By the Numbers

Seizing life in Paris, seizing life in your practice

Dear Reader,

This marks my 40th year as a consultant and a 34-year collaboration I am humbled to have enjoyed with SLACK Incorporated/Ocular Surgery News all these years and all the years remaining. With spring upon us, thoughts turn to Paris (the best place for springtime!) and a column I wrote for OSN 17 years ago on April 11, 2002, at the Cafe Rue du Bac, exactly 7 months after 9/11. Our contemporary stresses have shifted, and arguably deepened, since those days. But the cure described below endures. I hope you find it effective.

Warm regards,
John Pinto
J. Pinto & Associates, Inc.

I am sitting close to the north entrance of the Louvre Museum, in a small outdoor café, counting down the last few hours of a 10-day bittersweet trip. A dear old friend from my youth, a mid-level French bureaucrat named Jean-Philippe Atger, had died a few months earlier on Oct. 31 from some indeterminable collusion between his poorly managed diabetes and hepatic cancer. So it goes.

Jean-Philippe and I were supposed to see each other about a month before he died, but Sept. 11 intruded, international travel was thrown into question, and that visit was replaced by this one, to attend a series of small gatherings in his honor.

Along with many old friends, I have just spent several days with Marie-Claude, Jean-Philippe’s mother. She and I first met some 25 years ago. I had reminded her back then of the young American soldiers who had liberated Paris when she was just 14 years old. It was love at first sight for both of us, back then, as now.

Here was a woman who had spent her tender, formative years under the leering eye of the Gestapo. She had lost a husband, and now, not one but both of her sons. Yet, like her vibrant children, she is squeezing the juice from life even now. A semiretired librarian, 72 and bearing a cane, she had just returned from a research visit to Italy the day I arrived in Paris. On the phone, she sounded like a schoolgirl. She still attends the opera weekly. She entertains lavishly. Her cooking one-ups Wolfgang Puck. And at one of our parties, when I poured her a whiskey, she insisted, with a frown, then a smile, that I tipple a bit more into the glass. That’s Marie-Claude.

It is nearly impossible to be somber in Paris. But sitting here in the shadow of what remains of the world’s greatest artists, perhaps the world’s greatest thinkers, it is abundantly easy to be philosophical. Perversely, here at my sidewalk seat, my thoughts return to the work that is waiting for me back home as a consultant — and the growing misery of the average ophthalmologist in America.

Are we again at the fringes of a gathering storm in the American health care system? As one academic surgeon recently wrote me, “We are like pilots, with the nose of our plane pointed down, approaching terminal velocity, while we are screaming, ‘Mayday! Mayday!’” And no one is listening. I should know. In the weeks before I left for Paris, I had separate calls from a couple of clients — active, nominally successful, young-for-their-age doctors who each said they were ready to hang it up.

The Washington Post and New York Times op-ed pages now regularly print columns that have not been seen since a decade ago in the early 1990s. “It is virtually certain that health care will be as big an issue in the 2004 presidential election as it was in 1992. ... Conventional wisdom in politics has held that only incremental change [the muddling through we have all experienced in ophthalmology] makes sense. But a growing number of major players are now challenging that view,” David Broder wrote. He quotes a leader of the emerging National Coalition on Health Care (with august members like AT&T and the retirement system for all of New York state), saying that the problem is far more serious than anyone in politics is acknowledging. Incrementalism must yield to a top-down national policy fix, they are now saying.

Once again, medical spending is growing much faster than the rest of the economy. Simultaneously, the number of uninsured and underinsured is growing. Employers are shifting a larger portion of health care premium costs to workers, who, quite naturally, will acquiesce to watered-down coverage to maintain the largest possible share of their shrinking real incomes. “Surely, this is intolerable, and change will follow,” Leon Eisenberg, MD, of Harvard Medical School, said in a 1999 speech. “What is not self-evident is what will be left in its wake.”

