I finished my orthopedic residency in 1993 and moved to Indiana ready to take the world by storm. I loved orthopedics and quickly built up a large, lucrative practice centered on well insured patients. I worked most evenings and many weekends, and I never turned away a case. I was very conscious of the money that I was making and my importance in the local medical community. My life continued in this way for several years until I was shocked by the death of my friend and neighbor, Jon Barwise, from colon cancer. Within a year of his diagnosis, this seemingly health and esteemed professor was gone. The speed of his demise disturbed me, and I started to make changes in my life. I began by spending more time with my family, and I reassessed my practice. I realized that while I loved my patients and my work, money had become a very significant motivation for me and had, in fact, become far too important in my calculations of life's decisions. So, I moved my practice to a rural part of the state where costs were much lower, and I could open my practice more widely to both insured and uninsured individuals. I ran a bare bones office with no ancillary services or equipment--nothing that would pressure me to cater to more affluent patients or entice me to see more patients than I could easily take care of.
Then, shortly before my 43rd birthday, I was diagnosed with non-Hodgkin's Lymphoma, myself. Instantly, I moved full circle from confident physician to scared and troubled patient as I slouched through 6 cycles of R-CHOP. Despite this appropriate chemotherapy, the cancer recurred, and I was forced to undergo a bone marrow transplant, and, 3 years later, a stem cell transplant using my brother as my stem cell donor. Through all of this, I've had quite the opportunity to see medicine from the other side of the knife and stethoscope, and I realized that my preliminary efforts to open my practice were not nearly aggressive enough. The medical providers whom I've encountered have ranged from the very kind and sensitive to the rushed and even callous. Procedures have been mild or exceedingly unpleasant; treatments have sometimes yielded great benefit or not been very successful. I've been told that I was terminally ill and been given the opinion that my disease was eminently curable within weeks of each other. The only constant in all of this has been the enormous expense. No discounts were ever offered for non-diagnostic tests or failed procedures. The bills would roll in every day. Thankfullly, I am one of the lucky ones, an affluent professional with good health insurance, but many are not so fortunate.
From this experience, I realized the horrific burden that health problems pose for those Americans living on limited means or without health insurance. I decided to start doing everything that I could to help them. I believe that all doctors possess a tremendous desire to help other people, and we must, as a profession, keep access to our services as accessible and affordable as possible. Despite greatly reduced income, I have never had more fun as an orthopedist than I have had since my own illness, and I think we would all be well served by focusing more on the non-financial rewards and joy of our service to others than on attempting to hold lightning in a bottle in an effort to maintain incomes and fight inevitable reimbursement cuts.
I love orthopedics, and it has given me a great life. I enjoyed my practice of general orthopedics with an emphasis on athletic injuries in Spokane, Washington. During the latter stages of my practice, I began to teach our local Family Medicine residents as a volunteer. I found the work very rewarding. I began by giving lectures on orthopedic topics relevant to Family Medicine and then became a preceptor in their musculoskeletal clinics. As my professional interests evolved, I decided to retire from my orthopedic practice to develop a new career teaching orthopedics.
At this point, I worked for six months at the NYU Orthopedic Residency Program at Bellevue Hospital in New York as a volunteer. However, I really felt that I could be more effective and make a greater difference by working with Family Medicine residents. A light bulb went off in my heal, and I decided to teach Family Medicine residents around the country, not just in Spokane. We all know the huge number of patients with orthopedic problem that they see, and I wanted to do my part to improve their training in musculoskeletal evaluation and treatment. I contacted all of the Family Medicine residencies in New York City and was able to convince a couple of them to let me work with their residents on a trial basis. After that, it was easy. The residency directors loved having an orthopedist available who cares about teaching the basics of our specialty to their residents, and the residents really seem to appreciate a teacher who wants nothing more than to teach them orthopedics and make them better doctors. Now, in addition to teaching at the Spokane Family Medicine program and occasional other programs in the west, I spend six weeks every fall in New York teaching and precepting at four residency programs. I have joined the Society of Teachers of Family Medicine where I receive many curious looks and questions. STFM, however, has provided me with many good learning and networking opportunities.
In addition to actual teaching, I have three related professional interests. First, I am working to increase and improve the musculoskeletal training given to FM residents. This is a difficult project due to bureacracy within residency programs, ACGME requirements and competition for the residents' time. Another goal of mine is to interest other orthopedists in using their skills and knowledge to teach Family Medicine residents. Most of us retire at the height of our powers and have a great deal to offer. Once one begins teaching as a volunteer, one discovers how fulfilling it is to work with the residents, and he or she would become hooked like I am. I would love to talk to anyone who is interested. My third interest is health care reform. Of course, I believe that support of primary care is essential. To me, this means boosting the numbers and pay of Family Medicine specialists so we can get control of the current expensive, specialty driven system.
