Enclothed Cognition

 Our new Residency Options series will focus on the wide variety of specialties and areas of practice that medical residents may consider to pursue.  We will be interviewing MDs and exploring their decision making process as they decided what career path they would take. Concierge Medicine is described on Wikipedia (forgive us for going there, but we have discovered just how many residents use it):

Concierge medicine (also known as direct care) is a relationship between a patient and a primary care physician in which the patient pays an annual fee or retainer. This may or may not be in addition to other charges. In exchange for the retainer, doctors provide enhanced care.^[1] Other terms in use include boutique medicine, retainer-based medicine, and innovative medical practice design.

The practice is also referred to as membership medicine, concierge health care, cash-only practice, direct care, direct primary care, and direct practice medicine. While all concierge medicine practices share similarities, they vary widely in their structure, payment requirements, and form of operation. In particular, they differ in the level of service provided and the fee charged. Estimates of U.S. doctors practicing concierge medicine range from fewer than 800^[2] to 5,000.^[3]

To find out more about working in Concierge medicine, we interviewed Dr. Tiffany Sizemore of Choice Physicians of South Florida to learn how she decided to pursue a career in Concierge:

Where did you attend Medical School?

Nova Southeastern University in Ft. Lauderdale Florida.

Where did you do your Residency?

At Palmetto General Hospital- Miami FL

Where there other specialties you considered before deciding on Concierge Medicine?

Internal medicine and cardiology.  I am currently a cardiology fellow as well. Upon completion of my cardiology fellowship, our concierge members will be grandfather'ed in to the cardiology practice as well, if they need to be. I have not yet decided how I am going to approach my outpatient cardiology practice when I graduate. I may offer concierge cardiology as well.

Did you have a mentor who guided you towards Concierge?

Honestly, no. I had heard about concierge medicine from various sources and did a tremendous amount of research on the field prior to jumping in.

What first piqued your interest in Concierge? 

After finishing internal medicine residency, I was convinced that seeing 50 internal medicine patients in one day was not right for me (or for the patient, for that matter). I began to research how I could make a good salary, yet practice medicine the way I thought it was meant to be practiced. I liked the idea that I could see 8 patients a day, not 50. I also liked that I would have the time flexibility to actually follow my patients in the hospital if they had to be admitted. I am a true believer in continuity of care, and concierge medicine helps make that process easier.

What was the biggest challenge beginning your practice right out of Residency?

Lack of business knowledge. My husband and I had to teach ourselves everything. We had to get a business set up with the state, get group NPI numbers, get on all of the insurance plans, market, make brochures and logos, design a website...not including hiring a staff and building a sleep lab. I think I learned more about opening a business in 6 months than most learn in a lifetime.

What has been the biggest ongoing challenge? 

Getting patients! Let me tell you, it is easier said than done. Nowadays, the vast majority of new grads are becoming employed. As a "private" doc, you are in a constant struggle to fight with big groups hospitals for patients and contracts. Most of our patients  have found us through a Google search or by word of mouth. I don't regret the decisions I have made, but it is taking me much longer than I thought it would to get patients;  not just concierge patients but general patients too!

What is the greatest benefit in the choice you made for your career? 

Time and independence. I enjoy being able to form my office schedule around my life. I am very involved with the American Heart Association as well as my fellowship, so having the ability to work around my schedule is wonderful. I am blessed to have my husband in on this adventure with me so he can help with patients during the day if need be. Also, the independence is wonderful. There is no one I have to answer to but myself. If I don't like the way something is going, I change it. If I want to close on a Monday, I do. I have the autonomy to be flexible and do what works for us, without having to run it by someone else first. My husband and I make all of the decisions.

What advice would you give a Resident considering Concierge?

Do your research. Opening an office and practice is VERY time consuming and very costly. We were lucky to have enough money in savings, so we did not have to take out another loan. Have solid goals (but be realistic with them), and make a business plan. Talk to other concierge practices and see how they are doing. Research if your community is in need of such a practice model, before jumping in.  Dr. Tiffany Sizemore owns and practices at Choice Physicians of South Florida, and blogs at www.SizemoreHeart.com.  You can also follow her on Twitter and connect with Choice Physicians on Facebook, Twitter and Google+, 

