September 2nd, 2011

health care

Doctors' hours

Aaron Carrol is a pediatrician who posts at the wonderful Incidental Economist blog. Today, he posted about the working conditions of physicians and attitudes about how physicians should approach their profession, past and present.

I think anyone who has worked in healthcare for awhile has observed the staunch old-guard that mutters about how kids these days don't want to work. These are the people who complain about the 80 hour rule that prevents medical residents from working more than a certain amount of time in a stretch. My own father is a member of this group. He's been training residents and students for over 30 years, and he's seen a lot in his time.

Aaron had some observations about his father in his post:
My father, now retired, was a general and thoracic surgeon, who was triple-boarded in critical care, and ran a trauma unit in inner-city Philadelphia. He was in private solo practice for most of his career. He worked seven days a week for much of my childhood, and seemed to be on call all of the time. I can remember multiple Thanksgivings that were cut short or scrapped because someone needed him.

I’m the oldest of three children, and we were all born during his residency and fellowship. He spent pretty much every other night in the hospital. My memories of my father when I was little are of a man who came home every once in a while, sometimes yelled, and then fell asleep.

This is when you should remember how I began this post.

But my father was a phenomenal physician. He was immensely dedicated to his patients, who knew that he had – literally – saved their lives. He always seemed available, regardless of their ability to pay, regardless of how frustrated he might become. I worshiped him. He was awe inspiring, the reason I became a doctor was likely because at some level I wanted to be like him. But he was also demanding, sometimes short-tempered, and not always present. His career consumed so much of his life. He always so very tired.

In the mid 90′s, my father had a terrible ski accident. He needed to have complicated surgery, with bone grafts to repair his leg. He was off his feet for six months, and still can’t stand to do long procedures. He was forced to quit surgery, and to give up the career that he loved.

Personally, I think it’s the best thing that ever happened to him. For the first time in his adult life, he slept. And I mean slept. He also slowly became a different person. He became more interested in his hobbies, and became a pretty impressive woodworker. He read, not just journals, but fiction and non-medical non-fiction. He played golf. He made friends.

He became a better human being.

I started to respond to this post in the comments, but it got too long, so I decided to bring it over here. I don't have solutions or anything profound to add, but I did have my own father's approach to the practice of medicine as an example.

I think my father is very much like Aaron's father. He's the medical director for many years of a well renowned critical care unit in Houston, a critical care pulmonologist in one of the highest volume cardio-thoratic surgical hospitals in the country. He wins teaching awards on a regular basis at a top medical school. I can't even count how many committees and positions he's been asked to serve on over the years in the Texas Medical Center. He is a solo-practitioner that shares call with other similarly situated pulmonologists. He has hundreds of patients that absolutely love him. I can't even count the number of people who have told me that my father saved their or their loved one's life. He is extremely well respected in his field, and grumbles about how the current crop of residents, students and new physicians "don't want to work."

My father's big choice in the 1970s was whether or not to continue the clinical research route. He had a fairly large lab and published quite a bit, but he realized that the travel and hours involved in research would take him from his growing family. His own father had been a GP in the town he grew up in, and my dad never remembered seeing his father at all when he was a kid. He did not want to be the same sort of father to his own children.

He and my mom came up with a few solutions to the work/life issues of an insanely busy physician. First, my three siblings and I were kept up unfed until he got home. My mom prepped dinner, but she didn't start cooking until he pulled in the driveway. When he got home, we'd pile into the kitchen and "help" my mom cook while talking about our respective days. We didn't eat until eight or nine o'clock at night--sometimes even ten--but we ate every single evening meal together. A lot of people mutter sometimes when they come over to dinner about the lateness of the meal, but it's what we're used to. I think being culturally Latin sort of helped with this, but I do acknowledge that sometimes getting food to the table after ten is a bit unorthodox in the United States.

Second, my parents bought a piece of property about 100 miles out of town for the weekends. It was close enough that we could get there within a few hours drive, but far enough away that my dad couldn't be called in to the hospital when he was off-call. I talked about this a little yesterday when I explained the Walhalla place. Before we bought the place, my dad had previously found himself over at the hospital if he was around, even when he wasn't on-call, and he felt he needed to physically remove himself from the hospital in order to stop working. We were not allowed to have any social or sports engagements that took up weekends, but we never really knew anything different. In the early days, the call schedule allowed us to be out there three weekends out of four, though over the years who my dad shared call with switched in number. The goal was to have 48 uninterrupted hours with the family. An added bonus, of course, was that he developed an outside interest in cattle ranching and ranch management. I remember that my family was a bit cash strapped at first, but it was totally worth it.

