Monday, June 27, 2011

The Part-Time Doctor

This is how I meet people:

Them:  "Nice to meet you."

Me:  “Nice to meet you, too”

Them:  “Dave said you’re a doctor.  What kind of doctor are you?”

Me:  “Mediocre, I guess.  Most of my patients do okay.”

Them:  “No, I mean what specialty…”  Then they apologize for the confusion or offense.  Rarely do I get the laugh I wanted.

The Dr Sibert piece in the New York Times got me thinking.  Or, mad, then thinking.  I couldn’t figure out why it rubbed so wrong.  Thanks to the many responses and the NPR discussion, my thinking took a direction.

What is a good doctor and what makes a doctor valuable?  Doctor value is productivity times quality plus happy patients, right?

 V = PQ + H
Or is it,
V = PQH
Or maybe,
V = PH + Q

Should we factor in benefit to society as a whole?  Doctors serving indigent populations get a large B and Beverly Hills cosmetic surgeons get a zero, unless of course I lose an ear there someday.  The equation becomes: 

V = PQ + H + B
Right?

My own view of what makes a good surgeon changes with the weather.  As a resident I knew first-hand which surgeon in our hospital had the most technical skill with a given procedure, and I would have chosen ten different surgeons for ten different operations.  Presently, I’m helping choose a surgeon for my nephew in consideration of cross-country travel, rapport, insurance coverage, ancillary service quality, subspecialty availability, and my nephew’s changing needs as he grows up.  I have no way to judge the technical competence of his docs.  And I couldn’t care less if his surgeon is part time if he/she has room on the clinic schedule for my nephew.  A part-time surgeon has a smaller patient load than a full-time, so continuity of care in the long term isn't affected.  In the heat of battle, such as a long hospitalization or a complication, continuity is also valuable, but so are the fresh eyes and rested hands of a partner.  The fears of the so-called shift mentality are overblown, in my opinion.  In fact, maybe the next generation has recognized that a system totally dependent on the continual presence of a single surgeon is a flawed system.

My qualm with the Sibert view is:  the number of hours worked is one factor among many determining a doc’s worth.  To focus on work hours alone is to miss the complexity of good care and debt to our benefactors. 

Imagine handing a career timecard to the taxpayers on the day of your retirement.  What if you’re a terrible surgeon who worked a hundred hours a week for forty years?  Did the taxpayers get their money’s worth?  Yes, if work hours are your only currency.

Qualm number two relates to her response on the NPR interview seeming to equate love for one’s work with willingness to work long hours.  I’m a part-time surgeon working forty hours a week.  I love all forty hours (minus documentation).  I also love sushi.  But even if I could afford it, I would not live on sushi alone, because I also love pizza.  I work part-time because I love my wife and daughter, I love my endeavor at OnSurg, I love writing, running, music, news, and travel.  I even love sleeping in.  I love taking care of patients and I sympathize with the generation who has re-framed work obligation in the larger context of life obligation.  Does this generation of doctors have to answer to the taxpayer?  Not really – this life-balance frame-shift is nationwide and crosses all professions; the taxpayer understands.

Qualm three:  Discouraging a potential doctor from medicine, part time or big time, only worsens the physician shortage Dr Sibert bemoans in the piece.

I welcome the future part-time doctor to our wonderful evolving profession.  Openly planning to balance work life with family life is mature and admirable.  Your contribution will be valuable.

Bring your kids to work, if your hospital doesn’t offer daycare, leave your toddler at the nursing station or in the admin suite while you round.  Management will come around.

I will now make a list of (largely overlapping) variables I consider relevant to a surgeon’s value to the community.  Math whizzes are welcome to provide me the quadratic equation of surgeon awesomeness:

Outcomes
Operating for the right indications
Acumen
Adherence to proven processes/protocols
Availability
Affability
Ability to operate
Adaptability
Efficiency
Cost effectiveness
Teaching
Research contribution
Experience
Dedication to an institution
Service to an underserved population
Development of programs or new services
Charity
Mentoring
Department leadership
Hours


PS – I am an above-average surgeon.



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