Medical Practice Insights 2015
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It seems to
Where does the satisfaction in medical practice come
It seems to
that I had times in my medical career when I felt
satisfied, inspired, and motivated, but it was
cyclic in nature, up one year and down the next.
Since then I have reasoned that most of that
intermittent satisfaction was the result of my
circumstances and decisions at the time.
Up to the time that I made the decision to begin
private medical practice I had been under the
control of the medical school system, US
Navy/Marines, OBG residency, and Kaiser Permanente.
Although it was all exciting and interesting, I
never felt fulfilled or free to make my own
decisions, didn't hate it but didn't love it either.
So when I cut the cord at Kaiser, it became a new
world for me.
Delving into my new private medical practice in 1973
was the most inspiring time in my life. My first
year I grossed about $75,000 and knew that it would
get better for sure. So my family would be supported
and not have to worry about going broke.
Over the next 20 years the most exciting times for me
were the times that I "experimented" with my medical
talents. Kaiser forbid me to do any infertility work
because insurance paid nothing for that. But my
interest was in doing a lot of that. I researched
the literature on infertility, found no medical
courses being given on that topic. For the next two
years I was blessed to get many referrals of
patients for infertility. No other private doctors
were doing it in any serious fashion.
I began doing reparative tubal-plasties using the ENT
instruments. It expanded into reanastamosis
tuboplasties, reimplantation of oviducts in the
uterus, and more. It was a wonderful feeling to know
that what I did was helping a lot of patients that
other doctors wouldn't touch. About two years later,
in 1975 infertility courses came around. Other
doctors took the courses and my referrals dropped
My next peak was getting into laparoscopy procedures. I
took Dr. Curt Semm's first course in America early
1980s I believe. Dr. Semm had developed and taught
the laparoscopic techniques all over Europe, later
in America. My associate had taken the course a few
months earlier in Europe so he and I teamed up to
start the new kind of surgery at our primary
hospital. Then introduced it to other local
hospitals. That expanded into advanced laparoscopic
procedures and we were the only two in Northern
California doing them early on. I became aware that
my surgical talents were far more than I had
anticipated. I loved doing surgery.
Following that my associate and I began the LAVH
(laparoscopic assisted vaginal hysterectomies)
procedures and taught it to other doctors. This
surgery was safer, easier, and in demand by patients
later. Then surgeons who had criticized us so much
began doing laparoscopic surgery for gall bladders.
They were ashamed to ask me and my associate to
teach them the procedure I believe, they learned
from another general surgeon who came in new to the
hospital with the training.
It was rather humorous to know that the new doctor for
the first two years did over 90% of gall bladder
removals via laparoscopy, which made the other
general surgeons angry him stealing all those cases
from them. That made it important for them to learn
the procedure themselves, which they did.
These were the source of my inspiration at doing new
surgical procedures and teaching them to other
doctors. They were the greatest source of
satisfaction to me over all those years. These
events gave me immediate feedback on how well I was
doing in medicine, got me a lot of PR, and could
never have happened during my 14 years as an
Medical practice is much more complicated than in
It seems to
after reading a large number of books about medical
practice, starting a medical practice, dealing with
all the many licenses and requirements, and about
the business of medical practice, I have come to the
conclusion that medicine must be not only the
hardest career to qualify for, but also the most
difficult business to start compared to what I found
I probably today would never get into medical school,
let alone be able to handle the business of medical
practice requirements of today. I likely would get
my medical school training in England, lots cheaper.
Wouldn't it be interesting if all American medical
students did their training in Europe for money
reasons, and American medical schools survived
financially because they had to recruit the sons and
daughters from wealthy foreign families.
I knew the great advantage of having and using
computers in my medical office in the mid 1980s. One
day a computer dealer showed up in my office for a
PC demo. I bought the whole computer package they
offered for I think, $70,000 on a lease. They came
to my office several times to teach my office staff
how to use a PC.---first medical office in my town
to get computers. They spent a small amount of time
teaching me, because I was not interested as long as
the staff knew how to use them.
I never learned about computers and how to use them
until 1997. It took another 5 or 6 years for me to
really take seriously learning computers inside and
out. I missed a great opportunity in the 1980s and
have regretted it since, because I probably would
have gained the PC expertise at the same time that
kids were learning in grade school.
How does one orient their mind to a life of constant
change and unexpected incidents that force changes
in their path.
