of my patients who needed ERCP skills would be referred to someone who did it much better than I could. The quality of a physician – or any occupation – is determined by the weakest element of his practice. I hope that pruning my practice has made it sturdier.

These are vexing issues. When does someone give up an essential element of his occupation? Sometimes, the answer is obvious. We don’t want cardiac surgeons with flapping tremors to perform delicate heart surgery. We don’t want airline pilots who suffer from sudden blackouts to be at the controls. However, sometimes the deficits are more subtle, and it is not clear that the practitioner is impaired to the extent that a professional change is required. Where is the boundary line and who should set it?

Quality measurers from the government, insurance companies and professional medical societies will soon be unleashed on a mission that they can't succeed at. They will fan out across the countryside claiming they can measure the unmeasurable. Those of us who understand the guts of medical care realize that what really counts, in medicine can’t be counted. For example, these qualitycrats might have deemed my ERCP skills to be acceptable, using their check-off boxes and quality rubrics. Indeed, I was granted privileges to perform this procedure in my local hospitals every 2 years through the perfunctory recredentialing process. The reasons that impelled me to set the ERCP scope aside are real and legitimate.  But,  they can’t be weighed and measured.

I hope that the quality buzzards who will suffocate the medical profession give up before we physicians do. I can loan them my white flag.


Toni Brayer, MD said...

Great post. Your integrity and self awareness should be spread. Do you think quality metrics should set standards for number of procedures to ensure competency?

John said...

Hello again, Dr. Kirsch. I see you're still the gadfly. Keep up the good work. One of these days you'll hit the right nerve and get something to happen.

Meantime, Here's a link to the most recent Med Pac report. (You know, those "death panel" folks the scare-mongers talked about.) I haven't dug into the meat of the report (nearly three hundred pages) but the executive summary repeats the same old refrain indicating that as long as Congress has Medicare and Medicaid by the balls there isn't a lot of hope for changes any time soon.

Innovative purchasing policies could be employed to improve the delivery of health care services, but Medicare currently has legislative limits that constrain it from
adopting such policies expeditiously. Furthermore, Medicare might be able to improve health care quality and efficiency if it were given broader authority to demonstrate
and implement policy innovations.

(Summary page xi)

Here's another link to the Wonk Room post where I got that first link. I know your view of anything governmental is jaundiced at best, but as long as Medicare and Medicaid continue to be essential revenue streams for the disease management industry I'm afraid we're stuck with them.

I decided not to pollute your comments threads again with my layman's arguments. I know when I'm out of my league. But I remain interested in the subject of health care reform and persuaded that despite an avalanche of negativity from large segments of the industry we are on the right track.

When we see the day when the medical pros (physicians and their essential support services) practice medicine free of interference from non-medical pros (device peddlers, lawyers, insurance adjusters, politicians, lobbyists and ignorant opportunists of all kinds) we will all benefit. Until then that's a pipe dream worth keeping.

The next important step in reform will be getting Dr. Berwick approved to run CMS. The guy's clean as a pin, but that hasn't stopped the Party of No from blocking or attacking other qualified candidates.

Happy Independence Day!

Sharon said...

Missing from your list: Student loans. I owe $180,000 (despite choosing a public school), and although I love primary care, I'm starting to feel like an idiot for choosing it.

I disagree with health reform being the problem; it is a symptom of a system of for-profit health care run amok.

The Medical Contrarian said...

Not to be the skeptic here, but might there be another reason lurking? The reimbursement per unit time for the ERCP just might be simply not worth the effort required. To keep one's skills honed requires attracting more of that particular book of business which means these cases and the additional time required crowds out simpler procedures (e.g. colonoscopy).

It is a rational to decide that you cannot be all things to all people. Within the realm of medicine, the administrative pricing structure nudges us to make decisions about where to exercise strategic incompetence. I strongly suspect the payment structure has influenced the decision to declare yourself not sufficiently competent at ERCP.

