25 sure ways for a GP to survive, succeed and remain somewhat sane and solvent
DR. M. A. HOPKINSON
AS A PRACTISING GP I enjoyed Maclean's April issue with its emphasis on the "big shake-up in medicine.” The leading article. Quick Now: What's Your Doctor's First
Name?, particularly amused me because in my 16 years of practice in Ontario's Bruce Peninsula my patients have progressively simplified my name from Dr. Hopkinson to Dr. Hoppy to just plain Hoppy.
I regret, but admit, the gradual demise of general practice. As an advisory editor of the Journal of the College of General Practice I realize we are fighting a losing battle. As president of the Bruce County Medical Association i have seen our group dwindle from 39 to 22 in 16 years. Some medical prognosticators think we will be extinct by the end of this century.
However, on the optimistic premise that we still have at least a couple of generations to go. I'd like to offer impending GPs the following advice, which might be entitled "Hoppy's 25 Golden Rules On How A General Practitioner Can Survive And Remain Sane And Solvent.”
1. DON'T LET any community or group rule you. You make the rules and make damn sure they are kept. It you let your body, mind and soul be ruled by the people 24 hours a day. seven days a week, you've had it. And it's amazing how many have tried, to their eventual regret, frustration or breakdown. Patients have to be told this forcibly and often lor. heaven help them, they are worse than jealous lovers. Contrary to medical fiction and TV, life isn't a constant series of acute emergencies, near-deaths, catastrophes. In the average practice several of these occur weekly, but judged by the telephone's incessant ringing, the ratio is 100 times greater than reality.
2. THAI IEIEIMIONE: don't become its servant. The Bell doesn’t own you. contrary to what your patients think. If it annoys you. rip it off the wall. Don't talk to every patient who wants to talk to you—that’s your secretary's job. In one 10-hour oil ice day my telephone rang I S3 times. I his situation is impertinent, deplorable, and I feel that someone should say so. Canadians do more yakking over telephones than any other race on earth, and should bloody well change their inconsiderate bad habits. P.S.: If anyone calls you needlessly at meal hours, tell him he's rude and a boor to boot.
3. PURSUE AS MANY hobbies as you can. practice or no practice. As the
well-rounded citizen you are supposed to be. you shouldn't have to think of grumbling, griping and bellyaches every minute of the day—it's not good for your psyche. Take up something nice and quiet unrelated to medicine, like skiing, or tree-planting — anything so long as it's not medicine. You don't have to overdo the hobby bit. as I probably do — flying, music, painting, hiking, horticulture, rattlesnakes. to name a few. But at least when patients complain that I should be doctoring instead of flying. I can point out that I don't want to become as neurotic as they are.
4. DON’T PRACTISE alone. Acquire a partner, do less work, make less money, and you'll live longer.
5. CO-OPERATE WITH your colleagues (even if you don't like them). There is nothing like a good united medical front against the critical public. People accuse us of belonging to one of the tightest unions; so okay, be pais with your union buddy. Eventually you might even get to like him.
6. Rui E NUMBER FIVE doesn't have to be complied with 100 percent if your fellow-unionist is a specialist. Treat him ethically by all means, but with a degree of disdain, aloofness, perhaps even coldness. C constantly remind your patients that he knows conic a very small field, that he can't see patients warmly as you do — you know, "the whole person” bit — he doesn't make house calls, and that even it he is a fairly good scientific type, he has kost the human touch and. alas, the art of medicine. When you have a case properly worked up. refer the patient to the specialist so
Be kind to salesmen: they keep you posted on town gossip
lhat lie will he returned to you, oddly enough with the same diagnosis and treatment you initiated. The patient will subtly get the word around the community that you know as much as the specialist, charge one fifth his lee, and you're much friendlier. So remember, always play a game of oneupmanship in reverse, with those boys with the FRCSs and FRCPs.
7. Don’i HI AVARICIOUS. DO try to become prosperous (there’s a difference). Any doctor can make a good living in our so-called affluent Canadian society without gouging anyone. I he public’s criticism of the medical profession these days is largely over money (and availability). Let’s face tacts. Because of your long, rigorous training, constant responsibilities and decisions, overwork, and after-hours work, you arc entitled to decent remuneration frankly, to more than the average businessman, teacher, junior executive, accountant or engineer. However, no matter how clever, brilliant, hard-working or devoted you are, you arc not entitled to $50,()()()-$ I ()(),()()() a year. Ibis is what the public resents, and doesn’t realize that most of us, particularly in general practice, are not making that kind of money. That level is reserved for physicians who practise the surgical specialities. ( I respect and admire surgeons, readily admit their need, but why, when we have such a
deficit of GPs. pathologists, psychiatrists, ophthalmologists, researchers, and teachers, do we have such a surfeit of surgeons?)
