Fired for seeing her own patients: moral injury and life after medicine [PODCAST]

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A physician was fired by the doctors she had trained, in part because she preferred to see her own patients herself. Moral injury, she argues, does not require 100-hour weeks. Sarah A. Vlach is a physiatrist and sports medicine physician. This episode is based on her article “Moral injury doesn’t care how many hours you worked,” published on KevinMD. You will hear how her working conditions slowly deteriorated, including nine months without a medical assistant, and why her first response was to knuckle down and work harder. She describes how financial incentives like RVUs now shape decisions in both corporate and private practice, and why she sees a two-track system forming as more clinicians move to cash-based care. She offers advice for new physicians starting out with large loans, and she explains how the Physician Support Line and writing about the experience helped her. Press play to hear what she wishes she had done sooner, and why she has found there is life after being a physician.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Sarah Vlach. She’s a physiatrist and sports medicine physician. Today’s KevinMD article is “Moral injury doesn’t care how many hours you worked.” Sarah, welcome to the show.

Sarah A. Vlach: Thanks, Kevin. Thank you so much for having me. I’m glad to be here.

Kevin Pho: All right. Let’s start by briefly sharing your story, and then we’ll talk about why you decided to write this article on KevinMD.

Sarah A. Vlach: Oh, sure. I’m a physical medicine and rehab doc. I’m double board-certified in PM&R and sports medicine. I graduated from medical school in 2000, so I’ve been in practice now for roughly twenty years or so. I’ve lived in southeastern Idaho, so pretty rural Idaho, for the past twenty years, and had a practice in PM&R and sports medicine, which I built myself from scratch. It expanded from a two-person practice to eventually five physicians and a number of mid-levels. For the past ten years or so, we moved the practice mostly into regenerative medicine, so we founded PRP, stem cell therapy, and the advancing field of orthobiologics in our area.

I was in private practice for a number of years, and then I sold my portion of the practice to a physician-owned hospital. It was actually a pretty unique setup; this was back in the days when physicians could still own hospitals. So I sold the practice to this physician-owned hospital, but I was still an owner, so I worked on a contractor basis, and I worked under that model for about ten years and continued to expand. Then I sold my portion of that practice to two other physicians whom I had brought in, mentored, and trained, and I worked in that model for the past two years.

In May of this past year, the two physicians that I had brought on and trained terminated me with three months’ notice. They let me know the reason was specifically that I wasn’t making enough money for the practice and that I was not, quote, “feeding the mid-levels,” because I actually liked seeing my own patients. I wasn’t appropriately following their model. In PM&R, we did a lot of interventional procedures, and they wanted the mid-levels to see all of the patients and the doctors to do the procedures. I like to see all my own patients myself, and I guess I wasn’t making enough money for the hospital, and so I was terminated with three months’ notice, which to me was a pretty shocking state of affairs. As I mentioned in my article, I’d never been terminated from anything in my life. After taking a few months to regroup and see where things landed, I decided to take a sabbatical, so I’m currently on sabbatical.

Kevin Pho: There are a lot of things that we could bring up there, and really it’s a commentary about the state of medicine and the state of our health care system today. These owners wanted you to do more procedures, presumably because they get reimbursed more, and there’s a financial motive to the decisions that they make, of course. Now, before you got terminated, did you see any of this coming, or was it a complete surprise?

Sarah A. Vlach: That is an excellent question. I did not see it coming, I think partly because I was a bit of a frog in the boiling water. For the past two years, I would say that my working conditions had been gradually deteriorating, but it was so gradual that I wasn’t really able to process it. For example, we live in a pretty rural area. I worked without an MA, without a medical assistant whatsoever, for about a nine-month period, where the patients would come in and I would be the one grabbing them out of the waiting room, cleaning the rooms, turning them over, and doing all those things. It wasn’t that I was above doing those tasks, but, as a fellow physician, you understand it’s extremely difficult to do an enormous amount of clerical work and then try to switch on that physician brain and actually see patients.

So in hindsight, your question is very insightful. I felt like I was not being valued in the workplace anymore, and that message was being sent to me. But as a physician, my response to that was instead, “Oh, I’ll just knuckle down and work harder. I can work without an MA, and I can do all of these things.” So I think the writing was on the wall. I just really loved being a physician and loved seeing my patients, so I was willing to continue to work under deteriorating circumstances.

Kevin Pho: Now, what does this say about our health care system? Like you said, you work in a rural area, and presumably there’s a relative shortage of physicians there, yet they couldn’t find a way to make this work. They had to terminate you. There was no solution that was mutually agreeable to both parties. What does that say about our health care system?