Our Pathway to PA blog series will explore the varying career paths that brought Physician Assistants to their chosen profession.  We will be featuring Physician Assistants in all phases of their careers and learning about their educational pathway, the challenges and successes they've faced, and any advice they may have for someone contemplating a career as a PA. On this inaugural post in the series we interview Kimberly Mackey, MPAS, PA-C , who also guest blogged for us with her post on High Demand Practice Areas for PAs. Kimberly Mackey, MPAS, PA-Cis a Physician Assistant at UT Physicians- Orthopaedics practicing in the Department of Orthopaedic Surgery at the University of Texas Medical School at Houston and blogger for the American Academy of Physician Assistants PAs Connect. Kimberly began her studies at the University of Florida in Gainesville and majored in biology. She worked in clinical research at the Texas Medical Center before becoming a Physician Assistant. She attended the Physician Assistant Studies Program at the University of Texas Medical Branch. Kimberly graduated as an Interprofessional Scholar and a member of the Alpha Eta Society.

Why did you choose to become a Physician Assistant?

I chose the Physician Assistant profession because it combined everything I love: science, research, treating patients, assisting in the operating room, and performing procedures in the office.  In addition, the Physician Assistant master’s degree had a spectacular return on investment and very positive job outlook for the future.

How long have you been a PA?

I graduated from the Physician Assistant Studies Program at the University of Texas Medical Branch in December 2012; I have been a PA practicing in orthopedic surgery for about one year.

Did you consider becoming an MD or another career in medicine?

Yes. I considered becoming a Physician as our prerequisites are very similar in college. I also considered obtaining a Ph.D so I could become a scientist and work on clinical trials evaluating new drugs.

What are your biggest professional challenges?

I am in the early stages of my career having been in practice for one year. My biggest professional challenge was transitioning from a PA student to a practitioner. In school there is one answer, a correct answer when treating a disease. In practice, we treat people. These people have lives, jobs, and complicated medical histories. Often there is more than one correct answer. There can be different management options depending on how the patient wants to proceed. My first hurdle was transitioning from solely diagnosing and treating diseases during school to taking care of people.

If you could change any decisions you made along the way what would they be?

I would not change any decisions that I made along the way; each struggle has defined me as person. I could have made smarter decisions which would have made my life easier. For example, my life would have been easier in PA school if I took medical terminology as a course before attending. Medical terminology is like learning another language; having a strong background in this allows you to focus on the more important things like clinical medicine and the scientific concepts behind them.

What advice would you give a Pre Med student or anyone trying to choose between being a PA and another medical profession?

My advice is to jump in and get your feet wet. Shadow, speak to different medical professionals, and become involved in some aspect of healthcare. You can always start by volunteering at a hospital. Trial and error is the only way you truly find out what the right profession is for you. Also, look at the financials. What is the cost of school tuition or the average salary of each profession? There are a lot of great pathways to treating patients- physician, physician assistant, or nurse practitioner

What advice would you give a student considering Med School?

Our generation of medicine will be different from our parents' generation. There are three main pathways to becoming a medical provider: Physician, Nurse Practitioner, and Physician Assistant. It is important to sit down and try to figure out a couple of things. How much of your life do you want to dedicate to studying or working once you finish training? What do you want out of a career in medicine long-term? And how much of your personal life are you willing to sacrifice in order to pursue it? If you are a PA and would like to share your story and advice on this series, please email us here.

In doing the discovery work for our Resident Options series here on The Right Fit blog, we have often heard medical professionals lament the current state of Private Practice (among other things).  After I read the post Physician Compensation: Is Private Practice Financially Feasible? it prompted a  Twitter exchange with Suleman Bhana, MD  and Michael Laccheo MD, and Dr. Suleman stated this about Private Practice:

It is nuanced but trend is clear. Physician independence is eroding rapidly in the US.

In that same discussion, the following quote by Dr Laccheo  made me sit up and think, hard:

"I will remain in it until they make it illegal."

With US Healthcare in such a state of confusion right now, we don't think anyone can predict the future of Private Practice over the next 5 - 10 years; we decided to reach out to medical professionals and hear what they think will happen, so we started with doctors Bhana and Laccheo.

 A Bit of Background on Our Interviewees

Dr. Bhana and Dr. Laccheo come at this topic from very different perspectives as far as their working life within the Medical profession.  After graduating from St. George's University in 2006, Dr. Bhana spent 3 years in internal medicine residency, and 2 years in sub specialty fellowship.  He is currently employed as a Physician for a hospital owned group in Northern New Jersey. Arthritis & Rheumatic Diseases of  Williamsburg, Virginia is the private practice where Dr. Michael Laccheo is employed.  After graduating, he worked for 2 years for a large, national healthcare organization.  6 months ago he decided to change jobs; his clinic is owned by two other Rheumatologists.

