Memoirs of a Fourth Generation Physician

 

Medicine in the United States has undergone dramatic changes in the past 100 years.  I have been in an advantageous position to have a comprehensive and sometimes unusual perspective.  From my mother and other sources, I learned about my great-grandfather, Dr. Edward Reinert, who died before my birth.  I have many memories of my grandfather, Dr. Jesse Clarence Bohl.  I was raised by my father, Dr. Robert William Bohl.  I also have perspectives from watching my son, Dr. Casey Edward Bohl.  Along with that direct lineage, I have insight from my brother, my uncle, two nephews, and a niece, all of which are medical doctors in different specialties.

 

My own medical career began in 1970 when I started medical school, and it continues at the time of this writing in 2022.  My specialty is Urology.  With this writing, I hope to capture the nature of medical practice over a span of 5 generations.

 

I’ll begin with my direct lineage:

 

Dr. Edward Reinert (about 1870-1940)

Edward Reinert was a unique physician and an entrepreneur in his day.  He initially trained as a pharmacist and then as a physician.  After graduating from Starling Medical College (Currently Ohio State University Medical School) his work included an appointment as prison doctor for the Federal Penitentiary in Columbus, Ohio.  He was present for the last hanging and the introductory use of “Old Sparky”, the penitentiary electric chair.  One of the condemned inmates willed his body for science.  Dr. Reinert boiled the body in a cauldron in his back yard to create a skeleton for use in teaching medical students.

 

As prison doctor in 1898-1901, when O. Henry was an inmate, Dr. Reinert smuggled O. Henry’s writings out of the prison for publication.

 

When radioactivity was discovered by Madame Curie, Dr. Reinert traveled to Austria to learn about its use in medical treatment.  Dr. Reinert founded and owned the Columbus Radium Hospital, the only radium facility between New York City and Chicago.  There were no effective treatments for cancer or most other disorders in those days.  Little was known about the long-term effects of radiation therapy.  Dr. Reinert used radiation therapy to treat cancer, acne, inflammatory disorders and almost anything imaginable.  Some patients were probably helped, but many developed secondary problems as a result of this new treatment.

 

In these days, there were no real medical or surgical specialists.  Specialty training in surgery did not yet exist.  Most physicians were general practitioners.  Radiology, as a specialty had not been imagined because radiation was not imagined.

 

Dr. Reinert, himself, ultimately succumbed to the long-term effects of radiation therapy.  His fingers fell off due to repeated exposure, and he lost the ability to make blood.  Columbus Radium Hospital was sold to Osteopathic physicians and became Doctors North Hospital in Columbus, Ohio.  More recently, a long-term medical facility has been located on that site.

 

From what I can determine from his wife, my great-grandmother, who I knew as a child, Dr. Reinert seemed to live in moderate extravagance.  His wife traveled the world in luxury.  They did not accumulate great wealth by the time of my great-grandmother’s death.

 

 

Dr. Jesse Clarence Bohl (about 1890-1970)

My grandfather, Jesse Clarence Bohl, known as JC, was a small-town general practitioner.  After graduation from the Ohio State University College of Medicine, he immediately began his medical practice in the small rural town of Hillsboro, Ohio.  He continued that medical practice for over 50 years until he died between patients at the age of 80.   He never left town or took a vacation because, as he stated, “I’m the doctor and I’m needed here”.  We always traveled to visit him there.

 

Until he was very old, I always saw JC in a pressed long-sleeve white shirt and a dark suit.  This was his public image, even among family members.

 

JC made house calls, and he was available for emergencies any time of any day.  His office and home were attached together and located at the edge of the downtown stores.  In the earlier years of his medical career, JC performed deliveries, and he performed amputations and other surgery as could be performed in those days.  There were no available medical or surgical specialists in rural USA then.

 

In the basement of JCs house were large jars of the medical treatments that were available at the time.  I recall seeing opium, cocaine, strychnine, salicylate, sulfa, digitalis root, and other early remedies.  With no available pharmacy or pharmacist, JC measured and dispensed these early drugs from his office.

 

During his 50+ year career, most of this changed.  Commercial drugs and pharmacies became available.  Modern surgical training and capability was developed, new pharmacological treatments were discovered, and specialized medicine was beginning.  JC’s career encompassed a major transition in the science of medicine.

 

JC lived well but modestly.  Office visits were cheap, and some patients could not pay timely or with cash.  Patients were never turned away.  He accumulated only moderate wealth, even though he never traveled or purchased extravagantly.  His wife, my grandmother, lived for over 100 years.

 

 

Dr. Robert William Bohl (1920-2011)

Robert William Bohl was my father.  He graduated from the Ohio State University College of Medicine in 1945, near the end of WW2.  Although he had only general medical training, they needed psychiatrists to care for patients with PTSD.  Psychiatry was not his choice, he was told to be a psychiatrist and sent to a psychiatric hospital in Chillicothe, Ohio.  I was born in Louisville, Kentucky, in 1948 when Dad was stationed at Fort Knox.

Following his time in the Army, Dad moved to Columbus, Ohio.  He took additional training in medicine and cardiology, and he started a solo private practice.  His office was located only a few blocks from our home.  He made house calls, even in the middle of the night.

 

These were the early days of medical specialties.  Some of Dad’s colleagues specialized in gastroenterology or neurology, but all practiced general medicine.  Surgical specialists and sub-specialists, such as urologists and neurosurgeons, were beginning to show up in large cities.  Almost all physicians were in private practice, and most were solo practitioners.  Although Dad had no partners in his practice, he worked with 2 other solo physicians to cover for his patients when we was on vacation.

 

Following his training in cardiology, Dad volunteered in the cardiology clinics at Ohio State University Hospital to teach students and residents.  Along with other cardiologists, he read electrocardiograms at the local hospital. 

 

The basic tools of the cardiologist in the 1940s were primitive by today’s standards. History and physical exam were the primary tools of a cardiologist, or for that matter for any physician.   In the office, Dad had an EKG machine and something that looks like a defibrillator.  He had a fluoroscope that could image the heart.  Only a few medicines such as digitalis were available.  Over Dad’s career, all of this changed.  A wide variety of drugs were developed and marketed.  Most importantly, interventional cardiology and open heart surgery became common.  The entire field of cardiology was transformed, but Dad chose not to add invasive treatments to his repertoire.  Instead, in the later decades of his practice, he practiced mostly general adult medicine and referred patients for advanced treatments.  Dad retired from practice at 70 years old and he lived for another 20 years.  His wife, my mother, is still alive and reasonably healthy at 97 years old at the time of this writing in 2022.

 

Financially, Dad lived comfortably but modestly.  Office visits were inexpensive.  Patients did not have insurance to cover office care, and Medicare did not exist until the last decade of his career.  Toward the end of his medical practice, all of this changed, but Dad did not “cash in” on the windfall.  Expensive interventional cardiology procedures, covered by insurance and Medicare, converted cardiology from a moderately profitable career into an opportunity for great wealth.

 

 

Dr. Robert Daniel Bohl (1948-????)

This is me.  For generational continuity, I’m listing myself here.  I’ll return later to elaborate.  I graduated from Case Western Reserve University Medical School, and I became a urologist.  At the time of this writing in 2022, I’m almost close to retirement.

Dr. Casey Edward Bohl (1978-????)

Casey is my oldest son, and he is part of a new generation of physicians.  As a child, Casey said that he did not want to become a physician because he saw how medicine dominated my life.  He did not want to work that hard.  He found a compromise.  He is a medical doctor, and he works very hard, but medicine does not dominate his life.

 

Casey began his career more as a scientist than as a physician.  At the Ohio State University, his research mentor encouraged Casey to get his PhD in pharmacology.  At the same time, he was encouraged to add a medical degree from the OSU College of Medicine.  The combined program gave him both a PhD and MD in just 6 years.  Furthermore, they waived his tuition for both degrees, and they paid a stipend during those years.  The value of his research more than reimbursed the University for his compensation.  His work was supported by a combined program involving the University and the pharmaceutical industry.  His basic science work underpinned the development of drugs that currently have a multibillion dollar value and extend many patient lives.  University scientists generally don’t share in the market value of products that ultimately rely on the basic science for their development.

 

Following medical school, Casey worked for the pharmaceutical industry in Memphis for a year, then he enrolled in a radiology residency at the University of Tennessee.  This 6-year training program involved time at St. Jude’s Hospital, and it allowed Casey to continue some research.  Following this 6 years of radiology residency, Casey added a Fellowship in Nuclear Medicine at the University of Michigan.  He is now a nuclear medicine radiologist. 

 

Casey accepted a position with a large single-specialty radiology practice in the Charlotte, North Carolina area.  He is head of nuclear medicine for that practice with over 100 radiologists.  The practice is partly owned and managed by a private equity group, primarily to shield the physicians from a requirement to be employed by the hospital system.  The radiology group owns many imaging centers, and it contracts with hospital systems to read films and manage radiology departments.  Compensation is enormous by historic physician standards.  The pay is excellent for simply reading radiology studies, but most of the revenue is generated by owning facilities.  Actual direct patient care is compensated very poorly by comparison.

 

Radiology work is in shifts.  When a radiologist is finished with his shift, he can go home with no responsibilities or concerns.  Nighttime shifts are unavoidable, but currently the group is hiring night shift specialists to free most of the radiologists from required night work.  Most days, there is no direct patient contact.  Most contact is with other physicians as a consultant.  There is an opportunity for teaching and research.

Next, I’ll briefly mention close physician relatives outside of my direct lineage:

 

 

Dr. Raymond Edward “Ed” Reinert (1921-????)

Ed is my uncle, my mother’s brother.  He was also my father’s classmate in medical school.  Like my father, Ed was assigned to work as a psychiatrist for the Army.  Unlike my father, Ed decided to continue as a psychiatrist, and he transitioned to the Veterans Hospital system following his time in the Army.

 

Ed underwent additional training to become a psychoanalyst.  His research included experimentation with LSD on veterans with PTSD.  It was a failure.  This work preceded the recreational use of LSD as a hallucinogen.  Ed rose to Chief of Staff at the VAH flagship psychiatric hospital in Topeka, Kansas, associated with the famous Menninger Clinic.  Beginning around 1970, Ed became Director of the VA Hospital in St. Cloud, Minnesota.  His retirement coinsided with a VAH policy change to no longer require hospital directors to be physicians.