What's in a Name
A Vignette by Tom Boniface
If you looked up the word stoic in the dictionary, you might find a picture of Grace. She had endured more than her share of suffering—losing a child to suicide, being diagnosed and treated for rheumatoid arthritis, fracturing her other femur a year ago (despite proper anti-resorptive therapy), and now burying her husband after witnessing his two week cardiac demise, on the very morning of the day she missed her fateful step. Having known her for years, I had regretted that I did not go to calling hours for her husband due to work obligations. I thought I would express my condolences the next week, knowing she was to see me then to remove the cast from her right wrist, now 6 weeks out from her Colles’ fracture.
“I’ll be right in – when did she last eat?” was my reply to the emergency room PA. I expected Grace would be impatient with this injury, wanting to put it behind her so she could get back in the game and finish handling her husband’s affairs. I had spoken with the OR desk a little earlier, lining up the details of a case scheduled for the next day, and I knew they were slow that night. The nurse on the phone had even asked if I had something they could do that night as they were bored.
The whole family was with Grace in the ER, as those from out-of-town were still here after the funeral. They looked spent; the only emotion they had left was one of hope, that someone might help them clear this latest, unexpected, and undeserved hurdle. Grace was her usual self: “sure it hurts”, “glad to see you Dr. Tom”, “how’s your family”, “just like the other side?”, “can you fix it tonight?” Her internist knew Grace very well and had no objection. The OR was willing and able, and it would save her perhaps a day or two in the hospital – most importantly, she knew what was involved, and this was what she wanted to do.
The procedure was technically ordinary, but one I’ll never forget. Thanks to symmetry, we knew the implant dimensions and specs before induction, referring to last year’s Op Note. Grace’s general health and medium stature presented no challenges, and the marvels of modern technology and engineering allowed us to perform the procedure through two small punctures yet achieve anatomic, secure fixation which would speed recovery to normal function. These objective details were taken for granted, and they will be forgotten over time.
With our minds free from the mundane decisions about technique, the resident, staff, and I were able instead to reflect upon what it was we were really doing there that night. Discussions revolved about the recent events of Grace’s life, the impact that suffering has at some point in every life, and especially, what possesses any of us to put one’s individual needs aside, in the interest of those who need our help. This particular discussion was especially significant, as the resident I was working with had himself recently been diagnosed with leukemia and was working a full schedule despite his own therapies and their toxic side effects.
Believing it might help him to understand his circumstance as both physician and patient, I had previously given him a copy of Arthur Frank’s The Renewal of Generosity which reasons that contemporary medicine can and should be founded on the basis of relationships, true dialogue, and generosity toward others, and toward oneself. I personally found the book profound, as I sense that many of us feel so compelled by the current business of “providing health care” that we can forget the essence of why we chose this profession in the first place – to serve the needs of others. I was pleased (but not surprised) that he too found meaning in its pages, and that its ideas were most pertinent to understanding our own place in helping others, regardless of circumstance. In short, as a student, teacher, and physician, that night was an opportunity to understand and learn the difference between the mere laborer, or even craftsman, and instead behave as the artisan that this young man was clearly becoming.
Grace’s recovery has been uneventful, and throughout she has been her usual self – humble and appreciative of everyone’s efforts on her behalf. My only concern is perhaps a disappointment that our system of health care can allow us to get lost in the detail of protocols, technology, objective measures of cost, and arbitrary definitions of outcome. We are increasingly being asked to substitute statistical evidence for the more universal constant of one person putting the other’s needs ahead of their own. My comfort though will come from people like Grace who do cherish our relationships and who teach us about ourselves. It will also come from the knowledge that there are, and will be after I am gone, people like my resident, my fellow physician, who will rightly see patients as people rather than procedures.
Tom Grogan, MD
After finishing at UCLA, I pictured myself as always being an academician. After my fellowships I came back to Los Angeles to be on the faculty at UCLA with my position as the assistant chief of staff at Shriner’s Hospital Los Angeles. After enjoying several years of working at Shriner’s doing thousands of operative cases, I realized that what I truly loved about medicine was not the surgery, but the interaction with patients and the thrill of having a positive impact on my patient’s lives. I truly loved to be able to help guide a patient through the pain and disruption an injury or illness could cause to watch them overcome the obstacles and feel better. In short, I craved the thrill of improving patient’s lives.
