How surgeons can deal emotionally with the ongoing threat of Medicare fee cuts

Looming pay cuts present an opportunity for ophthalmologists to address their feelings about work, money and their worth to society.

“All human wisdom is summed up in these two words — wait and hope.”
– Alexander Dumas, The Count of Monte Cristo

Craig N. Piso

John B. Pinto

Once again, Medicare fee schedules are preserved, at least for the moment. Once again, an 11th-hour rescue has pulled us back from the brink. And once again, the average ophthalmologist has dodged a 30% or greater cut in personal take-home pay.

It is frustrating to live and work this way. And not just in those practical “Honey, can we still afford that summer vacation?” terms.

Standing endlessly on the precipice of a steep pay cut is having an adverse emotional impact on most of the eye surgeons we know. They are feeling increasingly teased and toyed with, the tangible value of their contributions to patients on the verge of belittlement. And all of this caps emotions made wary by 40 years of steadily eroding fees.

It got us to thinking together recently about the role of compensation in the psyche of the typical ophthalmologist and practical coping mechanisms for an ever-pending fee reduction. We have posed and answered several questions below that we hope will help you explore your own feelings about work, money and your worth to society.

Q: What role does compensation play in the healthiest ophthalmologists’ spectrum of professional reward — high, low or in the middle? How do we think this might compare to others, such as professional writers, for whom financial reward is less common and less assumed to occur?

A: A client once said, rather late in his very lucrative career, having amassed millions more than he or his children would ever likely spend, “I have no passions other than working, so I can’t imagine doing anything else. I’d miss the work and the money.” Our research and experience in this domain of physician happiness have informed us most clearly that the happiest ophthalmologists are those who live well within their means, spending the smallest percentage of their earnings. But rather than hoarding their wealth, we find that the happiest doctors have achieved a life of balanced priorities. To trot out an old concept, they strike a sustainable work-life balance. Money to them is neither a means to an end nor an end in and of itself. Instead, wealth becomes the natural byproduct of a career carefully conceived and a life well managed. The healthiest docs we know have a good grasp of money, so that money doesn’t have an unhealthy grasp on them.

Q: In what respect is compensation a kind of drug for well-paid professionals, and how does the involuntary withdrawal of this drug, such as by Medicare fee cuts, mess with their heads? What should one expect in terms of stages of shock, denial, bargaining or other coping sequences?

A: Another client recently expressed his opinion that financial rewards become especially addictive among ophthalmologists, who are both emotionally and financially drained by the time they complete their training programs. The subsequent rush to pay back education debts and start living the long-delayed good life spawns compulsive labor, too often of a workaholic nature. Any ophthalmologist who has become thus entrapped is usually in denial about this, like a person in the throes of a chemical dependency. Accordingly, any threatened withdrawal of their supply (ie, money) can predictably provoke any combination of the following negative emotions: rage, fear, panic, depression, insecurity and even paranoia (specifically, feelings of being persecuted or conspired against). Just as a person in recovery from addiction must usually hit bottom in order to make any significant change in lifestyle, any ophthalmologist who has allowed his earnings to drive feelings of self-worth with workaholic behavior can be expected to reach a kind of comparative crisis. However, such turmoil can also set the stage for growth and change to occur. The addictive, dependent behavior might finally come into view. Just as we are empowered by truth, no matter how unpleasant it might be, we are disempowered by lies we tell ourselves and others about our behaviors. The most common of such lies is: “I’m in control, so I don’t have a problem.”

Q: How might a drop in income, which is not in the least the fault of the eye surgeon, adversely affect mood and relationships with others?

A: While it might not be their fault in the least, MDs must take full responsibility for their response to any drop in income. Blaming the payor or any other external entity for one’s mood and happiness is a formula for misery, because power and responsibility are in equal proportion within any healthy person. Abdicating responsibility, while convenient and common, actually leads to a sense of powerlessness. Conversely, those who cope well during any crisis, financial or otherwise, shift their focus toward what they can still control. This includes control over one’s attitude. If Medicare one day does hand out a double-digit fee cut, there is still much that will be under each surgeon’s personal control, including practice and lifestyle costs, relationships with colleagues and patients, and finding the proper balance between work and life.

