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It is my impression that, with the looming prospect of “Obamacare” reforms and possible decreases in reimbursement payments, orthopaedists will have to work harder to maintain their incomes, possibly at the expense of personal and family life. The situation creates a “double whammy”—less income or less family life. So that’s where the “rubber meets the road” and the decision becomes which is more important—family or finance.

AAOS Now

Published 5/1/2011
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S. Terry Canale, MD

I ain’t much, but I’m all I think about

Personally, I had no decision to make and no excuse such as “Obamacare.” I wanted a great career at all costs. I prayed to the Lord to make me rich and famous—He not only didn’t make me rich and famous; He made me bald and ugly.

My practice, my career, and my reputation were all totally consuming, at the expense of everything else, including my family. “I ain’t much, but I’m all I think about.”

Looking back on my career, I have a modest 401(k) and did not become a Sir John Charnley or even a Dr. Jimmy Andrews, but don’t get me wrong—I love orthopaedics and what I do. To me, it is one of the few professions where, when you wake up, you want to go to work. “Me and my practice ain’t much, but we’re all I think about.”

I put orthopaedics and my career above everything else. That became the problem: I did it at the expense of my family. I raised two children by not being there for them. “I never missed an opportunity to miss an opportunity” to be there with them. As a consequence, there was an 18-year “black hole” during which their mother raised them because I, their father, was missing. Now, as a result, my relationships with them are pleasant but a little distant, and there is nothing I can do about it. I can’t get those formative “black hole” years back. I thought I was supplying them financially with a “good life,” but what they needed was a “good father” who was there for them.

I hear orthopaedists today saying, “I can’t make a living getting paid 105 percent of the Medicare fee schedule,” and “With some insurance plans, it costs me money to see the patient.” I understand the “four horsemen” of an orthopaedist whose practice is being strangled by low and slow reimbursement—(1) terror, (2) bewilderment, (3) frustration, and (4) despair—but most, if not all, orthopaedists enjoy a nice lifestyle, have a retirement account in seven or eight figures, and at retirement have enough to carry them through the golden years with some left over in their estate for their children.

At my clinic, I park in the “staff-only” spaces. To my left is a Porsche 911 Carrera, to my right is a Hummer with all the bells and whistles—now, who’s kidding whom? Patients frequently ask questions about an orthopaedist’s ability, but have you ever noticed that they never ask about how much money you make? It finally dawned on me that I wasn’t working hard for my family or even my lifestyle—I was working hard to satisfy my ego. As Ramon Jimenez, MD, reminds me, “My ego ain’t my amigo.” It was all about me: “I ain’t much, but I’m all I think about.”

John R. Tongue, MD, AAOS first vice-president, uses what he calls a “Happiness, Satisfaction, and Fulfillment (HSF) Factors” graph in teaching communication seminars (Fig. 1). Notice that when you first start your practice, you are happy as a clam. Your practice is small, but growing with new patients (red line on graph). You are happy, satisfied, and fulfilled (blue line on graph), and your medical liability risk is low (green line on graph). At some point, as you get busier and busier, you reach what is termed the HSF Inflection Point, where you begin to see too many patients and become overworked. Look what happens: Your happiness, satisfaction, and fulfillment begin to drop off and your malpractice risk begins to rise rapidly. Don’t let this happen to you.

Don’t get me wrong, I like a dollar as much as anybody; in fact, I’ve never met a dollar I didn’t like! But I have quit thinking about only the dollar.

My advice to younger fellows has changed. Today, I say, “Be there for yourself and your family. Try to pause and live in the moment.”

For me, trying to pause is like working up a sweat in an aerobic exercise—not easy. But I am trying to take off the blinders and look around.

The road gets narrower as you get older. By that I mean that you have fewer choices you can make about your life. Pause and sniff the fresh-cut flowers and wear the garment loosely. Walk on the beach into the wind with your family. Remember the old proverb: “Quit running so fast—the prize may be behind you.”

This issue of AAOS Now (May 2011) includes two articles on physical and mental stress on orthopaedic surgeons. The first is by Luis T. Sanchez, MD, who is the immediate past president of the Federation of State Physician Health Programs. Dr. Sanchez describes the physician who is unaware of his or her physical and mental health problems or, what is worse, is aware but unwilling to seek medical and/or psychological assistance. Dr. Sanchez outlines some practical solutions, including state-sponsored physician health programs that provide counseling and advice about more than addictive behavior; they also can help with all aspects of mental and physical health problems.

The second article, by S. Jay Jayasankar, MD, deals with mental decision-making. Quite often, correct decision-making is impaired by physical and mental overwork, thus making our patients vulnerable and our practice unsafe. Much has been said about resident work hours, but how about work hours for physicians on staff? Dr. Jayasankar uses a “pyramid” approach as a mental health model to determine how we make decisions, both good and bad. He also describes overwork, tiredness, distractions, and the “I’ve-been-there” attitude that can contribute to bad decisions.

Take it from someone who learned all too well that all I think about ain’t just about me. Think about the journey with you and your family, not the destination.