I also began to appreciate what patients needed and wanted in their doctor. First they want access. They want to be able to pick up the phone and talk to someone who cares about their problem. They do not want to talk to a phone answering tree. My receptionist is my first contact with a huge majority of patients. She is a single mom, who happens to also be an ex-model and airline flight attendant. She understands customer service and is very easy for the parents to relate to and trust. I have found patients want someone who is knowledgeable, thoughtful, and respectful of them as individuals. Above all, they want to learn about themselves, why did this injury happen – how can we prevent it in the future. Patients are sponges when it comes to medical information that they consider relevant. Instead of dictating or lecturing to them about what they should or should not do, I find myself acting as a life “coach” teaching and explaining issues on a level they understand.
This was not how I was trained. Our program at UCLA was about the Attending balancing research, patient care, and teaching residents. Our attendings typically saw patients in clinic one day a week and operated one day a week. They never fielded phone calls from patients or spent time explaining options. Their goal was to run the service as the captain and delegate to junior attendings and residents the patient care responsibilities.
I evolved into my current solo practice over many years spent finally understanding that my greatest asset to my practice was my patients, as opposed to me being theirs. I shaped my practice to be available, able, and affordable to my patients. I realize that they come into my practice to see me, not a PA or cast tech. I listen to them, learn from them, and hopefully improve their lives. I understand that the highest form of praise is for them to refer family and friends to me. I came to see third party payers (including Medicare and Medicaid) as an impediment to my caring for my patients so I dropped off all plans over 5 years ago. At first, there was a drop in the rate of new patients in the practice, but now I am seeing more than ever. Patients find a way to see me – lots are on payment plans over time. If a patient can not afford to pay, I give them services for free. In fact I give away on average 15% of my time for free. Yet these patients are some of my greatest referrers – if a child goes down on a soccer field my mane flies out. My collection rate is close to 96%. I take care of my patients and they take care of me.
Over the years I have finally learned that patients are not just what I need to generate cases for my practice, my patients are my practice. I wouldn’t have it any other way.
Joel Weddington, MD
Our freshman year of medical school included a quick course on National Health Insurance. What a great idea! I couldn’t understand why the U.S. was the only developed nation without it, but I soon learned that orthopedists made big bucks. Great - I could do what I loved, and make a nice living.
By the time I finished a residency at Cook County Hospital, I had a sense of entitlement for the good life that was sure to come. But the steady flow of Chicago’s severely injured gave me a new calling: getting patients with mangled limbs back into action. Setting out for an academic career, I published papers, presented at the AAOS meeting, and in 1988 entered a fellowship at San Francisco General Hospital. However, my academic career was to be short-lived.
“The General” had a reputation as a busy trauma center. A fraction the size of Cook County, the orthopedic department had twice as many attendings, and I was low on the list for surgical cases. Job offers came from local orthopedists, and I left the world of academia behind.
Private practice in San Francisco offered few cases. I was advised to be patient and wait my turn, but soon a request came to work at an east bay trauma center. Enthusiastic and longing to get back in the OR, I joined 3 hospital staffs and signed up for 20 call nights a month. There I was, in the middle of a major case at one hospital, with an injured patient waiting at another. My reward was a BMW and a big house on a hill, but I had no life outside the hospital walls. A nurse would bring a cake to the OR on my birthday: I no longer made it to the gym and would stress eat half the cake; I gained 60 pounds.
Perhaps I would have lasted if I knew how to say “no” to the crazy call schedule, but I was driven to give my all for everyone. At three AM one morning, while nailing a difficult tibia fracture, the life drained out of me. We surgeons are trained so well that we can operate on autopilot, and that’s what I did. I knew that was my last surgery, and entering a depression confirmed it. Regaining health, I joined a medical group. I had done enough surgery for one career and became busy as a non-surgical orthopedist. Focusing on rehabilitation and pain management, I found I could keep a surprising number of patients out of the operating room.
The evening news would announce that America’s health was declining, yet my colleagues were cherry-picking patients with the best insurance. A chance meeting with a healthcare consultant convinced me I needed to contribute, and I’m now on a one year sabbatical working full-time as a proponent for healthcare reform. I’m an active member of Physicians for a National Health Program, supporting single-payer insurance, and I’ve joined Doctors for America, whose mission is to protect Medicare and prevent the dismantling of PPACA. I have a deep interest in networking to use cognitive science to reframe our message to better reach the voting population. Obtaining access to healthcare for all is a multi-level project; the more one digs, the deeper it gets.
It was very rewarding to be invited to join the Society for Patient Centered Orthopedics. It takes courage to look beyond the immediate rewards of our specialty, and pave the way for physicians to take part in solving the healthcare crisis. Healthcare reform will move forward with or without us, but it is widely held that it is better with physician leadership. The health of our country depends on it.