8. DON’T HITÓME a medical politician. Wc have too many of them already, and as a GP you really shouldn’t have time for the politics of medicine. Organized medicine no doubt has its place, like organized religion and organized labor, but spare yourself a good deal of heartache by shunning it. Don’t forget that it is not doctors that the public dislikes; it is the organized medical profession — ami I don't blame the public.
*). HOUSE I AI IS: do make them if they arc honest-to-goodness emergencies. Don’t make them if they are simply for the patient’s convenience, or an excuse for a social chit-chat, or because the patient doesn’t like sitting in your waiting room. Stick to your guns, because this is one of the thorniest situations in medicine today. Let your patients know exactly where you stand on this issue, frighten them about crying wolf, hut then do your part — in a real emergency be prepared to jump and run and do what you were trained — and swore — to do. This applies to evenings, nights, holidays, weekends and busy office hours, and constitutes both the biggest nuisance and the biggest responsibility of general practice.
10. GET LOTS or modern equipment, and for heaven’s sake use it wisely and often. (íet into debt to the tune of at least $6,000 or $7,000 for an X ray, an electrocardiograph, a bronchospirometer, a good microscope and centrifuge, a tonometer, and good lab facilities. These are the tools of modern medicine and are extremely effective in screening all patients. The patients are impressed with this type ot approach, and you, in turn, will he doing a lot better brand of medicine. Too many doctors arc miserly about equipment, and depend too much on our overburdened hospitals. Do it yourself, and train your office nurse to help you out. We are not in the Osier era of strictly bedside medicine.
M. DEVELOP, PRESERVE, or improve your sense of humor, if you want to survive, and throw in a dollop of honesty. II your eye-blinking, fingerclutching, perspiring female patient says. "Doctor, do you think I’m a little neurotic?” you reply, “Lady, you sure as hell arc!” 1 once had a lanternjawed, rugged old matron demand whether I was dependable or;’not. I replied emphatically. “No,” and she flounced off to my colleagues in the next town. They in turn, admitted they weren't dependable either (what a question!). She finally saw my physician-wife, who admitted to dependability (what an ego!) and that settled that.
Seriously, and when dealing with the cancer question, tell your patients the truth. Pay no attention to the relatives; they are the ones who prod you into evasions, half-truths, and downright lies. If I had cancer I should like to have an honest doctor.
12. DON’T BE TERRORIZED by the Income Tax people. They’ll be the bane of your existence (as (hey are everyone else’s). Play the rules by their book, but take advantage of every exemption you can dream up. If you don't like their findings, appeal your case, and keep on appealing. Get a good tax accountant who knows the ropes. II need he, sue them.
13. DON’T BE TAUGHT medicine by salesmen (they prefer to call themselves “detail men”) from pharmaceutical houses. You teach them — you have the superior education. Remember that they are biased in favor of their own products. On the other hand, he charitable. They have to make a living, and once in a long while one of them might even have a superior product. You will quickly learn that they are born gossips and, once they have taken you into their confidence, will give you a monthly report of who is sleeping with whom in each town in their territory.
14. DON’T MIX BOOZE with work. But after working hours don't let the teetotalers in your practice coerce you out of your pre-dinner cocktail or your nightcap — it is none of their damn business. The first weck I was
Acquire a good-looking nurse and cherish her — as a sister
in practice I had an old biddy say, “Doctor, I hope you don't drink," to which l replied. “I sure as hell do. lady.” I’ve never seen her since — thank God! On the other hand, booze can be a real occupational hazard of the overworked, thwarted, frustrated GP. so watch it.
15. Do RUN YOUR OFFICE by the appointment system — none of this first-come, first-served nonsense. Expect your patients to stick to their appointments, and you stick to yours. Allow a couple of blank spaces for emergencies, for they will surely happen. Alert your secretary to the types w'ho won’t stop talking and she can always invent an emergency for you at the proper time.
16. REMEMBER YOUR WIFE and family deserve some of your time.patients couldn’t care less whether tney bust up a family or not, but you should. (If you’re one of the w'cittf types who are completely marriecr to medicine, then for heaven’s sake don’t marry a woman.) If you've planned a Saturday family picnic and just as you're leaving someone insists on discussing their Aunt Gladys's ailments, give them a real blast, and blast off. After all, they are taking Saturday off as w'ell as you! When patients are rude and inconsiderate, that’s time for you to be rude and inconsiderate.
The only other solution that I know to the wife problem, is do as I did — marry a female physician and put her to work! But then, there aren’t enough of them to go around.