Sarah A. Vlach: Well, first I’d just like to add as a caveat that I was offered the chance to be rehired after the three months at about a 50 percent pay cut. That’s five zero, not one five. So I was offered continued employment, but at that level of pay cut, along with the deteriorating work circumstances, I wasn’t willing to.

I think what it really says is that our model is moving toward one where physicians are increasingly devalued, I’m sorry to report. I’m sure you’re aware of this: There’s a mass exodus of physicians, especially physicians ages forty-five and up. We’re in the prime of our careers. We should be able to continue to serve, which I wanted to do, but I think that, frankly, other people are doing it more cheaply these days, the mid-levels, the PAs, and the NPs, and AI is coming. I just don’t think that physicians are currently valued in our model.

Kevin Pho: So this decision wasn’t necessarily made by faceless administrators. It was actually made by your physician colleagues, and like you said earlier, these were physicians that you brought in and mentored. So what do you think about the fact that these are physicians making the decision? I’m not going to say that they bought into it, but they are pressured by the realities of running a practice, and they have to make these decisions based on what seem to be purely financial motives.

Sarah A. Vlach: I think you’re exactly spot on there. Again, that’s something that I was not really aware of as medicine was changing: how much current thinking is being driven by the financials and not necessarily by what’s in the best interest of the patient. I was trained very old school. I’m a graduate of Mayo Medical School. “The patient comes first” was deeply ingrained in me, and in us, at the heart of our training. I do think that for a lot of the physicians coming out, the financials are really at the base level of how they think about things.

If I can just share a brief anecdote with you: One afternoon, I was a little stressed at the end of procedures because I had wanted to make it to my daughter’s soccer game and had overscheduled myself, and I was trying to figure out what I could do. One of my former partners came up and offered to take my last two procedures for me so I could go to the game. I said, “Oh, no. No, thanks. It’s totally fine. It’s not a big deal.” And he said, “Oh, I understand. Of course, you wouldn’t want to miss out on those RVUs.”

Now, that’s not the way that I was trained to think. The way I was trained to think is that it would be unethical to cancel or change the physician doing the procedure on the patient at the last hour, because that wouldn’t be good care for the patient, and the patient wouldn’t appreciate it. But that’s just not the way they think, and that’s a perfect example for me. I was like, “I don’t quite fit in here anymore. I think differently. I make decisions differently.” It’s just a sad fact of where things are these days.

Kevin Pho: Now, if you were to replay this whole scenario in your head, is there anything that you would do differently if this were to happen again?

Sarah A. Vlach: That’s an excellent question. I certainly don’t think I would do anything differently in terms of how I handled things after the termination. I was very professional. I took some time to think it over. I declined the offer to be rehired at the 50 percent pay cut. Initially, I was planning on rushing into private practice. I was going to open my own small micropractice, and I had a lot of patients who were very interested in that. I decided instead just to take a breath, take a pause, and really figure out if I wanted to be a doctor anymore. And that path has come easily.

Reflecting on the two years when I was the frog in the boiling water, is there anything I would’ve done differently? Yes. I think I would’ve stood up for myself, and I probably would’ve preferred to be the one to walk away from this toxic work environment and situation. I wish that I had more clearly articulated the things that weren’t working for me and then had the courage to walk away before being terminated, because that’s a piece of it that is still a little bit hard for me to process and to deal with.

Kevin Pho: Now, is there a role for physicians who practice the way that you do, where they put the patients first and financial motivations don’t factor into decision-making? You mentioned that you’re on sabbatical now, and I’m sure that you’re aware of potential job opportunities, or whatever path you’re going to take next. Do you feel that there’s a place for physicians who practice medicine the way you want to practice it?

Sarah A. Vlach: Again, I love the question. I do feel that way, 100 percent, first off because I’m an optimist by nature, so I always have to believe that there’s a role for people who are primarily interested in helping patients. I’m not convinced, though, that it’s in the corporate health model whatsoever. Where I live, a number of different providers, physicians, PAs, and physical therapists, are moving to a cash-based model, which is happening across the United States. I’m sure you’re aware of the DPC model. I think that’s really a way for physicians specifically to take control of their own practice and their own care, and then they can decide how much money they want to make and what the driving force is of what they’re doing. But I don’t feel that’s possible at all in the corporate health care model currently. I think it is completely financially driven. It’s driven by volume. It’s driven by high-revenue procedures, and at least where I live, I just don’t see that as possible.

Kevin Pho: And it’s not just the corporate model; it’s private practice as well, because I can’t imagine private practice not being influenced by these financial factors either.

