By Jeffrey Barg.

Published November 1999

• React to this article in the Discussion Forum.

PND: Can you tell me why you decided to retire from medical practice at the age of 39?

DS: I decided to retire from medical practice because I felt that the pressures external to the practice of medicine—the malpractice climate and the business aspect of medicine—were impinging to such a degree that they contaminated the entire practice to the point that it wasn’t rewarding.

PND: Could you elaborate?

DS: I started out in a two-person ob-gyn practice at Chestnut Hill Hospital in the early 90s. We were comfortably successful. And we felt that there were enough people that we wanted to take care of that we needed a third person. We tried to keep control of the practice so that we could see the people that we did see well without being stretched to our limits all the time. We had a number of crises where one person would have to cover the whole practice for a number of weeks. But because we kept it under control that could happen.

Then the climate in Philadelphia changed and the reimbursements were dropping. Things became tighter and tighter so that in order to have a good staff and be able to pay them adequately, we had to see more and more patients. Not to have any increase in salary but just to maintain. And then everybody told us that the big hospitals were buying up all the practices and that if we didn’t join in that the window of opportunity would be closed and we would be left out.

Right about that time the malpractice surcharge came around and almost wiped us out. We had no deep pockets. We had months that we didn’t cash our checks on time because the insurance money hadn’t come in from the work we’d done. And so we sold the practice to Penn.

And that was fine for a year or two. But then the big hospitals got into trouble because they had negotiated these contracts where they were paying people large salaries. We had normal staff attrition and people weren’t replaced. And then there was pressure to become profitable. They wanted us to increase our hours, see more patients. But we didn’t have the staff to answer the telephones or to be in the office before hours started. We had one summer where the staff was being paid to come in the same time as the first patients so you start off your whole day over-booked, behind and everybody’s mad at you all day long. And that’s without the emergencies that come up every day. The pressure to do more and more was constantly growing.

PND: What role did malpractice insurance and the threat of litigation play in souring you to the practice of medicine?

DS: When I started practicing medicine I truly tried to do the right thing medically. And I found an increasing pressure to do the defensible thing. Friends of mine said they never performed a C-section that they regretted. These are people who used to have a twenty-five percent C-section rate. Their babies weren’t any better than they are when you have a fifteen percent C-section rate. But you can defend. "Well I did a C-section. I did the best I could." That’s not always the best thing in the long run for the patient. But it looks like you did something. I found that there was an increase in pressure and hostility in patients when we try to explain surgical procedures and risks. They want to be told you know everything and can handle every situation. And that’s understandable because they’re scared and you’re potentially wielding a tremendous power.

But there’s always the threat that if things don’t come out right, you’re going to be spending hours writing down whatever medical text you’ve read in the last twenty years and grilled and made to feel like you’re stupid or incompetent. There’s more and more pressure to do what a patient wants in terms of time off because if they’re mad that you made them go back to work and if anything doesn’t heal perfectly, then they are going to blame you for saying she was okay and if only I hadn’t gone back to work, this incision wouldn’t have opened or whatever when medically they’re fine to go back to work.

PND: How did you come to your final decision to retire from practice?

DS: The daily practice of medicine was becoming more and more stressful. Dealing with people and their pain and their problems is very difficult. The decisions may not always be hard but trying to deal with the personalities is very hard. When you add people being angry because they have to wait. They couldn’t get appointments on time. They couldn’t get through on the telephone. You’re running late. That could push you over the edge. When every day there’s no slack in terms of the volume, leaving no room for catastrophes. And you work in an office where there is going to be catastrophes. For example, one of my partners had elderly parents and we knew at some point one of them or both of them were going to need major time and care. My other partner at the time I quit was pregnant. And I knew she would be out on maternity leave. One of the other practices owned by Penn had four women and within a few months two of the four quit. And it was known well in advance that they were going to quit and nothing was done to replace them. So these two women were left for over a full year carrying the patient load of four with some backup, some coverage and night call. But no day to day. They didn’t hire anybody else to help them. A full year is a big chunk of your family’s life and that’s a long time to be working on crisis level without even a medical emergency. And I felt there was no support in the big system and that was the whole selling point of the big system. They were going to have the resources so they would always be staffed. They were going to have the resources to always provide physician coverage. They were going to have the power to deal with insurance companies so that the reimbursements weren’t continually being whittled away.

PND: Did you consider going back into private practice?

DS: I considered it. But I would want to have a controlled patient load so that I could give good care to the people I saw rather than seeing zillions of patients in and out or being there all hours of the day. I don’t think that is possible in the current business climate and the way the malpractice insurance industry is these days.

PND: You feared that even if you left Penn, you would face the same overhead burden problem that Penn’s facing?

DS: Exactly. I don’t think that Penn’s an evil giant. They didn’t create the problem. They just haven’t fixed it.

PND: What are you planning to do now?

DS: My husband is an attorney and he and I are considering some form of malpractice review work where potentially we could mediate or evaluate charts to see what the real medicine was and whether something was just a bad outcome or whether there truly was a mistake of some kind.