17. SEEK OUT AND acquire a good (and if possible, good-looking) nurse, and/or secretary. Then cherish her (but as a sister), for she can make or break your practice. Unless you're in dire financial straits, don't try to run a practice without such help, or your life can be a veritable hell. She is your protector from the voracious public, your little-white-liar, your giver of injections, and taker ol electrocardiograms, your efficient accountant, your public-relations expert, your pleasant putter-offer. Treat her kindly, pay her well, wine her and dine her—but don't let her completely run your life and practice. When the day comes that she gets too aggressive and protective, lower the boom.
18. DON’T WORRY ABOUT the appearances of affluence. If you want a Rolls-Royce, and you can afford one,
go ahead. Or if you want to fly an airplane (which costs as much as a Rolls-Royce), fly one. A few patients will grumble, and the minute they do, remind them that if you can’t be prosperous in your practice, you'll just have to move on to another place where you can prosper. Better yet. start a campaign in your home town
to "Keep our Doctor Prosperous." Do well by doing good.
19. DON'T SET YOURSELF aloof from nonmedical civic responsibilities. One session a month on your local school board, or town council, or hospital board will be good for you (and your area), and will let you get away from
medicine for a few hours. Mixing with people other than doctors, becoming engrossed in some community problem have their rewards. Smaller communities, particularly, badly need someone with a good education and broad interest on their councils — and who is in a better position than you?
20. ABOUT CHIROPRACTORS: live and let live. Don’t fight with them — co-operate with them. Officially, they
Develop a specialty: it impresses colleagues and patients
may be regarded as a cult, but you would be better oft to regard them as members of the healing arts. You may not agree with them in theory, but you may find that in actual practice they can treat some of your patients better than you. They are practising physical medicine, of which you know too damn little. I hey are also practising
a good deal of psychology, which you should, too!
21. TAKE: COURAGE from the fact that 99 percent of medicine consists, not of highly publicized medical esotérica like cardiac-bypass operations or kidney transplants, but of boils, hernias, emotional problems and strokes, all
of which can be sensibly treated by GPs instead of specialists.
Our specialist and academic friends in ivory towers have promoted the myth about the complexities of medicine and perhaps all of us have nurtured it a bit. The truth of the matter (as many intelligent laymen have always suspected), is that a good deal
of medicine is straightforward and often rather humdrum. You don’t have to be an intellectual giant to do tonsillectomies, treat pneumonia, or deliver babies. Don’t let them kid you!
Any GP worth his salt, no matter how small the backwater in which he practises, can subscribe to several good medical journals, such as the Journal of the American Medical Association. or the weekly Lancet from Britain (but not the Canadian Medical Journal, it's too dull), and keep current with several hours’ reading per week. Graduate and postgraduate courses abound and most of them are excellent. A GP (or specialist) who doesn't keep abreast of the medical scene is guilty of intellectual laziness.
22. EVEN THOUGH YOU'RE supposed to be a medical jack-of-all-trades, develop some special ability -— some minor surgical procedure, or anesthesia, or blood work, or obstetrics. Play this up for all it's worth, and you'll get a little extra respect from colleagues and patients alike. Patients can be heard proudly saying. “You know, our family doctor takes a better X ray than those specialists in the city.’’ Comments of this nature should be subtly fostered.
23. DEVELOP A CORDIAI relationship with hospital superintendents and nurses. These girls (like secretaries) can make or break you. The public constantly checks with them as to who is a good doctor, and these fine girls probably get a fair bit of information extracted from them, unknowingly — so be nice to them. Actually, it's very easy, for every doctor has a soft spot in his heart for nurses — bless them!
24. DISPENSE MEDICINES, by all means, if you’re in a small community. The druggists will hate you for it, and the patients will love you for it. But don’t forget that drugs cost a good deal of money, and if they’re not handled in a businesslike way you can lose your shirt. Patients don't like paying for drugs and I have even had ministers of the gospel ask me to cheat and pad their insurance accounts for their drugs. Just tell them you prefer not to break the law.
By actually handling drugs every day you get to know them well, and it would be a crying shame if doctors were ever legislated out of dispensing. By having to buy drugs yourself, you know what an economic problem they are for the patient and. therefore, you buy and sell economically. In many cases generic drugs are perfectly satisfactory, at a fraction of the cost of those promoted by our large Americanand European-owned drug houses. If you can buy drugs economically from a Canadian-owned drug house, do so.
25. DON'T EVER DO your first illegal abortion — for it won’t be your last. From that sorry day on. you could he blackmailed into further indiscretions. 1 feel, as do most Canadians, that our present abortion laws are cruel, medieval and must he changed. Meanwhile, the law is the law. and remind your demanding patient that you don’t want to spend the next five years in a penitentiary, even if it is I a preferred pen. ★