I used to practice pediatrics. It has been several years since I decided to leave medicine, but people still ask me about it, and I find myself offering neat explanations between gulps of coffee. Of course, the full truth is much more complicated. The full truth has as much to do with our health care system and our culture as it does with me.
My journey in pediatrics was not entirely typical. I went through Georgetown University’s medical school on a Navy scholarship, which meant that, unlike most of my peers, I spent my formative years as a pediatrician practicing under a system of universal health coverage in the U.S. military. All patients — admirals’ sons as well as the stepchild of a seaman apprentice — received excellent care. Doctors were well paid, and the standards and quality of care were as high as I have observed anywhere. No money exchanged hands: Just show your card and you were in.
Fast forward 10 years and I was in a thriving private practice in suburban Rhode Island, along with several other dedicated, highly trained pediatricians, and an army of nurses. I quickly learned how methods of reimbursement shape the way doctors practice. Private insurance companies decide who gets paid for what, so pediatricians treat serious mental illness with little psychiatric training, use nebulous tools to diagnose attention deficit disorders, and valiantly tilt at the windmill of childhood obesity, not because we can do this most effectively, but because we are the only professionals who can get paid to do so.
At the other end of the treatment spectrum, free market forces often urge us to over-intervene with minor illness, where less really would be more. For example as baby spit up acquired more syllables, expensive medications to treat infant gastroesophageal reflux earned full page glossy ads in parenting magazines, pharmaceutical industries poured tons of money into self-serving clinical studies, and prescriptions flew off our pads.
The economics of health care trickled down into my exam room, into the conversation between doctor and patient, distorting the relationship. Most of my patients, children of the “worried well,” had self-limited illnesses that would get better without any intervention from me. I had to explain again and again to frustrated parents, who had just shelled out a $25 copay, why their child didn’t need antibiotics — or any other medicine — for a cold. I met skepticism, even hostility, as I explained for the hundredth time why a 3 a.m. earache wouldn’t improve with a visit to the emergency room. “Do you know how much I pay in health premiums?” parents would ask. Our system of paying for health care and the stresses on today’s families were pitting my best medical judgment for the child against all the other worries and desires of the parents.
Important things have been happening to keep kids healthy — things like vaccines, nutritional advice and safety education — and these have been provided most effectively by nursing staff, expertly doing what they were trained to do. If a mom was hanging on to her crummy job just to keep health benefits, then it was not too surprising when she insisted on potty training advice from no one less than a board certified pediatrician, thank you very much. I loved chatting with families, but I was spending too much time as Dr. Mary Poppins, pulling an endless supply of fuzzy child care advice out of a carpet bag as I burned up $60 office visits weighing the benefits of naps vs. no naps. (If there were any lectures on naps in my residency training, I must have slept through them.)
I, like most of my colleagues, valiantly stepped up to the plate and kept on swinging, even as I was being pulled farther and farther from the doctor I was trained to be. I did my part to put a scientific spin on our highly subjective approach to learning disorders. I patiently played along with obsessive discussions on toilet training without acknowledging the toll such indulgence took on precious health care dollars, as I tried to meet the ever-expanding expectations of the “worried well.” I taught myself as much as I could about mood-altering drugs so that my depressed patients, denied appropriate access to psychiatrists, would have some one to turn to. In short, I helped put the “dys” in dysfunctional.
In the end I just got tired. Literally. At 46-years-old, being up all night and working the next day left me physically ill. Meanwhile, my own two teenage daughters were spending too many nights at home alone while both their parents tended to patients. So when I was unexpectedly presented with a way out — the chance to teach chemistry at an all-girls’ high school — I took it. It was a painful, difficult choice, but it was the best decision for me and my family.
I have hope for my profession. I believe our society will eventually see the economic sense and moral imperative of universal health care coverage, paving the way for health care to be designed by health professionals, and to be viewed as a right and a responsibility, rather than a commodity to be purchased. I believe that pediatrics can evolve, too, in a way that will truly meet our society’s health needs. We will always need pediatricians to understand and cope with complex or dangerous illness. We will also need trained health care providers, like pediatric nurse practitioners, to deliver competent, less expensive care for health maintenance and minor illness. Pediatricians in turn will need to be trained in how to support those practitioners.
Finally, in an age when public health issues like obesity are what pose the greatest threats to our children, pediatricians will need to move out of the confines of the fee-for-service exam room to advocate for effective health care policy in the wider community. This shift in how we focus and pay for pediatric expertise will be challenging, but I know there is a whole new generation of young students out there who will be up for the task, and a new generation of children counting on us.
Maggie Kozel is the author of The Color of Atmosphere: One Doctor’s Journey In and Out of Medicine, forthcoming from Chelsea Green Publishing, and blogs at Barkingdoc’s Blog.
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