Profession from cover Osler’s observation, more than a decade ago, about a life in medicine: “To have striven, to have made the effort, to have been true to certain ideals—this alone is worth the struggle.” We hope you enjoy reading these essays about medical education and practice, and we welcome your comments. Thanks to the contributing physicians and medical students for their thoughtful and candid responses to our questions.
Robert Gumnit, MD Founder and Physician, MINCEP Epilepsy Care, Minneapolis Years in practice: 48 Medical degree: 1957 (University of Pennsylvania) What aspects of medical practice have surprised you (in good and/or bad ways)? When I first went into practice, in 1964, physicians were relatively few and there wasn’t that much competition. I was surprised by how physicians sorted themselves out, good doctors wanting to practice with good doctors who challenged them, more laidback doctors just wanting camaraderie. The other thing that surprised me, although it shouldn’t have, was the amount of denial on the part of patients who often waited far too long to seek help. What were the most important factors for you in choosing a medical specialty? I had initially thought I would have a research
career in physiological and learning psychology. After entering medical school, it was logical for me to move into neurology. What was your debt upon graduating? As best I can recall, my debt was in the neighborhood of $4,800. At the time, a minimumwage job paid about $1,900 a year and a good blue-collar job paid about $3,800 a year. My debt was somewhere between one and two years’ total pre-tax income of the average blue-collar worker. How has the culture of medical practice changed since you began practicing? When I started practicing, most physicians were dedicated purely to doing the best they could for their patients and trying to find ways to help them. Most patients had no health insurance and paid out of pocket. An enormous amount of charity care was given without making much of a fuss about it. Here in the Midwest, many of my patients were uncomfortable with receiving charity. Often, quite literally, patients would offer to wash my windows, cut my lawn, bring me eggs, etc., because they didn’t want to be “freeloaders.” Today the culture of patients is different. There is more of a sense of entitlement and patients often expect the best without making an effort to pay for it. From the physician point of view, when I started, if you were able, available, and capable, you had a successful practice. With the advent of billing by CPT codes in 1966, we physicians have been turned into shopkeepers “working” the system to gain appropriate reimbursement for our services. Often I feel like I’m running a checkout counter in a supermarket, keeping track of all of the minutiae, rather than practicing medicine. Federal and insurance company regulation and the electronic medical record make it tougher to delegate than it was in the past. I am unable to work as efficiently as I could previously, nor am I able to provide charity care “up front.” Unnecessary complexity lends itself to waste. On the other hand, Medicare has been a blessing to tens of millions of people. I would never want to go back to 1964. Another striking change has been in the attitude of pharmaceutical companies. When I started, a number of companies attempted to educate physicians, and contact with the physicians occurred as much through the research and educational division as through marketing. Twenty years ago or so, we saw a rapid shift into physicians becoming “marks” and heavily manipulated by the marketing side of the drug companies. In my opinion, it is an ugly scene. What advice would you give to physicians entering medical practice? You are moving into an era in which you will be viewed as just another replaceable technician by a large health care organization. If you want to be seen as an individual and influence what you are doing, you should move to a small town where the health care organization will be smaller and the relationships more personal. No matter where you go, don’t expect to be given any special consideration except when the administrators (hospital, practice, insurers, government) want something from you. Be suspicious when they massage your ego. On the other hand, the satisfaction you will receive when you are alone with the patient in the examining room is enormous. It will make a career in medicine fully worthwhile. What, if anything, would you have done differently in your career? I would not have sacrificed so much of my personal and family life for my career. Most physicians did so when I started. In retrospect, it was a heavy price to pay. I should have struck a better balance. On the other hand, I don’t think I would ever have been satisfied working a standard shift and walking away without a sense of continuing responsibility to my patients. That, to me, is one of the essential parts of being a doctor. The relationship you build with your patient is one of the most satisfying aspects of practicing medicine.
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MINNESOTA PHYSICIAN OCTOBER 2012