Another Letter to Washington, from a Physician on the Front Lines.

 -by Matthew Moeller.

Due to the tremendous popularity of Dr. Moeller’s original post as well as some of the critiques and questions it raised, Dr. Moeller has written this follow-up post in response.

Thank you to everyone for the positive feedback. Over 57,000 Facebook “likes”, tweets, and newspaper requests over the past week was quite a surprise. I was especially moved by the multiple tweets from hospices, physician groups, and individuals recommending my article. This article really has hit a nerve and shed light on some of the issues at hand in today’s healthcare debate. I am writing a follow up article to further address some issues.

First, I wrote my original letter to illustrate some sacrifices doctors on the front lines of care make. In order for doctors to continue providing the highest quality comprehensive care, we need our leaders/ lawmakers to understand the perspective we face so that the best solution can be found to care for our population. I do not feel that this particular perspective was voiced on Capitol Hill during the health care reform debate. Yes, there are lobbyists, but they are not those who are treating patients and may not know the nuances that individual doctors can provide. In addition, I am concerned about my colleagues in private practice (specialists or primary care doctors) whose livelihood is threatened because of the potential cuts in reimbursement (up to 26%). This measure could force these doctors out of practice simply because their expenses (which rise yearly) are exceeding their declining reimbursement, which has declined steadily over the past several years already. If this does happen, it may force doctors to stop seeing Medicare patients because reimbursement is usually lowest for this group. It will take away the physician-patient relationship that is needed for great medical care. A recent Forbes article explains this. In my opinion, Congress needs the help of doctors who take care of patients daily to give their advice on possible remedies.

Despite these lingering issues, I nevertheless love my profession and my patients. Becoming a doctor was the right choice for me; I was interested in science since I was a little kid and am thankful that I can use my education to help my patients and their families. I have also learned a tremendous amount from my patients. I cannot see myself practicing any other field other than medicine and I am humbled daily serving my patients. I definitely would do it all over again as well because I feel this profession is my calling and I get an enormous amount of personal satisfaction taking care of those in need. Anyways, who would go into medicine in the first place with its long hours, large debt load, delayed earnings, risk of lawsuits, and daily life and death decisions if they didn’t true care about the human race? I am happy to say that most of my colleagues feel the same way. Our concerns rest on the idea that we may not be able to provide quality care to all patients if the tools and resources we need are reduced.

Second, I was trying to speak for ALL doctors, not just GI doctors. People have commented that I was complaining about my salary and the salary of GI doctors. This article was not intended for GI physicians, but, rather, for all physicians. Not all physicians get paid the same and primary care doctors typically get paid significantly less than specialists. The article was a personal anecdote to illustrate some sacrifices of a typical doctor who is paying off his or her loans themselves. I am not complaining about my current compensation. Doctors do have the highest average salary of any other profession despite the financial sacrifices early in our career. But I am concerned about the FUTURE CUTS that may force doctors to

either stop seeing Medicare patients or encourage them to do concierge medicine (which charges a premium to patients for access to the doctor). I have this concern because most of my colleagues in practices have seen their reimbursement cut and their expenses increase. When these two things happen, one either works more hours in the week to make up the difference or their expenses increase until they can no longer afford to see patients without going into debt. This in turn could lead to the decline of quality advanced health care that Americans enjoy. There are numerous articles out there as well that show concierge medicine is growing). Continue reading “Another Letter to Washington, from a Physician on the Front Lines.”

An Open Letter to Washington, D.C. From a Physician on the Front Lines.

-by Matthew Moeller M.D.

I am writing this letter because I feel that our leaders and lawmakers do not have an accurate picture of what it actually entails to become a physician today; specifically, the financial, intellectual, social, mental, and physical demands of the profession. This is an opinion that is shared amongst many of my colleagues. Because of these concerns, I would like to personally relate my own story. My story discusses what it took to mold, educate, and train a young Midwestern boy from modest roots to become an outstanding physician, who is capable of taking care of any medical issues that may plague your own family, friends, or colleagues.

I grew up in the suburbs of southeast Michigan in a middle class family.  My father is an engineer at General Motors and my mother is a Catholic school administrator in my hometown. My family worked hard and sacrificed much to enroll me in a private Catholic elementary school in a small town in Michigan.  I thought I wanted to be a doctor in 5th grade based on my love of science and the idea of wanting to help others despite no extended family members involved in medicine.  Winning a science fair project about the circulatory system in 6th grade really piqued my interest in the field. Throughout high school, I took several science courses that again reinforced my interest and enthusiasm towards the field of medicine.  I then enrolled at Saint Louis University to advance my training for a total of eight years of intense education, including undergraduate and medical school.  The goal was to prepare myself to take care of sick patients and to save the lives of others (four years of undergraduate premedical studies and four years of medical school).  After graduation from medical school at age 26, I then pursued training in Internal Medicine at the University of Michigan, which was a three year program where I learned to manage complex problems associated with internal organs, including the heart, lungs, gastrointestinal tract, kidneys and others.  I then went on to pursue an additional 3 years of specialty medical training (fellowship) in the field of gastroenterology. The completion of that program culminated 14 years of post-high school education. It was as that point, at the tender age of 32 and searching for my first job, that I could say that my career in medicine began.