Doctors Bhana and Laccheo are the founders, with Dr. Paul Suftka, of The Rheumatology Podcast, a bimonthly conversation between of three board-certified, clinical rheumatologists in private practice.  In the interest of full disclosure, we met them because they did a review of our Lab Coats (unpaid and honest).

Defining Private Practice

The shape shifting nature of healthcare over the recent past and foreseeable future makes it necessary to define what we are discussing when we talk about private practice. The Oxford English Dictionary sees the definition of Private Practice quite simply as:

the work of a professional practitioner, such as a doctor or lawyer, who is self-employed.

In the medical profession it is not always so cut and dry, and  the growth of large corporate entities buying smaller practices confuses the issue.  For our purposes, we will go with Dr. Laccheo's description:

I personally only consider private practice to be small, physician owned and run clinics that are not associated with any larger organizations.

There are many bloggers and journalists who make their living pontificating on the state of US Healthcare, but for us, there is no more credible source than to ask Physicians who are actively working in the profession.  Following are our questions and their answers.

Exploring Private Practice

Q: What is the greatest benefit of working in Private Practice:

A, Michael Laccheo:

I think that private practice makes the physicians most accountable to the patients; it is our name on the door. We make all the decisions about the practice. We live and die by those decisions. If we take good care of our patients, then we will flourish. If we are unresponsive to problems, poor in character, and inept in medical skill, we will be out of business…and working for a large healthcare organization. (Think about that.) What I love about private practice is that I can create it to be how I would want things to be if I was a patient. When a patient says to me “I wait for hours getting an infusion. It would be nice to have WIFI,” rather than writing up a proposal, doing a cost analysis, taking it to a committee, I can just come in early the next morning and install it, because I’m not happy when I go someplace that doesn't have WIFI either! I always approach the setup of my practice and the way I practice by thinking about what I would want if I was the patient. In private practice, I can make it a reality. Before, I couldn't. If I couldn't work in private practice I would want to work at the VA. While that might seem antithetical to why I like private practice, the VA really takes care of its own, they strive for high quality of care, and their prior authorizations really do seem to be based on science, not on finances. Basically, it would be the next best way to take care of my patients and that is why I am here after all. They also have the best EMR.

Q: You have never worked in Private Practice. What played a role in keeping you from doing so?

A: Suleman Bhana:

For me, it was a combination of reasons:

1. After graduating from fellowship, the Rheumatology private practices in my geographic area of choice that were advertising were not desirable from a practice model or compensation perspective
2. Possibility of solo practice was never fully considered due to the significant costs of business and financial risk of private practice in the NY/NJ area
3. High student loan debt from med school means I need a steady source of income right away, can't wait to build up a practice as a small business owner
4. Current health care policy environment skews heavily against the private independent small business practice, and towards large health care organizations/ACOs. If you "skate where the puck is going", then working for a private practice in a large metro area does not seem viable for long.

 Q:  Currently, what the biggest challenges to being in Private Practice?

A, Michael Laccheo:

One of the hardest things about being in private practice is that you are responsible for everything from staffing of the nurses to staffing of the toilette paper rolls. You will get complaints about anything that isn’t perfect: quality of toilette paper, lack of WIFI, grumpy attitude from the front desk, nurse that smells like smoke, crowded parking, etc. This is not a job for someone who wants to show up at 9 and leave at 5. Granted, being a doctor is rarely ever like that, but even if you get done with your “doctoring” work at 9pm, now you have to start thinking about the administrative aspects. This is both the best thing about private practice, but also a lot of work. You are running a business, and as all business owners will tell you, you constantly worry about going out of business. All of your employees count on you for their livelihood. It is a terrible responsibility. The thing I worry most about these days is that some legislation will be passed that basically makes private practice impossible. This could come in the form of mandated care that is reimbursed at below the cost of providing the care. It could come in the form of egregious red-tape that can only be complied with by large organizations with numerous administrators and lawyers.

Q: What are the currently the biggest challenges not being in Private Practice?