Q: What unhealthy, unhelpful coping can be anticipated as a substitute for the figurative drug of a high income?

A: Initially, it would be normal for compulsively driven ophthalmologists to redouble their efforts when threatened with or actually experiencing financial decreases, just as a chemically dependent person can often become more frenetic in their drug-seeking behavior during periods of diminished supply. Both can be expected to branch out in more diverse efforts to get a fix. Without being overly dramatic here, the drug addict might try new drugs and suppliers, while the eye surgeon might branch into areas of practice previously outside his or her interest or even competency. Increased utilization rates for special testing and overly aggressive surgery could be expected. It is important that managing partners and practice administrators remain vigilant regarding any troublesome requests from their physician staff, such as wanting more patients when already working a completely full schedule or wanting to perform procedures not previously in their repertoire.

Q: How long might it take for the average, healthy surgeon to adjust to something as major as a 30% or greater pay cut should it come to pass?

A: Most will make a moderate and satisfactory adjustment within a few years. A small percentage of ophthalmologists, unfortunately, will never make a healthy adjustment, even with professional assistance such as therapy. However, we expect there will also be a very small, gifted percentage that will make a very good adjustment, some even becoming happier than before their drop in earnings. How is this so? Instead of bemoaning their plight, assigning blame for their unhappiness and otherwise demonstrating degrees of helplessness, they will reframe the economic crisis as opportunity, and they will do the inner work of realigning their priorities as part of a larger resolution. They will take stock of any addictive or overly dependent relationships, including that with money, and they will then become freer as they gain real control over their work and personal lives. This will be in stark contrast to the illusion of control that characterized their earlier workaholism and denial.

As for a specific time line for all providers, it is less a matter of how long the journey will take and more a matter of which road they choose to follow. Some, unfortunately, will become ever more workaholic, struggling even harder to retain the past. Others will work with a shift in awareness to build a new kind of life.

Q: What is the best, most practical way to cope emotionally with the dreadful and frustrating uncertainty of on-again, off-again fee cuts?

A: The simplistic but profoundly helpful answer comes from Reinhold Niebuhr’s “Serenity Prayer,” a version of which is prominent in most 12-step programs: “God, give us grace to accept with serenity the things that cannot be changed, courage to change the things which should be changed, and the wisdom to distinguish the one from the other.” Put that up somewhere you can see it every day. Most of us are stronger than we think. When put to a real test — if the cuts really come — it is likely that most eye surgeons will find a way to cope with grace. Most surgeons are logical people. They are good at maintaining confidence and not letting emotions override logical thinking. This is the root source of coping and resilience in the face of trauma, even life experiences that are vastly more traumatic than a federal pay cut.

Q: Some ophthalmologists in weaker practices may be facing a 50% or greater personal pay cut if Medicare fee cuts ensue. With a cut of that magnitude, what can we predict in terms of adverse mental health status, depression and even suicide?

A: Doctors already have about twice the suicide rate compared with the general population, even before the stress of fee cuts. Those who study suicidal behavior have found that a perception of hopelessness is the most powerful factor driving serious depression and suicide. We know that any serious loss (eg, death of a loved one or unwanted divorce) usually triggers depression. This is because our energy for living day to day is drawn from the well of our dreams, both personally meaningful and within our grasp — if not in the present, then at least in our expected future. Therefore, any significant loss of or threat to our dreams robs us of our energy, an experience known as exogenous depression (ie, determined by external rather than internal events). Researchers have also found that the critical period of acute suicidality often lasts about 10 minutes, often in a recurring manner, ebbing and flowing. If a person becomes acutely suicidal, it is most important that they speak with another person right away, ideally a trained professional counselor, in order to help them endure the limited periods of greatest vulnerability and weather the storm. If you are reading this and believe that a real fee cut could put you dangerously close to serious depression or suicide, you should develop a panel of resources now that will be at the ready to help in the event of a crisis.

Q: What warning signs should the people in an eye surgeon’s world and life look for to help stem the tide of such a crisis?

