Pager PTSD… A Beep that Won’t Go Away

It’s Friday night and I’m not on call. It’s a welcome break from a hectic and stressful 80+ hour work week. We are about to sit down to watch a movie – popcorn included of course – and enjoy a nice relaxing evening. The microwave starts beeping to let us know that the popcorn is ready. As the beeping continues my heart rate and blood pressure increase ever so slightly, and I reach down towards my left hip. But something is amiss…

The beep of our microwave is eerily similar to the sound my pager makes when I’m on call at the hospital. Of course, the weird thing is that tonight I’m not on call! Yet I still reflexively reach towards my hip, my mind assured that there is a threat to someone’s life, a threat that I might be able to fix. It’s “pager PTSD”, a condition that seems to afflict many young medical trainees.

I’ve tried battling this baffling condition, but to no avail. Perhaps a different beep tone on my pager’s settings would do the trick? It worked for a little while, but invariably my mind would pick out the tone in a favorite TV show and I’m right back to square one… Reaching for that damn left hip.

I’ve even tried putting my pager on vibrate mode. This also worked for a little while until my psyche accommodated… The gentle pull of a blanket, or even my shirt moving in the wind would mimic the vibration, and of course I would reach down. Clearly, someone needed my help, and if I wasn’t there to answer the chirp (or this time vibration) of the pager something catastrophic might happen.

A close friend of mine has a similar story… Although his is a bit more intense! As a soldier in Afghanistan, he would carry a 9mm handgun on his left hip. In hairy situations he’d reach towards his "nine" in case he needed to quickly defend himself. After his second tour he confided that whenever he heard a loud sound, like a car backfiring, or an ambulance siren, he would instinctively reach towards his left hip, hoping that his gun was there to keep him safe.

Unlike my buddy, we are never personally in danger when our pager’s start chirping. And please don’t get me wrong, most pages a doctor receives are not "life and death" situations. In fact, most are easy to handle, a potassium replacement order here, or a Tylenol order there. However, the real problem lies in the fact that every time the pager starts beeping it’s dealer’s choice. It might be something simple, or it might be someone bleeding to death. You don’t know until you reach down and check the message sitting on your left hip.

It’s funny, but humans are not that much different than animals. We can be conditioned to experience a surge of catecholamines. Like a mouse that gets an electric shock a couple of seconds after a tone is played. As the tone goes off the mouse gets visibly nervous, its heart rate and blood pressure start to rise until the shock is administered. It’s similar in pager PTSD, although the mouse is some poor intern, nervously navigating the hospital, waiting for the next medical emergency to present itself.

As I’ve become more senior in my training I fortunately no longer have the visceral reaction when my pager beeps. This is probably because I am more confident in my ability to handle most of the things that might be waiting for me. But interestingly, I still find myself reaching for my left hip even when I am not on call… It’s ingrained in the deepest part of my being. It’s part of being a doctor…

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Book Review: The White Coat Investor

The White Coat Investor: A Doctor’s Guide To Personal Finance And Investing written by Dr. James M. Dahle is an excellent overview of many of the financial issues that face physicians. At 157 pages, it is not meant to be an exhaustive review of each topic; that being said, I found the length of the book to be just right, especially for a busy practicing physician.

The book starts with medical school and progresses through the attending years. Each chapter addresses an important topic that is salient to physicians. I found the chapters on life insurance, taxes, and estate planning very interesting because I had little understanding of these topics.

If you are ignorant like me about many financial concepts, this book is a must have! You may need to read deeper on certain topics, but again, this book is not meant to be exhaustive; it provides a much needed solid foundation on which doctors can build their financial futures. A 5 star book that I will read and re-read as the years go on.

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References and Resources

The Flaws of RVUs: Why They Fall Short in Measuring Physician Worth

Relative Value Units (RVUs) have been utilized in the United States healthcare system for several decades as a standardized method for quantifying the “value” of medical services. They have become an important component of determining physician reimbursement. While the RVU system was initially designed to bring uniformity and transparency to physician payments, it has been increasingly criticized for its shortcomings in accurately reflecting physician worth. This article will discuss the key reasons why RVUs are a flawed measure of physician worth and explore alternative methods of evaluation.

Focus on Quantity over Quality

One of the most significant criticisms of the RVU system is its emphasis on the volume of services provided rather than the quality of care. By assigning higher RVU values to more complex and time-consuming procedures, the system inadvertently incentivizes physicians to prioritize high-revenue-generating procedures over less profitable, but potentially necessary, patient care activities. This focus on quantity can compromise the quality of care and hinder a physician’s ability to provide patient-centered care.

Lack of Personalized Care

RVUs are based on standardized averages, which do not account for individual variations in patient needs, physician skill, and the complexity of cases. Consequently, the RVU system fails to recognize the nuances of personalized care that physicians provide. High-quality care often involves tailoring treatment plans to each patient’s unique circumstances, which may not align with the fixed values assigned by RVUs. For example, if a primary care physician spends an entire hour discussing a patient’s mental health issues in a caring and compassionate way they are reimbursed substantially less than an orthopedic surgeon who takes an hour to pin a fracture or a neurosurgeon who spends an hour doing a cervical discectomy and fusion.

Limited Scope of Measurement

The RVU system only captures a narrow scope of a physician’s worth by focusing solely on clinical procedures and services. It does not account for the many other essential aspects of healthcare, such as patient education, interdisciplinary collaboration, care coordination, and research contributions. By overlooking these non-clinical activities, the RVU system fails to provide a comprehensive evaluation of a physician’s value.

Inadequate Incentive for Preventative Care

Preventative care plays a critical role in promoting public health and reducing healthcare costs. However, the RVU system does not adequately incentivize physicians to engage in these activities, as they are generally assigned lower RVUs. This discrepancy may lead to an underemphasis on preventative care and a potential increase in long-term healthcare costs.

Perpetuation of Disparities

RVUs can contribute to healthcare disparities by allocating resources based on service volume rather than patient need. Physicians practicing in underserved areas may find it challenging to generate high RVU values due to lower patient volume or a greater focus on primary care. This imbalance in resource distribution may inadvertently widen the gap in healthcare access and quality.

Lack of Collegiality

RVUs also tend to foster a lack of collegiality amongst physicians. In my experience, especially doctors on an “eat what you kill” compensation model, meaning they are paid for the number of RVUs they produce, are much less likely to refer to colleagues who may have more expertise or skill in a particular area. In other words, the doctor may “hold on” to patients to generate more RVUs rather than getting them to a colleague who may be able to provide a higher level of care for their particular ailment.

While RVUs were initially intended to standardize physician reimbursement and provide a transparent measure of physician worth, their shortcomings have become increasingly apparent over time. By focusing on quantity over quality and failing to capture the full spectrum of a physician’s value, the RVU system has inadvertently compromised patient care and perpetuated healthcare disparities. It is essential for the healthcare industry to consider alternative methods of evaluation and reimbursement that better align with the goals of patient-centered care, quality improvement, and equitable resource distribution.

It can be a fine line between incentivizing physicians to “work harder” and “earn more” while maintaining a high level of care and maintaining a highly ethical medical practice. I don’t think RVUs are a great answer to this dilemma, but for the time being it is the best we have in the United States. Let’s here your thoughts below…