A, Suleman Bhana:

It depends on the practice model, but loss of autonomy is the biggest challenge. Physicians by nature tend to be independent thinkers and somewhat OCD about how to do things. When working as an employed physician, you have to get used to a lot of non-physicians (hospital administrators, nurse managers, IT managers) telling you what to do and how to do it. This could include type of patients to see, volume of patients, practice locations, capital expenditures for the practice, ability to offer patients new services, and obvious IT/EHR decisions. As described by asymco.com's Horace Dedieu, a protege of Harvard Business School's Clay Christensen, large corporate organizations tend to require tremendous inertia to change course and tend to have "corporate antibodies". Corporate antibodies are the internal mechanisms that quell changes or innovations that are disruptive to the corporate organisms structure and function. A smaller organization (like a private practice) has more freedom to maneuver. Sometimes, the benefits of a steady paycheck for a physician may not outweigh the acceptance of the reality of a particular practice setting.

 Q: What worries you most about the consolidation of Healthcare in regards to the future of Private Practice?

A, Suleman Bhana:

The realty of our current healthcare policy debate and of the large healthcare organizations is the the voices of physicians are not being amplified or listened to. Some of this fault may be on physicians themselves, but I know plenty of physicians that are very vocal about the challenges we are facing now. Physicians are the ones who are responsible for establishing and maintaining the trust and relationship with patients, which is the core of all of healthcare. We are in the trenches trying to implement new technologies, spend hours per week trying to convince "medical directors" of insurance companies to authorize medications and tests on patients we know best, and have the power of the pen (or now keyboard) to decide who gets which test or therapy. As physician autonomy gets eroded and we move from small business owner to employee, our ability to impact the micro and macro system on whole becomes less effective. The exception may be physician run healthcare organizations in which the physician has more of an active role in directing care on the ground and within the system as a whole.

A, Michael Laccheo:

In general, consolidation by itself doesn’t concern me. I believe that we private practice physicians take much better care of our patients so as long as there is free competition, I don’t think we have anything to worry about. Tiffanys doesn’t worry because Walmart sells necklaces cheaper. What I am concerned about is when governments and insurance companies try to force policies and legislation that basically excludes private practice from the game. We can compete on quality and service. We can’t complete with lawyers and money.

Q: If you could make 3 significant changes, what would they be?

A, Suleman Bhana:

I'm not even sure where to start, but a few things come to mind

1. Change the billing/payment system to at least reflect the cost of care. If inflation rises, costs increase, but reimbursements go down, then inevitably the private practice will become unsustainable
2. Allow reimbursement of many of the non-reimbursed activities such as care coordination (some minor changes are already coming), patient phone calls, and time spent with insurances doing pre-approvals. If an insurance wastes 25 minutes of my time bouncing me from dept to dept then my time should be reimbursed by them.
3. If a private insurance market is what this country chooses as its system (as opposed to single payer) at least have a true market system where there is an equal playing field for insurance products to compete. Many areas of the country are still insurance monopolies. A large hospital based group can negotiate better rates, however a small private practice has no power as there are no other insurances in town. Any situation with a monopoly is ripe for abuse. This cost gets shifted to patients inevitably by forcing practice to become high volume based simply to make up overhead.

A, Michael Laccheo:

I would get rid of the “insurance” model for payments. I believe that part of the reason that costs are so ridiculously high is the third party payment system, similar to how the explosion of the college loan market led to the dramatic increase in student loan debt or housing prices are inflated by the mortgage market. Basically, there’s no free market and costs get inflated. Sadly, so much of the health care ‘industry’ is supported by these inflated costs, it may be “too big to fail” but I’d be willing to see that happen. We basically have whole industries that exist because of these bureaucratic inefficiencies. For example: billing and coding. Second, I would create a universal data format for the medical record and get rid of Meaningful Use. Typical of government, they approached the whole EMR problem backwards. Doctors weren’t using EMRs because they were terrible not because we are luddites. They’re still terrible, but now we’re forced to buy them so were’s the competition in innovation? I bet Apple and Google would love it if we were all forced to "meaningfully use" an iPad and Nexus rather than having to innovate a great product that we stand in line to buy. When you make something good, you don’t have to force people to use it. We’re at the point in EMR technology that instead of a bunch of “meaningful use” mandates we need a standard data set for the medical record that start ups could then innovate around to create the Facebook, Instagram, Twitter equivalent for EMRs. Finally, I would do something about the lawyers. There’s some old adage about how to deal with them. I can’t quite remember it off the top of my head...

