ACP Internist Blog


Monday, December 9, 2019

The illusion of employment job security

It's something we are taught from when we are very young and is a core middle class belief: work hard, get a qualification, and then you'll be able to find a good employer who will send you a nice pay check every month. On some levels, this seems like an attractive option. Yet on so many others, it falls apart. For physicians in the United States, the concept of “employment” is relatively new, because prior to the corporate takeover of health care over the last 20 years, nearly all physicians were self-employed—so essentially working for themselves.

I was recently having a discussion with a colleague about physicians breaking away from full-time medicine and working in a more flexible way. As many readers of my blog know, I took the decision after a few years of working as a full-time employee that there was no way I could carry on like that in the current health care environment. I took the decision to independently contract with facilities on a regular basis, doing a mix of inpatient and outpatient work—but on my own terms. This allowed me to (i) not burn out, (ii) avoid getting dragged into excessive administration and bureaucracy, and (iii) spread my skills and avoid monotony. Dare I say, earn more and work less too (which any professional, not just a physician, can do—you just have to be savvy).

I love clinical medicine, serving my patients, and have no intentions of ever leaving the front lines. I've never been happier and moreover have ample time for other creative non-clinical ventures too. The arguments I've heard against working in this way are most often along the lines of: “I need job security”. I hate to break it to anyone, doctor or not, but there is no job security as an employee. You will always be beholden to your employer and the nature of your job could change on a whim.

Been loyal and dedicated for 10, 20, 30 years? Well guess what, no matter what your position, your organization would fire you in a second if they ever needed to. It's a total illusion to think that an employer gives you security. That may be what your corporation wants you to think, to get you hooked on them and completely dependent. Yes, that will suit them well. But think about this: look at any of the top executives. Most of them are on a merry-go-round of promotion after promotion, company after company. That CEO who completely reorganized things, trimmed down departments in the name of “efficiency”, and gave a speech about how proud of the place he or she was—is gone after a few months. Nowhere to be seen. If they get it, so should you.

What you should believe gives you security, however, is this: Your own skills in whatever you do. Keep working on them, be as good as you can possibly be, and make yourself indispensable. An asset to anywhere that hires you. Know that if you ever needed to, you could walk away in a minute and be totally okay. If you are in a market where demand far exceeds supply, you'll be just fine. And even if you are in a market where demand doesn't exceed supply, and you've made yourself far from average, you'll be just fine too. That's where your security lies.

Ironically if you have this attitude in your career, your employer will also respect you more too. Health care or not, the era of our parents and grandparents joining an organization and staying there throughout their 40-year career, is long gone. Millennials realize it, hop from job to job, frequently freelance, and are on an upward curve always seeking the best possible deal. And that's how it should be. If you work in health care, whether you're a doctor, nurse, or any other frontline professional, focus relentlessly on your own skills and be secure in the knowledge that they will always be needed.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.
Thursday, December 5, 2019

What health is for

All too readily in my world, health can masquerade as a moral imperative—the admonishment attached to a wagging finger and reproaching scowl. While there may be responsibilities wound up with health, for ourselves and one another, the main reason to pursue it is far more enticing. Other things being equal, healthy people have more fun. Health is for pleasure. This is perhaps especially noteworthy as the holiday season, with its inevitable blend of temptation, indulgence, and guilt closes in on us.

Health is for pleasure. The only real problem with that otherwise quite valid assertion is the potential for profligacy and excess. All pleasure must respect the limits of propriety and autonomy. So, for instance, perhaps it pleases me to swing a stick. My right to do so ends where your nose begins. All respectable pleasure honors such boundaries.

Perhaps, then, we might apply a related term, less prone to slippage on a slope toward decadence: quality of life. Health is for maximizing the quality of life.

This term offers many advantages, while preserving the main theorem. The quality of your life is informed by many factors, including pleasure, but perhaps others even more importantly: fulfillment, gratification, satisfaction, pride. These all borrow from pleasure and contribute to it as well, but are all distinct. Quality of life also passes the filter of medical legitimacy, having evolved into a term of that trade and a valid measure of outcome. More often than not, quality and time are commingled into “quality adjusted life years.” My routine user-friendly reworking of this is: years in life, and life in years; vitality conjoined to longevity. Health fosters both, by these or any other words.

