HELPING PHYSICIANS ATTAIN FINANCIAL SECURITY
By Robert M. Doroghazi, M.D., F.A.C.C.
Many have asked me to comment on this, so here it goes.
But first, a disclaimer: I consider my area of specialty to be personal investing and finances, especially as it relates to physicians and other professionals who receive a high degree of remuneration, but who may not have a commensurate degree of business acumen, such as dentists, entertainers, artists, athletes, airline pilots, etc . I do not consider myself an expert on the politics of medicine, the economics of health care, or the finances of a medical practice. With that in mind, here are my thoughts.
Because we live in a liberal democratic society, and because of our oath as a physician, it is our responsibility to provide care for those who truly cannot afford it. Physicians have done this for two millennia. Everyone should have access to adequate medical care.
Secondly, the more the government interferes in almost anything, the more likely it is to mess things up and the more expensive it is likely to be (In Monday’s Barron’s, Jim McTague uses a medically-inspired metaphor when he calls the health care bill “a money-sucking tapeworm that will increase the size of the federal deficit dramatically in the next 10 to 20 years”).
Lastly, and this is the point I want to address in detail, I am concerned the bill will make a career in medicine less desirable.
It is a fact: we want our physicians, the people with whom we entrust our health and welfare, our lives, to be the smartest, best, and most honest people in our society.
Every pole I have ever seen of the most respected people in the US lists Federal Judges (literally the Solomons of our society) and physicians at the very top. Complete trust is an essential part of the doctor-patient relationship. When you see a physician, you expect they will do what is best for you; not what is best for them, for the hospital, for the insurance company, for the government, for anyone else. There is not another profession where you go in and say “These are my most personal facts that no one else on earth knows, you have all of my money at your disposal, do what is best for me”. Physicians must be of the very highest, unimpeachable integrity.
When our lives are on the line, we want (need) our physicians to be the smartest people around, to seemingly know everything, to be able to diagnose diseases they have never personally seen, and may have read about once only years before (see below), and who are willing to make whatever effort required to provide us with the best of care.
The average doctor graduates with almost $150K of student loans (the average DO grad, an increasing proportion of our physicians, has 10-20% more debt). Since this is the average, many physicians are even further in hock. Paying that off at a rate of $15K/year, the average doc won’t be out of debt until somewhere in their mid to late-40s. Then add other sources of debt (or marry another doctor—-and double your debt in one day), and who knows when they will be in the black.
Add further cuts in compensation and more intrusion of the government into every facet of medical practice, and many of our most honest, best and brightest young people will just say “Forget it. I don’t need to put up with this. I am a smart, hard-working guy, I can do whatever I want, and it ain’t going to be practicing medicine”.
RMD
What could be the “unintended consequences” of this health care reform bill (“reform” can be a dangerous word)?
Several times recently I mentioned Louis D. Brandeis: A Life (Urofsky, Pantheon Books). Brandeis graduated Harvard Law in 1877 at age 20 with scores not equaled for decades. He was the first Jewish Justice on the Supreme Court, nominated by Wilson in 1916. He retired in 1939.
Brandeis noted that during the early years of his career, around the turn of the last century, there was a basic change in the practice of law. Prior to this time, a lawyer was a “counselor”. They would provide sage, independent advice that was, of course, always in the best interest of their clients, but also hopefully fair to all. Brandeis thought, at least in part due to the rise of large corporations, the role of the lawyer changed from sagacious counselor to an agent hired only for the express purpose of representing the interest of their employers. (This is not a criticism of lawyers. My older son John is a lawyer, and a very good one. Many do still act as counselors. Seek them out, one of these Solomons, and retain them as your attorney).
Could this health care reform bill result in a basic change in the doctor-patient relationship, the practice of medicine, or how our society views, respects and compensates physicians? I hope not.
These are some of the diagnoses I made over the years of which I am most proud. Because a good percentage of my subscribers are non-physicians, I will provide lay explanations.
1) About 3 years before I retired, I saw a man in his early 50s in the office for possible coronary artery disease (CAD). The first thing I noticed when I walked into the room was the melanotic macules on his lips. I thought “I don’t know if he has CAD, but he does have the Peutz-Jeghers syndrome. He had actually had surgery for a bowel tumor (the main problem with this disease) 11 years earlier and they never considered the diagnosis.
2) I saw a man in the hospital sent for CAD. He clearly had atrophy (wasting) of the muscles around his shoulders. I made the diagnosis of the Limb-Girdle Dystrophy of Erb.
3) If the mother has syphilis while pregnant, the child can have early manifestations (when born) or problems later in life. I made the diagnosis of late congenital syphilis in a man in his 40s with VIIIth nerve deafness and trident tongue. Interestingly, he did not have Hutchinson’s teeth (notched upper incisors) or “mulberry” molars.
4) Argyll Robertson pupil: Accommodation Reaction Present, Pupillary Reaction Absent. When looking at something close (accommodation), the eyes converge and the pupils constrict. ARP is one of the classic signs of paresis of the brain (late neurosyphilis), but now usually seen in diabetes, where I made the diagnosis.
5) Our group sees patients at outlying hospitals. I saw a middle-aged lady with thumbs smaller than her little finger=Holt-Oram syndrome. She did not have an atrial septal defect (ASD).
6) Several years after I inherited an elderly patient from a retired partner he developed a tremor. Some years before he had had encephalitis. I made the diagnosis of post-encephalitic (von Ecomono’s) Parkinson’s disease.
7) A middle-age lady came in with GI-bleeding. She had skin lesions consistent with hereditary hemorrhagic telangiectasia (Weber-Osler-Rendu).
8) Malignant papulosis, a rare, and unfortunately fatal, disease.
9) Munchausen Syndrome (there is an umlaut over the first u) is when people feign disease to gain attention and sympathy. A young man was sent from another hospital with a diagnosis of the Marfan syndrome and chest pain. He did not look Marfan’s (Lincoln almost certainly had Marfan’s), and, while taking the history, told me he also had hypokalemic periodic paralysis (a very rare disease). I said to myself “This guy was either dealt a terrible genetic hand or he is BS”. Both times I made the diagnosis of Munchausen I never received another referral from that physician because they were so embarrassed they had been duped.
10) The diagnosis of which I am most proud. I was a 3rd year med student on the dermatology rotation. An older man had spots on his legs and a high eosinophil (a type of white blood cell) count. I read all afternoon and evening, but his disease just did not fit any of the other causes of “spots on the legs”, such as erythema nodosum or nodular subcutaneous fat necrosis, or even any the other more remote possibilities, such as morphea.
When I presented the case to the attending on rounds the next day, I concluded the patient had an eosinophil inflammation of the fascia (connective tissue) that did not fit any know disease.
The attending just started to smile. Only months before Schulman described an eosinophilic inflammation of the fascia that now bears his name (the disease had not yet made it into any of the textbooks). Wouldn’t it have been cool if our case was the first and there was now a “Doroghazi’s eosinophilic fasciitis”?
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