Q: What advice would you give a Med Student about to graduate and go into their Residency?

A, Suleman Bhana:

During residency, much focus is given towards the practice of diagnosis and management of patients. Which is very necessary. However, I find there are many important questions that the resident must find out on his/her own:

1. How do you take these degrees and skill set you developed and turn it into a career that gives you a good work/life balance, and allows you to pay off your debts.
2. What are the specialties and sub-specialties that will see the most opportunity in the coming decade, and which will have the most challenges? Can that knowledge give you an advantage?
3. What are the skills sets you will need to excel in the current healthcare landscape, and how can you acquire those skills as a resident and put those skills to use?
4. How does healthcare policy on a local or national stage affect your ability practice your chosen specialty?

These are all questions the graduates need to be investigating and asking before and during their residency.

A, Michael Leccheo:

See as many patients a day as you can. Work hours have greatly cut back on the number of patients you’ll see, and the number one thing that will make you a better doctor is the number of patients you see. You’ll see more diseases, you’ll see more variations of diseases, and you’ll see more variations of patients. Not everyone with the same disease needs the same treatment, in spite of what the books will tell you. “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” - Hippocrates

Q: What advice would you give a student considering Med School?

A, Suleman Bhana:

Very tough and charged question. Considering how much uncertainty there is right now about the future of healthcare in the US, its hard to predict what their experience will be like. A few related problems are soon to be coming on like a tidal wave.

1. Cost of medical education is astronomical, and continues to go up. Average debt after graduation (as of 2012) is about $178,000. Its likely higher by now. Can someone in college now thinking about medical school afford being saddled with decades of debt? What would that debt do to them as a career choice? Would they go into low paying primary care, or would they try make themselves more competitive and reach for a high paying specialty like Radiology? If the goal is to be healthcare provider, perhaps another route such as RN then LPN may be a more cost effective goal, or even becoming a PA.
2. Very soon, if not already, we will be seeing unemployed US trained med students. New med schools are popping up all over the place "to relieve the doctor demand." Keep in mind that 100s of foreign medical schools train US and non-US citizens also with the intention of practicing in the US. In order for a med student to practice, he/she needs to be accepted into an accredited residency training program in the US, complete some term of it, and pass the 3 1/2 step licensing exam (not to mention $1000's of dollars of examination fees). States think opening new med schools will help relieve the demand of the doctor shortage. The real problem is the residency training slots are capped by Congress and funded by the federal government, namely CMS. Unless Congress will authorize more funding and more spots for graduate medical education, there will be no relief to the amount and slow rate of doctors trained. More importantly, with limited slots of residency, and higher supply of domestic med students, there will reach a point soon in which there will be more graduating med students then residency spots available. A med student will be $200,000 in debt, and not be able to get into a residency spot to eventually be able to work as a physician and pay off this debt over time. I am not hopeful that our dysfunctional partisan government can come to logical consensus to relieve the burden of doctor shortage and prevent devastating economic burden to well-intentioned young people sacrificing time and money to go into medicine.

A, Michael Laccheo:

Don’t. Do something else. Anything else. Whatever you think medicine is, whatever noble or selfish reasons you have for going into it, most likely by the time you graduate the entire landscape will be different, for worse. If you want to make a lot of money, definitely do something else. If you want to help people, be a research scientist and find a cure for something. You’ll do more good that a single MD ever will. I know that I was given the same advice, and I was too bull-headed to listen, so I assume you won’t either. Therefore, I’ll give you my second best advice: dual major in Computer Science and Business.

Thank you for bearing with us for this very long post. We are actually big believers in the oft quoted "edit, edit, and edit again," but we think the subject and our interviewees' views are too important to short change. We also think the conversation is one that needs to continue, and Physicians need to be the most vocal voice in that conversation. We'd love to hear your thoughts here in the comment section.  

At Medelita, we have always recommended that you purchase more than one lab coat at a time. I'll admit that it's easy for us to make such recommendations; we are in business to sell you as many lab coats as we can,  and I won't pretend otherwise. 