Being a physician is the greatest honor in the world. Our patients give us a “gift”. They share their lives with us and put their trust in us to heal them. Francis Weld Peabody, a Harvard professor of medicine, stated it best when he wrote, “The secret in the care of the patient is in caring for the patient” (~1923). Unfortunately, the complex nature of the American health care system and the present models of specialty care in medicine and orthopaedic surgery often prevent us from caring and healing our patients. As orthopaedic surgeons, we see patients most frequently for episodic conditions, never develop relationships and tend to focus on the musculoskeletal complaint instead of the individual seeking help. Our intentions are pure and we strive to care for our patients, but at times we also may become victims of a hammer seeing everything as a nail. We completely loose our focus of caring for an individual and the imperative of patient centered care. Patient centered care is the embodiment of everything we all aspire to as physicians, healing our patients. Patient centered care readily incorporates the four principles of bioethics, shared decision-making and informed consent and also allows us to meet our fiduciary responsibilities that are the foundation of professionalism.
I am a fellowship trained orthopaedic trauma surgeon. I spent the first 18 years of my professional career as a fracture specialist and the rewards of being part of a team that is able to restore function of individuals with multiple injuries and severe extremity fractures is immeasurable. I have worked as the head of the division of orthopaedic trauma at SUNY at Stony Brook for nine years and subsequently in both solo practice and group practice in a community hospital setting. Over the past ten years I have been the vice-chairman of orthopaedic surgery at Montefiore Medical Center. MMC is not a trauma center and my practice transitioned from being a fracture specialist to a general orthopaedic surgeon. Recently, due to the nature of our subspecialty practice and the limited volume of operative cases for a generalist, I felt it was ethically necessary to discontinue my operative practice. Although I miss the rewards and challenges of operative care, I haven’t lost the love of being a physician and an orthopaedic surgeon. I receive tremendous professional fulfillment in my ambulatory practice, caring for a very challenging, multicultural population in the Bronx. Having a patient thank me after an outpatient encounter and tell me that it was worth the wait is as rewarding to me, as a successful repair of a challenging fracture. Guiding a patient through their postoperative recovery and the psychosocial challenges that many patients face after injury is as important for recovery as a successful operation.
My decision to end my operative practice has afforded me the opportunity to spend more time studying and teaching the issues that I have been passionate about for my entire professional career: bioethics and the Golden rule. My entire professional career, including time in private practice and as a full time faculty member, has included an ongoing involvement in teaching bioethics to medical students. Our classes also focus on an understanding of the bio-psychosocial aspects of patient care, and the economic and system challenges faced by our patients. I have been a small group facilitator for both second and third year medical students; discussing and learning the importance of these issues in the successful care of our patients. My activities outside of my medical practice are all related to improving my own professional encounters with my patients as well teaching medical students, residents and my medical colleagues a variety of principals, philosophies and strategies to improve patient care and outcomes. I am presently enrolled in a certificate program in bioethics at the Benjamin Cardozo School of Law of Yeshiva University. I am an AAOS communication skills mentor and Team STEPPS trainer. I have been a member of the AAOS committee on ethics and will be assuming the chair of the committee at our next academy meeting.
My family has also experienced orthopaedic trauma. My 19-year-old daughter, Emily and I have recounted in JBJS Orthopaedic Forum, the narrative of her multiple trauma and subsequent, frightening and harrowing three-month hospitalization, (J Bone Joint Surg, Am. 2008; 90: 2026-2036). We were surely not the first health care providers to describe their health care experiences, nor will we be the last. Physicians often don’t recognize what their patients are experiencing until they experience health care for themselves. Emily’s life was saved through the rapid care in a trauma center and her musculoskeletal and soft tissue injuries were successfully treated. Our goal in the publication was not to be critical, but to debrief the events and offer suggestions of what we can do better. My daughter is an amazing woman; her personality clearly contributed to a successful recovery, but undoubtedly I was able to fill in the missing support and guidance about therapy, self directed rehabilitation, pain control and answering questions related to her anxiety and fear for the future. This is not a critique on any individual provider, but an obvious observation on the failures of medical education and our health care system. These are the issues that often make the difference in achieving a successful recovery and that are addressed when we remember that all of our patients are individuals who experience the normal gamut of human emotions. Patient centered care recognizes the individuality of all of our patients and the equal importance of treating the disease (musculoskeletal pathology) and the illness (individual psychosocial needs of the patient and their family). WE can only heal our patients when we successfully treat the disease and illness. It is truly an honor for me to be able to work with this organization to publicize and teach the moral imperative of caring for our patients and their families as unique individuals. Patient centered care guides us in our mission to be successful physicians. Not only does it improve outcomes, it also improves professional satisfaction.