 

Ed retired from the VA system after 30 years and with full retirement benefits.  He is still alive and well at over 100 years old.  He has enjoyed retirement benefits for over 40 years.  He lives in a cabin on a lake in Michigan, and his hobbies have been beer making and mushroom hunting.

 

 

Dr. William “Bill” Reinert Bohl (1946-????)

Bill is my brother, and he is an Orthopedic Surgeon.  Bill and I learned surgical skills cleaning fish every day during summers together in Canada.  As children, we learned precision and speed as we used a combination of instruments and hands to see who could clean the most fish without damaging the meat or leaving good meat behind.  I’m certain that this early life experience helped both of us to be faster, more accurate, and more focused when we advanced our careers in surgical specialties.

 

Both Bill and I went to Case Western Reserve Medical School.  Bill stayed in Cleveland to train in Orthopedic Surgery at Case Western Reserve University Hospitals and then at Cleveland Clinic.  Following his residency, Bill joined a small single-specialty private orthopedic group practice.

 

Bill became a very successful, high volume surgeon.  He worked at a couple of small private hospitals.  He was also an entrepreneur who learned how to monetarize his practice.  He developed a physical therapy training program and some physical therapy facilities.  These were used for rehabilitation following orthopedic procedures and problems.  He managed physical therapy staffing at his hospitals.  At one time he was the team physician for the Cleveland Indians and the Cavaliers along with some school teams.  He has been able to accumulate substantial wealth.

 

Later in his career, Cleveland’s 2 large hospital systems, University Hospital Systems and Cleveland Clinic, were acquiring most of the smaller local hospitals and acquiring associated medical practices.  Medical economics made it almost impossible to resist acquisition.  Bill’s practice was acquired by Cleveland Clinic.

 

During the past 20 years, Bill has engaged as a volunteer in international medicine in undeveloped countries.  Each year he has gone to 2-3 countries, including areas of Africa, Asia, and South America, to teach or provide surgical services in these areas.  I have gone with him a few times.

 

Bill recently retired from patient care at the age of 72, but he continues to perform some disability evaluations.  He remains healthy, and he enjoys extensive international travel.

Dr. Jennifer Bohl Johnson

Jennifer is Bill’s daughter and my niece.  She is a general ophthalmologist, and she is employed by a health-care system.  Her husband is also an ophthalmologist.

 

 

Dr. Matthew McCreary

Matt is my sister’s son and my nephew.  He graduated from the Ohio State University School of Medicine.  Matt lives in California and Practices as a Hospitalist.  This is a newer specialty that takes care of only hospitalized patients.  Hospitalists work in shifts, and they have no patient responsibilities when they leave the hospital.  Most hospitalists are employed by hospital systems, but a new paradigm is developing.  As the physician shortage worsens, private equity companies are employing hospitalists and offering them an equity stake in the practice.  Because hospitals are dependent on hospitalist physicians to care for the patients, these private equity groups can command higher compensation than individual physicians can achieve through a direct employment contract.

 

 

Dr. Michael Bohl

Mike is Bill’s son and my nephew.  Mike went to Brown University for both his undergraduate and medical degrees.  During medical school, Mike interned with the Dr. Oz television show.  Subsequent to graduation, Mike advanced his education with degrees in Public Health and Journalism rather than preparing for patient care.  He is presently working to develop software to be used by the medical industry.

And now my story:

 

A career as a physician was never in doubt.  My father and grandfather were my leading role models.  Primary care in a small town was very appealing.  I considered psychiatry at one time.  I read psychology texts extensively and had enough college credits in psychology that I could have declared it a major, but I majored in chemistry.  I never considered surgery until the second half of medical school.  Importantly, I never expected to get rich from the practice of medicine.  I assumed that I would live well and be successful, but money was never a goal.  I learned that attitude from my grandfather and father.

 

Getting accepted in college, medical school, and residency was easy.  My credentials were never marginal, and I knew this.  My decision was more about where I wanted to train.  I went to Denison University because it was close and popular.  I completed graduation requirements in 3 years, but I stayed for the fourth year because I enjoyed college life.  Half way through my fourth year, my chemistry professor found a research program at Argonne National Laboratory for me and sent me to Chicago. At the end of the academic year, I returned to Denison to graduate with my class, Summa Cum Laude.

 

I attended Case Western University Medical School (CWRU) because it was close, it was considered one of the top 5 medical schools in the country, and my brother was there.  At a single interview with Dr. Caughey, Director of Admissions, I was offered a position at CWRU Medical School, and I accepted.  Academics were easy and effortless for me.  The first 2 years were mostly academic, and the second 2 years of medical school involved actual experience working in the hospitals and caring for patients.  It was during the third year of medical school that I decided to be a urologist.  I passed my Medical Boards in the 99th percentile (top 1% in the USA).

 

What happened to my plans for family medicine in a small town?  What happened to psychiatry?  These changes did not happen just to me; rather, this was a trend among medical students at high-pressure institutions.  Those students that excelled were led to believe that primary care was less important than specialized medicine.  Unfortunately, many students were attracted to specialties by statistical evidence of much higher compensation.

 

Personally, I was attracted to urology by a single person, Lester Persky MD WGLU (which he said meant “World’s Greatest Living Urologist”).  Unexpectedly, it turned out that technical surgery was easy for me, perhaps because of my years with competitive fish cleaning.  Dr. Persky convinced me that urology offered the best of all worlds: high success rate for actually solving rather than just managing real patient problems; broad combination of medical management and surgery; mixture of acute management and lifelong care; mixture of adult and pediatric care.  Dr. Persky was probably the hardest working and most dedicated physician in the hospital.  Patient rounds were at 5:00 a.m. and he stayed at the hospital well into the evening. Following morning rounds, he would see a few patients in his office before going to surgery.  Following surgery, he would return to the office.  Dr. Persky ran 3 operating rooms 5 days a week. He would personally perform the simple and quick procedures in one room, while his residents performed the complex operations at the level of their abilities in the other 2 rooms.  Between the simple procedures, Dr. Persky would check on his residents in the other rooms. I loved the energy associated with working with Lester Persky.

On Sunday afternoon, we would routinely admit about 20 patients to the hospital for Dr. Persky.  In 1973, all surgical patients were admitted to the hospital at least 1 day prior to surgery.  Outpatient surgery was in the distant future.

 

Although he was dedicated to patient care, Lester Persky was a proliferative researcher.  His residency trained more academic Urology Department Chairmen than any other urologist in his day.  Even though Lester Persky was my role model, I declined his offer to enroll in his residency.  The 6-year residency with Dr. Persky offered Board Certification in both Urology and General surgery, and it was probably the most coveted urology residency in the country.  Dr. Persky was surprised and disappointed when I declined, but I decided that I wanted a different style of residency.  CWRU was a high-pressure academic and research institution, and I was looking for intense direct patient care and independence.  I found it.

 

An interview with Arthur Evans MD, Director of the urology residency at Cincinnati General Hospital and Chairman of the Education Committee for the American Urological Association sealed my decision.  Dr. Evans was just the type of person that I wanted to work for, and his residency was focused only on patient care.  Dr. Evans offered me a position in his residency and I accepted in a single interview.  I wanted to do his required 3 years of general surgery at the same institution, and he promised that he would arrange a position for me in the surgery program with William T. Altemeier MD FACS and President of the American College of Surgeons at the time.  Even then, residencies were supposed to be selected through a formal ”Match” program, but in those days, program directors tended to ignore those rules.  Today, the rules are strictly enforced.

 

It is notable that Dr. Evans required 3 years of general surgery before starting urology while the base requirement at the time was 2 years.  The extra requirement was because the urology residency at Cincinnati General Hospital involved much more complex surgery than other programs.  Today, most urology residencies have less general surgery and more urology.  To perform complex surgery, today’s urology residents generally need additional training following the basic residency.  Those programs did not exist in 1974.

 

 

Surgery residency:

 

Cincinnati General Hospital was the quintessential public hospital.  There were no paying patients, and the administration in 1974 did not send bills. The hospital was supported by the community with tax dollars.  Insured patients went to private hospitals, and private hospitals directed uninsured patients to Cincinnati General Hospital.  Toward the end of my residency, billing began to change.  Because all serious trauma in the entire region was directed to Cincinnati General Hospital, the administration began to recognize that they could get paid for many of our patients.  This was the beginning of the end for charity hospitals.  Eventually, Medicare and insurance companies required the presence of private staff to pay for surgical procedures.  Because our volunteer mentors had trained with our system, they would sit in the lounge and sign required paperwork to allow billing.  Over time, these same individuals were required to participate with the surgery, and they were paid for their time, but that was long after I was gone.

 

There were only a couple of employed instructors at Cincinnati General Hospital, and the patient care was managed exclusively by the Resident staff in 1974.  Dr. Altemeier’s surgical residents worked for 7 years, with 36 out of every 48 hours in the hospital, before completing their training.  This was considered to be one of the best and one of the most intense surgical training programs in the USA.  Most of the teaching of younger residents at Cincinnati General Hospital was performed by chief or senior residents who were very capable after 7 years of intense surgery.  All of the surgical residents had rotations in private hospitals such as the Holmes, Christ Hospital, and Children’s Hospital where they could learn from experienced private physicians caring for their private patients.

 

It was sometimes stated that “the biggest problem of working every other night is that you miss half of the good cases”.

 

General surgery residents rotated through all of the surgical specialties during their 7 years of training.  They learned neurosurgery and orthopedics.  They performed thoracic surgery and kidney transplants.  Following this training these general surgeons were prepared to work in a rural area and manage almost anything that would be encountered.

 

Dr. Altemeier was a strong believer in the superiority of general surgeons.  He considered all subspecialties to be subservient.  He reviewed the surgical schedule daily to see what cases were scheduled.  For example, when he saw that the ENT surgeon had scheduled a thyroid operation, Dr. Altemeier cancelled the case because he felt that only general surgeons should do these procedures.  This was a political battle that he would ultimately lose.

 

Dr. Altemeier pointed out that he had been trained by Dr. Mont Reid and that Mont Reid had been trained by Dr. Halstead, the “father of modern surgery”.  We all understood that Halstead was probably trained by God, as was sometimes expressed by the surgery residents.

 

Dr. Evans’ urology program began with 3 years working as a general surgery resident with the same schedule and intensity as the 7-year surgery residents.  The 36 out of 48 hour work schedule continued through most of the 3 years of urology training.