If this is your first venture onto our Pathway to PA series, you'll find that our focus is on highlighting the unique routes professionals took to becoming a Physician Assistant.  We hope to inspire and encourage young people with an interest in medicine and the sciences to consider exploring becoming a Physician Assistant as a career option, as well as build a community source for those currently working in the field. [caption id="attachment_3045" align="alignleft" width="200"] Lara Francisco, PA-C, Medelita Founder[/caption] Today we are thrilled and honored to highlight Lara Francisco, PA-C, and the founder of Medelita.  Here is the interview:

Can you tell us about your education route to becoming a Physician Assistant and how you decided on which schools to attend?

I was in the pre-nursing program at Emory University in Atlanta, and during that time came to realize that my personality might be better suited for a clinical role in medicine.  I was considering the Nurse Practitioner route, but found that I could cut out a few years by going the PA route instead.  I became very serious about applying to PA school the summer before my Junior year of college.  At the time it was listed as the #1 “up and coming” profession and so I knew it would be difficult to get into a program; this was back in 1995/96 so there were not nearly as many programs as there are today. I applied to numerous schools and was accepted at Catholic Medical Centers Physician Assistant Program, which was renamed St. Vincent’s Catholic Medical Centers PA Program.  This inner-city program really shaped my entire career path, as I was able to focus in Emergency Medicine and do an extra rotation in ER.  Larry Herman, RPA-C and current AAPA president was my EM preceptor – best experience of my life and a good friend still today. I wasn’t competing for good cases because there was a plethora of good ones to go around.  I was doing spinal taps on AIDS patients on my 2^nd rotation and there were absolutely endless learning opportunities.  Also as class President it was a great learning experience for me in a leadership role, very much shaping my ability to take on larger roles in the near future.

 How long have you been a PA?

I graduated in July 1999.  I worked clinically from August 1999 through May 2008, mainly in Pediatric Emergency Medicine and Urgent Care.  In May 2008 I transitioned full-time to run www.medelita.com. 

Did you consider becoming an MD or another career in medicine?

I never considered becoming an MD but I did consider becoming an RN or an NP. I think being a PA is the absolute perfect career for someone with a strong personality, someone who is very bright and has great clinical judgment, and especially for someone who has strong interpersonal skills. It’s a job ideal for someone that wants to balance a family and a career, and that was one of the main reasons I chose to be a PA.  I could not fathom sacrificing so much time away from my family/children if I was to go down the MD path.  If I were working clinically right now, it would be ideal to work the traditional three 12’s, as we have one year old twins and a three year old.

What are your biggest professional challenges?

I think my professional challenges (when I was working clinically) were not unique, in that we all share the same sort of issues.  Varying degrees of connectivity and  clinical preferences with supervising physicians, wait times in all directions – to be seen, for x-ray, for lab, for a room, etc., and liability risks with certain ER cases (headache, abdominal pain, etc.).  My professional challenges today (working at Medelita) revolve around the classics of a start up – fundraising, profitability, long lead times, quality control, weighing new product risk, and sourcing. I enjoy my current position very much and am very proud of what we have achieved in our 5 years as a start up, but to be honest I do miss working clinically, especially with children.  I know that I had a special gift in working with children and also just how well my training prepared me for all situations – I picked up on so many cases that were unusual or life threatening, and still to this day I am so grateful for that judgment.  I could always hear Larry Herman in the back of my head saying “Zebras.  Lara just think about the zebras. What’s the worst thing that this could be, and did you make sure it wasn’t that?”  It stuck with me and I got lucky more than a few times.

 If you could change any decisions you made along the way what would they be?

Always, always go with my gut clinically and don’t let anything – not time pressure or personality pressure or time of day influence me otherwise.

What advice would you give a student considering Med School?

Please study the www.aapa.org web site and find a PA in your area whom you can shadow.  It is absolutely the most amazing career.  You work at the level of a physician but are not “stuck” in a specialty.  For example, as a PA you could work dermatology for a few years, and then, if you choose, you could go on to work orthopedics or any other specialty.  No one is limiting your education and/or journal reading. Go to the very best MD CME programs in the country.  Gain the highest level of licensure in anything/everything related to your specialty.  Pursue leadership opportunities within your work setting and beyond.  Be a clinical preceptor.  Become active in your state and national organizations.  The sky is the limit in this profession and you’ll never regret it. In terms of salary, there are recent published articles pointing out that a PA is likely to make more money over their career than an MD in certain specialties, as the debt is so high for med school and many women, especially, are forced to work part-time as an MD in order to balance family and career.     If you are a PA and would like to be interviewed for our Pathway to PA series, please email us here. email us here.

