COMMENTARY

July/August 2003: Ob/Gyn Today -- Straight From the Horse's Mouth

Ursula Snyder, PhD

Disclosures

August 22, 2003

Introduction

First and foremost, thank you! Thank you for responding to the questions I posed in the May-June issue of this column, which addressed the working lives of physicians and healthcare professionals working in the field of obstetrics and gynecology. So many of the responses were inspiring and passionate. I decided that the most interesting way to follow up was just to share some of the responses with you. By the way, there was general satisfaction with the content on our site. We won't rest on our laurels, however, and will continue to work hard to provide a useful and otherwise interesting source of information.

I feel that litigation does color a lot of our judgment. The malpractice crisis probably won't be solved until Congress and the Senate can't get their babies delivered without traveling 100 miles to see the last doctor in the state delivering babies.

The most pressing issue we face today, in California, is managed care dictating our practices. Our hands are often tied by insurance companies, and we either do not get paid for giving good care or patients are denied services that they really should have. It makes us try to connive new ways to fool insurance companies to get what we need. For example, I would try not to give a diagnosis code of depression for fear the woman will be denied insurance in the future. I would use a code for anxiety or PMS to make sure the patient's best interests were being met.

The most pressing concern I have about my practice is how to make the patient I am taking care of at the moment feel satisfied and cared for to the point of loyalty. A newly pregnant patient was in last week and she asked me how many babies I had delivered. I told her it must be over 4000 but that it did not matter as the only baby that was important at the time was the one I was going to deliver for her. If I worry about "the profession" then I am forgetting the prime directive. McDonald's has sold billions and billions of hamburgers. Does this matter to you if your sandwich is bad?

Medicine today has become a business-to-business enterprise when it should be doctor to patient. This has been largely due to third party payers' attempt (successful at times) to make medicine a commodity. They (the purchasers of healthcare) would have the patient believe that medical care is the same regardless of who is delivering it. In fact, nothing could be further from the truth.

One of the most pressing issues is that it is nearly impossible to give patients what they want and make a living. Patients want you to listen, to discuss integrative care, to counsel, to nurture, to cure without surgery or hormones or antidepressants (convincing people that this is not always possible is a challenge), and to get the opinion of a doctor they trust in their dealings with other MDs. I do all these things and am not making enough to pay myself after paying the bills. People don't want to pay for medical care or counseling. Many think the emergency on-call line is for questions any time of the day or night... They are bombarded by health news that goes beyond what is commercially available.

Rent, insurances, taxes, malpractice premiums, salaries and supplies are very costly. Hospitals cannot afford to pay for these things, either. Insurances undervalue Gyn care. Medicare pays less than $30 for an exam... I can struggle with tough fibroid or endometriosis hysterectomy for 3 hours and get paid less than an ophthalmologist makes for a 15-minute laser surgery (that is essentially done by a computer). For the difference in malpractice premiums, with or without OB, I would have to pay my first 3 deliveries' fees per month to the malpractice insurance company. I don't see how this is going to get any better. I gave up OB and started a solo Gyn practice just over a year ago to try to practice the way patients want me to without answering to anyone else. I am happier working this way, but will be bankrupt before too long.

Now, 3 states and 5 jobs later, I am in the process of merging my practice with a local academically oriented multispecialty group. My CV was a source of concern to the other specialists in the group ("there's a lot of job change here, isn't there?"), but my experience is far from unique. Of the 3 docs who left the first group I joined with me after plunging reimbursements took their toll on us, only 1 remains in the position he moved to. Another struggles along at the end of a distinguished career in his mid-60s by moving from setting to setting in a single community, and the third has finally found some security in his fourth position since we were associated.

The concern in this practice is the rising costs of running the practice and the declining payments that contribute to a net loss of income yearly.

I am happier now than ever before. My patients appreciate my efforts. I am making a good living. I am not killing myself with work, but rather having fun in the office, fun in surgery teaching residents and nurses, fun in my nonmedical life (playing golf with my wife and friends, riding motorcycles, playing tennis, reading). I see no profound changes coming. Patients will need care, and I am good at what I do.

I have been in practice for 20 years. I have a mature practice, but I never take any patient for granted. I always keep in mind that they can always go somewhere else. As for the future, I am concerned with attracting, hiring, and retaining young doctors who can "buy in" to our philosophy (ie, "we are here for the women we serve, they are not here for us"). I don't see any profound changes as long as we can find doctors who fit our corporate character. The challenge is to avoid hiring the doctor who does not fit, or worse, does not find out that he/she does not belong until after he or she has been here a while. I am concerned that because of the remuneration we are not going to get many doctors who can express a love for the practice of medicine so strong that they would rather be dead than do anything else. These are the doctors who will be successful in any payer climate. We are looking for doctors who know that the reason they were created was to serve on the altar of medicine.