Whatever is left, I promise you, will translate to less net income per unit of service you provide as an ophthalmologist to your patients. Consider it already a fact. And given that fact, you have three possible responses:

  1. You can leave the profession. This is suitable to those who are financially and otherwise prepared for retirement. Unfortunately, for the majority who are short of retirement — by age or net worth — there is relatively little to go on to with your highly customized skills that, without significant additional training and luck, will yield more income (and I dare say more satisfaction) than will be enjoyed by the average eye surgeon even 15 years from now. The average ophthalmologist this year will make about $230,000 before taxes. Cut that in half, and your income is still easily in the top 10% or so of American wages. The green grass on the other side of that fence may be Astroturf.
  2. You can kick and fuss and make yourself miserable. But consider this: Very few fellow doctors, much less the general population, will have much sympathy for your cause. And everyone around you will be miserable, too. Your patients. Your staff. Your family. Many surgeons I know are still trying on this option for size.
  3. You can commit to making those aspects of your practice that are under your control be as successful and pleasant and joyful as possible — and somehow live with the parts you cannot really control. Still want to make as much income as possible? Simply learn how you can transit 90 patient visits a day (it can be done in a way that keeps patients happy). Be more productive. So long as we are in a largely fee-for-service environment, expand the scope of care you provide, within the envelope of your personal competency, and refer a little less out to subspecialists.

Yes, your work must be clinically correct. And it must also be commercially practical. But there are limits to perfection in both cases. Your medical and surgical judgement will never hit 100%, not even on a single day. The next era of reimbursement constraints will likely drop both the clinical and profit altitude of your practice. In France they have a saying that uses the analogy of a hunted bird, that while surviving, nonetheless takes a few lead pellets in its wings and thus flies a little lower to the ground. That is where we are headed, I am afraid.

Try being a little more European in your outlook. If in the future you cannot have the thrill and cash flow of what medical entrepreneurism used to provide, you can at least reintroduce a little alternative control and joie de vivre:

  • Surround yourself with staff who please you. Do not hire anonymous cogs in your machine (old thinking), but fascinating, extraordinary individuals who you truly love working with (and who love working with you and your patients, so their wage demands will be tempered). Ask yourself: “How many of the staff I employ today would I love to take out for a long lunch to talk about the world?”
  • Decorate your office in a manner that pleases you. I don’t care if that means several pieces of fine art or Uncle Louie’s stuffed moose. You are in the vision-enhancement business, dear reader; start by first enhancing what you get to stare at 8 hours a day.
  • The same goes for sound. Pick out 100 CDs of your favorite music and play this in the background all day long. You are the boss, why not? And when your favorite piece comes on, instruct your staff to crank up the volume. Your office, your rules, I say.
  • Tell your office manager he or she is now really a “happiness manager,” charged with making you smile, not just fiscally, but in lots of other ways. With fewer hassles. With great, independent decision-making. Be sure to return the favor.
  • Tell your management consultants, accountants and attorneys to change their focus from just maximizing profit each year to helping you be as productive and as happy as possible, given the times ahead of us.
  • Dismiss those patients you really do not like. Are you still in free enterprise or a slave? Even the most modest retail establishments still post a sign: “We reserve the right to refuse service to anyone.” Skip the sign, but cop the attitude. It will be good for your head, while everything else is slipping a bit further out of your control in the coming years.
  • Stop being so darned deliberate. You are working in one of the most precise fields of medicine. Do not simultaneously put your life in the vise grips of orthodoxy. If you wake up and feel like wearing a wild tie and high-tops, go for it. Revolt. As Thomas Jefferson said, “A little rebellion is a good thing.”

While we are at it, eat delicious, moldy cheese, even if once out of 10,000 times it will send you to the hospital. Have wine with dinner and, afterward, the cognac and the espresso, even if it keeps you up at night. And for God’s sake, enjoy an occasional cigar. Stop being safe, sane, conventional and sanitary.

