with commentary from Past President of the American Academy of Orthopaedic Surgery, Dr. David Teuscher
We are so much more than providers, and physicians are taking back language.
I have the good fortune to call Dr. David Teuscher, past president of the AAOS, my mentor, and my friend. In a recent call, I shared with him my passion to steer our AAOS culture away from the word “provider.” I shared my views and some pieces that I have written on the subject. We agreed to work together to share our thoughts with our AAOS membership and community.
The term provider has been used for generations to refer to the role adults play in our families and community, as we provide shelter, food, education, and love to those that depend upon us. In recent years, administrators in the field of healthcare have used the term “provider” to lump physicians and surgeons together with other clinicians. This can be disrespectful to doctors, other clinicians, and patients, as the confusing language obscures the roles of different clinicians play on the team that takes care of patients. (The term was also used in Nazi Germany to strip Jewish physicians, starting with female pediatricians, of the title “arzt,” or doctor, and instead refer to them as “behandler,” which loosely translates to provider.) Language matters.
Teuscher shares his thoughts below:
“We are not ‘providers’ for our patients; they expect and deserve something much more. We as physicians and surgeons are professional first and last in all that we say, will and do. When we answer the call from a statue of repose after midnight or afternoon, whether downrange, the ER, or the office; we are not providers.
We are providers for our families, our communities, our nation, our earth, and our own personal families of faith and worship. Every day we are asked to provide and we are leaders of providers in those realms, but there is our other true higher calling.
We have earned titles of higher responsibility: physician and surgeon. People respect us because they seek us on one of the worst days of their lives. Full of fear, injury, pain and/or dread of what we might reveal as their mortal truth, they seek hope that a true physician and surgeon can heal, treat, connect, communicate, and deliver.
Earn it. The only pathway to becoming a surgeon is a hazardous and steep climb through a narrow gate. Through the precipices of preparation, scholarship, leadership, certification, and proven professional practice is the only pathway to become one of us.
He who defines the word in the war of words is the one who wins the war. We are physicians and surgeons, not providers. Just as Shadrach, Meshach, and Abednego emerged from the fire, we have all been there and are now doctors. As physicians and surgeons, may the administrators of healthcare, the government, other clinicians, and most importantly, the patients who we serve, no longer call us providers. We earned it.”
As I spend more time interacting with the administrative leadership in healthcare in 2019, I find myself asking again and again, “Why can’t we call them patients?” I am hearing words like customer, client, patron, and member are used in place of the word “patient” more and more. Yesterday I heard a managing director of a healthcare consulting practice speak about disruption in the market place. There was nothing surprising to me in her well put together presentation about innovators like Marriott and Starbucks and customer service industries that healthcare can and should learn from. But what I kept waiting for from her was the aha moment… I was sure she would acknowledge the differentiator, that healthcare is different. That we are in the business of caring for our patients, not selling goods to a customer. So I took the opportunity to ask her to comment on her choice of the word “customer” instead of “patient.” I was disappointed in her answer. She told me that as a physician she would not recommend that I call my patients “customers”. I reassured her that this would not ever happen. But she did tell me to let the people who get them in the door call them “customers.”
The dichotomy suggested by this consultant gets to the heart of healthcare in the United States in 2019. Language matters. If healthcare administrators define themselves as people selling healthcare, and patients are customers, then physicians and clinicians are relegated to employees on the assembly line of production. I hold the doctor-patient relationship sacred. But in the era of 2019 it is frightening to witness the transition from doctor to provider and patient to customer.
When did my profession decide to fall into step with consumerism? I am as enamored with the innovations of 2019 as anyone. Starbucks and Amazon and Nordstroms and Uber have so much to teach us about evolution and meeting people where they are. These people are customers to these companies. But I cannot advocate a leap to allow people to be termed “customers” by organizations that care for the sick.
If one side of the house, the administration, calls the people seeking healthcare “customers,” the consumerism story bleeds into direct patient care. The paradigm that allows for mutual respect between doctor (or clinician) and patient, for shared decision-making, for compassionate care, cannot be confused with consumerism. Perhaps the differentiator that healthcare needs in 2019 to reignite our north star, the doctor patient relationship, lies in the language. The reinvention of language will not modernize the delivery of healthcare. Healthcare can learn from customer service industries. Healthcare can adapt and evolve, to improve convenience and access. But please, let us differentiate ourselves. Let us respect the delicacy, intimacy, and sacred nature of the bonds of medical professionals to those we care for.
From the Tennis Court to the Operating Room, how my experience as a camp counselor prepared me to be an Orthopaedic Surgeon
In 2019, women continue to make up less than 10% of practicing orthopaedic surgeons in the USA. I made the decision to pursue a career in this male dominated profession at the age of 24. I was young and fearless. I am getting older, and I am trying to reach back to my 24 year old self to understand who I was and what made me think that it was a good idea to immerse myself in the challenge of surrounding myself with mostly men. This summer I have had time to reflect, as I have returned to the place that I spent my summers during those influential years.
