My First Real Manifesto
The original of this was written in 2015. I lost it many times. My now again boss (pro-tip if you can’t be your own boss, you absolutely should work for someone who saves the manifesto you write and send her bitching about your job and who re-sends it to you over and over because she thinks you were spot on) has resent this to me. We have a newer doc who I think is the best on the team who reminds me of myself when I started as an attending Geriatrician in the nursing home realm, although a more hilarious version of me. So I asked our boss if she still had this. She did. Sad news is, this was originally written in 2015. It’s 2022, post COVID, and things are not better. They’re worse.
EVIDENCE BASED REALITY MANIFESTO
Multifactorial Reasons for why no one is and no one will go into Geriatrics......and also while despite Primary Care Specialties like Family Medicine are matching and training doctors they are indeed burning out at rapid rates from very early on in their careers. In effect:
YOU WILL NOT BE ABLE TO GET A DOCTOR IN THE VERY NEAR FUTURE
When it comes to the actual "Art of Medicine"nothing beats Geriatrics. To practice Geriatrics, one has to have an appreciation for the diversity in our aging process, genetics, environments and cultural differences. One also has to be an expert in pharmacology and diagnoses, as well as interactions with family's and patients in sensitive subjects. A Geriatrician has to be able to recognize subtle cognitive difficulties, and work to protect patients from the ravages of age on the mind. There is no such thing as a one-size fits all approach to a geriatric patient. There are no protocols. As Geriatricians we know that we are specialists too, and so we fight for what is best for our patients as a whole, even when that is standing up to the medical system and saying "enough is enough!" We are the ones who sensitively and empathic ally initiate the tough conversations, which indeed are getting tougher and tougher. There was a time when Geriatrics was attractive to people despite the major pay discrepancy because it was so fulfilling. However I would argue that is no longer the case.
Let's get into why....... from the start.
First of all, medical School is obscenely expensive. And unless you are coming from an uber wealthy family (those are becoming more and more numbered each day) chances are you are going to need to take out $50,000 plus per year in tuition and then some for living expenses. These days, almost all of the loans come with a 6.8% interest rate (or more). And depending on where you finally do your residency after 4 years of medical school, your family situation (kids vs no kids) and the cost of living, it is highly likely you won't be able to put an iota of a dent in that now $200,000 plus sum with 6.8% interest that starts accumulating immediately when you start residency where you're working 80 -100 hours per week but getting paid only $50,000 per year. And you realize fairly quickly in medical school that certain specialties get paid a heck of a lot more to do a heck of a lot less. Even after a 3 year residency in either family or internal medicine, another 1-2 years of fellowship in geriatrics at training salary just adds that much interest onto your scary accumulating debt when you could at least make a meager attending primary care MD salary of say $140,000 per year. And plus there is this very false assumption that primary care docs also really get trained well in residency to do geriatrics, so why waste time and money on a fellowship? So what does that mean?.......Do the math, from the get go there is 100% NO financial incentive to do geriatrics, at all. Oh by the way, despite the massively aging population and our country's complete inability to care for the aging population, there really isn't any substantial loan re-imbursements offered for becoming a geriatrician. Oh there is for primary care docs who dedicate 3-4 years in a rural area, but nope, not for those who sacrifice a year of attending salary to become adequately trained in caring for the elderly. And to add on to the general stress that is inherent in being a doctor with the financial stress of ever-accumulating debt is a recipe for mental disaster. So ultimately, if you are someone who wants financial stability, not luxury and extravagance, but just a smidgen of stability whether so you can take one small vacation a year or so you can support your family, then Geriatrics is off the table these days.....from the outset.
You're one of the crazy few (such as myself) and you've decided to go into family medicine and then Geriatrics......Let's talk about what the system is becoming and what it really feels like to practice. One disclaimer to start for those who look down on Family Medicine. I did not need to go into family medicine because it was my only option. I am, actually, quite smart. I was competitive in medical school and likely could have gone into a variety of specialties. It was not a fall back, it was a choice based on what I thought at the time was the best path to become trained to be the most well rounded doctor I could be. And indeed, I went to an amazing residency which was ranked the number 4 Family Medicine Residency in the country the year after I graduated. Keep in mind, those of us who do go into it have already made a calculated choice about doing something we are passionate about despite the financial sacrifice. No one initially goes into family medicine and then geriatrics for the money. Job security....maybe, but it certainly is not and never has been about the money.