 

Today, this intense schedule is illegal.  It was determined that sleep deprivation from long work hours caused medical errors and interfered with good quality care.  I have always believed that the loss of continuity in care was more harmful to patients than a tired physician.  Beyond that, we worked as a team of residents.  We took care of each other and allowed time for rest when someone was worn out from a difficult night.  I recall my intense years as a resident favorably, and I do not believe that patient care was sacrificed.  Instead, today’s less intense resident schedules selects physicians who are less dedicated to caring for their patients and who are more interested in an easier lifestyle.  This was the beginning of “shift-work medicine”.

 

Cincinnati General Hospital was an ominous looking institution by today’s standards.  There were multiple “pavilions” connected by a series of underground tunnels.  There were the patient pavilions, the radiology pavilion, the emergency area, the surgical pavilion, the administrative pavilion, and others.  As a surgical resident, I had a sleeping room on the top floor of the surgery pavilion.

The hospital provided and laundered white pants, coats, and scrubs for the residents.  All meals in the hospital cafeteria were free for residents.  Pay for a starting resident was about $10,000 per year in 1974.  Considering that we were required to be at work about 120 hours per week, this was about $2 per hour.

 

My first year of surgery residency began in 1974.  General surgeons rotated through 4 hospitals: Cincinnati General Hospital, Christ Hospital, Cincinnati Children’s Hospital, and the Cincinnati Veterans Hospital.  Additionally, I had a 3-month rotation at the Shrine Hospital for Burned Children.  Most of the first year was at the Cincinnati General Hospital where we could develop our skills caring for charity patients.  Considering that our team leader was a highly accomplished 7th year chief resident, patient care at Cincinnati General Hospital was probably superior to any other hospital in Cincinnati, but patients did suffer from repeated evaluations by multiple medical students and less trained individuals.  My chief resident advised me that this was the only thing that most of these patients could provide for the greater society, and he was probably correct but not politically correct by today’s standards.

 

There were no IV technicians or phlebotomists.  Medical students and interns drew the blood and started the intravenous lines.  There was no transportation service.  Interns and students rolled carts to the x-ray department and to surgery.  We also performed EKGs.  At night, when the lab was closed, we used the resident’s lab to do blood counts, urinalyses, and other uncomplicated tests.  This was great experience.  It also meant that we knew the patients and they knew their doctors.  I loved it!  It was me!

 

Surgical training at Cincinnati general Hospital was a sink or swim opportunity.  Hernia repairs and amputations were performed by interns assisted by junior residents until their skill levels were adequate.  Splenectomies and colectomies went to junior residents assisted by senior residents.  Chief residents performed complicated cancer cases, transplants, and difficult trauma.  The chief resident sometimes invited an outside experienced surgeon for an unusual difficult procedure. 

 

Surgery was divided into the general team and the trauma team.  Each team had a Chief Resident, Senior Resident, Junior Resident, Intern (First Year Resident) and medical student.   The Junior Resident would stay in the hospital on alternate nights from the rest of the team so patients would always have one of their physicians immediately available.  There was always an available chief resident in the hospital.

 

The elective surgery schedule was always full.  The trauma schedule had only a few follow-up procedures scheduled in the mornings.  The trauma team managed any emergency coming through the ER including auto accidents, gunshot injuries, and acute abdominal surgeries such as appendicitis.  There were always plenty of cases.  Trauma cases usually began to show up in the middle of the day, and they tended to end around 2-3:00 a.m.  I recall one busy night when my trauma team did 12 major surgeries.

 

I also recall one night when I was told, as an intern, to amputate diseased legs on 3 patients before morning.  When the always-present trauma cases were complete at about 2:00 a.m., my medical student and I completed the requested tasks without the help of any more experienced surgeon.  My team allowed me a nap to recover in the morning.

 

Junior residency as a surgeon offered more experiences.  Unforgettable, is my 3-month rotation at the Shrine Hospital for Burned Children.  The Shrine Hospital is adjacent to Cincinnati General Hospital.  This institution accepts the worst burned children in the country, with up to 90% body burns.  Many do not survive, and those that are saved are scarred for life.  It is emotionally draining to care for these children.  And our service there continued at 36 out of every 48 hours, continuous for 3 months.  The schedule was organized with 2 teams.  For the first 24 hours I cared or the acutely burned children.  For the next 12 hours, I performed reconstructive procedures on children who had survived the acute burns but had been left with burn contractures that could be helped with reconstructive surgery.  The other team did the same on an alternate schedule.  This was a great learning experience both on a technical and an emotional level.  It was emotionally overwhelming, and I would not like to repeat the experience.

 

Another junior residence experience was my 3-month rotation as surgical resident in charge of the Cincinnati General Hospital Emergency Department.  Cincinnati General Hospital had the busiest emergency room in the 3 state area, and it was the only hospital that accepted major trauma patients.  In 1975, a junior surgery resident was given the responsibility for this emergency room.  There were medical residents and other physicians, but surgery was in charge. The surgery resident was backed by an extensive team including the full general surgery trauma team, a neurosurgical resident, a cardiothoracic resident, the ENT resident, and an orthopedic resident, all of which were in the hospital 24 hours a day.  Commonly, I was required to evaluate 12 patients hourly or about 1 patient every 5 minutes.  The rotation was a break from the usual 36 out of every 48 hours.  We worked 24 hours on and 24 off for the 3 month ER rotation.

 

In the emergency room we saw many routine problems and some serious problems.  We had gunshots to the heart that were opened and stabilized right in the ER.  We had multiple overdoses and drunks with head injuries that were strapped to carts in the hallway so that they could be easily observed.  A call for “doctor needed outside” meant that the squad had a dead person and needed a physician to certify the death.

 

I recall one patient with a large abscess on his buttocks.  I incised, drained, and packed this abscess in the ER, then I signed his release.  It was a cold night, and the patient said that he had no place to go, so I referred him to social services and moved on to the next patient.  Recall that I needed to evaluate a patient every 5 minutes.  I remember a call for “doctor needed outside” on the following night.  My patient had died from exposure to the cold.  I don’t know exactly what happened, but the experience is unforgettable.  Because the hospital was always so busy, there was pressure not to admit patients unless absolutely necessary.  Physicians that avoided admissions were called “rocks” while those that admitted too freely were called “sieves”.  We could not routinely admit to the surgical service for social reasons because the beds were needed for patients with serious surgical problems.  Nevertheless, the outcome was painful.

 

In the late 1970s, emergency room staffing was beginning to change.  The specialty of Emergency Room Physician was just beginning, and Cincinnati General Hospital developed one of the first residencies for this specialty.  Today, busy emergency rooms are usually staffed by ER specialists.

 

My rotations to Christ Hospital were opportunities to learn from private physicians and to develop surgical experience.  Theoretically, we were assisting these surgeons with their private patients, but more commonly, we were doing the surgery, with or without their assistance.  Patients may believe that this represented a compromise in their care.  In fact, some of these surgeons were not that skilled, and the resident staff improved the quality of the procedure.  Beyond the technical surgery, the resident staff took great postoperative care of patients on whom they operated.  I recall one very capable general surgeon, Howard, who taught me to perform a complicated small bowel bypass operation.  After a couple of procedures and when he was confident of my capability, he would talk to the patient before surgery, write the postoperative orders, then leave to see other patients in his office while I performed the surgery with a surgical technician.  At the end of the procedure, he would return to check on my work then have me and the technician close the wound.  Although patient care and surgical results were excellent, this would be illegal today.

 

At Christ Hospital, we were required to stay in the hospital 36 out of every 48 hours just as in our other rotations, but the nights were much less busy.  We were required to manage the “in-service” surgical patients, but we had no obligation for the “out-of-service” surgical patients.  One of the perks at Christ Hospital was the opportunity to manage the out-of-service surgical patients for the additional compensation of $20 per hour ($240/night) since we were there anyway.  This was easy money for a resident making only about $2/hour considering the number of hours worked.  It also helped the private surgeons avoid nighttime calls.

At Children’s Hospital, I worked with Lester Martin, an amazing and highly skilled pediatric surgeon.  Lester was a great teacher and a humble man.  We admitted patients during the night for Dr. Martin.  We would call him to offer our opinion and plan.  Sometimes, in the middle of the night, he would quietly come to the hospital without telling us so he could personally examine these patients to confirm or refute our opinion.  I’ll never forget a story from Dr. Martin.  His next door neighbor was concerned about her child with abdominal pain, so she asked Dr. Martin who could help her.  Her child had appendicitis, and she did not understand that her neighbor, Dr. Martin, was a nationally recognized pediatric surgeon.  Lester did the appendectomy.  He told us that our friends and neighbors were the least likely to realize our capabilities. 

 

One of the benefits of working with Lester Martin was the opportunity to suture children’s injuries in the emergency room at night.  This was a great opportunity to practice skills with plastic surgery and local anesthesia in children.  Beyond the experience, Dr. Martin collected our records and billed for the procedures.  He believed that the residents should receive the insurance pay for these procedures.  While I was making only about $1000 a month as a resident, I received up to $4000 in addition on a good month for my suturing in the emergency room.  These children received far better surgical treatment than they would have received from any ER physician having much less training in plastic surgery who might otherwise have done the repairs.

 

My rotations at the Cincinnati Veterans Hospital offered a different experience.  The VA had paid surgical staff, but all patient care and teaching was by the resident staff.  The paid staff were older or inadequate surgeons who had no interest in working for their pay.  These paid staff would show up in the hospital only every week or two to sign our records and collect their pay.  Everything considered, the patients were better off without involvement from the paid staff.  On the other hand, most of the nursing staff at the VA were dedicated and capable.

Resources at the VA were limited.  Beds were always full, and operating room time was limited primarily by the shortage of anesthetists.  We had 2 operating rooms and only one nurse anesthetist.  Surgery residents administered the spinal anesthesia, and the nurse monitored the patient.

 

One of the best things afforded by our shortage of anesthesia was the opportunity to develop skills doing surgery using only local anesthesia.  Because general anesthesia in the USA has become so available and safe, few surgeons today have developed these skills.  My capability with local anesthesia has been particularly helpful with my mission work in undeveloped countries where safe general anesthesia is nonexistent.  I frequently offer local anesthesia as an option for my patients today.  Even when I had my own hernia repair, I selected an older surgeon who I knew to be capable using local anesthesia alone.