It seems to
that adapting the mind to constant and recurrent
changes in a medical career, or any other career,
should be a priority. It should inspire a person to
become a deep thinker in order to have a knapsack
full of acceptable backup alternatives. To have a
brain full of experiences, is a great advantage in a
world that is changing daily.
I don't think that this approach to life is very
prevalent among physicians. All they really know is
how to practice medicine, nothing else to rely on
later. Physicians don't ever seem to have a Plan
B for their careers, which makes it much more
troublesome when they have to give up their private
practice as so many of them do today.
Right after I started my solo medical practice, the
malpractice insurance rates became so high that all
the insurance carriers left California. It left
thousands of medical doctors there without medical
malpractice coverage... and for OBGs it was
terrible. I used arbitration agreements for about
two years before I could again afford to buy
malpractice insurance in California. Totally
Soon after that the mandate for managed care in
medicine was passed and then we all began losing our
patients to the HMOs, IPAs, and Kaiser in the 1970s.
It was unexpected because most of us never
understood how it would effect our own practices.
You see, we though we might lose a few patients and
keep all the loyal ones. It was just the opposite
effect, most lost a third or half of their loyal
patients and had no idea how to recruit a bunch of
new patients (no business or marketing knowledge) to
make up the difference.
These are reasons to train you mind for deep thinking
to be successful. Get and read the book by John C.
Maxwell titled, "How
Successful People Think."
Professional poverty doesn't seem to bother most
It seems to
as long as
physicians can quit private medical practice anytime
they choose and get a
job as an employee in some healthcare organization,
the issues of income will never impress any of them.
Eventually when the available jobs and employment in
healthcare facilities become rare, as it will be
soon, then private medical practice may get more
attention. Those jobs are already hard to find.
For non-specialists, jobs will likely continue to be
available because there will be a continuous
turnover of doctors leaving and coming into those
jobs. For specialty doctors, however, job
availability is now, and will become, more rare with
For specialists, it involves many more barriers to
finding a job position. It means finding a job
position that matches their choice of city or state,
licensure, family desires, compatibility with peers,
and being able to practice their specialty in the
manner they prefer. What is so obvious a problem is
that there are many restrictions when practicing
under an employer of any type. Some procedures you
know how to do, won't be allowed. Some ideas about
patient treatment and management you may have, may
Forward thinking by physicians is commonly far short of
adequate. Otherwise they might have made different
decisions over time than they did. My experience in
the military, Kaiser Permanente, and as a
Hospitalist has solidified my mind about the huge
disadvantages associated with being employed.
Imaging leaving medical school all prepared to do
great things in medical practice only to discover
that you will only be permitted to do part of that
expectation, because you do not control your income
or your career.
What a shame it is to meet reality head-on only to
discover that in medicine things are not as they
seemed to be. Take the medical school teaching
curriculums. These have been re-oriented to teaching
medical students how to get jobs and make decisions
relative to spending their medical careers in
employed positions. That should logically make all
medical school applicants hesitant to continue in
the profession. Yet they do, because they are easily
kept ignorant about what lies ahead. Students are
never told the truth about what's ahead.
Could it be that what's happening to the medical
profession today is just one example of many that
lend strong evidence to Biblical prophesy?
It seems to
to be all part of a growing
disintegration of America as we used to know it, as
well as an overall world wide economic, political,
and educational deterioration of societies leading
to the end of times. If in fact this might be the
case, then there will come a time soon where there
will be no great desire to improve anything
especially in the practice of medicine.
Maybe the sustitutionary changes (doctors being
replaced by mid-level medical providers rapidly and
extensively) happening over the last decade or so is
in reality part of the decaying process already in
healthcare, at the same time that the world
societies are decaying. Is it a clear and present
danger that we are too distracted to realize?
Just think about it. Medicine is rapidly moving from
physical diagnosis to technical diagnosis of
disease. Physicians and PA's no longer ascult the
lung functions through layers of clothing instead of
directly on the skin. Patients are unable to afford
the best medications for their health problems.
Employment incomes are gradually leveling out, not
keeping up with inflation. Patients can't afford
nursing homes. Society survives on increasing
numbers of handouts. Advanced education in now
unaffordable and education is funded by ever
increasing debt that will never be paid back.
All of these issues point towards one final end.
Politics are unable to fix it. Religion hasn't been
able to change things around. The economy blunders
escalates the situation. People are becoming
incapable of changing anything except by violence
Medical schools in order to remain functional have
resorted to recruiting students from many other
countries, normally those who are wealthy enough to
pay the tuition. Additionally, with government
financial support fading and already bankrupt,
medical schools now are marketing alumni for
donations more than ever. A good number of the
foreign doctors educated here go back to their
countries to practice.
