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Jul
27
2006

Guest column
Angela Heider, M.D.

I recently retired from the practice of obstetrics and gynecology at the young age of 32 and after only two years in practice. My reasons are, of course, complex, but they boil down to the impossible logistical, financial, and familial implications of practicing medicine within the confines of the current system. Alarmingly, four of my young female partners have also elected to hang up their stethoscopes – a growing trend. If we are to reverse this trend, we need to reform our health care system.

Some health policy experts believe comprehensive reform is impossible in the absence of a national disaster. I believe we can make a difference but a really important first step is to make insured people understand the necessity of such an endeavor.

True enough, there are millions of uninsured and underinsured Americans who are clearly suffering under our current system. However, there are many more happily insured Americans who are completely unaware of the horrific state of a system they trust whole-heartedly. The fact is, even wealthy Americans are impacted by the looming health care crisis. They just don’t know it yet.

For example, a physician who is cramming obstetrical visits into five-minute time slots in order to make a living, who is struggling to keep up with rising overhead costs and declining reimbursements, who spends way to many hours away from her children, who is faced with bureaucratic red tape at every turn, and who is now behind schedule because she had to play catch-up on patients who have not come in for prenatal care (because they can’t afford to), just may not provide the quality of care we have come to expect. An obstetrician might be trying to squeeze in a few extra cases while on-call, in order to keep up with declining revenues. She won’t then be readily available in case of an emergency, will she? For that matter, the obstetrician might not be the best or the brightest in the first place. Smart young people are not likely to continue to make career choices that will impact the lives of their families negatively.

If insured people understand how the health care crisis might impact their lives, people may be more outspoken about reform. They will fight for their lives, and if it helps a few other people along the way, then great.  In other words, the message needs more mass appeal. Once a majority of Americans are on board, together we can formulate a national health care plan to be placed before Congress. We should all begin to educate our friends and families, to let them know how health care reform will impact them. I hope to do that on a national level. I want people to know how defensive medicine, rising overhead, antiquated physician training, and medical mistakes impact health.

People react to my decision to retire uniformly.  “What a wonderful decision for your family,” they say, followed by, “but what a waste of skill and education.”  They then get an earful about health care reform and my hopes for the future.  It doesn’t seem like such a waste to me.  In fact, I am rather enjoying myself.

Author Bio

Angela Lowe Heider, MD is a retired obstetrician and gynecologist.  She trained at The University of North Carolina at Chapel Hill.  She is the author of “The Rise and Fall of Dr. Mom: Women, the Health Care Crisis, and the Future,” available through www.authorhouse.com or any major retail outlet.

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Join the dialogue here

Aug 2, 2006 12:02:33 PM
sweet lou says

I guess the key is HOW do we get insured people to “understand how the health care crisis might impact their lives?” People are willfully blind when it comes to these big issues, at least if not impacted directly. And by the time the issues reveal themselves more intimately, most folks find themselves overwhelmed, struggling to survive, and - more than likely - disenfranchised. To the author, while I understand your decision-making process, I question how effective you can now be as an advocate for change outside the system. Without your previous vantage point, your views are just one of the millions of disparate voices sounding out dissatisfaction with some aspect of modern life.

The article glosses over what seems to be the most important step: giving the message "mass appeal." That’s the actual challenge. Elected officials will respond, though perhaps slowly, to popular movements. The question is not what changes will we make in the system (also important but able to be figured out by those in the field who are smarter than I in these matters) but how can we make our voices heard? How can draw attention to the issue? Where are the protests, the sit-ins, the marches? If the problem is really as bad as it seems, dropping out of the system to complain to your friends might make YOU feel better, but it does nothing to promote change...

Aug 2, 2006 6:39:07 PM
Angela Heider says

Sweet Lou is correct. Complaining to my friends would not likely result in change. That is why I have chosen instead to write a book - one that I believe can help create change - and why I am working to get needed information to the public.

As opposed to being willfully blind, I would say that middle and upper class women are blissfully unaware of any problems with the health care system. To make them aware, we have to bring the message to them - either through a book they may enjoy or through media outlets that can attract their attention. These women are not evil; they are just busy.

Once these women are informed, we can move on to action. A nationwide group of women unified around health care reform may just be the only group of people with the power to demand action. I think insiders are actually at a disadvantage. If physicians call for reform, it is too easy for those opposed to said reform to accuse the physicians of encouraging change for personal gains such as higher incomes. Since I am no longer practicing medicine, I can also speak more frankly. It is the honesty with which I am able to write that makes my story compelling.

Once we have an educated public, we can organize a national health care summit, one that has the support of women nationwide (and men, of course). Hopefully, we will come away with a plan backed by the public, a plan that can then be presented to Congress. Of course, many health policy experts do not generally believe that we can all agree on any single plan. If they are correct, change will be painfully slow. I think if we can get a little help from the media, comprehensive change can be a reality.

Oct 10, 2006 5:42:43 PM
James Orran says

I think the author brings up two disparate, but related issues.

I am a physician, so I have some perspective.