From time to time, be a little less Protestant in your work ethic and goof off for the day. Putter. Do not be entirely practical. Your life — and by extension your practice — should be a work of art. How is the canvas coming out so far? Have you just been using paints called “surgical volume” and “net after tax income,” or is there more to your palette?

If your practice and where it is going is not making you happy, find additional passions to replace those you used to get from earnings, case volumes and competing with Joe down the street. If you are alone, join others. At least 20% of the clinical facilities, equipment and support staff in this country are wasted. Sit down with a few local colleagues to see how you could use the excess a little more efficiently, sharing a visiting subspecialist, perhaps.

A few days ago, here in this great city, I had dinner with another old pal, Michel Arowns, and his friend, Anne. She is a clinical psychiatrist and probably one of the more successful doctors in Paris, yet she drives around a 12-year-old beater, so she can spill resources with abandon into the things that seem to be more important in her life: a beautiful, art-filled office, a “little place in Corsica” and some of the best wine I have ever tasted.

Her path is the path followed by medical professionals all over Europe. And soon, perhaps, to be followed by her colleagues in this country. In America, we spend about 14 cents out of every dollar on health care. In Europe, that figure is 5 to 10 cents, depending on the country. There is simply not as much to go around. European physicians have been resource-starved for decades, but their world has not come to a halt. They have compensated with smaller homes and office spaces that are still immaculately appointed. They have compensated with shorter work weeks and by taking the time to not only smell the roses but to grow them as well.

Do not let the distress of your practice rob you of the pleasures that are all around you. Certainly not now, and not even later, as the inevitable reform pressures are reapplied to all of us in the years ahead.

Slack off a little. You will live longer. But do not slack off entirely. Set aside enough extra income for your own foreign fact-finding visit this year. I promise you the things you will learn here in a few days on the streets of Paris will serve you better than any management course I could ever hope to give.

Faîtes que le rêve devore votre vie afin que la vie ne devore pas votre rêve. – May your dreams devour your life before life devours your dreams.

Dear Reader,

This marks my 40th year as a consultant and a 34-year collaboration I am humbled to have enjoyed with SLACK Incorporated/Ocular Surgery News all these years and all the years remaining. With spring upon us, thoughts turn to Paris (the best place for springtime!) and a column I wrote for OSN 17 years ago on April 11, 2002, at the Cafe Rue du Bac, exactly 7 months after 9/11. Our contemporary stresses have shifted, and arguably deepened, since those days. But the cure described below endures. I hope you find it effective.

Warm regards,
John Pinto
J. Pinto & Associates, Inc.

I am sitting close to the north entrance of the Louvre Museum, in a small outdoor café, counting down the last few hours of a 10-day bittersweet trip. A dear old friend from my youth, a mid-level French bureaucrat named Jean-Philippe Atger, had died a few months earlier on Oct. 31 from some indeterminable collusion between his poorly managed diabetes and hepatic cancer. So it goes.

Jean-Philippe and I were supposed to see each other about a month before he died, but Sept. 11 intruded, international travel was thrown into question, and that visit was replaced by this one, to attend a series of small gatherings in his honor.

Along with many old friends, I have just spent several days with Marie-Claude, Jean-Philippe’s mother. She and I first met some 25 years ago. I had reminded her back then of the young American soldiers who had liberated Paris when she was just 14 years old. It was love at first sight for both of us, back then, as now.

Here was a woman who had spent her tender, formative years under the leering eye of the Gestapo. She had lost a husband, and now, not one but both of her sons. Yet, like her vibrant children, she is squeezing the juice from life even now. A semiretired librarian, 72 and bearing a cane, she had just returned from a research visit to Italy the day I arrived in Paris. On the phone, she sounded like a schoolgirl. She still attends the opera weekly. She entertains lavishly. Her cooking one-ups Wolfgang Puck. And at one of our parties, when I poured her a whiskey, she insisted, with a frown, then a smile, that I tipple a bit more into the glass. That’s Marie-Claude.