Over that 14 year time period of training, I, and many others like me, made tremendous sacrifices.  Only now as I sit with my laptop in the dead of night, with the sounds of my children sleeping, can I look back and see where my journey began.

For me, it began in college, taking rigorous pre-medical courses against a large yearly burden of tuition:  $27,000 of debt yearly for 4 years.  I was one of the fortunate ones. Because I excelled in a competitive academic environment in high school and was able to maintain a position in the top tier of my class, I obtained an academic scholarship, covering 70% of this tuition.  I was fortunate to have graduated from college with “only” $25,000 in student debt. Two weeks after finishing my undergraduate education, I began medical school.  After including books, various exams that would typically cost $1000-$3000 per test, and medical school tuition, my yearly education costs amounted to $45,000 per year. Unlike most other fields of study, the demands of medical school education, with daytime classes and night time studying, make it nearly impossible to hold down an extra source of income. I spent an additional $5000 in my final year for application fees and interview travel as I sought a residency position in Internal Medicine.  After being “matched” into a residency position in Michigan, I took out yet another $10,000 loan to relocate and pay for my final expenses in medical school, as moving expenses are not paid for by training programs.

At that point, with medical school completed, I was only halfway through my journey to becoming a doctor.  I recall a moment then, sitting with a group of students in a room with a financial adviser who was saying something about how to consolidate loans. I stared meekly at numbers on  a piece of paper listing what I owed for the 2 degrees that I had earned , knowing full well that I didn’t yet have the ability to earn a dime. I didn’t know whether to cry at the number or be happy that mine was lower than most of my friends. My number was $196,000. Continue reading “An Open Letter to Washington, D.C. From a Physician on the Front Lines.”

Offer Hospice Patients a Smile.

Hospitals are busy places to work. The work is fast paced, and never seems to stop. For most physicians, the work ends when the work is done, or until you fall over, whichever comes first. So as a consultant, when I am seeing a patient wherein there is no longer anything that I am contributing to a patient’s care it’s routine that a physician would “sign off” the case, meaning I would not continue to see the patient on a daily basis but would be available if I were needed. Sure, I might have a good repoire with a patient, and some even tell me that I have a nice smile, but it hardly seems like a reason to continue to bill their insurance company without actually contributing any expertise. Despite how nice I think my smile is, I have yet to find an insurance company  willing to pay to see it.

It’s no surprise then, that in such a busy workplace the physicians-in-training that I regularly work with would want to sign off a case as soon as possible. Unlike most of their bosses, they get paid the same no matter how many patients they see. There’s no incentive for them to see more, and if they see too many, it becomes difficult to learn anything.

So for many specialists who round on patients in a hospital, and for physicians in training in particular, the typical approach to a patient who has enrolled in hospice or decided to otherwise stop all treatments other than comfort measures, is to sign off the case.

For those patients, the thought is, most of them are waiting to be discharged home or to another facility, and have accepted that the end of life is coming. In such situations families are typically grieving, making end of life arrangements or simply trying to spend as much time with their loved one as possible before the end comes. Why would it be necessary then for a specialist or a team of physicians to enter the room of such a person, ask a plethora of unnecessary questions, perform an exam and offer meaningless platitudes like “hang in there! you’re doing great!”?.  All this to a person whose one certainty is that they’re not doing great, and they’re most definitely not going to be able to “hang in there”!

Thus my approach has been to sign off such patients, and based on what I’ve seen, it’s the approach of most other physicians as well. I had always thought that ridding people of my pestering presence at the end of their lives was the most reasonable and humane thing I could do.

But things changed for me recently, when my own father entered hospice. He was in the hospital for a few weeks, and being a physician himself, he knew the end was coming. My mother, of course found it difficult to let go. After 50 years together, who could blame her? She agreed grudgingly to hospice, but needed constant reassurance that it was the right thing to do. I remember the constant look of consternation and worry etched on her face in the days after he was enrolled in hospice (but was still in the hospital). One by one, the physicians who had convinced her that there was nothing more to be done, disappeared. The physicians who reassured her that he would be well taken care of no longer visited, at just the time that she needed their reassurance more than ever. Her face wore a look that said, “Are we doing the right thing? Are they just trying to get rid of us?” Despite having a pulmonary, critical care physician for a son, there are some things you just need to hear from your doctors, the people who have been taking care of you, the professionals who know you.

Ultimately she came to accept the inevitable, she’s a strong person, and she knew she had no choice. He passed away peacefully.

But that experience taught me to change something in my own practice. I still round with my physicians-in-training, as I always have, we still sign off those patients who are going into hospice as we always have, so  the team does not needlessly pester a person at the end of their life. Instead, I walk into the room by myself, I perform no exam, I ask no medical questions. I offer them nothing but my smile. And it’s for free.

Related Articles: An “Untouchable” Who Touched the Lives of Many.   Code Status and Living Wills, and Why They Might Not Matter.

EMR and the Loss of Eloquence

Much has been made of the downside of the increasing use of EMR systems by physicians. But I am not going to  dwell on those pervasive complaints concerning the cost and complexity of setting up the systems. Nor shall I rehash the well known issue of what I call “doc blocking”. . . wherein a computer (or other entity) stands between the patient and physician, slowing the exchange of information to however many words can be typed per minute. No there’s another more pressing issue to me personally that is rarely discussed in regards to use of the EMR. The loss of eloquence. Continue reading “EMR and the Loss of Eloquence”