Basta la Vista, Baby
(Enough Is Enough)
By E. Noel Preston, MD

   Many years ago I had a totally dreadful experience with an ugly, slovenly woman and her horrible toddler Jeremy. The woman had a high-pitched cackling voice and needed to have almost everything repeated, because Jeremy flicked the light switches on and off, opened all the doors of the examining room cabinets and crawled inside each one, screamed and fought when I tried to look in his ears or listen to his chest, and constantly interrupted whenever I tried to talk to his mother. She did nothing whatsoever to make him behave. I thought, "Who needs this?" and gave serious thought to quitting pediatrics and becoming a dermatologist. But then I thought if I did, this oafish, toad-shaped creature would be able to tell all her friends for years and years, "Yes, my little Jeremy was such a handful he just drove poor old Dr. Preston right out of practice. He just quit on the spot and walked out the door!" and I didn't want to give her the satisfaction.

   Practice has become harder and harder, and not just because of the escalating cost of liability insurance, wages, rent, energy, or vaccines and medical supplies. Blue Cross/Blue Shield will approve a charge for an "intermediate" level visit for a 2-year-old child with a cough, but will downgrade the charge to a lower paying "brief" level visit for the same child's 4-year-old sister with the same illness.
Apparently insurance companies think it takes less time to diagnose and treat a preschooler than it does a toddler, and so they pay less for taking care of an older child than they do a younger one.

   Every two years or so the insurance companies send a nurse to inspect doctors' offices to see if we are a menace to the public. There must be a fire extinguisher visible from the waiting room. We must have a disaster evacuation map and plan posted everywhere so our patients will know what to do if there is a fire or tornado. We are required to measure and log the refrigerator temperature twice a day to protect our vaccines and pharmaceuticals. None of this measures a doctor's integrity or sense of responsibility to answer a late night call from an emergency room or intensive care nursery. The nurses are paid to report deficiencies, and they won't leave a doctor's office until they find one -- otherwise their bosses would think they are lazy or nonproductive. After I wised up to this I started hiding the fire extinguisher, so they would have something to report and I would be assigned a deficiency that would be easy to correct.

   The federal government requires every doctor to keep a vaccine log for every vaccine we give, and most infants get four vaccines at every well baby visit. Each entry must have the name of the vaccine, its manufacturer, lot number, expiration date, the date we give the vaccine, the name of the child who gets it, and the initials of the person who administers it. All this information must be written in the patient's chart as well. This is in addition to filing out a claim for the insurance company and entering this information on the patient's account record. There is a mountain of paperwork needed for every baby's visit to the doctor, and none of it indicates how fine or shabby is a doctor's performance.

   Pediatricians, in addition to keeping records of babies' heights and weights, diet, and developmental milestones, and, by the way, listening for heart murmurs and checking for hernias, enlarged livers, and looking at tonsils, have to answer questions about orange vegetables and green bowel movements. We are also supposed to ask about bicycle helmets, smoking, seat belt use, toilet training and sibling rivalry. How can we do all this and still know if a child's father has lost his job, or the child's grandmother just died, or if the mother's gone back to work and put the children in daycare?

   I seem to remember nationally syndicated columnist Charles Krauthammer, himself once a practicing MD, calling the 50+ year old pediatrician one of our national treasures. This man (or woman) has probably endured and survived most of the life experiences any parent would encounter throughout a lifetime: the birth of a new child, buying a new house, transferring to a new city, the birth of another child, toilet training, sibling rivalry, thumb sucking, school problems, adolescent rebellion, and regrettably, perhaps divorce, teenaged pregnancy, or the death of a parent. Who else could possibly be better trained, experienced, or qualified to help families rear and nurture their children? But there are fewer and fewer of us every day, and the constant increase in silly, stupid minutiae simply to keep an office open is a good reason why.

   Over the years people have asked me how long I planned to stay in practice, and I would always answer, "As long as it's more fun than not." And it still is fun. I enjoy my patients and their families. I enjoy seeing an illness I haven't seen since medical school. I like the challenge, the responsibility, the intellectual exercise, and the human contact. But the fun ratio is getting smaller all the time. A porno shop opened up next door and new families (and some of the older ones) are hesitant about coming to my office, and so the patient volume is down. The paper work is getting worse. The insurance companies have one reason after another to deny payment for claims. Most of my upper middle class families have moved away and go to other doctors, and the not so upper middle class families don't stay in the neighborhood very long.

   If I were a younger man I would move, but I don't want to sign another lease or go through the physical discomfort and financial strain of moving. And so when I got back from a week in Italy and Susan, my nurse who has been with me for decades, said she was fed to the teeth with all the non-medical procedural (bird droppings) she had to do and wasn't going to put up with it anymore and she was quitting in 30 days, I just said, "WelI, I guess that's it." I could pay $600 or $700 for a help wanted ad and spend a lot of time interviewing a bunch of bird brains and then hire someone I would pay to watch me do their job for several months and then hope for the best -- or not.

   Practicing without having to run the practice might be an option, so I asked a colleague about working part-time in his office. He asked me if I had children living at home, or in school, or if my daughters were married, and I said none of them lived with me. All four are grown, married, educated, and have children of their own. He said, "Why in the world would you want to keep on doing this? I would love to be in your situation. I'm 55 years old, I have two children at home and both their colleges in front of me, and I see no end in sight."

   And so what can I say? Practicing pediatrics for the last 36 years has been a wonderful experience. If I haven't enjoyed every minute of it, I've enjoyed the overwhelming most of it. I've seen and done things people in other kinds of work can't even imagine. I've been important to my patients, but they've become even more important to me. The kindnesses, the sympathies, the friendships they have given make me realize how interconnected all of us are to each other and how terribly lonely people are who have no interconnections at all.

   This has been a grand experience, and I've been torn between continuing to see patients and their families and being a part of helping children grow into adults, and the temptation to chuck it all and get out. But just this morning a young man from the State of Georgia called. He needs to come inspect my office on July 12th. I told him I was retiring and closing the office and it would be a waste of time for both of us. He said he still needs to come to see if I am using fresh reagents. I told him the only lab tests we do are dip stick urinalyses and fingerstick hemoglobins and we don't use reagents. He said he still needs to come to see if we are recording our proficiency testing, and I said we are a "waived" laboratory and don't do proficiency testing. He said the federal government requires the individual States to randomly inspect physician laboratories, and my office is in the random sample and he's coming anyway.

   This is the sort of nonsense that drives doctors like me out of practice!!! As some of my Hispanic patients would say, "BASTA!" Enough is enough. August 31 is the day I will see my last patient, and I'm looking forward to it -- even if it's Jeremy!

E. Noel Preston, M.D. is a pediatrician in solo practice in Peachtree Corners. 6063 Peachtree Parkway, Suite 202-A, Norcross. (770) 448-1553. More information can be found at www.PeachtreeCornersPediatrics.com

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