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Changing practice environment requires that ophthalmologists examine their attachments
Four exercises provide surgeons with insight into how they will adapt to changing circumstances.
“Attachment is the great fabricator of illusions; reality can be attained only by someone who is detached.”
– Simone Weil
“The reason many people in our society are miserable, sick and highly stressed is because of an unhealthy attachment to things they have no control over.”
– Steve Maraboli
“What we have to learn … is to be free of attachment to the good experiences, and free of aversion to the negative ones.”
– Sogyal Rinpoche
Editor’s note: It is fitting that on the heels of writing several columns for OSN on practicing “frugally” in the challenging era that lies ahead, John Pinto waxes philosophical with his thoughts below on a surgeon’s attachments to various dimensions of his or her professional life. Insights in this area may be even more practically helpful to surgeons than cost containment advice if practice economics change for the worse in the years ahead.
Ophthalmology is a sticky profession, with much to become attached to and much to be anxious about losing.
As an ophthalmologist today, your attachments and aversions started early. From the first days of grammar school you ego-identified with being the smartest or at least the second smartest kid in the class and were crushed on those rare days when your class standing slipped. Not knowing the answer when the teacher called on you or bringing home a “B” on your report card generated the same motivation that a dropped nucleus does today.
Then, after 25 long years of clutching for academic mastery and performing for others — at the far end of a long, long tunnel — abstract knowledge became a bankable skill. The net value of your work shifted from $8 per hour to $8 per minute, or $18 if you became a retina specialist.
And then the real attachments began. To earnings, to fast-accumulating assets, to all the cool technology of eye care, and to the admiration of patients, peers and the community you serve.
In a once-stable, now-fast-fading era dating from the creation of Medicare in 1965 (and yielding soon to Medicare payment reform and an increasingly cranky national economy), ophthalmologists who paid the 25-year educational toll could until recently nurture a host of attachments with little fear of loss.
- Keeping up your surgical skills? This was easy back in the ’80s, when you only had one, maybe two, new ideas to master each year.
- Technical currency? It was easy when buying the latest gizmo was a $5,000 impulse purchase instead of a $500,000 leap of faith.
- Retirement savings? Rock-solid and growing at a safe 12%.
Not so much now.
For those surgeon-clients nearing retirement, I routinely hear sighs of relief. They will not have to agonize over femto. They will give electronic health records a miss. And their nest eggs are all incubated and ready to be hatched to buy lifetime annuities.
For the next-younger generation of surgeons — the 30-, 40- and 50-somethings who paid the same 25-year toll as their baby boomer colleagues and who developed the same fondness for wealth and mastery — it is going to be a different story. Their attachments to many of the superficial perquisites of the ophthalmic lifestyle — accustomed income, total control — will be stretched. Some attachments will be strained. And some will be ripped away.
Adapting to change
Psychologists, mystics and most of the world’s major religious traditions counsel against the misery of unsustainable attachments. As Deepak Chopra once put it, “You are not your Toyota.” Ego identification with mere “stuff” causes pain when that stuff is taken away.
As the fees paid per service unit fall in the years ahead, the healthiest surgeons will adapt. They will realize that they are not their Toyotas (or their BMWs or ski cabins, for that matter). Some, in markets where hospitals will inexorably buy up specialty practices, will realize that life does not end when you move your skills into a larger context.
Other surgeons will rail against their changing circumstances. Some are moaning now, spitting nails at the injustice of disallowed fees, more documentation, new hoops to jump through and the dawning realization that private, independent practice could largely morph into institutional practice within the next generation or sooner.
How much will you have to adapt? Nobody knows at this point. How well will you adapt if forced to? That is the important, highly personal question.
Here are four 1-day exercises that may give you some personal insights:
- For 1 full clinic day, set aside any thought of personal financial gain. Practice for 1 day on a break-even basis. If you normally generate a net profit after all expenses of about $1,000 (a typical mid-range figure, after taxes are removed), write a check out in that amount at the start of the day to a favorite charity. Then do your work. Serve each patient knowing that you will get nothing, financially speaking, for it. Then sit down at the end of the day. Did you feel differently about your job? Did the frank absence of a paycheck for that day make you miserable about your work? If, as when conducting a foreign mission trip, you felt somewhat invigorated giving your services away for free that day, you will be better prepared than most for what is coming down the line.
- For 1 full clinic day, practice as if you were never going to retire. Would you arrive at the same time in the morning or a bit later, lingering over the paper or perhaps starting the day at the gym? If you were going to be working the rest of your life, are there staff or patients you would dismiss from your practice, not worrying really about the near-term financial consequences because, hey, you are going to work the rest of your life anyway? May as well make it fun, right? Based on this exercise, and your actual retirement plans, what insights do you have about how you should be practicing in the years ahead?
- For 1 full clinic day, practice solely as an homage to your teachers. Begin by sitting quietly and alone for 30 minutes before the first patient arrives. Write down the names of your most influential teachers, starting with your parents and grammar school classes, and continuing through to the most recent pearl you received from a colleague at a national meeting. When the first patient of the day is roomed and prepped and as you walk in to greet them, imagine that all of the teachers you wrote down are in the room shadowing you, nodding approvingly at your work. Continue in this manner until the last patient is discharged. At the end of the day, sit down for another quiet 30 minutes and write down what you noticed about the day. How much have you advanced since your first lecture on glaucoma? Did it matter how many surgical cases you booked? Was the difficult patient a bit less irksome?
- Finally, practice for 1 full clinic day as though this were your last 8 hours as a physician. Imagine that each patient encounter is your last time with that patient, and that as the afternoon wears on and the countdown proceeds until the very last visit, the sand is running out of your ophthalmic hourglass. Notice how it feels to say good-bye to each patient and perhaps how you linger a bit or smile a bit more warmly.
Most eye surgeons attend clinic 4 days a week. Pick any week you like. Next week will do. Perform these exercises and you will have a good read on how the rest of your career is likely to go.