Finally, he backed out of the clinical research aspect of his career. The lab and associated time involved were just too much and too unpredictable to be able to dedicate any time to his family. He had been recruited to the hospital he began his career in because of his fairly brilliant research while in the army during Vietnam. But, but his clinical skills were also top notch, and he felt that he had more control over his time as a clinician. He switched hospitals, opened a practice, and he's been there for 35 years.

I'm sure also that he and my mom made other arrangements to ensure that their marriage stayed strong. She certainly worked very hard to manage his practice and the family. I don't think it would have been possible for him to have been working the way he did without a full-time partner helping ensure that things were steady at home. I always felt that everything that they did was for the good of the family as a whole, and I think that remembering that goal was important.

I never really felt his absence when I was growing up, but I was very aware that his patients and his work dictated the family schedule. Sometimes, I think mainly on weekends when it was quiet, he'd take us on rounds with him at the hospital. We'd stay in the nurses' station and watch the ekg strips and the nurses would give us syringes to play with. I don't think it's possible for a physician to do that anymore.

My father is still practicing as a solo, a couple of years into his 70s, switching off call every other weekend with another solo. His patient volume isn't as big as it used to be (I think he'd have a patient list in the 30s and 40s when I was in high-school, now he's more in the teens), but he still gets calls in the middle of the night and he still works pretty hard. Because his practice is almost entirely hospital based, he can't semi-retire or work part time. He does read sleep studies and pulmonary function lab results, but that's a small part of his practice, and quite frankly, I don't think he'd be all that happy doing only that. He's either working or he's not, and he can't set his hours because he never knows when he'll either get called in for a consultation or he'll be needed by one of his current patients. I think it'd be very difficult to find someone who would be willing to take some of the load off and eventually buy out the practice, because no one practices medicine that way anymore. Bigger groups with more diffuse call-schedules are popular nowadays, and I don't think that many people at all are hanging their own shingle, especially with ACOs and other incentives to work on a larger scale.

Still, my dad absolutely LOVES what he does, and he's reluctant to retire. I think he wonders what he'd do if he didn't have the practice of medicine. I don't think he'd change too much about the way he raised his kids, either. We're all very close to one another, and we all did fairly well with our respective lives. I think that he feels that we prioritize family before all other things, and working hard is the best way to ensure that family is well taken care of.

I spend a fair enough amount of time with physicians and students and residents coming up. I think that the trending is away from the type of practice that my dad and Aaron's dad had. You just don't see that many people willing to put in 90 hour weeks to the detriment of all else. But, I also see people struggling. I have a friend with three kids, six and under. Both parents are physicians. The parent in a large institution has a much easier time balancing work and life than the parent who is trying to make a small practice work. Call schedules are brutal, colleagues aren't necessarily aligned in interests, and in order to get referrals, you have to a) be good, and b) be willing to take a lot of consults when referring docs call them in. If your referral base doesn't trust you on either reliability or performance, then your practice suffers. I'm not sure that my friend will pull off the type of practice that my father (and her father) had, because the work-life balance just is so hard to achieve. My mom's help was instrumental to my dad's success. She doesn't have that, because though her husband has a more flexible and forgiving schedule, he is also a hard working physician.

I don't know if I'll have similar choices about how to approach my work/life as my dad. I am about three years older than he was when he started having kids (hopefully by this time next year, we'll be getting ready). I work longish hours, but I leave closer to six thirty than eight, and it's fairly predictable scheduling. I do actually sometimes make life-or-death decisions on a fairly immediate basis (as I'm sure every lawyer who works directly for a healthcare entity that treats patients does), but those aren't a regular part of my day. And when I leave work, it usually stays where I left it, to be picked up when I get back to the office, not when the patient crashes. But family is the most important thing to me, and everything I do is for the family. Fortunately, what I'm good at and what I do is something that I enjoy immensely.