Sarah A. Vlach: Right. For sure. I think we’re in a difficult situation, and interestingly, I actually do see a dual-track health care model opening up. I think over time more and more physicians, and all providers, are going to be leaving the insurance-based industry just because it’s so difficult and so toxic. I actually think that people who are using the insurance model are probably going to get lesser care over time, and people who are using their own cash-based resources are going to get a higher level of care. I think that’s already happening, and that’s actually a bit of a part of my ethical dilemma of what I want to do next. I’m not sure that I want to treat only wealthy people who can afford cash for services, and so these are a lot of the thoughts I’m having as I figure out where to go forward.

Kevin Pho: Do you have any advice for physicians who are coming onto the job market, newly graduated? There’s certainly a tension, like you said, between the financial incentives and the way medicine should be practiced, and they’re caught between the two. Any advice for these physicians who are entering the job market?

Sarah A. Vlach: Another excellent question. This past summer, in the three months that I had left, I actually had a pre-med student acting as my medical assistant. It was interesting having her with me because she’s applying to medical school and looking at taking out half a million dollars in loans. I wasn’t telling her not to go into medicine, but I was hoping that by watching me she would learn some of the experience of what it’s really like out there, because I do think there’s an enormous tension in coming out, especially with huge debts and needing to make money.

I think my best advice would be, number one, to pay attention to what’s going on in your work environment and to what you’re feeling. If you feel that you’re in a situation that is downright toxic, like mine, or that is just not supporting you as a physician, start to make slow changes to improve your situation, and really listen to yourself and to what your needs are. I know other physician friends who are much younger than me who came out with large loans, quickly realized that the toxic corporate health environment wasn’t for them, knuckled down and paid off their loans very quickly, and now have the freedom to do what they want to do.

Kevin Pho: Now, you mentioned that after that initial shock, it took you a little bit to adjust to that new normal. Did you have any support? How did you adjust? You said that it was a little bit unexpected, the frog in the boiling water. What are some things that you did to adjust after you were let go?

Sarah A. Vlach: Yes. Thanks so much for asking, because that was one of the things I wanted your listeners to hear: It is very difficult. I had an enormous amount of identity in being a physician. That’s what I’ve done for twenty-six years. There are a few things that I did. I reached out to the Physician Support Line, which you can call. It’s a national number. It’s staffed by volunteer psychiatrists, and it’s available for physicians to talk things through if they’re distressed.

And it’s funny: Initially, when I was going to call, I felt sort of bad about calling, like, “Oh, somebody must have it much worse than me. I don’t want to take up somebody’s time.” But that’s physician thinking, right? That we’re not valued, that our feelings aren’t really valued, and that we’re not allowed to really have feelings and emotions over things. So that was super helpful.

Writing the article was enormously helpful. I wrote that article in about an hour and sent it off to you with absolutely no edits. Again, my hope is just that my message, that this can happen to any physician and that it’s a difficult circumstance out there, will reach somebody who is also struggling. I don’t feel like I’m struggling anymore, I’m happy to report. That’s one of the things that surprised me the most. I kind of feared retirement, although I’m not retired yet, and feared not being a doctor and what that would feel like, because there’s so much identity in being a doctor. It turns out I’m actually fine. There’s great life on the other side. Again, I don’t know what’s next, but the world doesn’t stop just because you’re no longer a physician.

Kevin Pho: Now, in your article, you share how the Physician Support Line helped you recover, or helped you through this situation. Tell us more about that.

Sarah A. Vlach: Well, I just needed to talk to other physicians and other doctors. Lots of people have been terminated from jobs, right? And it’s funny: At one point, probably during my 2 a.m. scrolling, I was looking up life’s biggest stressors, and being terminated from a job is number two, I think, or number three. But there’s a unique perspective from being a physician when it happens, and I found talking to other well-trained physicians, who were aware of the background model of everything that’s going on in corporate health care, to be enormously helpful. There are lots of other ways you can go. You can find your own primary therapist. You can lean on friends and family. Do whatever you need to do, but I just think getting support for yourself is important.

Kevin Pho: We’re talking to Sarah Vlach. She’s a physiatrist and sports medicine physician. Today’s KevinMD article is “Moral injury doesn’t care how many hours you worked.” Sarah, we’ll end with your take-home messages to the KevinMD audience.

Sarah A. Vlach: Thanks, Kevin. My first message is that moral injury is real, and you don’t have to work one hundred hours a week to experience it as a physician. My second message is that there’s really life after being a physician, and my third is that there are lots of support and resources out there for doctors.

Kevin Pho: Sarah, thank you so much for sharing your story, time, and insight, and thanks again for coming on the show.

Sarah A. Vlach: Thank you, Kevin. Bye.

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