The author is absolutely right about the fact that payment to physicians. The fact that "visits" get reimbursed so poorly, that providers who base their incomes on outpatient visits are getting killed. The only solution is to see more patients. I personally know OBGYN's who see 75-80 patients a day, and get paid quite a good deal of money-- but can't possibly deliver any kind of comprehensive problem analysis, and certainly can't present a decent bedside manor while seeing these patients. I know of others who are seeing about 35 patients a day, and not quite making a decent salary-- being called away, doing multiple deliveries, and essentially being "killed" for not so much salary.

The reason is simple: insurance plans make money by rationing/denying/delaying care, by reducing payments to providers/hospitals, and by leaving glaring holes in a patient's "coverage" for health.

The fact is that private medicine, of all types, is being destroyed, and is being replaced by monster organizations that employ phsyicians (Kaiser, IPA's, County Hospitals, Universities, etc.). These organizations are either endowed or have actual bargaining power with the mega-corporations (Blue Shield, Aetna, etc.).

Many people are going through a University training program, where instructors give the student/resident absolutely no instruction whatsoever, in business operations, or the vicious insurance environment that a business needs to survive in.

Many of these people, like the author, have become disgusted after trying to live like an animal, with brutal call schedules, stress from patient care, and HR/operations nightmares for a couple of years, and then leave the field.

This is in line with what the author describes. The gender issue she brings up is another matter.

The author states the truth: we live in a society where females serve a disproportionate burden of child rearing. This remains, despite "liberation". Women are now expected to have a career and a family, and yet fill the (used to be) full-time position of mother.

My point is that this is extremely difficult in medicine.

I think that males cannot, within our current social structure, honorably be "Mr. Mom" and sacrifice career. Too much stigma. That leaves a full time nanny. This is expensive-- currently, you would need a full-time nanny and that costs at least 40-60k/year in total expenditures. That means you have to generate 80-120k/yr in income to make up that gap. That leaves you generating roughly 60k/year in take home income (tax bracket). Average pay is between 170,000-220,000/year.

Most people don't want to work 60hrs a week, delivering babies at random, never knowing what time you come home, covering ER admissions, and taking fixed night call, and running a small business with multiple employees for 5000.00 a month.

This doesn't take into account that the author didn't have a real job until age 30-- The author is also probably about 200,000 in debt from undergrad/medical school. Residency pays less than about any other job, and that was only 4 years out of the 12 required to be educated. She'd be able to work that off in about 8-10 years, with average beginning-career salaries.

Men are less pressed by family issues than women will-- it is "okay" by today's society to have a woman fulfill a disproportionate burden of responsiblity and suffer no status loss in the eyes of society.

The ironic thing is that 90% of the positions in OBGYN residencies are occupied by women-- go figure. I think we will find that women with no interest in childbearing will be selected for, while those wanting to have a family will leave the field.

Oct 25, 2006 10:25:15 AM
Angela Heider says

Dr. Orran acknowledges the fact that physicians now training in obstetrics and gynecology are much more likely to be women than men – which some might say is unfortunate since the field is not terribly accommodating for young families. Women attempting to foster careers and be primary caregivers become frustrated and leave the profession.

Actually, the financial implications are even greater than Dr. Orran calculates. Lower insurance company reimbursements for outpatient care disproportionately affect those who are attempting to practice on a part-time basis (and by part-time I mean about 40 hours a week). Usually those people are mothers, but they could also be fathers. When a private practice physician moves from fulltime to part-time work, her overhead costs remain essentially stable. For instance, her malpractice insurance premium remains the same. Revenues generated, of course, decline. This results in a large reduction in salary. I went from earning the $120,000 Dr. Orran mentions to earning $70,000. After the $35,000 in childcare (I still needed a fulltime nanny as I was still working nearly 40 hours a week including nights and weekends) and taxes, I had little to show for my efforts.

I think this is a problem with a solution, though. We could allow for multiple tracks within specialties. Physicians could then train to occupy a smaller niche. For instance, I could have specialized in obstetrics only, not gynecology. I could then have worked as a laborist (an obstetrician who works like an er physician covering shifts at the hospital) or as an office obstetrician caring for ob patients (say in a health department setting). I could do either of these say one day a week. I could then keep up my skills, contribute to society, and enjoy working outside the home. The narrow scope of my “field” would allow me to keep up with new developments. Retraining should then be available for women (or men) who want to rejoin the fulltime workforce and expand their focus. Given such a paradigm, I (and many other women) would gladly continue to work for fair hourly wages and without benefits. Of course, malpractice costs currently prohibit me and others like me form so much as volunteering in my local free clinic.

We could learn a good deal from the field of nursing. They already have many options in place for women who need all sorts of different job manifestations to match different demands from their family lives.

WE WANT TO AND WOULD CONTRIBUTE. JUST LET US DO IT WHILE CARING FOR OUR FAMILIES AND WITHOUT RISK OF FINANCIALLY UNDOING THEM.

I think women in all walks of life want the same.

Doesn’t this sound better than just concluding that women with familial aspirations should not be obstetricians??

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