Surviving the hikes in indemnity insurance despite never having been sued in 31+ years -- this is another challenge I face.

I worry about my retirement, now that I haven't been able to put enough away for a cozy, not extravagant, retirement. I have paid too much out in insurance premiums.

The actual issue of women's health -- what's best for women-- is getting lost in the issue of business and malpractice.

The most satisfying aspects of my practice are helping women make important decisions for prevention and treatment of disease and making sure OB patients have a wonderful childbirth experience. The most frustrating aspects are "no shows." It is so disrespectful to not call and cancel an appointment that you could have filled with another person.

The most satisfying aspect of my practice is the deep and abiding faith and knowledge that my "raison d'etre" is to be a physician. It is what makes the day so much fun. Even after 20 years I still get a kick out of seeing patients, and delivering babies, and doing surgery.

Getting to know the patients and sharing wisdom with them is the best part. I learn from my patients, and I enjoy teaching them. I enjoy doing a surgery that has a good outcome. I have a bit of a plastics sensibility, so I am proud of a well-healed, well-made incision or pelvic reconstruction. I am gentle in doing exams, and am proud that women have at times been moved to tears of joy because I didn't hurt them like others have.

Helping people; accompanying them on the path from conception to a safe birth. That is a real privilege. I am frustrated my mediocrity and penny-pinching, petty, ill-educated bureaucracy.

I still love what I do, taking care of patients, and sometimes making a considerable income on their lives. My patients surprise and delight me endlessly. I love the emerging technology of our specialty and the opportunities I have to pass on my experience to students and residents. All kinds of people face trials in life, and the trials we docs face are not really all that serious in comparison. We are in general useful and better paid than most. It would do us well to remember that from time to time.

What other specialty's patients name their babies after you? I have babies named after my first name, my middle name, my confirmation name, and my last name (just like Denzel Washington, named after Dr. Denzel, his mom's OB). I have seen these children grow up and learn to call me by name... I keep pictures of most of my babies on the walls of my office and it is great fun to see the children as teenagers come and see their infant pictures. I even have delivered babies of the daughters of the moms I delivered the daughters from (if that makes sense). What other specialty in medicine has such joy and life? It is good for my soul and recharges my life energy. Where else can you take a patient who had a baby, had a hysterectomy, had another exploratory surgery (all in one day) for bleeding and 2 weeks later she is in your office with her baby thanking God and you for helping her survive? Her heartfelt gratitude was worth the 2 nights I slept in the hospital near her hospital room, so worried that she might not make it through the night. I have great nurses and consultants and fantastic ancillary staff.

The most satisfying part is working with women and helping them in one of the most exciting times of their life -- the birth of a new baby. One patient, with whom I worked in a prenatal care group, told me she felt "blessed" by being in our group. That was really touching and a great reminder of how satisfying providing care can be on a daily basis.

How do you find colleagues who are truly suited to this profession?

Frustrating parts? Not getting paid for the time I spend with people. People trying to take advantage of or trying to manipulate me or my staff. I hate when someone calls at 11 PM on Saturday night for something that has bothered her for 5 days... Or insists on calling me on-call after their work hours are over for prescriptions or test results, knowing the office is closed ... Or trying to continue to refill prescriptions without coming to the office for check ups... Or calling late at night for antibiotics for bronchitis and not wanting to go to the 24-hour pharmacy, so suggesting I call in the prescription in the morning... Or the growing no show/no call trend (at least 2 patients per day, even with reminder calls the day prior)... Or the calling 10 minutes before the appointment time to cancel without a reasonable excuse.

I have few frustrations. I consider dealing with insurance companies a challenge, and it is one of my goals to help educate insurers to designate the proper pay for proper work. I have staff that have been with me for anywhere from 25 years (when I was a resident learning in the office) to 7 years... My staff makes my life much easier in the office.

There have been more than a few occasions when I have seriously considered leaving medicine. Our own specialty has become a cynical and cold place for many of us, and the state of medicine at large is little better. My income this past year hovers at a level one quarter of that I made during my first year out of residency... my malpractice premiums doubled this year from last, even though I've never had a claim made against me. I might well have taken my depressed reveries seriously and left the practice of OB/GYN -- were there anything else I could do!

Ob/Gyn is a very time-consuming field. It's hard to balance with family life. Malpractice is driving up the stress, and the financial concerns in practices are also stressing people out. Also, you can't run a business at a loss, and that's what managed care is pushing the field to. It's not about driving fancy cars, but it is about paying docs enough so that they can do this difficult work and live their lives, pay their staff, etc.

The trends are that women will pay exorbitant fees for anything cosmetic but resent a $10 copay!