 

Patient wards at the VA had cubicles of 4 beds in groups of 4 cubicles, so it was possible to view 16 patients from one location.  This included postoperative patients, chronic patients with terminal disease, and even relatively well patients who did not want to go home.  It was considered to be wrong to discharge a Veteran against his will, even if he didn’t need to stay.  Also, the Administration wanted to keep all beds full.  Our problem was that we needed these beds to admit patients for upcoming surgery.  It was said that you could do anything to a Veteran but send him home.  Actually, I believe that the resident staff delivered excellent surgical care to our Veterans.

 

The surgical clinic at the VA was overwhelming.  No Veteran was turned away. 2-3 surgery residents would see up to 90 Veterans in a 3-hour afternoon.  This was a patient every 3-5 minutes.  There was no opportunity for lab or x-ray tests.  If anything was needed, the test could be ordered and the patient would be scheduled to return.  Fortunately, charting requirements were minimal.  A few written words would suffice.  Also, many patients had almost nothing wrong.  They had nothing better to do, so they came to surgical clinic primarily to hang out with other Veterans for the afternoon.  Because we had so little time with each patient, we were advised not to sit down in the room and not to take our hand off of the door knob.  This is the opposite of what is considered proper behavior for a physician, but the Veterans did not seem to mind.  We really had no alternative.

 

Another of my “moonlighting” jobs during my surgery residency was Deputy Coroner of Hamilton County.  This position was passed down from more senior residents to junior residents.  Jack McDonough, Chief Resident when I was an Intern, gave this position to me when he finished his residency.  The only required credentials were a medical license and a recommendation from the predecessor. The Coroner preferred surgery residents.  I filled out my application, presented my credentials, and was given a badge.  My job was to evaluate deceased individuals who were technically “coroner’s cases”, but who appeared not to need serious consideration.  I would review available information and records then visit the location to examine the corpse.  If I saw no reason to suspect “foul play”, I would write my report and release the body.  If I had concerns, the body would be brought to the morgue for further evaluation by a trained forensic physician.  Rarely did I discover anything concerning.  Each month, I would sign up for days that I would cover the job.  Pay was $100/day regardless of the amount of work.  Sometimes, I had no calls.  I was able to do this job while I was also serving at the hospital.  Understandably, families were in a hurry to have the bodies released, but nothing was a true emergency.

Urology residency:

 

Following my 3 years as a surgery resident, I began my training in urology.  My schedule wasn’t greatly changed with about 14 nights in the hospital each month.  I worked in the same 4 hospitals: Cincinnati General Hospital, Christ Hospital, the VA Hospital, and Cincinnati Children’s Hospital.  My co-residents and I were already experienced surgeons, so the focus was on urology.

 

Cincinnati General Hospital had no paid staff urologists, and no outside urologist ever saw our hospital or clinic patients. Junior urology residents learned from senior and chief urology residents.  Rarely, a chief resident would invite an outside private urologist to assist with an unusually difficult procedure.  We always had a busy clinic and a full surgical schedule.

 

Dr. Evans and the other private urologists managed their private patients at Christ Hospital, so we learned from them when we rotated to that facility.  The private staff never gave educational presentations.  Weekly educational presentations were delivered by the residents, and the private urologists commented as they chose.  Today, the Residency Review Committee (RRC) would consider our training program to be unacceptable.  They have a maximum and a minimum amount of surgery that is required in a residency, and we greatly exceeded the maximum.  Today a “case log” is required. They believe that excessive surgery detracts from educational experience and suggests that residents are providing a service rather than engaging in learning.  I disagree.  Also, the RRC requires a minimum number of educational conferences.  We fell far below that requirement, but the RRC probably didn’t even exist on the late 1970s.  Beyond that, my program director, Dr. Arthur Evans, was the Chairman of the Department of Education at the American Urological Association.  Nobody today is even allowed to leave their urology residency with the amount of surgical experience that we had in my residency.

 

I was always a “self-learner”.  This is one reason that I preferred the residency at Cincinnati General Hospital.  From the time that I chose urology as a specialty, I have read every Journal of Urology and every important text.  Lectures were too slow for me, and the presented information wasn’t always correct.

 

My experience with urology at the VA Hospital mirrored my general surgery experience at that facility.  The single paid staff urologist was never seen, but I was informed that he signed our reports.  The surgical volume was enormous.

 

At the Cincinnati VA Hospital I performed the first inflatable penile prosthesis implant that had been performed in the Cincinnati area.  This was in 1979, and the procedure was new.  I was advised during the surgery by the American Medical Systems product representative.  I operated as Chief Urology Resident assisted by my Junior Resident while several private urologists from surrounding hospitals observed the procedure.  Following this successful procedure, I was invited by private urologists to assist them in performing this procedure in their private hospitals.  In 1979, none of this raised any eyebrows.  Today, it would certainly not be allowed.  The private hospitals did not even review my credentials before allowing me to operate in their facility.

 

Cincinnati Children’s Hospital had a weak urology capability.  There was a single paid staff urologist who I considered to be marginally competent.  The complicated pediatric urology surgery was performed by Lester Martin who was as accomplished in pediatric urology as he was in pediatric general surgery.  I was fortunate to have learned from him during my general surgery rotations at Children’s Hospital.

 

The final year of residency is the Chief Resident year. The manufacturer of Macrodantin, probably the best urinary antibiotic for the past 50 years, sponsored a conference at Lake Tahoe exclusively for Chief Residents in Urology.  Today, this would certainly be illegal and considered a kickback.  To be included, the resident was required to give a presentation on their original research.

 

To qualify, I decided to study a drug called phentolamine to see if it would benefit patients with a common condition known as “urethral syndrome”.  Historically, urethral syndrome had been treated with painful urethral dilation, but this treatment was falling out of favor.  Dilation appeared to offer short-term benefit, but it probably caused long-term harm.  I hypothesized that the condition was caused by high smooth muscle tone in the urethra, and I knew that phentolamine acted on neuromuscular receptors to relax those smooth muscles.  Phentolamine was available to lower the blood pressure, but it had never been used to treat voiding disorders.  Experimenting on patients in my clinic, I used questionnaires and newly-developed electronic “urodynamic” testing to show that the drug improved symptoms, lowered the urethral pressure, improved urinary flow, and improved bladder emptying.  Clinical use was limited by side effects, particularly low blood pressure.  My oral presentation was critiqued and panned by an arrogant recognized expert in bladder function disorders from California, Emil Tenago.  He said that he didn’t believe my results and my conclusion.  Years later, pharmacy companies refined phentolamine into more selective drugs that have fewer side effects.  Today, tamsulosin (Flomax), a drug related to phentolamine but more selective, is the most commonly prescribed drug to treat restrictive voiding problems.  I learned to never allow aging “experts” to discourage me from progress.

 

Every year, we were required to take an “in-service” Urology Board test.  At the completion of the 3-year urology residency, we took Part 1 of the Urology Board Exam.  Part 2 of the Board Exam, required for final Board Certification, could not be taken until after 1.5 years of practice following completion of the residency.  In 1981, Part 2 involved an oral exam, a radiology exam, and a pathology exam.  We were required to bring our “case log” for review by our examiner. I scored in the 99th percentile (top 1% in the nation) on each in-service exam and also on Part 1 of the Urology Board Exam.  So much for an RRC determination of an inadequate educational experience.

Private urology practice:

 

In 1980, I began the private practice of urology in Columbus Ohio.  I joined an existing small group practice with John P Smith (JP), Mark Saylor, and Steve Smith.  JP was a nationally recognized pediatric urologist who had authored textbook chapters.  Mark was my father’s classmate in medical school, and Steve was JP’s son who had recently completed a fellowship in pediatric urology in Chicago.  Both JP and Mark were nearing retirement, so the full practice would soon belong to Steve and me.

 

My beginning compensation was $3000 monthly.  This was low even by the standards of 1980, but I was allowed to share in any bonus that resulted from excess earnings.  Also, I was assured of early partnership, particularly considering that JP and Mark would retire within a few years.  Thankfully, the practice was very busy, so I immediately had a large patient volume with a full surgical schedule.  After 6 months our excess earnings were so high that my bonus was twice as large as my guaranteed salary.  After only one year of practice, I became a full partner at Urological Associates, Inc.

 

I had hospital privileges to care for patients and operate at 5 different hospitals in Columbus, Ohio: Mount Carmel Medical Center, Grant Hospital, Riverside Methodist Hospital, Mercy Hospital, and Columbus Children’s Hospital.  Because JP and Steve were both pediatric urologists, I saw only adult patients.  My privileges at Children’s Hospital were only for unexpected situations.  I visited all of my hospital patients every day before beginning surgery or office hours.  Sometimes I went to 4 different hospitals before starting surgery at 8:00 a.m.  I needed to begin seeing hospital patients by 5:00 a.m.

 

For the first 7 years in private practice, I was on call 7 days weekly and 24 hours daily.  I saw my hospital patients every day.  JP and Mark did not carry pagers, so they frequently could not be reached.  Steve and I covered for their emergencies and urgent calls.  Within 5 years, JP and Mark had retired leaving only Steve and me to cover the busy practice.

 

JP, then Steve, held the title of President of our medical practice, but neither had any interest or aptitude for business management.  They just liked the title and the status.  Mark was Treasurer, and he managed the practice.  After my first 2 years, Mark turned all Treasurer and management responsibilities over to me.  I developed all practice policies and essentially managed the practice for the next 25 years.  We functioned as a democracy, so I needed to develop consensus for important decisions, but nobody else really wanted the responsibility.

 

After 1.5 years in private practice, I needed to take Part 2 of the Urology Board Exams.  This required a trip to Oklahoma.  All candidates gathered at the same hotel for the oral exam, radiology test, and pathology test.  My “case log” folder had about 200 pages, while most candidates had only thin folders.  There was widespread anxiety about the rumored grilling from the oral examiners.  I was taken to a room with 2 older urologists for my oral exam.  They first asked me about Art Evans, JP Smith, and Mark Saylor, all friends of theirs.  They reviewed my thick folder of cases and politely asked me about a couple of my more complicated surgeries.  The remainder of the interview was simply relaxed conversation.  Considering my prior scores and relationships, they had made their decision even before we met.  Today, Part 2 of the Urology Boards is administered using standardized questions so the decisions will be less biased.

 

Radiology and pathology are an important part of urology, and this exam was also easy.  During my entire career in urology, I always personally examined the x-rays and pathology slides.  These days, digital technology makes it easier to examine the imaging, but it has become more difficult or impossible to personally review the microscopic pathology.