1) REGULATIONS
- There is a huge variability in the geriatric patient. I have 100 year olds on NO medications and doing great. I have 70 year olds that look 100 and have med lists a mile long (that I am trying to wean). There is no one size fits all approach, as I've already stated. But increasingly the powers that be seem to think that if we just do the same thing and take the same approach for every patient every time, and then click buttons in a computer so they have data to judge the conformity, that we are giving the best quality care because the numbers in the computer say so and that fits well into the "evidence base" to prove it. This is similar to the national trend in education which judges schools and teachers based on standardized tests which in no way whatsoever reflect the true narrative behind the success and sometimes failure of students. It's the same thing with patient care. I actually would argue that the good idea behind the Patient Centered Medical home has been completely corrupted by the regulations and false assumptions regarding the value of Electronic Health Records for all family doctors. However it is most concerning in the geriatric outpatient care. The fact is the regulations are tying funding and already underpaid physician payments to "Meaningful Use" and PCMH status. So the large hospital/insurance organizations that own and subsidize the geriatric practices now tell their physicians what they think is good for their patient’s health. Really this is what looks good for big data. Is it necessarily tailored to the geriatric population?.......Of course not. So now rather than really getting to dig deep with a patient, figure out why there are discrepancies, maybe assess their function and their day to day life to try to optimize their quality of life, geriatricians must divert their attention to the computer, and clicking the pre-designated "important" boxes and if not clicking the desired answer documenting why in a way "data" can extrapolate. And there it is, art of medicine is lost. I will touch more on regulations later, because this is a pervasive problem in both medical training now and in outpatient and inpatient geriatric care. Doctors spend at least 20% of their time in nursing homes signing paperwork for regulations, or having to document extra to justify their clinical judgment based on regulations. This is time again that really does not help the patient, their family or the overall system but does serve to further the ever-increasing numbers of burned out physicians. Our bosses are Directors of Nursing and Administrators who ultimately know nothing of the full story or context behind some of our decisions (time spent with family or asking nursing what would help and what is realistic) but are quick to judge us if we have a patient on a medication that looks bad or in some way question their agenda. We went into medicine to make a difference, to serve, and ultimately are finding that it is impossible in this system to do so despite how smart, kind, compassionate and hard working we may be. Doctors are in many ways powerless. If we try to make change or suggest alternative approaches that would likely be better for
patients and it goes against the grain of whatever top dog is running that facility, we are labeled as trouble makers immediately.
2) Electronic Health Records (EHR)
- This was a good idea, until our Political System ruined it. Truth is, EHR's are theoretically a good idea. In theory we should have the technology to document legibly in a computer and share necessary health data between EHR's smoothly. This is only theoretical however, it is certainly not reality. Due to political reasons, there will never be a Universal Health Record. There are hundreds of companies that have engineers writing code for EHR's that are not physician or medical professional directed that charge an arm and a leg for their EHR's. Then, they lock their code for each institution. For example, EPIC is a big EHR. However EPIC is completely different at different institutions and doesn't talk easily within other EPIC users. So do we think then that varying EHR's will talk to each other? They should, but they don't. So essentially if you don't get ALL of your care within the same system, you are going to have tests re ordered. The system is extremely fragmented and is only becoming more so. Things repeated, notes missed. Your docs won't actually know what has happened elsewhere because the computers don't talk. Nor do your doctors in this screwed up system have the time to call and have to be diverted through a medical records department only to NOT be able to speak directly with your specialists. THE EHR is now just as fragmented as paper records was, and actually more time consuming for providers to document in. If you want good documentation, it takes forever. Either it needs to be typed or dictated into a computer that makes tons of errors so that the editing process takes forever. Oh yeah, transcriptionists are being eliminated. The days of being able to talk into a recorder and have a human transcribe it for you are numbered, or actually gone. The doctors that have figured out the way to do it fast essentially document the bare minimum for data collection and self-protection but do not really put anything meaningful in their notes. Yeah they are legible, but completely useless with what I like to call "chart vomit." So know as a doctor you have 2 choices. 1) Stop caring and just go with the trend and do absolute junk and useless documentation that is efficient and gets you sort of paid. OR 2) Continue to care and spending all of your already limited free time at home in which you are supposed to be giving to your family finishing documentation in an Electronic Medical Record. Both are terrible options. In the first you give up part of your soul, but then in the 2nd you also do too because you give your soul to your patients instead of your family. It is a loose-loose situation. Not to mention the time we spend documenting or fulfilling regulations actually detracts from the time we would otherwise be reading up on patient presentations and developing diagnostic acumen. And in fact, the physician burn out rate, especially for young doctors, is higher than it has ever been. Even worse, the physician suicide rate is far higher than in any profession and the highest it's ever been, ever. I will touch on this further in another section, but the point is the Electronic Health Records have not helped Doctors care more or better for their patients but have indeed significantly increased our burdens and unpaid time feeding the machines and regulatory bodies that monitor them. Of note, I am not bashing technology here, or the Internet. I am telling it like it is for the reality of current use of the Electronic Health Records.
