Are Physicians Drowning?

Raoul Concepcion, MD

Editor-in-Chief of

Urologists in Cancer Care

Director of Clinical Research Urologic Surgeon Urology Associates, PC Nashville, TN

I have always found the summer to be an interesting time, especially as I walk through the doors of the hospital to make my rounds. It conjures up memories of my first few months as a general surgical intern at Vanderbilt Hospital in 1984, wondering why I was driving with the traffic lights still blinking in Nashville to start rounds at 4:30 in the morning, knowing that I would not return to the comforts of my apartment until sometime the following night. Many of you probably remember putting on the standard hospital-issue attire—white pants and short lab coat, looking as if we had just finished working a shift at the ice cream shop. (And we wonder why many of our colleagues possess peculiar sartorial tastes.)

The routine was the same, irrespective of your location or what teaching hospital you were affiliated with: Make rounds, meet with senior residents to be assigned cases (for which you would then be the primary object of verbal abuse), round again and make sure everything was checked off your scut list, hopefully grab a meal in the bowels of the hospital cafeteria (not a food court with multiple options!), and then start the evening grind of preparing patients for surgery the following day. There was no such entity as early-morning admissions or 23-hour stays. I checked pre-op labs and x-rays, made sure that operative permits were signed (whoever heard of informed consent?), and still managed the 20 or so patients on my service, without the benefit of a nutritional support team, IV therapy, or in-house hospitalist. I believe back then they were called your “friends” on other services. This pattern would repeat itself every other day for the next two years. Who would believe that I voluntarily asked for this schedule?

Many of you would agree, however, that despite this grueling and insane way of life, the learning curve was exponential, and our ability to take care of and manage the acutely ill patient served us well as we became attendings. More important, the friendships forged as a result of those shared efforts will last forever. I personally look back on those times and would not trade the experience for anything.

Times have certainly changed for residents and house officers (can we still call them that?). The Libby Zion law has limited the number of hours that they can spend in patient care on a continued basis. The support at most hospitals is far superior compared with what was previously available. Technology has driven the market to a more minimally invasive/robotics-assisted world. I have had the distinct pleasure, despite being in “private practice,” to work daily with the Vanderbilt Urology residents as a part of their training for the past 22 years. I am not saying that the residency system is better or worse. It is simply different.

Now we are certainly entering into a changing system in the healthcare environment. It is, and certainly will be in the future, different. As you know, the Patient Protection and Affordable Care Act (ACA) has been upheld by the United States Supreme Court. Dr Deepak Kapoor, current president of the Large Urology Group Practice Association (LUGPA), has written a very thoughtful piece in this edition of Urologists in Cancer Care, discussing the potential effects of this legislative action on urology groups in the United States. (View article >>> The Affordable Care Act: An Analysis of Its Impact on Urology Practices).

Many out there do not want to accept the fact that traditional fee-for-service is going away. As with most industries where outcome metrics are crucial for continued success, the government is wanting physicians to deliver care that is outcome- and evidence-based, which will hopefully result in lower costs. Payment will be based on the ability to implement such a system. This will be a very daunting process, to say the least, but one that is clearly critical to long-term success and viability.

The management of the urologic cancer patient may well be a great starting point. As many of you are keenly aware, we are often on point for the early management of these patients. Now, with new therapies being introduced and fast-tracked for approval, we need to begin to develop integrated models within our existing practices that will allow us to continue to direct patient care well past the immediate postoperative period. We need to venture outside of our traditional surgical toolbox in order to survive in this changing environment. Generally, we physicians are resistant to change and prefer the status quo. It won’t be easy for most of us, but it will be worth it. (A bit like trying to change your golf swing: If it seems simple, you probably haven’t really changed anything.)

Because we are in the middle of an election year, and depending on the November result, the battle over the ACA likely will not commence until 2014. Now is the time for us to look forward and be proactive in our efforts to effect change. As my good friend, Sandy Siegel, MD, (of Chesapeake Urology Associates, Baltimore, MD) says, doctors usually do not know they are drowning until the water is up to their chins. The waters are rising rapidly. Let’s put on the life vests now before it’s too late.