 

Following the retirement of Mark and JP, Steve and I decided that we should grow the practice.  In about 1986 we added David Stewart.  We added an additional urologist about every 3 years until we had 9 urologists in our practice.  Everyone was treated well, and each new urologist became a full partner after only one year as an employee.  We all shared profits equally, and we all had the same amount of vacation regardless of productivity.  This approach allowed us to choose excellent urologists as partners.  We shared a culture of hard work and dedication to our patients.  As we grew the practice, we also began to share the weekend call rather than each being available all of the time.  Nevertheless, I always encouraged my surgical patients to call me directly with any problems or concerns.

 

The policies that I developed and had approved through a democratic vote of my partners became important over time.  For example, we approved a policy to cover for any partner suffering from a disability until our Corporate disability insurance kicked in.  This decision prevented controversy when one of the partners suffered from a stroke.  We developed a policy about disciplinary measures in the event of a problematic partner.  This became important twice, once with an issue of dishonesty and once with a mental health issue.

 

Urological Associates, Inc. always accepted patients regardless of their insurance coverage or inability to pay.  We believed that charity care was an obligation that came with the territory, and we all made a nice income.  Because we divided profits equally, there was no concern about who accepted the most charity patients.  During my first decade of practice, I believed that I was being over-compensated.  Fortunately, I saved and invested my proceeds, because the economics of private medical practice would eventually change.

 

Over the years of practice sub-specialization became important in urology along with other medical specialties.  We already had pediatric sub-specialists in our practice.  We hired a fellowship-trained pelvic floor surgeon.  One of our urologists was selected to perform all of our prosthetic implants.  We developed a robotic surgery team.  Because I had the most technical capability and experience, I focused on bladder cancer and major cancer surgery, and I stopped doing some other types of urologic surgery.

 

Early in my medical practice, I was involved in limited research.  Most notably, I participated in the early trials using BCG to treat non-invasive bladder cancer.  I was intrigued with early reports of success with this agent, and I wanted to try it on my patients.  I contacted the principle investigator through the Community Clinical Oncology Program (CCOP) and began enrolling patients using their standard protocol.  I did not learn until many years later that my name was included on the original research papers that resulted in this treatment becoming the standard of care tor this disorder.

Over the next 2 decades, I was involved in many more research projects to determine the best course of treatment for non-invasive bladder cancer.  Even today, BCG is the preferred treatment.  I was paid nothing for this research, and I get nothing from the commercial use of BCG.  In the early days, no special patient consent was used to become a subject in this research.  Over the years, this type of clinical research became reasonably well compensated and the consent process for patients has become elaborate.  Eventually, we were engaged in several clinical research projects at a time, we had a separate research area in our office, and we had a dedicated research staff.

 

Urological Associates moved twice and expanded office space twice during my 29 years with the practice.  Each time, I personally designed the layout of the office.  Along with Mark and JP, we started with a small office on the corner of Broad Street and Grant.  My secretary worked out of a closet.  Ultimately, our primary office was 12,000 square feet that included a dedicated research area, an ultrasound department, an operating room, 2 cystoscopy rooms, and a urodynamics room.  We had a smaller office on the other side of town, but I did not use the secondary office.

 

When I started private practice, charts belonging to JP and Mark were in manila folders with a few sheets of paper.  Many office appointments were documented by only several words.  Typed letters were sometimes created by the secretary without any specific wording from the doctor.  I soon transitioned to the SOAP (subjective, objective, assessment, plan) method that was developed by Larry Weed at Case Western Reserve.  I added a medication list and a problem list.  Eventually, records were dictated and typed.

 

In the 1970s, physicians were compensated by insurance companies based on “UCR”.  This meant that the charge needed to be usual, customary, and reasonable.  In the 1980s, surgeons were paid primarily for their surgical procedures based on a standard fee schedule.  Office charges were low, and the office simply broke even.  Hospitals were paid with diagnosis related groups or “DRGs”.  This meant that the hospital was compensated at a fixed amount based on the diagnosis or surgical procedure.  Over time, the amount paid for surgery was lowered while compensation for office care increased.

 

The problem arose when Medicare needed to define how much care was delivered in the office to set the compensation level.  About the early 1990s, Medicare and insurance instituted a standard CPT (current procedural technology) code and RVUs (relative value units) to determine compensation for office visits.  The CPT was based on a formula that related to the number of items that were included in the office note.  Nothing else was considered.  An entirely new industry was born: medical charting. Initially, we used paper templates to meet the requirements.  Charting was frustrating and time intense.  We actually sometimes took more time completing the chart than caring for the patient.  These were the early days of government involvement destroying our medical systems.

 

The medical industry retaliated by developing electronic medical records (EMRs) that would automatically chart historical information and physical exams that never actually occurred.  Almost 100% of medical charts contained fraudulent information, and it was nearly impossible to locate and trust the important elements of a patient visit.  Medicare and insurance companies recognized and assumed a percentage of fraud, so they progressively lowered the compensation.  Additional employees were required to manage these new systems, so overhead increased. 

 

The requirement for extensive charting on a computer screen also decreased efficiency.  Physicians could see fewer patients.  An honest physician who spent substantial time listening to his patient and explaining the situation could no longer get paid enough to cover the costs associated with running an office.  Inflation was also an issue.  Something had to change.

 

One thing that changed, at least for several years, was Lupron.  Physicians recognized this as corruption, but it economically saved urology practices for a while.  Lupron was an injectable drug that was used to treat prostate cancer.  The corruption came in the profit margin.  Abbott labs lobbied Medicare to allow compensation to the physician office of about $2000 per injection, then they sold the injection to the physicians for about $1000.  This was good treatment when responsibly used, but some urologists were lured into overuse of Lupron.  Although I believe that Urological Associates prescribed Lupron only responsibly, the excessive profits were still clearly corrupt.  Eventually, the Department of Justice identified the corruption as a form of kickback and stopped the excessive profit margin.  Abbott paid a large fine.  Certain physicians who engaged in clear quid-pro-quo activity faced criminal charges.  The end of the windfall meant that private physician offices needed to develop a new strategy to keep the doors open. 

 

Another factor was physician ownership of healthcare facilities.  The first for us was AKSM (American Kidney Stone Management).  In the mid-1980s, Dornier in Germany discovered ESWL (extracorporeal shock wave lithotripsy).  This technology broke up kidney stones by focusing shock waves through the kidney.  Sandy Wise, a capable urologist but a superior entrepreneur, organized 40 urologists from throughout central Ohio to invest in one of the first of these machines in the USA, even before FDA approval.  We formed Ohio Kidney Stone Management with 40 initial investors.  Through a series of mergers and acquisitions, this company eventually became AKSM with nearly 2000 urologist owners.  With ownership by the referring urologists, we effectively prevented hospital systems from acquiring this technology for many years.  Amazingly, Sandy lobbied the government to limit competition by legislating a requirement for a CON (certificate of need) before anyone else could establish a competing facility.  Additionally, we were able to get an exemption for lithotripsy that excluded us from laws prohibiting self-referral.  This is one situation where government corruption worked in our favor.

Another development was increasing use of outpatient surgery.  In the 1970s, all surgery was inpatient.  As this changed, outpatient surgery occurred only in hospitals.  Then hospitals began to develop their own outpatient surgery units.  Herb Riemenschneider, another urologist/entrepreneur, coordinated a group of surgeons including several urologists to establish our own outpatient surgical center, Knightsbridge.  This was a financial success, but the real payoff came when Riverside Methodist Hospital purchased a 50% stake in Knightsbridge Outpatient Surgical Center.  For the same procedure in the same facility, Medicare and insurance compensation is much higher if that facility is owned by a hospital.

 

My partners and I also had an investment stake in Green Street Outpatient Surgical Center. This facility was developed and partly owned by the Mount Carmel Health System.  Eventually, we were required to sell our stake, but at a nice profit.

 

In the 1980s and 1990s, as we added urologists and moved into progressively larger quarters, we needed to grow our staff.  Profits were good, so we could afford to hire the best and treat them well.  Each physician had a personal secretary who got to know that physician’s patients and who made sure that the patients were satisfied.  We had a wonderful receptionist, Jackie, who stayed with us during almost my entire career at Urological Associates.  She always made patients feel welcome.  Barb, initially a secretary/receptionist, then my personal secretary, eventually was promoted to Office Manager.  We had several registered nurses to manage clinical care.  They developed extensive urology experience and stayed with us for many years.  We hired outstanding ultrasound technicians who became masters at urology ultrasound.  Our office was like a family, and patients could feel it.  With this large staff, overhead was high, but our work volume was more than enough and revenue high enough to easily support the overhead.  And our quality of urology care was far superior to anything else in central Ohio.  If you had a urology problem, this is where you wanted to go, and we were proud of our office.

 

Our mission was focused on caring for our patients.  We developed a good balance between efficiency and quality.  All calls to the office were answered by actual people rather than answering machines.  Patients with clinical problems were triaged and managed by experienced clinical staff.  Patients consistently were given appointments when they were needed and not when we found it convenient.  Compensation for services was adequate to support this quality.

 

In the 2000s, government policy and the monetization of medical healthcare changed the economics of medical practice, and not for the better.  Regulations and requirements continued to raise the cost of providing good quality office care, while the reimbursement for each service was decreasing.  Profit margins were becoming non-existent.   My younger partners needed a better income to support their somewhat extravagant expenses.  I decided that it was time to allow them to change our business model.

 

An important development was the difference in reimbursement for even an office visit whether performed by a private physician or by a physician employed by a hospital system and working in their facility.  A visit compensated at $50 could become a $250 visit even by the same physician and for the same service.  Beyond that, the hospital could receive additional compensation for any laboratory test or x-rays ordered by the physician.  Our government was squeezing independent practitioners out of business in favor of hospital employment.

 

We considered our options.  Several private urology practices in central Ohio were in the same situation.  Most of the hospitals wanted to employ the urologists working in their hospitals in order to capture the ancillary business and associated revenue.  They offered excellent salaries, but the physicians would lose control over their futures.

 

The alternative was a urology super-group combining several urology practices.  This business model had been successful elsewhere.  The super-group could employ professional management and streamline administrative tasks.  There would be a competitive advantage when negotiating compensation with insurance companies.  Most importantly, the super-group could develop their own laboratory, radiology, outpatient surgery, and other facilities in direct competition with the hospital systems.  We would be in control of our own futures.