This is more important than it seems, and directly relevant as you look for some balance between doing what you want to do, and doing what you think you should do. Should you eat, or resist, that dessert? Have, or decline, that mulled wine? Take, or decline, that hors d’oeuvre making the rounds?

When health is relegated to the abrasive realm of moral imperatives, these and many other holiday temptations (and, for that matter, temptations year round) are choices between what's right, and what's fun. But if within reason, maximizing “fun” is what doing what's right is for, it changes the equation.

More and more evidence favors the powerful, health-promoting effects of fairly modest, but consistent commitments. The evidence that sitting is harmful points toward a simple, potent, and for most of us quite easy remedy: stand, stretch, and walk around briefly throughout your standard day.

Recent evidence shows that running in even very modest doses is a potent defense against premature death. Don't despair if disinclined to run. Evidence suggests that just walking, exercise readily accessible to most of us, confers powerful health benefits.

As for eating, the weight of evidence, regarding weight, and every other outcome of importance, is comparably encouraging. Despite an obscuring fog of boisterous bickering, there is no one diet you must adopt to profit your well-being. There are many variants, albeit on a common theme, that empower us all to love the foods that love us back. Shop your options with that goal in mind.

There is no magical combination of foods you must maintain to maintain your weight; the latest and best evidence on that topic indicates, clearly and emphatically, that calories count above all. Don't count them, that's very tedious, but acknowledge their imperium by doing what you can to favor wholesome and simple foods, free of willful manipulation, while avoiding ultra-processed foods. Among the many virtues of the former, they fill us up on many fewer calories than the latter.

While the pop culture narrative about intermittent fasting is, inevitably, hyperbolic, implying some metabolic magic the research fails to reveal, there is a happy take-away from this tale nonetheless. Fasting periodically works as well for weight control as daily restraint, and thus provides an alternative tactic. The tactics that work best for you are … those that work best for you. So, options are a very good thing.

Blended, these and related tidbits of evidence and ingredients of argument come together in a rather lovely recipe. Almost all exercise is good exercise, and you will support your health just by making some movement part of your routine. The more the better for health, generally, but maybe not for net pleasure and quality of life. Some of us love exercise (I do), but some don't. Across the spectrum from love it to hate it, the optimal dose, intensity, and frequency that lead to the greatest net pleasure and quality of life vary. Only you can choose your sweet spot. You're the boss.

So, too, for food. An inveterate foodie is perhaps apt to be happier, truly happier, with culinary latitude and a somewhat larger waist to show for it. Conversely, a health and fitness fanatic would almost certainly favor more dietary asceticism in the service of stronger, faster, fitter, leaner. If the formula that maximizes quality of life varies with our dispositions and character, it is no health professional's place to impose a one-size-fits-all decree.

My whole career is about optimizing health, so of course I think it is important. But I recognize that health, per se, is not the prize. The prize is having the best possible life, and health matters so much because of the contributions it makes to that measure. But the pursuit of health can at times compete with other sources of pleasure, fulfillment, and fun, and at those times, there is a balance to be struck.

The holidays are, quintessentially, such a time. My advice is guilt-free holiday pleasure and a year-round commitment to health by the means that work best for you as one among your priorities. Not because someone says you should. Just because, other things being equal, healthy people really do have more fun.

David L. Katz, MD, FACP, MPH is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his Linked In page.
Monday, December 2, 2019

Physicians should love patients and families using Google

It's difficult to imagine a world now without Google and the internet. It's also strange to think that most people alive right now received the bulk of their education in the pre-Internet era. I remember in the United Kingdom, where I went to medical school, Google only became a thing perhaps midway through university. Since then of course, the internet has exploded and penetrated every facet of our lives. And while we all know the many drawbacks of our current addiction to the online world, it's difficult for anyone to say that it hasn't been a net positive to society.

One of the most important ways we are now using the internet is to make informed health choices and read up around our illnesses. Unfortunately this hasn't always been met with enthusiasm by all members of the medical profession. A very popular online meme that's been circulated for years by frustrated doctors has been: ”Don't confuse your Google search with my medical degree.” I've heard that said countless times, albeit by a minority of physicians, and it's always disappointed me. I actually love the fact that patients and families can be well informed and read up around their condition. For goodness sake it's their or their loved one's life we are talking about. They should be totally clued in and always asking questions (despite being a doctor myself, I want to say to some of my colleagues: What the hell are you talking about, not wanting your patients to read up about the diagnosis afflicting their bodies!). I cannot imagine going back to a world where the doctor's opinion was absolute, and there was little option for otherwise educating yourself.