A: The most common warning signs that a person might be seriously depressed or suicidal include a lack of interest in activities previously found to be enjoyable, withdrawal, isolation, a lack of communication, sullenness, negativity, and verbal or behavioral expressions of hopelessness (eg, “It’s no use, I’m finished, I give up.”). Other critical signs include giving away one’s possessions, extreme changes in work habits, impaired concentration and memory, restlessness or boredom, or self-destructive behavior such as drinking to excess. Any changes in eating and sleeping habits can signal depression.

Q: Does the current general anxiety and malaise from the Great Recession and pending health care reform prime ophthalmologists to be especially sensitive to the threat of Medicare fee reductions?

A: Eye surgeons, by their nature, are high-strung and disproportionately responsive to stress. Psychologist and author Wayne Dyer is often quoted saying, “What you focus on tends to expand,” meaning that our sustained attention tends to influence how we see things. The understandable preoccupation with fluttering retirement funds and economic uncertainties certainly makes all of us less optimistic and confident. It is essential to shift your focus and take constructive action steps. Focus on the doors you can still open, not those that may now be locked for the rest of your career and life. Adjust your dreams.

Q: Fee-cut jitters are also affecting lay staff and associate doctors. What are some leadership pearls for practice owners who have to manage not only their own feelings, but those of the people dependent on them?

A: To the greatest extent possible with authenticity, model optimism amid strife. Remember the power of self-fulfilling prophecy: We tend to create the reality that we expect, whether positive or negative. So, work consciously to instill confident expectations among staff members. Even when positive expectations are later disappointed, start with new expectations and make a new Plan B. Staff take their cues about how to feel from those in authority. They look especially closely at your actions more than your words, so “walk the talk” with conviction and confidence, not simply good acting in front of the crowd. The most important victory is a private one, in which the leader grasps both the situation and a plausible game plan with confident resolve to inspire others to follow.

Q: What readings, Web sites or exercises can help at a time like this?

A: Here are some methods to strengthen individual and group confidence and spirit, especially in the face of threatened leaner economic times:

• 1. Read and discuss the well-known “Fish!” program during a monthly staff meeting. This arose in a Seattle fish market and teaches four key strategies for making work more fun while becoming more productive and efficient. Go to www.charthouse.com.
• 2. Cross-train workers in your practice to be prepared for workforce trimming, if necessary, and to build stronger ties among co-workers.
• 3. Communicate regularly with the staff about the real status of the business, its economic health, and your plans for adapting and changing in response to economic challenges. Remember that information is empowering and that people tend to incorrectly imagine the answers to questions when they are not informed from the top of the organization.
• 4. Be proactive. Plan ahead for all possible scenarios, including an austere budget and related strategic options, in order to remain the driver of your practice rather than a passive passenger.
• 5. Share as much about these plans as possible with your staff in order to engage them in constructive, solution-focused activity, as opposed to being negative and problem-focused.
• 6. Make sure that practice planning is mirrored in your personal planning. If double-digit fee reductions ever do ensue, home budgets, retirement time lines, and feelings about the balance between work and life will all be reshuffled.

• John B. Pinto is president of J. Pinto & Associates Inc., an ophthalmic practice management consulting firm established in 1979. Mr. Pinto is the country’s most published author on ophthalmology management topics. He is the author of John Pinto’s Little Green Book of Ophthalmology; Turnaround: 21 Weeks to Ophthalmic Practice Survival and Permanent Improvement; Cash Flow: The Practical Art of Earning More From Your Ophthalmology Practice; The Efficient Ophthalmologist: How to See More Patients, Provide Better Care and Prosper in an Era of Falling Fees; The Women of Ophthalmology; and his new book, Legal Issues in Ophthalmology: A Review for Surgeons and Administrators. He can be reached at 619-223-2233; e-mail: pintoinc@aol.com; Web site: www.pintoinc.com.
• Craig N. Piso, PhD, is president of Piso and Associates, LLC, an organizational development and psychological services consulting firm based in Northeastern Pennsylvania. A consultant/psychologist with 30 years of corporate executive and clinical practice experience, Craig is the author of a new book, Dream of Life … Live Your Dream – A Manual of Skills for Living for Today’s Young Adults. He can be reached at 570-239-3114; e-mail: cpiso@pisoandassociates.com; Web site: www.pisoandassociates.com.