 

We decided in favor of the super-group, and COUG (Central Ohio Urology Group) was formed.  This group included about 25 urologists from about 7 different practices with Urological Associated being by-far the largest.  The COUG Board was composed of 5 younger urologists, and they hired an MBA to manage the practice.  At this time, I was in getting close to 60 years old, and my financial savings were more than I could imagine spending in my remaining lifetime.  I chose not to participate as a Partner in COUG, and instead I became an employee.  I informed my partners that I planned to retire from the practice in 2-3 years. Considering the number of partners in the practice and the quality of our sub-specialists, I wasn’t really an essential part of the practice.  I considered my personal mission there to be complete.

 

COUG, under professional management, completely changed the mission.  Many of our most experienced clinical staff were replaced with inexperienced but much less expensive medical assistants. Uninsured patients and patients who were unable to pay their balance were turned away at the front desk without being seen. One of the final blows for me was when one of my longstanding patients needing follow-up for bladder cancer was turned away at the front desk while I was in my office anticipating the appointment.  He was a good and honest patient who had always paid for his care, but he had recently developed problems and did not have his required co-pay.  I can understand my Partners’ desire to generate an income, but I was then certain that I no longer belonged with that practice.

 

During my final year with COUG, I arranged continuing care for each of my patients with whomever of my partners I thought they would get the best care.  I also obtained a license to practice medicine in North Carolina.

 

After years of building the practice, it was time for me to leave Urological Associates and COUG, but I had no plans to completely retire from the practice of urology.  I love taking care of patients, so I made new plans.  We moved to Edenton, North Carolina.  This is a small rural town located on the Albemarle Sound about 1.5 hours from the nearest city.  Edenton is a beautiful town, but it is a healthcare desert.  No other competent urologists were available in the area.  I decided to establish a small and very limited urology practice and to refer anything difficult to the large urology group at the distant medical center.  We did not need an income, and there was almost no profit from the practice.  Overhead was low, mostly because Brigid provided the nursing care at no cost.  I hired a single, part-time employee.  We took no income from the practice and used all surplus revenue to pay for our many overseas medical mission projects and for other charities.  Nobody was turned away for financial reasons, and nobody was sent to collection due to failure to pay.

 

Primary care rural urology is fun and it’s gratifying.  I always allow at least 30 minutes for a routine patient visit.  I get to know my patients, and I commonly encounter them on the town streets.  I have hospital privileges at the 2 large nearby hospital systems.  This allows me to see patient records and to enter information into their EMRs.  I’m allowed to admit and operate on patients, but I’ve chosen not to admit anyone in the past several years.  I jokingly advise my patients that, if they have anything serious, I’ll send them to a better doctor.  They generally prefer the doctor who listens to them, spends time with them, and accurately and honestly advises them.  The ”better doctors” at the medical centers to whom I refer patients for surgery appreciate that my patients arrive already informed and prepared for surgery.  I often manage their postop care locally.  I also make occasional house calls, for example to change a suprapubic tube on a quadriplegic patient.

 

I purchased a historic brick building across the street from my home.  This has become my medical office.  I have the ability to perform cystoscopy, vasectomy, and other minor procedures in this office, but mostly, I perform simple patient evaluations and consultations.  I am unable to obtain urology coverage when I’m away, which is much of the time, but my patients have my cell phone number and I answer 24 hours a day.  I even meet patients at my office during the night if, for example, they need to have a catheter placed for urinary retention.

 

I use a billing company that charges 3% of receipts.  This is a simple software program.  I enter my own charges, and this takes less time than telling someone else what to enter, perhaps 30 seconds per patient.  I do not use commercial EMR because these systems are designed for billing, and they are dysfunctional systems for recording and communicating medical information.  Using Microsoft Word, I have developed my own patient record template and record filing system.  This costs me nothing.  I am able to copy-post these Word files directly into the hospital EPIC EMR so the notes are available for other physicians.

 

I have contracts with all of the major insurance companies, Medicare, and Medicaid; beyond that, I mostly ignore them.  Frequently I receive record requests or other demands from insurance HMOs.  These go directly from the fax machine to the shredder.  I refuse to waste my time with their issues.  They’re free to remove me from their physician list, but they’ll find nobody to replace me.  Beyond that, I’m their least expensive option.  Everybody else is a hospital system employee.  Not only do those physicians get a facility fee, but they tend to order a variety of expensive and unnecessary tests to satisfy the hospital administration.  I’m not in practice to generate revenue for insurance companies, hospital systems, and big Pharma.  My loyalty is to my patients alone.

 

My other source of gratification is my work with resource-poor cultures in other countries.  In 12 years, Brigid and I have engaged in about 24 international volunteer medical projects lasting up to a few weeks each.  These projects include surgical operations on the local population and teaching the local physicians.  We have served in Bolivia, Ecuador, Ethiopia, Togo, Haiti, Dominican Republic, and Honduras.  Recently, our work has been with World Medical Mission/Samaritans Purse, but we have also worked with other humanitarian organizations.  Mostly, we have paid for our own expenses and added personal contributions to support the involved facilities, but we have also had generous contributions from wealthy patients.

 

As I write these memoirs, I’m getting close to final retirement, but I’m not quite ready yet.  I’m 73 years old and healthy, so we’ll see how things go. 

Trends in medicine USA

 

Economics of office practice:

For most of medical history, a career as a physician assured a good income but did not result in great wealth.  Physicians who became rich generally did so from ventures outside of the practice of patient care.  This began to change with the advent of Medicare in 1965 and with medical insurance.  Medical and surgical specialization also played a role.

 

Dr. Edward Reinert was a unique exception.  Columbus Radium Hospital probably attracted a wealthy population that was willing to pay a premium for this specialized care.

 

Dr. J C Bohl was a more typical example.  As a country general physician, his arrangement was directly with his patients without involvement of the government, insurance companies, big Pharma, or any other outside influence.  He needed to charge only what patients could reasonably afford, and he needed to be respected in his community.  As they said in the country at the time, “you don’t go to the doctor unless you’re $5 worth of sick”.  Also, there was little to offer for many problems.  Unless the patient had a significant problem, he was as likely to be harmed as benefitted.  That’s probably still true today.

 

With the advent of Medicare and insurance around 1965, the situation changed.  Patients were no longer directly responsible for the medical bills, so physicians could increase charges without respect to the ability of the patient to pay.  The insurance industry developed the UCR (usual, customary, reasonable) system of accepting charges for payment.  Fees were generally paid unless they were way above charges by other physicians.

 

As a resident in 1977, I recall being told by Dr. Evans that he didn’t mind taking care of unpleasant patients.  He just doubled their bill.  Without clear guidelines, physicians gradually increased their UCR charges, so insurance companies simply increased their premiums.  This was an unsustainable system, and it was the beginning of the end for honest and affordable health care in the USA.  Surgical and medical specialists led the way with high and increasing charges for their procedures.  The practice of medicine became a much more profitable career, but something needed to change.

 

What changed was CPTs (common procedural technology), DRGs (diagnosis related groups), and RVUs (relative value units).  A series of standardized codes were used to estimate the amount of work that was involved in caring for a patient.  It was an imperfect system by any measure, particularly because it could be manipulated by the provider, but it was used to limit the compensation that Medicare (and subsequently private insurance) would offer for the service.

 

Insurance companies required a contract with physicians who wished to be paid by the insurance company for their services; otherwise, the insurance company would pay to the patient the standard fee and the patient would be responsible to pay the physician for his full charge.  Requirements from Medicare became much more complicated such that essentially all physicians needed to accept Medicare’s fee schedule.  Understandably, most patients went only to physicians who contracted with their insurance carrier and who accepted their fee schedule as payment-in-full.

 

Initially, insurance companies simply adjusted the patient premiums up to cover the cost of care.  Over time, Medicare and private insurance lowered payment schedules to improve their competitive positions and to improve profit margins.  Insurance was now directly adverse to physicians, and insurance was winning.  “Managed care”, which is basically a system of limiting care, added to insurance company profits.  HMOs attracted patients by lowering premiums and increased insurance company profits by restricting care to only contracting physicians.  Various strategies were developed to increase insurance carrier profit while lowering physician payments.  At the same time, requirements for “pre-certification” by physician offices decreased the services that patients received and increased overhead in physician offices.  A busy physician could need another full-time employee just to manage pre-certification for needed tests and procedures.  Another full-time employee could be needed to manage the billing using the CPT system.

 

Many physicians and virtually all hospitals learned how to game the system.  Excessive and often fraudulent chart documentation was used to justify higher paying CPT codes.  Medicare compensated by assuming fraud and lowering payments for all codes.  An honest physician motivated to only care for patients in a private office could no longer cover practice expenses and earn an income.  A new business model was required.

 

The primary outcome was hospital employment of physicians.  Hospitals could not function without physicians.  One estimate in 1995 was that a busy urologist generated about $5,000,000 gross revenue yearly for an associated hospital, considering radiology, laboratory, operating room and inpatient charges.  Hospitals were more than willing to hire physicians, particularly surgeons, to assure their revenue streams.  This changed the dynamics between physicians and hospitals.  Previously, hospitals were tools used by physicians to care for their patients.  Now physicians were expenses for hospitals, and they were tools for hospitals to generate revenue.  And hospital systems were trying to market themselves as providers of care rather than allowing the individual physicians to have this designation.

A significant concern is the nature of a hospital board.  The focus is on revenue and less on patient care.  This was increasingly true for “not-for-profit” institutions and more obvious for “for-profit” hospital systems.  Physicians are inclined to do what is thought to be best for the patients.  Institutional Boards are inclined to do whatever generates the most profit.  This pits employed physicians against the interests of their employers.  And this is not just a theoretical consideration.  Today healthcare systems commonly incentivize employed physicians to order tests and even perform surgery against the interest of the patient.  This is one of the drivers of excessive medical costs in the USA.

 

My favorite example is prostate specific antigen (PSA) screening.  This test has been determined to cause more harm than benefit based on guidelines from the United States Preventative Service Task Force, The American Association of Family Practice, and the American Academy of Medicine. The American Urological Association (presumably for obvious financial reasons) recommends the test with limitations, but has stated that institutional screening events are inappropriate.  Nevertheless, hospital systems continue to arrange for their employed urologists to engage in “prostate screening fairs” that offer this screening test for free.  An administrator from a recognized cancer center was quoted as saying that each “free” PSA test is worth $5000 to the healthcare system.  A positive test leads to a biopsy; a positive biopsy leads to radiation therapy or surgery; and these treatments almost invariably lead to complications requiring treatment.  More complications result in increased profits.  Institutional systems are predatory to the degree that they may be willing to harm patients if enough revenue is involved.