Our Residency Options series focuses on the wide variety of specialties and areas of practice that medical residents may consider.  We interview MDs and explore their decision making process when they decided what career path they would take.

When we read about The Society for Healthcare Epidemiology of America (SHEA) guidelines for healthcare workers attire, of course we perked up.  Our business is built upon providing attire for healthcare professionals. The study's intent is described within the study as:

...to prevent transmission of healthcare-associated infections through healthcare personnel (HCP) attire in non-operating room settings.

The post on the SHEA website continues with:

" studies have demonstrated the clothing of healthcare personnel may have a role in transmission of pathogens, the role of clothing in passing infectious pathogens to patients has not yet been well established," said Gonzalo Bearman, MD, MPH, a lead author of the study and member of SHEA's Guidelines Committee. "This document is an effort to analyze the available data, issue reasonable recommendations, define expert consensus, and describe the need for future studies to close the gaps in knowledge on infection prevention as it relates to HCP attire."

Honestly, my initial thought was: What does the white coat have to do with it?  Physicians and medical professionals have to wear something. Whatever that something is can also transmit pathogens, right? My second thought was: All the more reason to purchase more than one lab coat (yes, this can accurately be portrayed as self serving because we are in the lab coat business).

What does the SHEA Study Mean to Medical Professional Attire and its Future?

The way 'information' and misinformation spreads across the internet, I began to be concerned that this study could possibly impact part of our business. Yes, the white lab coat itself has a long history and is indicative of respect, knowledge and singularly stands for the important role medical professionals play in our society. However, it wasn't so very long ago that Physicians wore black; you can see the rabbit hole my mind started to go down. And then I read two blog posts that made it all make sense, and eliminated some of the sensationalism from the study. The first was by Dr. Whitecoat himself, and it carried the title No More Dr. Whitecoat. Within his post Dr. Whitecoat skewers the SHEA study with these  four lines:

The authors repeatedly note that there aren't enough studies to make firm recommendations: “There is a paucity of data on the optimal approach to HCP attire in clinical, nonsurgical areas” “Appropriately designed studies are needed to better define the relationship between HCP attire and HAIs” “No clinical data yet exist to define the impact of HCP apparel on transmission”

After quoting Dr. Whitecoat in a tweet:

"But if you don’t have scientific evidence supporting your recommendations, then STOP MAKING THE RECOMMENDATIONS."

...one of our favorite bloggers, Skeptical Scalpel, joined the conversation and pointed us to his January 24th post on the SHEA guidelines. I encourage you to read that post in its entirety, it is a short but straightforward taking apart of a study that makes suggestions, sort of, based on a study that itself admits requires more in depth research. And we echo Skeptical Scalpel's closing question:

 "Why issue guidelines if you have no evidence to base them on?"

Much Ado About Nothing in The White Coat Controversy?

Perhaps calling the SHEA study and its impact a controversy is a stretch, but the fact that it hints at, and then steps away from the idea that a uniform that has become ubiquitous for medical professionals worldwide does cause a bit of concern. And again I come back to my initial thought: What does the white coat have to do with it?  Physicians and medical professionals have to wear something.  Whatever that something is can also transmit pathogens, right? We will continue to watch the fallout from the SHEA study as patiently as possible, and we will continue to recommend that our customers own more than one Medelita Lab Coat and keep them in rotation so as to launder them regularly. After all of this, we can't help but ask the question of our medical professional community:

How would you feel about the demise of the white coat?

This week our Resident Options series focuses on Critical Care with  Ednan K. Bajwa,M.D.,M.P.H. Dr. Bajwa born and raised in New York where he attended medical school at New York University.  He later moved to Boston for residency in Internal Medicine at Massachusetts General Hospital.  After residency, he remained at Mass General for his Pulmonary/Critical Care fellowship, and was hired onto the faculty after graduating. Currently Dr. Bajwa is the director of the Medical ICU at Massachusetts General Hospital as well as an NIH-funded researcher. He primarily does clinical and translational research involving the Acute Respiratory Distress Syndrome. He also attends in the MICU and runs the educational program in Critical Care for  Internal Medicine residents. In addition to all of that, Dr. Bajwa is also the clerkship Director for the Intensive Care Medicine clerkship at Harvard Medical School. Obviously, Ednan Bajwa is a very busy man; we are thrilled that he took the time out of his schedule to answer the following questions:

When did you finish your Residency?