Add to that the drop in number of Americans applying to
medical school should tell where medicine is headed.
Then add the inability of physicians to make enough
income in practice to remain solvent, at least until
they become employed and then are paid in one way or
another with government money that won't last
Why aren't doctors provided both a business and
medical education? No one says that it is
impossible to do, but that's what the medical
education scholars think and propagate by their
If all schools beginning with elementary education
provided economic and business education for all
students, the world would be in a much better
situation. The world runs on business. All money is
derived from business.
wonder what the government will do when most private
physicians choose a
cash-only medical practice?
It seems to
me... if private
practice disappears as most are predicting, then all
physicians that have become fed-up with being an
employee and those who choose to control their own
careers will go for the only available option left
in the USA---a cash-only practice method. Then again
the reality of this happening is next to none. I see
two reasons for that. First, the same problems will
continue to thwart the cash-only medical practices
the same as they are today for one big reason...
physicians aren't being provided with a formal
business education and most all will fail
financially. It's inevitable.
Secondly, I would expect that the government and
politicians wouldn't tolerate the exodus of
physicians from government medicine and legislate
physicians out of their cash-only practices. You may
think that you can't be forced out of a cash-only
practice, but remember that the medical boards and
state politicians that run them make the medical
practice rules in each state. They could easily
increase the requirements for state licensure,
require increased CME credits, and a dozen other
restrictions that would or could bring doctors to
their knees again.
I believe it is inevitable that with the outrageous
education debts that keep increasing with no end in
sight will serve as the primary leverage for forcing
all medical school graduates into employed
positions. Of course, medical education in Europe
and other countries is much cheaper, especially in
France. One could get the doctorate there and come
back to the USA and practice. Actually, it's no
different than the thousands of doctors from foreign
countries now practicing in the USA today. Doctors
from wealthy families who can pay cash for their
education are left with the best options.
The one remaining and unresolved issue today is
whether the Supreme Court knocks out ObamaCare, or
if the new president and congress can overhaul the
healthcare system will enough to bring medicine back
to a level that satisfies all the doctors.
Patient care will be neglected, the same people
without health insurance will never change, and tax
dollars now doled out to medical education and
medical research by the government will control the
whole system anyway. It's a no win system.
I have always been happy and privileged to practice
in the way I chose for all those years and before I
had to face the present day challenges that
certainly would have made me miserable in my medical
career. I never loved medicine that much!!
Are No Longer Wishing to Join the Medical
It seems to
I can't blame them for that. Any smart American
college student should have enough brains and
intellect to discern where the medical profession is
headed, and it isn't good. What is quietly hidden in
the recruitment of medical students are the rapidly
increasing numbers of foreign students joining the
profession while carrying their biases, cultural
tendencies, and behavior patterns with them. That's
where the money is, needed by medical schools, and
wealthy foreign parents or supporters more than
willing to spend what ever is needed to make it
Americans are quickly becoming the minority of
medical students. Who wants to become a medical
professional to be forced into being an employee to
survive, having their medical career determined for
them, earn much less than comparable business
people, lose the freedom to practice medicine as
they want. The thought that a physician can't earn
enough to put the kids through college, fund a good
retirement plan, keep their medical office open,
meet their expectations for their careers, and to
live above the poverty level is a national disgrace.
So foreigners are filling the gaps along with women
doctors, half of which practice part time.
At the same time the medical schools contribute
directly to the frustration and disappointment of
the physicians they graduate. That's because of
their complete and intentional avoidance of
providing a business education of physicians, whom
they know will probably not financially survive in
practice, which we see the results of today. Doctors
are blinded to the need for business knowledge in
practicing medicine, so they don't know how to run a
profitable medical practice business.
At least physicians who obtain business knowledge
can see the truth for what it really is. There are a
truck load of reasons to correct this deficiency and
a truck load of ways today to do it effectively. No
one gives a damn about upgrades when they are
sliding downwards more every day.
Every Doctor's Investigative Nature"
It seems to
government controlled healthcare program, in the
name of cutting medical care costs, has awakened a
monster within every practicing physician's soul.
This is a monster that has been unleashed to feed on
the motivation and passion of every doctor's
investigative mind compromising not only the quality
of medical care delivered, but also the intensity of
their diagnostic abilities pounded into their heads
while in medical school.