3) Society and American Culture - Yup, I am going to say it. American culture is a problem for geriatrics. Actually, our views in our society on aging and thinking we are immortal are SO harmful for geriatric patients. My glimmer of hope in the past year was Atul Gawande's book "Being Mortal." Dr. Gawande is one of my heroes. But I am not going to be as sensitive or politically correct as Dr. Gawande was in his book. This is the truth. There are a few major trends in medicine and American culture that have caused immense harm to our geriatric patients. The trend in medicine that has gone too far is that of full patient autonomy. I am not saying that the old completely paternalistic model of medicine was necessarily good. Yes, there should be more "shared" decision making. However the pendulum has swung so far to the right (or left, not sure which, it's too far to one side though) on the patient autonomy scale that now very uneducated patient's and their family members are driving the medical care for themselves and loved ones. In geriatrics, many of our patients have dementia and really can't make meaningful decisions. So their children, who happen to be in their 40ies - 60ies, drive their care. And they are terrible at it. Why? Because they didn't go to medical school, they frequently know very little about reality and the human body, and they are too emotionally vested to make sound decisions. And guess what, medicare does not pay me to have conversations with families. Unless I am seeing the actual patient for the time, I do not get paid for the 40 min conversations with family members trying to condense medical school and all my experience into a 40 minute lecture on why we shouldn't be so aggressive in their 90 year old mother. Combine this trend with our highly litigious society and it is a caustic combination. Read the news, an amazing doctor in Boston (and father of 4 children) was shot by a belligerent family member of a patient of his that died. Americans have lost their minds on this and understandably doctors are now just avoiding it. I was called on my cell phone by a family member of a patient who passed away and verbally assaulted (she was dying of end-stage COPD and pulmonary embolisms and knew it and family couldn't accept it). Rather than engage families in these crucial conversations which we do not get paid for and which take away time from seeing other patients, most docs just have given up. When they see a highly discrepant advanced directive or POLST form on a patient based on what they know would be better for their patient's quality of life, they don't call the family to engage or discuss. Rather, they move on. Well, scratch that. I used to always initiate and engage families in the discussion, and frequently I was able to help families make much better decisions. However, this approach was a fast track to burn out. Many families were amazing, but the one's that weren't literally eat your soul. They don't trust doctors, they can't accept that everyone including their parent will die, and they will not listen to truth because it's not want they want to hear. Furthermore they are fed negative media images on a daily basis demonizing doctors. And they're not paying for the overly-invasive and expensive care that they are requesting us perform on their aging loved one, the system is (ie our taxes and our future generations are). I was probably the least productive provider in my practice because of the time I took that was non-reimbursable. Another societal trend is the notion that is fed to all Americans that we are somehow invincible. We seem to think that there is always more to do, more to treat, that we don't die. People for some unclear reason to me are unable to stop doing things to their loved ones. In TV, radio, journalism we are fed this notion that to not intervene, to not send back to the hospital, to not force feed with a stomach tube is in someway a horrendous error and "giving up." But then we cling to the wave of "physician assisted suicide" as if it is the humane thing. Why won't we allow those who are near their natural end of a long life die comfortably and peacefully rather than wasting resources that could be used to better the lives of young children, mothers and families trying to make it today?
4) PHYSICIAN BURN OUT
- This is where Evidence Based Reality is really important. The numbers don't lie. Doctors, and frequently young doctors, are burning out and leaving medicine at higher rates then ever before. This is despite all the new ridiculous regulations on residency work hours and all the stuff jammed down our throats about recognizing when we're burned out and trying to treat it early. I can admit it, I am burned out. But at the same time, the answer is not that I need to reconnect with old friends, meditate, exercise more, work to make balance, rediscover myself. I could do all of those things, but it wouldn't change the reality of the system today or the source of my burn out. I am burned out because I am an extremely talented doctor who passionately cares about my patients and the elderly population in this country as a whole and literally daily I am fighting, truly fighting for them and getting nowhere. I have literally no control. The administrators, insurance agencies, family members, Directors of Nursing, surveyors, etc are all my bosses and none of them actually have a clue about the full stories of my individual patients or their unique clinical context. They did not go to medical school, then 3 years of residency, then a year of fellowship to then only have their opinions and sound clinical judgments either completely ignored or disrespected. Well some of them did, but they have been so far out of clinical practice that they are indeed out of touch with the reality of what it is like to be a clinically practicing doctor in today's culture. I know I am valued by those whose opinions actually matter. My nurses, my patients, even their families, the therapists, the nurse practitioners I work with, everyone who I co-manage patients with tell me how much they appreciate the work I do. They want me to continue to fight for our mutual patients and them because they've seen and experienced what my expertise has to offer. They tell me this frequently. But the powers that be do not appreciate me. That is reality and that