By Juliet Farmer
Maggie Kozel graduated from Georgetown University School of Medicine in 1980 and specialized in pediatrics, completing her residency at the Bethesda Naval Hospital. She then served as a general medical officer on board the U.S.S. McKee and as a pediatrician at the U.S. Navy Hospital in Yokosuka, Japan.
Upon returning to the U.S., Dr. Kozel worked as a pediatrician in the active reserves at the U.S. Navy Hospital in Bethesda before entering private practice, first in Washington, D.C., and then in Rhode Island. For the next decade, she was a pediatrician/partner at Narragansett Bay Pediatrics in RI.
Throughout her medical career, Dr. Kozel struggled with the politics of medicine, which she chronicles in her memoir The Color of Atmosphere: One Doctor’s Journey In and Out of Medicine. After 17 years practicing medicine, Dr. Kozel left the field and is currently teaching high school chemistry in the Providence area.
In the introduction to your book, you cite a 2003 Massachusetts Medical Society survey that indicated less than 50 percent of physicians under the age of 60 would choose a career in medicine if they had it to do over again. Yet, anecdotally, physicians say they would do it again. In your opinion, why the disparity?
This survey has been carried out annually, and the most recent data (www.massmed.org/workforce) for 2010 documents minimal change in workplace satisfaction vs. dissatisfaction (43% vs 41%) and adds the disturbing news that 22% of surveyed doctors are planning a career change, but did not offer comparable results, as far as I could find, on the issue of “would you do it again.” In 2009, however, 44% would not choose or were not sure if they would choose medicine again. So, only a small downward trend.
What was it like to be one of only 40 female med students out of 200 at Georgetown University School of medicine in ‘76?
Surprisingly fun. I tended to have mostly female friends before that, and I had several close female friends in medical school, but I really enjoyed the male companionship. I think the commonality of purpose and shared experiences drew us all close together, and eclipsed the gender piece in many ways.
You talk about the privilege of being a doctor coming at a cost—what do you mean by that?
I suppose it’s true of many of life’s meaningful experiences – they are also the most personally demanding. Having people in your care is a tremendous responsibility, and you are in a situation when others’ needs have to constantly take precedence. On top of that, you have to measure your words and demeanor carefully, and maintain strict confidence. This is true whether things are going well or not, whether the patient is satisfied with you or not. And finally, if you make a mistake, it can torment you for a very long time. The fear of making a mistake is the greatest burden a doctor carries.
What role does truth play in medicine?
We are often inclined to want to protect our patients’ (parents) feelings, or not upset them. That is often true in pediatrics at least. And on top of that, we have a health care system that has cast patients into a consumer role, while we sometimes feel like customer service representatives. That is not a healing relationship. We have to be clear on the boundaries of our expertise, and offer no more or less than that. We need to be able to talk honestly to our patients, and hopefully develop enough trust that they will not simply walk away if we say things they don’t want to hear. That kind of relationship takes time, but is key to a healing partnership. It is our responsibility to deliver truth mixed with compassion.
Do you agree that it’s better to be conscientious than smart? Why?
The best combination of course is to be both, but most errors I have seen have been due to not being careful enough rather than not knowing enough. If you are careful and thorough, you will know when something is wrong, and when you need help. And you are less likely to have miscommunications with your patients. It is when we are rushed, or impatient or dismissive that we make mistakes. Not knowing the answer is a relatively easy fix. Plenty of other people can help you.
Sleep deprivation seems to be a constant theme in medical school…do you think that’s a rite of passage, or a danger?
It’s absolutely a danger. It makes us prone to mistakes, and steals our humanity and compassion. It is a vestige of an old-boy, survival-of –the fittest mentality that serves neither doctor nor patient well. Yet, the current economics of medical practice push us to work harder, see more patients, hire less help. And we all pay the price.
In your opinion, is “to do no harm” unrealistic in medicine? Why or why not?
So many of our interventions have adverse effects or unintended consequences. Mainstream medicine has traditionally geared toward laboratory, imaging and pharmaceutical intervention. We have to be more discriminating about the effectiveness of our interventions if we are going to be able to justify the inevitable adverse effects – not to mention the costs! Yet, our fee-for-service system rewards short conversation and quick fixes. That means knee jerk tests and prescriptions – and all too often more harm than good.
Why do you think the U.S. military seems to embrace universal health coverage?
Part of it is the mindset. Every other area of American life is grounded in an idea (myth?) of rugged individualism. The military doesn’t stress the individual. It stresses the most effective and hopefully most efficient way to address the needs of everyone in the group. The down side of this is that military spending in our society has not had to pay as much attention to cost control as the private sphere has. If we were to adopt such a system in the civilian world, we would have to pair up the efficiencies and benefits of single payer, universal coverage with cost-effectiveness.
What do you think the fundamental difference is between practices that take Medicaid and those that do not?
Business choices. It’s difficult for even the most altruistic primary care physician to absorb the cost of seeing Medicaid patients. My husband, for instance, gets paid $27 for seeing a developmentally-delayed adult on Medicaid; he’s paying for the visit out of his own pocket 10 minutes after the visit begins. The larger the practice, the more the group can absorb the income loss. Smaller groups may simply not be able to afford to. If our national strategy is to have doctors cover the costs of caring for disadvantaged patients, then we have no strategy.
What is your opinion of Medicaid—do they make it easy for doctors to treat patients, or difficult?
These programs are underfunded and do not offer primary care physicians anything close to adequate compensation. As a result, Medicaid patients have inadequate access to care because too few doctors can or will see them. We have a two-tiered system of healthcare in this country, and we need to acknowledge that.