What a suboptimal situation. If there's any physician who gets annoyed, intimidated or frustrated by patients and families who Google search and ask them questions, that doctor should take a long hard look at their internal belief system. I for one, always welcome questions and challenges to what I'm saying, and see this as a natural part of being a professional. Sure, there will always be the odd annoying person or family that will take things too far, but these are the exception and not the rule. I am okay being quizzed or having someone cast doubt on something I say based on their own research, as long as it's asked in a respectable way (which it invariably always is).

I did see an online patient comeback to the above meme that goes like this: ”Don't confuse your one-hour lecture on my condition with my 20 years of living with it.” Yes. Doctors, we are here to serve, answer questions, and show empathy. Not judge our patients for researching their own health issues.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.
Thursday, November 14, 2019

3 reasons to be a doctor and have a career in medicine

There's so much negativity out there when it comes to health care, it must be a concern to any young person thinking about entering the field. I certainly spend a lot of time writing about all the challenges we face, and have to hold my hands up to (occasionally) spreading some of that negativity as well! Guilty as charged. That's why it's important for anyone outside of health care (or any field) to be wary of a certain type of “negativity bias,” which can occur when you are only exposed to people with things to complain about—who tend to be the only ones speaking up.

Another honest truth not to be overlooked, is that we as humans will always tend to overly focus on what's wrong, and not what's right, about our current circumstances. Looking at this in a positive way, it's also a useful survival mechanism to make sure everything keeps getting better.

I've written previously about all the good things about health care in America (see this article) and why I have no regrets becoming a doctor, despite any bumps in the road and disillusionment with our current health care system. Here again are three of them:

1. Job demand
If you're a doctor, rest assured that barring any unforeseen unique circumstance, you will never be out of a relatively highly-paid job. Demand for physicians in most specialties far outstrips supply. For sure, we keep hearing all the usual stuff that everybody does, about their jobs “being replaced by robots.” If this ever happens—which it won't—doctors will be the last it will happen to (in a highly improbably world where apparently where only 1 percent of the population will have jobs). Every year I've been in practice, the physician shortage only gets worse as the population ages and chronic comorbidities continue to rise. The job security in health care is really second to none.

2. Options
As a trained physician, you have a multitude of options about how you work, and on what terms you practice. America is a big country, and there are endless environments to work in. Even if you want to break away from working clinically, there are administrative, startup and also other industrial routes you can go down. Some doctors out there have only worked in one place for decades since finishing their residency, and eventually bemoan feeling stuck. Don't listen to them. Be open, look around and network!

3. Meaning
No matter what specialty you are in, being a physician means that you will never go home at the end of the day feeling like you haven't done anything important and worthwhile with your day. I used to tell my residents when I was a teaching Attending that you have the opportunity to do more good and touch more lives in one hour in your work, than most people get in a month.

No doctor should ever let their job become so routine that they forget that simple truth about what we do. If there's any physician out there who really feels disrespected and trodden on every minute of the day, they really need to take a long hard look at themselves. There are a lot of people out there in their 40s, 50s, and 60s, who find themselves working in office cubicles and have a realization that their job lacks any true meaning or worth. That should never happen to anyone in health care.

None of the above means that we should not talk about the immense challenges to physician practice that we face, nor turn a blind eye and seek to improve our dysfunctional and ridiculously expensive health care system. But it does mean that we should have some perspective too. If you're reading this and considering a career medicine, two other huge sacrifices should also be mentioned: debt and time. If you're not fortunate enough to have had family support or trained at a cheaper medical school, debt is a realistic concern and something to carefully plan for. It's good to see some medical schools slashing their fees and implementing other initiatives like loan forgiveness for those going into primary care. Second, sacrificing your 20s (and for some, their 30s) to be in lengthy relatively low-paid training. And aside from these two things, it's damn hard work becoming a doctor!

Choosing a career in medicine is not for the faint-hearted, but the above three things will always be there for you as a physician. I have no regrets whatsoever doing medicine. It has allowed me to meet unbelievably inspiring people (both physicians and patients), travel the world, and have a sense of appreciating every moment in life— that I don't think I would have gained doing anything else.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.