It is nearly impossible to be somber in Paris. But sitting here in the shadow of what remains of the world’s greatest artists, perhaps the world’s greatest thinkers, it is abundantly easy to be philosophical. Perversely, here at my sidewalk seat, my thoughts return to the work that is waiting for me back home as a consultant — and the growing misery of the average ophthalmologist in America.

PAGE BREAK

Are we again at the fringes of a gathering storm in the American health care system? As one academic surgeon recently wrote me, “We are like pilots, with the nose of our plane pointed down, approaching terminal velocity, while we are screaming, ‘Mayday! Mayday!’” And no one is listening. I should know. In the weeks before I left for Paris, I had separate calls from a couple of clients — active, nominally successful, young-for-their-age doctors who each said they were ready to hang it up.

The Washington Post and New York Times op-ed pages now regularly print columns that have not been seen since a decade ago in the early 1990s. “It is virtually certain that health care will be as big an issue in the 2004 presidential election as it was in 1992. ... Conventional wisdom in politics has held that only incremental change [the muddling through we have all experienced in ophthalmology] makes sense. But a growing number of major players are now challenging that view,” David Broder wrote. He quotes a leader of the emerging National Coalition on Health Care (with august members like AT&T and the retirement system for all of New York state), saying that the problem is far more serious than anyone in politics is acknowledging. Incrementalism must yield to a top-down national policy fix, they are now saying.

Once again, medical spending is growing much faster than the rest of the economy. Simultaneously, the number of uninsured and underinsured is growing. Employers are shifting a larger portion of health care premium costs to workers, who, quite naturally, will acquiesce to watered-down coverage to maintain the largest possible share of their shrinking real incomes. “Surely, this is intolerable, and change will follow,” Leon Eisenberg, MD, of Harvard Medical School, said in a 1999 speech. “What is not self-evident is what will be left in its wake.”

Whatever is left, I promise you, will translate to less net income per unit of service you provide as an ophthalmologist to your patients. Consider it already a fact. And given that fact, you have three possible responses:

PAGE BREAK
  1. You can leave the profession. This is suitable to those who are financially and otherwise prepared for retirement. Unfortunately, for the majority who are short of retirement — by age or net worth — there is relatively little to go on to with your highly customized skills that, without significant additional training and luck, will yield more income (and I dare say more satisfaction) than will be enjoyed by the average eye surgeon even 15 years from now. The average ophthalmologist this year will make about $230,000 before taxes. Cut that in half, and your income is still easily in the top 10% or so of American wages. The green grass on the other side of that fence may be Astroturf.
  2. You can kick and fuss and make yourself miserable. But consider this: Very few fellow doctors, much less the general population, will have much sympathy for your cause. And everyone around you will be miserable, too. Your patients. Your staff. Your family. Many surgeons I know are still trying on this option for size.
  3. You can commit to making those aspects of your practice that are under your control be as successful and pleasant and joyful as possible — and somehow live with the parts you cannot really control. Still want to make as much income as possible? Simply learn how you can transit 90 patient visits a day (it can be done in a way that keeps patients happy). Be more productive. So long as we are in a largely fee-for-service environment, expand the scope of care you provide, within the envelope of your personal competency, and refer a little less out to subspecialists.

Yes, your work must be clinically correct. And it must also be commercially practical. But there are limits to perfection in both cases. Your medical and surgical judgement will never hit 100%, not even on a single day. The next era of reimbursement constraints will likely drop both the clinical and profit altitude of your practice. In France they have a saying that uses the analogy of a hunted bird, that while surviving, nonetheless takes a few lead pellets in its wings and thus flies a little lower to the ground. That is where we are headed, I am afraid.