The proof will be shown in the marketplace, flawed as it may be. Is it harder to find someone who does ERCP's than colonosocpies where you practice?

Michael Kirsch, M.D. said...

@TB, thanks for the comment. There's a twist to your suggestion that volume of procedures be considered as a quality determinent. This is already occuring. Is this all about safety for patients? I'm not sure. The volume thresholds are determined by academics who work in academic teaching institutions. They set volume standards that many in the community cannot reach. While it is claimed that this is to protect patients, it also serves to shut down community procedurists and siphon these lucrative cases 'downtown'. I am not stating this as fact, but believe this is a fair question.

@John, as for health care reform being on the 'right track', this depends if you approve of the destination. I am a deep skeptic of the process, the path and the destination.

@Sharon, you are an example of why concierge practices are emerging.

@MC, skepticism always welcome and desired. In my case, I assure you, that economics had absolutely no bearing on my decision to set the ERCP scope aside. It was purely a competency issue.

Ellen Kagan said...

Great to read your blog. If you want to get a great perspective from a patient's side, log onto my blog at, a chapter from my book, Ellen in Medicaland, which tells the bizarro story of my crazy experiences at a Harvard-teaching hospital. You can learn more about me at

Transor Z said...

Doc, this post is a real gem. Kudos for your integrity. The concept of honest self-evaluation should be a part of ethics training across professions. In the law, new attorneys are encouraged to be greedy for experience while at the same time professional ethics state that attorneys should not take on matters beyond their skill level.

In fairness, there is something to be said for fostering independence in practitioners via "sink or swim," but the cynic in me read your comment about the net effect being to siphon business from small practices to "downtown" and said "RIGHT ON!" As long as the big-name hospitals and big-name firms remain the brass ring destinations for professionals, this will continue. The gatekeepers, often products of those shops, will continue to display a bias. It's culture and economics and it's a lousy combination for consumers.

Paul said...

You'll probably not answer my question, but I have one. I live in Brazil now. I have health insurance here, there is public health care and big names work only for direct patient payment. For a consultation, the insurers pay very little, around $40, and the same doctor charges $400 for direct patients. I looked at that and thought, "I'm willing to give $200 for this service", but I used the insurance and felt sorry for the doc. Why is it so difficult for doctors and patients to establish an insurance-free relationship that is not luxury medicine?

Anonymous said...

Doctors have diagnosed so many around me: case #1 lady seeing doctors for 3 years with stomach and abdominal pains and weight gain. Dismissed with the reasons she was a newly wed women and flu and colds. Finally, when too late see was found to have hernia and had to have all her reproductive system removed. Second case my mum, for almost 10 years see had abdominal pains and stomach problems. Same dismissals. See had to have a Emergancy surgurey because she had bowl disease which her large intestine burst. See had to have it removed. She almost died. 3# a man

Anonymous said...

Case #3 a man I know complaining of head aches and migraines. Dismissed over and over. By the time he was diagnosed with a brain toumor all the doctor could say was sorry you have a month to live. Case #4 a lady complaining and complaining about pain all thro her body all the time. A year later when too sick to do any thing diagnosed with cancer all through her body. 3 months to live. Case #5 me I seen doctors for a year about pains and cramping in abdominals as they keep dismissing me it came to a point I couldn't get out of bed I reseated and diagnosed myself and then Tehran and asked for the correct scans. I was diagnosed with PCOS. And also after two years of back pain with no offerings of scans curvature of the spine. I don't believe that just my spine is what makes my left lung and rib cadge super sore like a brick strapped to it and some one hit me with a base ball bat so infantry a year of seeing doctors Everytime asking for a MRI scan I finally got offered one. I'm want to be scanned for cysts tumours and cancer of the lung. I feel it may now be too late. All my cases I have reachearced and diagnosed myself before telling the doctors to give me the scans to prove it. All these people have suffered almost died and have died and not had the chance to even fight when doctors prefere to push peolple away with basic every day symptoms. Like its so had to send someone for a x ray

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