 

An increasingly common strategy for physicians has been the formation of the super-group.  This is a large group of physicians who combine to consolidate administrative functions.  The group may be single-specialty or multiple specialty.  The pay-off comes when the super-group purchases facilities and capabilities in direct competition with the hospital system.  Understandably, hospital systems often attempt to partner with these super-groups to preserve their revenue.  Super-groups are usually not an option in rural areas.

 

The most recent development is private equity purchase of physician practices.  Private equity companies partner with physician practices, usually starting with a super-group and then add smaller practices.  These companies leave clinical decisions with the physicians, but they add professional administrative management including fee negotiation with insurance companies.  For specialties such as hospitalist and emergency room physician, private equity management will negotiate compensation with the hospital systems.  By controlling a high percentage of available physicians in a specialty, the private equity company is in a strong bargaining position.  The developing physician shortage makes this even stronger.

     

This story is not over.  The economics of medical practice in the USA are unsustainable.  But I can’t predict the future.

Continuing medical education:

Medicine is a science, and medical knowledge is in a constant state of evolution.  Change has significantly accelerated in the past few decades.  A medical education can’t prepare a physician for a career that could last for up to 50 years.

 

In the first half of the 1900s there was no formal requirement for continuing medical education.  Physicians in rural USA had few if any opportunities to stay informed of new developments.

 

Edward Bohl was a leader.  He was the source of new developments, bringing radiation therapy from Europe to the USA.  Staying on the top of his field was not an issue for him.  He was the top.

 

JC completed the basic requirements for a medical degree, then he practiced for 50 years without much real continuing education while medical knowledge was rapidly changing.  There was no formal requirement, and a rural community offered little opportunity.  He probably read a few journals, but he never traveled to conferences and there was no internet.

 

Dad had primarily an office practice, but he lived in Columbus, Ohio, so was able to attend conferences at Ohio State University where he had a faculty appointment.  There was no formal requirement for continuing education for most of his career, but his environment was a continuous education.

 

About the time that I completed my residency, state medical boards were beginning to require at least a minimum of continuing education to maintain a medical license.  In Ohio, eventually 50 hours of education were required yearly, and 20 of these hours were required to be formal “Category 1” training.  When I received my Urology Board Certification in 1981, no further urology training was ever required to maintain my Urology Board certification.

 

In about 1985, the American Board of Urology began to require a re-certification exam every 10 years.  Thankfully, those with Board certification before that time were indefinitely exempted from re-certification.  Over the past 20 years, the re-certification has evolved into a “maintenance of certification” program.  This is a time-consuming and expensive program that involves case logs and testing.  Problems with the current program are widely recognized, but the program remains in place.  A licensed physician is allowed to call himself a urologist and continue the practice of urology without Board certification.

 

Today, medical continuing medical education is inexpensive and readily available.  Although good information may be available, it is not consistently accessed.   Unfortunately, free but highly biased education is provided by pharmaceutical companies and the manufacturers of medical devices.  Today, in rural areas, pharmaceutical companies are often the primary source of education for many physicians.  Treatment decisions based on this biased education may be more inclined to serve the financial interests of the industry than the medical benefit of the patient.

 

In Columbus, Ohio, I had access to conferences and a variety of opportunities to advance my medical knowledge.  I read every Journal of Urology from 1973, when I decided to become a urologist, through 2021.  I read every Yearbook of Urology and every Quarterly Reviews in Urology.  But my best source of continuing education was the partners that we added to Urological Associates about every 3 years.  We added urologists who had trained at University of Chicago, Case Western Reserve, University of Cincinnati, Harvard, and Ohio State University.  My partners had fellowships from Long Beach, California, and Detroit, Michigan. We operated together, giving me an opportunity to directly learn new techniques while I was able to teach the less-experienced surgeons some of my established techniques.  We consulted each other about challenging cases.  Although I never was required to take a re-certification exam, I would have easily passed.  I was fortunate to escape the expense and inconvenience.

 

Since retirement from Urological Associates and re-location to rural Edenton, NC, the opportunity for local continuing medical education has changed.  Local medical practices in Edenton may be 10-20 years behind current medical knowledge.  Fortunately, internet-based conferences have become available.  There is no opportunity for face-to-face learning of new surgical skills.  I still have been accumulating about 200 hours of formal educational credit yearly.  Due to educational contamination from financially motivated interests, it has become difficult to trust most educational content.

 

Today, most published research papers and educational materials are sponsored, at least in part, by the medical industry.  Published reports tend to be biased toward the financial benefit of the industry.  Few physicians have the time or training to carefully analyze the source data; accordingly they tend to rely on only the published conclusions.  Even formal guidelines are subject to bias motivated by industry profit.

Big Pharma:

Medical treatments have gone from primitive and inexpensive to complex and unaffordable over the past century.  Early medications were frequently derived from plants and produced by small local laboratories.  Regulation in 1900 was essentially non-existent.  Most discoveries of medical treatments came from chemists in Germany.  This is consistent with the many bottles of powder that JC kept in his basement.

 

Early regulations in the USA were focused on safety rather than dose or effectiveness. Large pharmaceutical companies did not evolve until the mid-1900s.  This evolution involved increased medical research, new drug discoveries such as penicillin, increased profit, regulation of prescription drugs, and FDA oversight.

 

A variety of new medications such as anti-hypertensives were developed in the 1960s.  Along with the many new drugs came a new job description, pharmaceutical product representatives.  Pharmaceutical companies marketed their prescription drugs only to physicians, and physicians prescribed to patients.  Along with marketing came gifts to physicians.  As drugs became more profitable, the gifts became more elaborate.  This was my first corrupt relationship in the medical industry, although I did not see it that way at the time.

 

My career involved substantial corruption between Pharma and physicians.  At first, the relationship appeared to be harmless education, but it evolved into an overt interference with the physician’s obligation to act in the best interests of the patient.

 

As a beginning medical student, in 1970, Lilly (large pharmaceutical company) gave me and everyone in my class a doctor’s black bag that contained basic instruments that would be needed for a routine physical exam.  Value was probably $300.  During my years as a resident, we were commonly taken for lunch by the drug reps.  The pinnacle was the sponsored vacation at Lake Tahoe for chief residents in urology, probably valued at $4000.

 

During my years in private practice as a urologist, drug reps frequently provided free lunch for my entire office staff during which time they discussed the benefits of their product.  It’s notable, that the reps were frequently attractive young ladies, and they rarely knew anything of value about their product.  Their talking points were generally misleading and often completely incorrect.  Fortunately, I consistently studied the actual research and data relating to new products, and I ignored advice provided by reps.  But I enjoyed the meals, and my staff also benefitted.

 

Reps occasionally brought in “experts” to help market the products.  These paid physicians and scientists gave conferences using talking points developed by Pharma.  I call these physicians “industry whores”, and I quickly learned that they could not be trusted.  Unfortunately, many physicians do not study the source data and they base patient decisions on biased advice from the industry.

 

Around 1990, the government was developing rules to “rein in” product reps and pharma gifts.  These were now considered illegal “kickbacks”.  Pharma developed a new strategy of paying exorbitant fees to physicians for insignificant speaking engagements and of paying nice “consulting fees” to physicians who traveled to resort areas to discuss the drugs with industry executives. 

 

Because I was identified as a thought leader, I was invited to some of these “consultant meetings”.  I flew, by private jet, to a meeting in Seven Springs to discuss Elmiron.  I advised them that, in my opinion, Elmiron was useless and should not be prescribed.  Elmiron had been approved by the FDA based on what I considered to be no good evidence.  There was a single, poorly constructed study with marginal evidence of benefit for an uncommon disorder of uncertain cause known as interstitial cystitis.   Once Elmiron was approved by the FDA, Pharma sent their physician spokesman (industry whore) around the country to encourage use of the drug citing anecdotal reports of benefit.  Also, Pharma influenced physicians to expand the definition of interstitial cystitis to make the condition common rather than rare.  Subsequent well-constructed investigations established that Elmiron is ineffective and causes potential significant harm.  Nevertheless, the FDA has not withdrawn their approval.  Elmiron was sold for many years and continues to be sold, generating profit for Pharma while probably doing more harm than good.  This is true for many currently-available drugs.  Clearly, we should not rely on the FDA to protect the public from ineffective or harmful drugs.

 

There was a meeting in Orlando with a sponsored private event at Universal Studios to discuss Proscar.  Family was invited.  Proscar was approved to treat large prostates.  I advised them that Proscar also was effective to prevent bleeding from the prostate.  This was not recognized by the company or by any other consultant at our meeting, and it had not been published.  20 years later this has been published, and it is one of the most important usages for Proscar.  Although not required, I submitted my opinions in writing.  I think that my input was actually worth what they paid for my involvement.

 

Another time, Pharma paid for my trip to the Four Seasons in Las Vegas.  They were introducing a drug called Taxatere for use in advanced prostate cancer, and I was considered a local leader in prostate cancer management.  At this meeting they were more focused on influencing me than learning from me.  I wasn’t really very impressed by the data.  I’m sure that their speakers were well compensated.

 

I was invited to become a preceptor for a new treatment using collagen paste (Contagen) to inject around the urethra to treat urinary incontinence.  For this, Pharma sent me to Michigan to learn from an expert and one of their researchers.  I observed as he completed 5 cases.  I considered them to be disasters, and I was particularly unimpressed with his technique.  I tried the technique on a few patients with mixed results, then I decided that Contagen was poor treatment.  I never recommended this treatment again.  I believe that Contagen is still on the market, but subsequent studies have shown consistently poor results.

 

One of my partners, Jeff Carey, was paid $500 per case by the manufacturer of urethral mesh slings when he assisted other urologists to teach the technique.  I did one case with him to learn the technique.  I decided that this surgery was a bad idea, so I never performed this surgery on one of my own patients.  Jeff actually achieved good short-term results, but my other partners often had complications and bad results following this rapid teaching approach.  Today, it is recognized that these procedures carry serious short-term and long-term complications.  There are multiple class-action lawsuits and FDA warnings.  The rapid teaching approach has been criticized.  The manufacturers (Johnson and Johnson, Bard, and other companies) were focused on profit at the expense of patient safety.