I see the problem every time my wife or I see a
doctor for medical issues. What I see being done is
a great disregard for good physical examination,
barely being examined close enough to catch any
unexpected sign or symptom that could lead to a
different diagnosis completely. For example, my wife
had developed a chronic dry cough which persisted
for months, sometimes interfering with sleep and
daily activities. I listened to her lung fields but
heard no rales or other pathologic signs. Finally
took her to the ER when her breathing became
difficult, and no cause for it.
Not only did she wait an hour to be seen by a
doctor, but had to urge the doctor to listen to her
chest and lungs which took maybe 20 seconds through
her clothing. No lab was done. His diagnosis was
"just a virus that is going around". So I asked him
if the virus he was talking about was one that
lasted 6 months or more without improvement. I never
heard about a virus like that in my medical career.
He never even considered a differential diagnosis of
lung cancer in a 77 year old, allergy to something,
or something related to a secondary mycoplasma
infection I read about.
They knew I was a physician and hadn't brought her
to the ER for a unessential or dumb medical
reason---this was a significant medical problem and
worsening and with no diagnostic work done to corner
a tentative real diagnosis. I finally told the ER
manager that if he missed a serious problem by not
ordering a chest x-ray that night that they would
have a malpractice suit to contend with. I was
The Internist she saw soon after --- almost exactly
the same thing. For the medical care in an HMO I
expected such poor care, like my three years at
Kaiser Permanente where I witnesses a lot of that.
It is obvious, at least to physicians who were
trained 50 years ago, that the pressure to do less,
spend less, and save money for the HMO was a direct
influence on what doctors are coerced into doing for
patients today. It sickens me what I'm seeing. I can
give you about 20 more good examples of this, but
you probably already see what I see as well.
Millionaire Physician I Met Recently"
One that beat the odds,
never had a business education, and started medical
practice in OBG about the same time I did.
It seems to
serves as a testimonial to the fact that an academic
business education or an MBA degree is not required
to make all the money you care to have... whenever
you need it for something. But you have to
understand that it still requires a business
knowledge of a reasonable degree no matter how or
where it came from. The amazing and intuitive
ability he had about business building came from
For one thing he understood that medical
practice was a business right from the start. It was
his daily affirmation. Even Wayne Dyer, a world
renowned expert in self improvement, said,
you change the way you look at things, the things
you look at change!"
it did for my doctor friend.
He started his practice in a southern state
without considering the economic and demographic
effects on building a medical practice in that area.
Was he just lucky? Maybe. A few times during his
career he has dealt with business and marketing
experts and found them to be money-sucking
predators, even though he had no trouble with paying
I immediately knew he was highly intelligent
and was the kind of self-confident person
feel like trusting from the start. I can't equate
his background and family ties to the degree of
wealth he created for himself. The remarkable thing
to me was that he had been marketing his medical
practice without knowing that he had since he
started been doing it... just seemed right to him.
This doctor is an excellent example
of what can be done in solo medical practice when
you have the right mindset for business... something
that is never instilled in the minds of students by
our medical education academics. The educational
concept that seems to be working here is that most
belief systems are formulated at an earlier age. If
such people are later confronted by a new or
different system that they have never been exposed
to previously, rather than giving the new system
your ear for a while, most outright go to and use
their early beliefs and standards instead.
It's an automatic response to what seems to be
a barrier that our mind creates. Therefore, most
people must first be exposed to the new system for a
period of time before they can recognize the value
of adopting that system. And the person must be able
to understand and accept what they are being taught
or told about it. When these things are missing,
people will naturally reject it from the start, even
to the point where they tune-out the further
teaching and instruction on the new system.
It's almost like having to desensitize a person
to new ideas and information first, then they are
ready to learn and accept. It's a matter also of
decreasing a person's resistance, arrogance, and
objections. The strength of these three things is
different for every person. The defensive nature of
most people in today's world prevents most of new
and reliable information from being recognized or
This is why there are very few physicians who
by the time they finish medical school
any interest, inclination, or personal desire to
either recognize medicine as a business or accept
the business of medical practice as a legitimate
Skills for Today's Gynecologist"
It seems to
being the title of an upcoming CME conference in
NYC, would entice a large number of private
practicing gynecologists who are feeling the sting
of governmental fee restrictions and regulations. On
reading the mail flyer I received about this
educational event, I again discovered that their
approach to helping physicians is to learn more and
higher skills in gynecology that are "solidly
reimbursable" elements of medical practice.
