Robert DeMuro
The Occupy Wall Street phenomenon and the nonsense arising from it has made it apparent that too many of us are ignorant of our fellows' working lives, so we are inaugurating a series, "Americans at Work," which will, in the words of the workers themselves, explain their jobs, their motivations, and their satisfactions.
As a child growing up on a dairy farm I felt medicine was about as far away as the moon. We hardly saw a doctor because there was nothing existing such as Blue Cross and Blue Shield, and it was cash for visits. Not to say my parents neglected us. They just realized, unlike most of the country today, I did not need to go see a doctor if my nose was stuffy. I think my daily toil in the garden and hours of canning did more for my health than any government check.
I look back at my childhood on the dairy farm with very fond memories and I wouldn't trade it for anything. I learned what the word "work" truly means. Physicians may think they work hard but they don't compare to the dairy farmer. Up to milk the cows at 4:30 a.m. and by 4 p.m. it was time to get ready to milk them again. Dad would be in by 6 p.m. on a good day to have dinner and then fall asleep on the couch. Vacations? Those did not exist unless the cows could milk themselves. Sure there were times he tried to hire somebody to milk while we went one state over for a long weekend, but it almost always led to a disaster that brought us home early.
There were a few things in medical school that really made me wonder how I lived beyond the age of five. For one, we learned of all the terrible organisms in unpasteurized milk such as bovine tuberculosis. That class had you thinking that if you just drove past a dairy farm you would have 10 days of bloody diarrhea. To think we drank that stuff three times a day! Not only did I beat the odds, but it seems my brothers and sister were also very lucky. Wait . . . what about all the people who came to the farm to get milk? Surely one of them must have suffered this terrible fate? I guess my parents must have just hid this terrible incident from me.
During the second year of medical school we started to get out of the classroom in small groups with clinical preceptors assigned to teach us physical exam skills. I was assigned to the VA with an elderly retired physician who practiced in Buffalo his entire career. Along with physical examination, he was also supposed to teach us how to "act like doctors." He made a point of telling us that we need to stay calm and in control at all times. "A doctor never shows emotion," he would say. Along those lines he felt the physician should never have anything but a physician-patient relationship with his patients. If the patient were to ask you anything such as "How is the family?" you were
not to answer. At the time it seemed to make sense but that was only because that guy was supposed to know everything while I knew nothing. As far as giving a patient a hug . . . well that would be reason enough to just turn your license in and move to a commune. It turns out in the rural area it would be a little odd to act in this manner, considering I sit next to my patients in church, I bring my kids over to play with theirs, I have them over for dinner or God forbid even vacation with them. I guess the proper way would be to only accept patients that are not friends also. That might make it a little tough to pay the bills.
The practice of medicine is full of contradictions - both the practice and the patients' expectations. Everyday somebody makes a sly remark about how I might be 10 minutes late for their visit. Of course, when it comes to the end of my time with them they are more than happy to ask 10 more questions, and then pull that list out of the back pocket from "the spouse" to double check that they covered everything besides the sore throat they came in for. The list is, or course, always written by a wife and given to a husband. After thousands of patient visits I have yet to have a woman pull out the list of concerns that her husband had written for her.
I see many children with the diagnosis of "ADHD" and this was a very new thing to me as a doctor. Growing up on the farm if one was hyperactive it would have been a real plus because it might have given us that boost to get all the chores done in time. To even think that by the end of a summer day putting in hay one would be labeled as having too much energy would be unfathomable. I only wish I needed to take a pill in the morning to slow down. I never recall any friend from all the other farms needing a pill because he wouldn't sit still. I do recall that ALL of us couldn't sit still in a classroom, but we were, after all, kids.
During my 13 years practicing medicine I have seen more change than I would have expected for 30 years. As anyone can see by watching the nightly news, healthcare change is inevitable and as physicians we will either help lead the charge or lay down and have it shoved down our throats. When I hear an old-time physician lament about the "good old days" I realize that we will never see them again, but importantly, it was some of the abuses of the good old days that got us where we are. It is quite fascinating, and disturbing, to see the daily recommendations coming out of the government on how I can be a better doctor. Those that have not practiced are fairly convinced that my 70-year-old retired miner with abdominal pain can somehow be fit into a neat little algorithim of care that will also work for his neighbor and his brother. We are heading towards cook-book medicine, but no patients fit the recipes given. When I have to make mashed potatoes the "thought leaders" say I can just use the baked potato recipe.
We are entering into a day and age of "pay for performance" which is another wonderful term that would make any layperson think that I will only get my paycheck if I give good care. The reality is that they will only be tracking a few indicators such as if I looked at the feet of my diabetic patient. Let me correct that . . . . if I DOCUMENTED that I looked at the feet. I am not saying that it is a bad idea to look at diabetic feet but I can tell you that if I make a poor choice in picking a medicine for this diabetic while also ignoring her concerns about the major family stress that is causing her to eat poorly I will not get a low rating. The fact is that at every office visit there are many intangibles that determine the quality of the visit and these cannot be measured. We have a major problem with overprescribing narcotics in our area, as do many rural and urban areas, but I can tell you I have seen no major "pay for performance" measures that will look at this. As it stands I can walk in the room and tell my diabetic patient that I don't want to hear anything about what is going on at home, document the foot exam, send them to an eye doctor yearly, order some labs and then give them 120 percocet pills and many groups that measure my performance will say I hit the indicators and congrats on doing a great job.
One could take this rant as coming from a pessimistic, burnt-out physician but I assure you that is far from the truth. I have at least another 20 years of medicine ahead of me and look forward to the challenges. I guess I just wish the challenges did not come from physician "leaders" who could not do what I do on a daily basis, so instead they got themselves into a position where they think they know what I should do. *