is fact. If they did, then they would have recognized years ago how necessary geriatricians were and worked to attract more of us to the field. If they did, they would stop adding more and more regulations that detract from real patient care but take up my time. Or they would pay me (meaningfully) to talk with crazy warring families in order to help my patients. Or they would recognize that the demographics of this country are shifting and we are in a crisis in which not only elderly people, but also everyone who is a bit aged with a mental illness, are all convalescing now in skilled nursing facilities. If the powers that be (yeah I am referring to the heads of hospital systems, insurance companies and all the rich people that run the policy and control America from Washington) valued me they would put in place real malpractice reform so that I could not be sued anytime somebody didn't like the reality of life (that is that we all die and that if we are prevented from dying we get old and frail and frequently develop dementia which places us at all sorts of risks that ultimately can not be prevented - although I am way better than your average doc at preventing a lot of the bad stuff if they'd let me). If they did value me, they would actually listen to some of my suggestions instead of labeling me a "trouble-maker" when I bring important and valuable feedback to the table. If they cared about me, they wouldn't force me to pay loads of money to retake both a family medicine boards AND a geriatrics boards every ten years when ultimately I am only going to practice Geriatrics (note I am actually fine with taking a test every 10 years, but the test should be applicable to my practice – ie Geriatrics). The numbers don't lie. Geriatric fellowships are not matching fellows because no one is going into it. We pay for what we value in this country. And America DOES NOT VALUE primary care doctors, and even more so America does not value Geriatricians. And from there it follows, quite frankly, that America does not value its elderly (I can write an entirely separate manifesto on why we should and must value our elderly).
Now there will be a ton of doctors who read this who are filling those administrative roles now and think, we need to reach out to Dr. Tapia because she is clinically depressed and experiencing burn out. Here's the thing, I am the queen of recognizing BS (it served me quite well as a family medicine resident), and that current approach which prevails is completely that. Until this system changes and my very professional and skilled expertise is valued and I actually have a voice, I will remain "burned out" because I will be grieving the fact that my vocation is dead. My passion, my skill, my sacrifices, all my money (or non money since I am way in debt), my lost fertility, my lost time with my son and family, are ultimately wasted in the current American Medical system and culture. And I grieve because I do still CARE. I care for the patients that I can't help, for the many elderly who I know I could help but won't be able to. I won't stop caring. Telling me to take MORE of my time to exercise and pray/meditate and balance my life (by the way I am part time and currently work for an amazing private practice who really does care about its providers, a rarity these days) only diverts the attention from the real issues in a way to make it seem like I am the problem, like there is something wrong with me. I assure you, there's not. I am quite resilient. But I am also smart and good at recognizing patterns. The pattern that prevails is that geriatricians are a dying breed, and family doctors are burning out young at staggering rates now-a-days. As I mentioned before, the physician suicide rate is higher than it's ever been. No, it is not because we are afraid of hard work, long hours, and lots of it. We knew what we were signing up for when we entered medical school. It is because the system and reality of practice is fundamentally different from what it was even 10 years ago and we are more and more being forced to do things that ultimately do not help our patients but only drain our time, energy and feeling of actually making a difference. Moreover, a lot of the docs who are later in their careers can't fully appreciate the changes because their children are grown and independent. They did not have young kids or an early marriage during the era of never being able to leave your charts at work because the EMR is always with you. They think we just need to balance our lives now but at the same time can't really appreciate what it is like to try to balance ones’ life with a young family and the ever-increasing regulations. Also many of these physicians are men, so they never had to manage the real tole of parenthood because their wife did. I married my husband and had my son in medical school then matched to residency with a husband who was also a resident and a child nowhere near family. I liked residency better than I do practicing as an attending. There is a huge disconnect and the older docs aren't really fighting for the younger ones in practice because they don't realize the discrepancy in what it is like to practice now with a young family and what it was like 10+ years ago.
Many, including myself, have realized that there is no good option anymore. So rather than start the slippery slope of choosing between not caring about patients as much but also not vesting enough time in our personal relationships (young children, early marriage), we are just quitting medicine. We are smart people, we have worked our butts off to get this far because we care. We also know how to calculate risks, and continuing to practice medicine with no meaningful change for the better in the system in sight is a major risk to our own sanity. Doctors in America don't go on strike, we never will. Rather, we stop practicing medicine all together. This is no easy thing to do.
And I think I deleted the rest……I think it was about family stuff and my father in medicine as my original hero (he was also a Geriatrician) not understanding my plight as a newer woman doctor in a system very different from the one he built his career in which both catered to the white male but also allowed for time with patients even in Geriatrics. That time is gone so I think I deleted the rest. So the end for now.