I finished my residency in 2003 and my fellowship in 2007.

Did you have a mentor during Residency?

I had many mentors! One of the greatest things about my residency experience was having a number of smart and thoughtful attendings to work with and learn from. More than anything, they helped shape my career.

What played a role in you choosing not to work in private practice?

I don’t have anything against private practice, but it wouldn't have worked out well for me with my interests in having a career that involves research and teaching.

What is your specialty or area of practice?

I’m boarded in Internal Medicine, Pulmonary Medicine, and Critical Care Medicine.

What particular skill set is necessary to work in your specialty?

I spend most of my time doing Critical Care. It’s basically like being an internist or hospitalist for extremely sick patients. As such, it requires having a thorough knowledge of Internal Medicine, with an intense focus on understanding the physiology of the patient’s illness. In addition, it requires being comfortable with a variety of procedures including endoscopy and placing central or arterial lines.

Currently, what are the biggest challenges you face professionally?

As with any profession, changes in health care economics are requiring us to adjust, particularly at academic medical centers. There is also a large shortage of Critical Care physicians looming as the population ages. It will be challenging to try and meet this need and probably will require training more physicians, nurse practitioners, and physician assistants to practice in ICUs, along with increased use of telemedicine.

What decisions would you change on your path to Residency?

I had a great experience and wouldn’t change much. However, if I had recognized how important physiology was to Internal Medicine and Critical Care, I would have taken more physiology courses, including as an undergrad.

What advice would you give a Med Student about to graduate and go into their Residency?

I would advise them to do their best to enjoy it. It’s an extremely challenging time, but it’s also a unique experience and will be the most important formative experience of their career. I would also say that when they’re making career decisions during residency, they should also think about what aspects of medicine they find most engaging and exciting. While lifestyle and economic considerations are important, truly enjoying what you do is invaluable.

What advice would you give a student considering Med School?

Medicine is demanding but can be an extremely rewarding and satisfying career for the right person. I would say that they should weigh the logical aspects of the decision carefully with regard to the education and training involved, the tuition costs, and the effects that being a physician will have on all aspects of your life. More importantly than that however, they should decide whether they’re really going to enjoy being a doctor. In order to do so, they should spend as much time as possible working in health care and learning as much as they can about what the job is like.   If you are a physician who is interested in sharing advice on their area of practice, please contact us via email.

Here at Medelita we have been quietly working on a campaign to recognize the heroic efforts of some of the most special members of our community, Medical Residents. We realize that everyone who chooses to work professionally in the medical field deserves recognition; each of you make sacrifices on a regular basis in order to care for your fellow man. With our  “Honoring Excellent Resident Observations” Award,  H.E.R.O.  we will be recognizing 100 Medical Residents who have gone above and beyond the already high expectations placed upon them. Our Mission is to highlight the personal sacrifices and educational commitment during a medical resident’s professional adult life.

A few things that are very obvious to those working in healthcare have become obvious to us;  one issue of great concern is the often talked about, looming physician shortage. As the cost of medical school has sky rocketed, the future of a career as an MD has become incredibly uncertain. Residents regularly lament the anywhere from $160K - $500K debt burden they begin their working life carrying. Our Pathway to PA blog series has clarified how many people who, in earlier times, may have chosen to become a physician are finding other jobs that make them happier without all of the sacrifices, and yes, without the debt. We don't have the answers, but we wanted to make a statement to acknowledge those who bravely embark on a career as a physician in these uncertain times. For that reason, this past weekend we launched our The Right Fit  H.E.R.O. Award. The Right Fit campaign highlights the personal sacrifices, long hours and educational commitment during a medical resident’s professional life. A Medelita embroidered lab coat and scrub set will be won by 100 residents. One H.E.R.O. winner, following a community peer vote of the top 10 and the final discretion of a judging panel, will take home a $25,000 honorarium to decrease medical debt. The Association of American Medical Colleges estimates this debt to be over $160,000 for each graduating medical student. The 100 winners are to be featured on www.medelita.com/therightfit. Damon Kuehl, M.D. vice chair emergency medicine, assistant professor Virginia Tech Carilion School of Medicine and Research Institute, frequently lectures and speaks nationally about ways to motivate residents. We are asking for your help to spread the word about our H.E.R.O. Award, and to nominate deserving residents here.