Try being a little more European in your outlook. If in the future you cannot have the thrill and cash flow of what medical entrepreneurism used to provide, you can at least reintroduce a little alternative control and joie de vivre:

  • Surround yourself with staff who please you. Do not hire anonymous cogs in your machine (old thinking), but fascinating, extraordinary individuals who you truly love working with (and who love working with you and your patients, so their wage demands will be tempered). Ask yourself: “How many of the staff I employ today would I love to take out for a long lunch to talk about the world?”
  • Decorate your office in a manner that pleases you. I don’t care if that means several pieces of fine art or Uncle Louie’s stuffed moose. You are in the vision-enhancement business, dear reader; start by first enhancing what you get to stare at 8 hours a day.
PAGE BREAK
  • The same goes for sound. Pick out 100 CDs of your favorite music and play this in the background all day long. You are the boss, why not? And when your favorite piece comes on, instruct your staff to crank up the volume. Your office, your rules, I say.
  • Tell your office manager he or she is now really a “happiness manager,” charged with making you smile, not just fiscally, but in lots of other ways. With fewer hassles. With great, independent decision-making. Be sure to return the favor.
  • Tell your management consultants, accountants and attorneys to change their focus from just maximizing profit each year to helping you be as productive and as happy as possible, given the times ahead of us.
  • Dismiss those patients you really do not like. Are you still in free enterprise or a slave? Even the most modest retail establishments still post a sign: “We reserve the right to refuse service to anyone.” Skip the sign, but cop the attitude. It will be good for your head, while everything else is slipping a bit further out of your control in the coming years.
  • Stop being so darned deliberate. You are working in one of the most precise fields of medicine. Do not simultaneously put your life in the vise grips of orthodoxy. If you wake up and feel like wearing a wild tie and high-tops, go for it. Revolt. As Thomas Jefferson said, “A little rebellion is a good thing.”

While we are at it, eat delicious, moldy cheese, even if once out of 10,000 times it will send you to the hospital. Have wine with dinner and, afterward, the cognac and the espresso, even if it keeps you up at night. And for God’s sake, enjoy an occasional cigar. Stop being safe, sane, conventional and sanitary.

From time to time, be a little less Protestant in your work ethic and goof off for the day. Putter. Do not be entirely practical. Your life — and by extension your practice — should be a work of art. How is the canvas coming out so far? Have you just been using paints called “surgical volume” and “net after tax income,” or is there more to your palette?

If your practice and where it is going is not making you happy, find additional passions to replace those you used to get from earnings, case volumes and competing with Joe down the street. If you are alone, join others. At least 20% of the clinical facilities, equipment and support staff in this country are wasted. Sit down with a few local colleagues to see how you could use the excess a little more efficiently, sharing a visiting subspecialist, perhaps.

PAGE BREAK

A few days ago, here in this great city, I had dinner with another old pal, Michel Arowns, and his friend, Anne. She is a clinical psychiatrist and probably one of the more successful doctors in Paris, yet she drives around a 12-year-old beater, so she can spill resources with abandon into the things that seem to be more important in her life: a beautiful, art-filled office, a “little place in Corsica” and some of the best wine I have ever tasted.

Her path is the path followed by medical professionals all over Europe. And soon, perhaps, to be followed by her colleagues in this country. In America, we spend about 14 cents out of every dollar on health care. In Europe, that figure is 5 to 10 cents, depending on the country. There is simply not as much to go around. European physicians have been resource-starved for decades, but their world has not come to a halt. They have compensated with smaller homes and office spaces that are still immaculately appointed. They have compensated with shorter work weeks and by taking the time to not only smell the roses but to grow them as well.

Do not let the distress of your practice rob you of the pleasures that are all around you. Certainly not now, and not even later, as the inevitable reform pressures are reapplied to all of us in the years ahead.

Slack off a little. You will live longer. But do not slack off entirely. Set aside enough extra income for your own foreign fact-finding visit this year. I promise you the things you will learn here in a few days on the streets of Paris will serve you better than any management course I could ever hope to give.

Faîtes que le rêve devore votre vie afin que la vie ne devore pas votre rêve. – May your dreams devour your life before life devours your dreams.

PAGE BREAK