The question that immediately comes to my mind, "How
is a struggling gynecologist going to have the
income to afford to attend this conference,
especially when it's being held at a high-priced
hotel in Times Square?" I do know that I could never
have afforded to attend it even at the height of my
OBG medical practice years in an affluent area of
The second question I have is, "Doesn't the thrust
of the conference mean that to survive in the
specialty one must work harder instead of smarter;
maybe skinny down their practice focus to doing only
those new "solidly reimbursable" procedures
It brings up another question, "Wouldn't that
narrowing down of practice focus automatically
reduce the number of patients joining the practice
because it would use up the time for the care of
routine gyn patients forcing doctors to accept only
patients needing those special procedures?" When I
focused my practice on infertility patients and
tubal microsurgery, patients began asking if I also
did routine gynecology work.
The overwhelming and still incomprehensable
inability of high-powered medical educators to
recognize the real core problem of medical practice
failure--lack of business knowledge and
education--will remain my nightmare until I die.
of providing physicians with an offensive weapon
(business education) they continue to provide only
the defensive weapons (work harder) and they will
continue to fail financially.
The obstructive nature of medical education
politics, tradition, and permanently implanted and
untouchable educational infrastructure continues to
be the fatal bullets for private medical practice
survival. The tragedy of all this is the fact that
medical education scholars are too close to the
profession to recognize where the real problems are
for the survival of the profession.
So, I ask myself every day, "If (maybe the
education scholars already know) the medical
education academics are at the seat of the cause of
the problem and do nothing to resolve the issue of
offering or providing a business education as well
to all physicians, then healthcare in our country
will certainly continually degenerate in all
aspects." It's not a guess, it's a prophetic
Medicine May Be The Biggest Malpractice
Trap of The Century"
It seems to me........that
the smart phone technology contains a significant
danger to all physicians in spite of the convenience
it offers to both doctor and patient. I was brought
up in medicine to interact person to person with
patients. If Dr. Hopkins caught us listening to the
heart of the patient through a shirt or blouse, or
not taking the time to specifically listen very
quietly for diastolic murmurs against the skin, he
would round up a patient with significant pathologic
murmurs that we weren't able to hear unless the
stethoscope was on the skin.
Today doctors depend on x-ray, ultrasound, and
CT or MRI to make diagnoses rather than by hands on
techniques. It increases the cost of healthcare,
reduces the diagnostic skills we were taught, and
leaves us dead in the water if those machines are
not available. Once you lose your skills you become
hostage to the machines.
I'm much more concerned about the misdiagnosis
risks associated with relying on technology. It used
to be that a man would walk into the clinic for a
laceration of his leg that he got from work and
during the undressing process noticed his scrotum
hanging down to his knees full of small intestine.
Usually men put up with the defect for long periods
of time. No visits to doctors, did his own
treatments, usually the old fashioned truss support
my uncle wore for 20 years or so.
It had what looked like a polished wooden
doorknob on each side that strapped in directly over
the inguinal canals. Men rarely went to a doctor for
medical problems that they could put up with and
still do their job. When we as medical students
found a patient like this we knew that it was a
perfect opportunity for being the first "doctor" to
find something else, maybe 3 or 4 other medical
problems that needed treating. That puts me in mind
of the test patient I was assigned to examine when
taking the Part-3 of the National Board exams at
I knew that if I missed an important medical
problem he had, I'd flunk the Board Exam. So I
examined him head to toe carefully. He had an
obvious large inguinal hernia that he didn't
complain about. He had several systolic and
diastolic heart murmurs, and had an active melanoma
on his arm. I thought I had scored well by
diagnosing all three things and doubted I'd missed
anything. When I listed all of the diagnoses I had
made, the examiner asked me if I had done a breast
exam also. The patient was about 80 and rather
I told the professor that I usually don't
examine men's breasts except by my manipulation
while listening to the heart. The man had been
admitted for breast cancer, not for any of the other
problems and I had missed the breast lump
completely. We discussed male breast cancer---5%
occur in males---I never knew that or even thought
of it. Luckily he passed me. But, I never forgot the
lesson, nor the patient.
All of these things remind us that many
patients have many medical or surgical problems that
they never tell doctors about, hide some issues, and
we only find them by physical examination of the
patient. When we find them, patients are willing
only then to listen to the dangers of delaying
treatment, what should be done, and what is
All of the digital technology used will never
come close to doing what needs to be done for
patients. My concern is that doctors are becoming
too trusting of remote medical tracking and
monitoring. I think it is easy to get into that
groove. And when fetal monitoring becomes a home
process, all the OBs will run for the hills. It will
be a field day for all the plaintiff attorneys.