Younger women cannot afford my fees any more, especially the women I have brought into the world who have now reached reproductive age themselves.

People are consumers now [with respect to] their healthcare. I spend a lot of time reviewing news reports, online newsletters, and books with the multiple bookmarks. Preventive care is becoming more important. Being fluent in alternative medicine is important. Despite the additional time spent, people are less appreciative. They expect more and are not as grateful for the extras as they used to be. Not that I need or expect it, but it was common to get a thank you card or flowers after a delivery or surgery when I started in practice 17 years ago. Now it is rare (they perceive us as making a lot of money already from the insurance or what they had to pay as a copay).

Yes. More women are coming to me because of my office availability (I see referrals from my colleagues on very short notice and always fax the consult to them after the office visit to keep them up to date), [my] ability to fix many bleeding problems in the office; [my use of] procedures other than hysterectomy to solve bleeding problems [for women in their] 40s and 50s; for providing contraception to the daughters of my patients; and [for the] free pizza on late Tuesday nights when we are running behind in the office. A lot of patients are very disappointed with the 2- to 6-month wait to see a colleague for a visit.

I'm in a group practice, hospital based, so we are moving forward okay. The ancillary staff is very short and stressed, which is too bad for patient care because the ancillary staff can help patients tremendously with access to resources (WIC, etc) and information.

We are considering cosmetic dermatology such as Botox, sclerotherapy, skin peels, laser for our practice to increase revenues. I have already taken the courses and am just waiting for the doctors on our staff to take them before we begin.

I do much more psychiatry than I ever expected. I have had to learn and get comfortable with this over the years. Becoming antidepressant fluent was necessary. I do general medicine screening or outline for patients what their internists are supposed to be doing (like colon screening for women). I still consider myself a specialist, but I try to be sure that my patients are being treated as a whole (not just as a vagina and breasts).

No. I am not into hair removal, facial peels, herbal supplements, office pharmacy prescribing, or Amway vitamins.

I do not, but I know of groups that provide laser hair removal and sell baby clothes in their waiting area, and I think that's very sad. The laser hair removal thing especially. It shows that doctors have time, but only for things that are paid for. So... prenatal care needs to be more valued by society and better reimbursed by insurers, so that patients can get the care they deserve and doctors can afford to spend the time.

Yes, we collaborate a lot with PCPs, endocrinologists, reproductive science experts, etc. I may start someone on thyroid or insulin but then refer them on.

Collaborate - too complex for a generalist like me.

Advice for future clinicians: Love what you do and do not go into it for the money! At least as an NP or PA. Physicians that are good still net $300,000 plus a year. [Our office] collects about $90,000-$100,000 a month. I do not feel sorry for the doctors! They work hard, but they do earn a lot of money! It is very hard to feel sorry for someone who complains about decreasing revenues but lives in a $2 million house, has kids in private schools, and buys anything he wants in life.

When my son was an undergraduate premed student, I had the opportunity to introduce him to ... a well-known and respected orthopaedic surgeon. [He] told my son that there would be those who would try to discourage him from the profession. He went on to say that some would tell him that medicine had changed, that the insurance companies had taken over. He then paused and in a quiet voice, with a twinkle in his eye, looked right at my son and said, "medicine always was and always will be about taking care of sick people," and he paused again and said, "and that's fun." So, if you don't have the burning desire to minister to people mano-a-mano, one-on-one, then don't become a doctor.

Have more than one string to your bow, as regards subspecialties within our specialty.

Only do this job if you love women and get excited about doing Ob. You will not get rich this way.

Take time out on a regular basis. Burn-out is a risk you face with long hours and demanding patients. Exercise, eat healthy, be creative, do all the things you tell your patients to do. Learn psychiatric screening. Many women who think they have "hormone problems" have much more serious problems. If you want to see your own children, take Ob call in groups. It is less satisfying to deliver people who don't know you (or you them), but it is better to have a life. Don't mistake the "instant intimacy" of relationships with patients (they'll tell you things with the white coat on that they'd never tell you if they met you at a party or on the street) for real relationships...Keep learning the new procedures and such. Don't be too proud to refer a patient out for the things you don't know how to do. Despite what the attorneys say, discuss your tough cases and bad outcomes with your peers. If we cannot support each other, it makes the practice more isolating and stressful. We all need to unload. Everyone feels inadequate some of the time. When in doubt, consult.

The same thing I tell my students every day at my tertiary hospital: Choose the practice of medicine that involves your passion, that makes you laugh, that makes you smile, that doesn't make you cry too often. Ob/Gyn is fun; lets you operate; lets you keep following your patients for years; lets you treat future generations of patients of your first years' patients; and you can always find work.

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