Why is record-keeping communication important in medicine?
Communication is key to good patient care. It offers continuity of care, minimizes duplication of tests or unnecessary interventions, and provides healthcare that is a process rather than a string of incidents. And, just as is true in most areas of healthcare, what is good for the patient is good for the pocketbook. Coordinated care is less expensive care. That’s what good record keeping can accomplish.
Why do you think a national medical recordkeeping system is not used?
One huge obstacle is the start up costs for doctors. A solo practitioner is not going to be able to handle the $20,000 start up costs for medical record keeping. It’s important to realize that switching over to electronic records is good for the patient, and good for cost control. But it is unlikely to generate income for the doctor. It’s just one more cost that is getting harder and harder to absorb.
Also, patients I have talked to have a lot of reservations about e-records, and they find their doctors now more engaged with a computer screen than with them. We will have to be conscious about how e-records impact the quality of the patient-doctor encounter.
Why do you think pediatricians have one of the lowest rates of malpractice suits?
Doctors who have had a good prior relationship with their patients seem less likely to be sued, and pediatricians are good at relationship. And, although poor outcomes are catastrophic in the pediatric population, they are not as frequent as in older populations. Much of malpractice is based on poor outcome as opposed to poor care.
In your book, you mention your assumption that doctors are supposed to be exhausted, aggravated, and maintain miserable schedules. Do you still feel that way? Why?
It is the reality of many practices, especially primary care practices, and will probably be the case as long as we rely so heavily on fee-for-service models where the encounter happens mostly in the doctor’s exam room. Our current system pays for productivity, not quality, and the only way to stay afloat is to see many patients with quick turnover. In addition, many primary care doctors, especially pediatricians, have to take their own after hours call, and this can be completely exhausting.
Why do you think insurance companies are willing to pay physicians to discuss potty training, bug bites, etc. rather than nurses?
It’s a complicated, obsolete system that goes back to the days when you only sought medical care if there was something specifically wrong with you for which there was a quick fix best delivered by a doctor. Medicine doesn’t look like that anymore, but we are still trying to use the same old paradigm of payment. If there is a health care need, even if it’s in the realm of child-rearing advice, or a socioeconomic issue like obesity, it’s hard to get healthcare dollars applied to anything but a doctor visit, no matter how cost-ineffective that is.
The pay by diagnosis notion seems particularly challenging for pediatricians/family physicians. Do you think there should be different insurance reimbursement structures for different fields?
Yes, yes and yes. Much of the Affordable Care Act is designed to address this outdated payment system of ours. Ideas like ACOs and Medical Homes shift the paradigm away from episodically treating illness to optimizing health in a coordinated way with a team approach. We need our public systems, like Medicare, to incentivize health care that has proven value, instead of paying enormous amounts for costly tests and procedures that accomplish little for patients.
How did the incident of the deathly ill infant brought into the ER (when you were paged after the physician on call passed off the patient) change the way you interacted with your peers?
If you are in practice long enough, you get to know many wonderful, dedicated doctors… and a few others. The reality is that there are some irresponsible doctors out there. But not many.
On the other hand, we have stood by a system that financially rewards bad behavior, and punishes good. So, as a society, we all have to bear some responsibility for the fact that bad doctoring can flourish.
Do you recommend sub-specializing?
Using my 20-20 hindsight, if I had to do it all again, I would subspecialize. I was born to do primary care, the way it existed earlier in my career. But if I had subspecialized, I think I would have had more staying power – less time on call, more reliance on the skills I was actually trained in. I might not have burned out. Then again, if our society is ever to turn our worrisome health trends around, we will need a lot more primary care physicians. We need to make practice more manageable and more attractive to this group.
The interview you had with Dr. Watson 30+ years ago seems telling now (in which he advised not pursuing a career in medicine). Do you think, had you been older, you might have considered what he said more seriously?
Yes, I am sure I would have. On the other hand, it is a good thing to enter medicine full of idealism, altruism and hopefulness. That is how we want our doctors to be starting out, isn’t it? I’d like to think that we could come up with a health care delivery system that won’t crush that hopefulness for so many.
Why did you choose to leave medicine completely? Why didn’t you look at other options, such as scaling back, becoming a pediatric hospitalist, working part-time or other options?
At the time I left my practice, I did want a total stop – temporarily. I was tired and demoralized and wanted to regroup. The teaching job gave me a way to do that that was financially sustainable. Still, I assumed I would be getting back into Pediatrics in a short time – a few years at the most. What happened in the process, however, is that I loved my teaching job, and even more surprising to me, I became totally engrossed in the writing process, which is something I did not have the time or energy to do in practice. Even now, with my memoir project completed, I blog regularly for Huffington Post and other outlets about health care reform. It has become my passion. I would love to have some clinical involvement, but malpractice insurance tends to be an all or nothing thing, and I couldn’t afford it on my own.
Meanwhile, I keep up my licensure, AAP membership, and continuing medical education. I am also interested in the fact that the AAP is developing a system to reassimilate inactive pediatricians back into practice. Apparently there are a lot of us who would be happy to be able to offer our skills again.
How do you think the closeted epidemic of sad disillusioned depressed doctors affects healthcare?
You can’t do as good a job, plain and simple. A doctor who is doing a good job is patient and compassionate. These are the first qualities to suffer for any human being who is chronically fatigued and or depressed. Yet, doctors are very slow to change careers. So what we have seen happen is not that all these doctors leave practice. They are just unhappy in their practice, and that is not healthy for anyone.