Beneath the Top of My License

I have practiced general pediatrics in an academic setting for more than 30 years, so I have observed many changes in pediatric practice. Some of these changes have been wonderful, almost miraculous. For example, Haemophilus influenzae type b (Hib) meningitis, a problem for many children I cared for during my residency, has virtually disappeared with the widespread use of the Hib vaccine. Other changes, such as the increasing application of a business model to the world of clinical pediatrics, have not been as positive. As Dr Howard Fischer wrote in last month’s Guest Commentary “I Am a Doctor—Not a Health Care Provider,” our patients have become “clients.” Helping children and their families with their medical problems has become our “throughput.”

Even for those of us who work in the once-ivory tower of academic pediatrics, we now live in a world of spreadsheets, benchmarks, and productivity bonuses. One principle in this new era of cost-consciousness is interdisciplinary teamwork, with each task being performed by the person in the organization who is the least expensive but is trained and credentialed to do the particular job. This is what is meant by the phrase, “working at the top of one’s license.”

I have a confession to make. There are times during the course of a day when I work beneath the top of my license. For instance, on the day I wrote this commentary, I gazed at a newborn’s face and smiled at him for a full 20 seconds before I continued on with the physical examination. During this same encounter with my patient (excuse me, my client), I might have made an unprofessional cooing noise.

Later, I held a 4-year-old’s hand and skipped with her to the front of the office so she could pick out a sticker. She seemed very appreciative for this frivolity, but I was unable to quantify any marginal benefit, and I may have forgotten to wash my hands afterwards.

Then I chatted with a 16-year-old about the stresses of school and life in general before completing his sports examination and asking the more important questions about sex and drugs. I knew that this chit-chat would likely prolong the visit and negatively affect my throughput, and I wasn’t even sure how to enter this kind of trivial information into his electronic medical record. Worst of all, it didn’t enable me to code the visit at a higher level in order to maximize reimbursement or productivity as measured in work RVUs (relative value units).

I suppose I can live with these lapses in judgment. Perhaps they can even be expected from a general pediatrician. After all, our salaries are among the lowest for physicians and much of our work involves calming anxious parents and providing care for well babies and children with pink eyes and snotty noses. An experienced grandparent might do nearly as well at resolving many pediatric problems.

So I have another confession to make. I sometimes enjoy working beneath the top of my license. I love well-child care and have developed a personal relationship with my pneumatic otoscope. When I consider many of the things I do, things that seem simple to me now, I remember how many years it took me to become proficient at retrieving pieces of plastic from toddlers’ ears and convincing parents to forgo the antibiotics for their child’s viral infection.

I cherish the spontaneity and unpredictability of children, and I enjoy the variety of general pediatric practice-—from perfectly well to extremely ill, from newborn baby to college student, from problems that are immensely complicated to those that are straightforward and self-limited. This variety may be why pediatricians have greater job satisfaction and lower suicide rates than physicians in many other specialties.

I love the life and career I chose and would do so again in a heartbeat. If current trends continue and pediatric practice becomes more businesslike with emphasis on accountability, metrics, and deliverables, I can only hope that future generations of pediatricians will be allowed to enjoy a few moments beneath the top of their licenses. 

Share Your Thoughts

Dr Hayden invites you to share your experience working as a general pediatrician in today’s cost-conscious environment. You can read this commentary and post your feedback online at: www.PediatricsConsultant360.com.

—— The Editors