Practice ‘efficiency’ is not a dirty word but a noble goal

Dr. RosevearI recently had the good fortune to spend a long weekend in the mountains with an old friend. He’s about my age but took a much more direct route into medicine and as a result has been practicing now for almost 10 years compared to my 2. He also went into academics, not private practice, and when the conversation drifted to medicine, it was that difference that seemed most pronounced. 

My friend is now an associate professor at a big-name university in a big city and spoke with great pride about his efforts to become a “triple threat": a respected surgeon, a well-published scientist, and a trusted mentor to his residents and fellows. Based on what I could ascertain via a quick Google search, I think he’s doing a great job at it too.

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The biggest challenge he described is one that I am very familiar with; specifically, balancing his career with his job. Interestingly, though, when I spoke of my similar challenges as I learn both to become a better clinician and to ensure that my practice is run efficiently, his attitude changed dramatically. He spoke almost with disdain about the business side of medicine and stated that it is not possible to simultaneously be an excellent clinician and a businessman.

I disagreed. Emphatically.

His arguments included the lack of formal training to run a business (no MBA), that the time spent running the business could be used to practice medicine, and the potential for “moral corruption” if a physician started practicing medicine to make money and not help patients. He seemed most bothered by my quest to become a more “efficient” physician.

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I countered that if you accepted those arguments, then the age-old academic model of being a “triple threat” was equally flawed. Scientific research would have to be left to PhDs, and resident teaching would be left to properly trained professors and not surgeons like ourselves. Further, while it is unfortunately too easy to find examples of physicians abusing the system for their own personal gain (one notable example can be found here), the willful ignorance of the medical economics that exist and that our patients face every day-especially in this world of ever-rising deductibles and out-of-pocket costs-is not the correct answer either. And yes, deductibles truly have doubled on average since 2003, even though the rate of premium increase has slowed dramatically, according to a recent report from the Commonwealth Fund, a non-profit health care research group.

Suffice it to say that even after what were probably too many good local beers, the argument was unresolved.

In reality, there are likely good points to both sides of the argument. Surgeon-scientists have a perspective that pure bench top researchers simply lack, and they have a proven track record for making valuable contributions to the scientific literature. Further, I doubt that any degree of formal training could ever teach the art of medicine like the attendings I had in residency.

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On the other hand, according to the AUA’s most recent census, almost two-thirds of urologists work in private practice, which means that the vast majority of us have a direct interest in the business of medicine (And please, if you haven’t yet made your contribution to this year’s census, do it, please click here! Further, I argue that all doctors, regardless of the business model in which they practice (private practice, academia, or employed position) have a direct interest in the business of medicine because it affects our patients.

Let me give you an example. I recently had a patient, late-50s male with a significant smoking history, who presented to me with a weeklong history of painless gross hematuria. He had no evidence of infection and no other signs or symptoms at all. I recommended an anatomical evaluation including computed tomography intravenous pyelogram, cystoscopy, and cytology. He declined because the deductible on his insurance was too high. We “compromised” on a renal ultrasound and cystoscopy.

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This is not a local trend, and in fact a recent article in USA Today highlighted this exact problem. (This is a great article that also well summarizes the rising cost of health care over the last few years.)

Another example from my practice was an early-60s man in reasonable overall health who presented with retention following an emergency surgery. He had a catheter placed and was discharged on Flomax. When I saw him a week later in clinic, he failed a voiding trial and when I asked if he was still taking the Flomax, he said no, he never filled the prescription due to cost. The National Center for Health Statistics states that 8% of all patients don’t fill the prescriptions that we write due to cost!

Being efficient in medicine means many things. It means that I am aware of the overhead associated with my office. It means that I try to move promptly between patients so that I don’t get too far behind (I can only think of one other professional who is always late, and Vladimir Putin is not someone I am proud to keep company with! (See: http://www.theguardian.com/world/2015/jun/11/why-is-vladimir-putin-always-late-russian-president-tardiness-pope-francis). It also means that I am conscious of the costs of the tests, drugs, and surgeries I recommend so that I can help my patients choose the best option for both their health and their pocketbook.

So to all my fellow urologists who spend their days in the trenches of the real world, and especially to all of the other urologists out there who run their own businesses and are trying to not only survive but prosper while delivering appropriate cost-effective medicine, I say stand proud, you uro-businessperson. Efficiency is not a dirty word but a noble goal, a goal that Hippocrates himself would be proud of.

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