Eventually, the government began restricting some of the strategies to compensate physicians for prescribing their products, but much of this activity continues.  The “Sunshine Law” now requires full disclosure of any compensation that a physician receives from Pharma.  This has had little influence.   It seems that the government wishes to have their own monopoly on corruption involving Big Pharma.  Our elected officials get plenty of “kickbacks” in the form of campaign contributions.  Dysfunctional laws are perpetuated because Pharma is one of the biggest contributors to election campaigns.

 

Currently, we have a crisis that is allowed and fueled by the relationship between the US Government and Big Pharma.  The FDA, influenced by lobbyists from Pharma, approves new drugs.  Big Pharma, in return, is allowed to charge whatever they want irrespective of their actual costs.  The public suffers the consequences.

 

Physicians must work with insurance companies through Pharmacy Benefit Managers to secure these overpriced medicines for patients.  The system is totally dysfunctional with enormous profits for all involved, and with patients and the public paying the bill.  Physicians are just pawns, and their overhead goes up as a result.

 

In 1997, the FDA approved “direct-to-consumer” advertisement of prescription drugs to the public.  Although the concept of educating consumers has definite merit, these artistically constructed advertisements, minimizing the risks and overstating the benefits, have financially benefitted Pharma while, in my opinion, probably degraded the quality of care.  Most of this information is too complex for the general public to understand, while this information is readily available to more knowledgeable individuals on the internet.

Medical research:

Medical research was initially performed by chemists in small laboratories, mostly in Germany.  Basic medical research was performed at academic institutions, often supported by government grants.  As Pharma became profitable, more of the work was performed by the industry.  Partnerships between Pharma and academic institutions have become popular.  As the close relationship between Pharma and private medical practice developed, it became common for Pharma to pay private physicians to conduct clinical research on their patients.

 

In 1900, medical research was largely unregulated.  Edward Reinert was able to bring radium to the USA and to use this treatment on everything imaginable without any oversight.  Although some patients certainly benefitted, the harm often did not surface for years.  For example, treatment for simple acne resulted in the later development of thyroid cancer.

 

JC Bohl and Robert William Bohl did not engage in medical research.

 

In 1979, when I conducted my experimentation using phenoxybenzamine to treat voiding disorders, I had no oversight.  Armed with an understanding of basic pharmacology and physiology, I developed my hypothesis.  I constructed a research design on my own, and I conducted the research on my patients. There was no faculty oversight because no faculty worked at Cincinnati General Hospital.  There was no institutional review board (IRB), there was no thorough research protocol, and there was no written and signed patient consent.

 

My intentions were pure. I received no compensation for my efforts.  Phenoxybenzamine was an available pill, although not used for this purpose. Phenoxybenzamine was inexpensive, and there was no valuable patent on the drug.   I did inform all patients of my intentions and of the known risks of the medication.  Regardless, my conduct would be illegal by today’s standards.

 

My research with BCG, a few years later, had been designed by Dr. Lamm in West Virginia.  Dr. Lamm developed the research protocol and constructed an informed consent.  Dr. Lam was working with Community Clinical Oncology Program (CCOP), so there was a formal process.  I simply participated using my patients and his protocol.  Still, no IRB was involved at my institution.  BCG was used to treat patients with potentially fatal cancer.  There was a real risk of serious side effects or even death from BCG.  BCG was commercially available for use to immunize against tuberculosis, although at a much lower dose.  Significantly, I received no compensation for this research.  I did the work in my office and at my expense.

 

Over the next 20 years, I participated in many research protocols to refine the use of BCG to treat bladder cancer.  We changed the dose and administrative schedule, we combined BCG with Interferon, and we compared BCG to other agents.  Each of these protocols was developed through CCOP, Pharma, or other institutions.  I simply enrolled patients and managed those individuals.  Over time, the protocol descriptions became more complex, the consent forms became more comprehensive, and IRB review became a requirement.  Eventually, human researchers were required to undergo government mandated research training and credentialing.

 

Medical research was transformed by the requirement for FDA approval assuring safety and effectiveness and by the increasing profitability of approved drugs.  Comprehensive “phase 3” trials were required that needed large numbers of enrolled patients.  This requirement led to multi-institutional drug trials to get enough qualifying patients.  The complex protocols made research costly, so private offices could not afford to participate without compensation from Pharma.  By 2000, Urological Associates participated in many multi-institutional drug trials.  We had a dedicated research area and dedicated staffing.  Compensation was in the range of $5000 per enrolled patient.  Even with this compensation, research was not a source of net profit, but it did keep us at the leading edge of medicine.

 

Casey began his medical career with research.  As a Pharmacy PhD candidate, he determined the 3-dimensional structure of the testosterone receptor, and he determined why resistance to the current drugs occurred.  He then predicted chemical structures that would not be subject to resistance.  Ohio State University partnered with GTX Pharmaceuticals to sponsor this research.  For commercial reasons, GTX prohibited Casey from publishing some of his results.  This research underpinned drugs such as Enzalutamide and Darolutamide that extended the lives of patients with prostate cancer by about 2 years and that had multi-billion value market values.  Pharma priced these drugs at $50,000-$100,000 per patient per year.  Casey received no financial benefit from these successful drugs.

Physician burnout:

Physician burnout has been a recent focus of professional medical organizations.  Depression and increased suicide rates among physicians have been recognized for many years, but the prevalence has greatly increased.  What is “burnout”, and why does it occur?

 

First, the high rate of burnout is not due to an increased workload.  Residents today are restricted to 80 hours weekly, while surgery residents in the 1970s worked up to 120 hours weekly.  Yet I did not observe burnout among my co-residents, and today over 50% of urology residents have been found to have symptoms of burnout.  Neither do I see evidence that current physicians are less committed to caring for patients.  More likely, they are prevented from caring for patients by our dysfunctional medical system.

 

Burnout does not appear to be caused by poor financial compensation.  It’s true that student debt is high, and it’s also true that a generation of physicians had an excessive expectation to get high compensation.   But, for a physician who is willing to compromise patient care to generate revenue for the medical industry, compensation today can be excellent.

 

I believe that “burnout” is primarily a dissatisfaction with our system that prevents physicians from providing care to patients in favor of generating revenue for the medical industry.  This is a moral insult, and today’s physicians feel trapped by our system.

 

 

Quality of care:

Clearly, our scientific ability to provide quality care has greatly increased over the past century.  But we should measure our quality of care compared to WHO standards, care in other developed countries, and care that could be provided with our resources compared to what actually is provided.

 

Statistically, we compare poorly to most other developed countries when considering WHO standards such as life expectancy and infant mortality.  Yet our expenditures per person are much higher.  Also, our statistics have worsened in recent years.  Why is this?

 

First, our entire medical system is influenced, if not controlled by financial motivation from the medical industry.  What isn’t profitable isn’t done.  And basic health maintenance isn’t profitable.  Finding and treating disease is very profitable, even if the disease is harmless, and even if the treatment causes more harm than the disease.  And , of course, there is little profit in caring for those without insurance.

 

Second, our medical system has become very inefficient.  As a physician, it takes more time to document a visit consistent with our mandated billing system than is needed to care for the patient.  Furthermore, 2-4 employees per physician are needed to manage the precertification, billing, and other efforts needed to comply with our overwhelming administrative requirements.  Less time is available for the patient, and quality suffers.

 

 

Corruption:

With money comes corruption.  After the military industrial complex, the medical industrial complex has become, probably the most corrupt segment of our society in terms of cost.  We have amazingly superior medical resources in the United States.  Unfortunately this capability has been degraded by financially motivated corruption at all levels.

 

Corruption probably begins with our elected officials who are dependent on contributions to fund their re-elections.  Contributions necessarily come from those with money.  And money most easily comes from and with corrupt influence.

 

The primary players, outside of our government are the insurance companies and Pharma.  These industries depend on favorable government policy to allow their excessive profits.  The Trial Lawyers are also large contributors because government policy allows favorable tort legislation to perpetuate their interests.  These 3 industries are frequently considered to be politically untouchable.  Our laws work against the public interest, but real change is unlikely.  The system is broken.

 

Insurance companies care about nothing but money, and they make no real contribution to patient health.  Pharma, at least provides benefit to patient care.  But, make no mistake, Pharma companies are predatory institutions that are prepared to harm the public if they can generate revenue without getting caught.  Usually, profit is their only serious consideration.

 

The American Hospital Association and hospital administrators are at an intermediate level.  They offer something of value because they directly participate in patient care.  At the same time, hospital Boards are primarily focused on profit rather than patient care.  While hospital systems are included with the “hogs at the trough” fighting for healthcare dollars, they are also adverse to insurance companies, Pharma, and the Trial Lawyers Association.

 

And then there are many intermediaries who glean revenue from our dysfunctional system.  Pharmacy benefit managers are intermediaries between Pharma, insurance, and physicians.  Pharmacy retail chains have integrated into the process.  Outside companies contract with HMOs to mine patient charts to secure higher reimbursement from Medicare.

 

Our medical system has become paralyzed by dysfunctional and corrupt influence.  And there is no end in sight.

 

 

Conclusion

 

 

I’ve had an amazing career as a physician.  There’s nothing else that I would have preferred to do with my life.  It’s in my blood.  Physician is not just what I do, it’s who I am, my persona. 

 

I have always considered it an honor and a privilege to care for patients, particularly when they literally put their lives in my hands during major surgery.  It seems that I was gifted with unearned technical and intellectual abilities.  Medical practice and surgery were always easier for me than for my colleagues.

 

The next generation of physicians seems to be doing just fine.  My oldest son, 2 nephews, and a niece have all adopted different career paths as physicians.  They’ve adapted into the medical system as it exists today.

 

The problems in healthcare in the USA are not with today’s physicians; just the opposite.  Our problems have arisen because physicians no longer control medical practice in this country.  Control lies with large corporate interests, and the goal of these interests is to make money.  Pure capitalism.  And the victims are not the physicians.  Physicians continue to do well.  The victims are our patients and the greater society.

 

Just as in war, the solution is political.  And we have not yet reached the political tipping point.  But I think that we may be getting close.

 

At 73 years old, I expect that my career as a physician will soon end.  I have absolutely no regrets or second thoughts about my chosen profession.

 

RDB