During college, I spent 2 summers as a counselor at a sports camp in the Berkshire Mountains of Massachusetts. Camp Lenox was established in 1917 as a boys camp. In the late 1980s, the camp opened to girls. In 1991, there was a small girls camp embedded within the boys camp, making up about 10% of the campers and counselors. This was my first summer as a tennis counselor. Of the 15 tennis counselors, I was the only woman.
I had to prove myself as an athlete every day. But every evening I went back to my cabin full of young women. And these female counselors and campers were pure fun. Many were fierce athletes. Some were not. Some were artistic or brainy, and the crew was a motley one. The thing we all had in common was fast friendship and loyalty… We knew how to stick together.
I made some unlikely friends that summer. My co-counselor was a fast talking incredibly intelligent woman named Michelle Gomez (GoGo). She had big Long Island hair. I learned immediately that NOONE messed with GoGo. She gave me a once over when I arrived, unimpressed with my Williams College Lacrosse T shirt, ripped up jeans, and Birkenstocks. Her hair was perfectly curled and her scrunchy rocks matched her tank top. She was fun and established. ]It was clear that she was in charge, both socially and in her job description. One of my best friends from high school joined me. She had just finished her Sophomore year at Duke. She was a great soccer player, and was unfazed by being the only woman among the male soccer staff. We also met a soft-spoken midwesterner who worked on the waterfront named Jennifer Hanson. She and I came from different parts of the country, from different kinds of families, but we had so much in common. We were a bit of a calm in the storm. We were quick to help, we worked hard, and we both fell in love with summer boyfriends. We did not think to push on the male hierarchy entrenched in decades of history and tradition. We did not know then who we would become.
I returned to Camp Lenox in 2016. My oldest daughter, Lila, was a camper. One of my campers had married one of the counselors from my 1990s version of Camp Lenox, and their daughter and Lila became fast friends. The director of the waterfront was the same old JJ, with the only real change in 25 years being loss of his blond wild mane of hair. So many of my people were still there. And I joined for a week as the camp doctor. In 2017, the camp celebrated its 100th birthday. Campers and counselors from far and wide returned, including Michelle Gomez and Jennifer Hanson. Michelle put her articulate strength to use, and is now the Mayor of her town in Florida. Jennifer is a tenured professor at Indiana University. And the 3 of us agreed, our experience at this camp was a huge influence on our professional success.
It turns out that spending a summer in close quarters in a male dominated environment might have been the best preparation for orthopaedics. There was no fear in competing with the men around me. I learned to separate myself from the behavior that was not interesting to me. I established boundaries. Most importantly, I learned to believe that I could do things differently but just as well as the men surrounding me, and I learned not to be intimidated. Probably the most important thing that these summers taught me was the meaning of a small tribe of women in a huge sea of boys and men steeped in tradition.
In 2019, the camp is almost 50% girls and women. The women counselors include top athletes, from basketball to softball to soccer. The stands for girls’ sports is filled by boys cheering, just like the girls cheer for the boys. The color war teams are led by a male and a female general each season. The girls and women are no longer a small minority among a male led majority. In 2019, I have spent 2 weeks watching my 2 daughters and 1 son inhabit a world that is teaching them gender equality in athletics and in life.
I have an ongoing email chain with 5 women of orthopaedics, true giants in my field. We exchange articles that motivate us and anger us, lift one another up, and remind one another to laugh. Last week I wrote to them about the shift I have experienced in my camp microcosm. As I received their supportive responses, I realized that these orthopaedists are my 2019 version of a tribe to return to after proving myself all day long in our world of orthopaedics.
I spent the past 48 hours with the society that I have come to understand is my professional home and happy place. The Pediatric Orthopaedic Society of North America (POSNA). These are surgeons that have dedicated their lives to fixing children. Children who break their bones, children who are born with crooked bones and spines, vulnerable little beings who cannot advocate for themselves. My pediatric orthopaedic family exists to support each other, to build each other up and pick each other up. Dr. Steve Frick, the outgoing president of POSNA, said something today from the podium that resonated fully with me. It went something like this, but I cannot do it justice… My clumsy paraphrasing of his words are as follows: This society is here to take care of its members so that the surgeons can take care of the children, their patients, in the best way possible.
2 years ago POSNA committed to embracing the work of wellness for pediatric orthopaedists. I had the honor of working with 2 of my heroes, Dr. Hank Chambers and Dr. Michael Goldberg, to spearhead this work. In the spirit of my own wellness, as I was overextended at that time, I asked for someone else to lead the WTF, as our Wellness Task Force was unfortunately named. That someone else has since joined the ranks of my heroes. Dr. Vish Talwalkar has a quick smile, humility, brilliance, and the kind of sense of humor required for this work. We started with a short seminar last year. We wrote a call to action, published in the Journal of Pediatric Orthopaedics. And yesterday Dr. Brian Scannell chaired a half day course on wellness that overwhelmed me with gratitude. My POSNA family showed up, learned, contributed, and sat in the hard work of the questions of our own vulnerability.
I had an “aha” moment as I planned the talks I would give during this session. In my quest for physician advocacy in the interest of wellness, and in my fierce battle calling attention to the moral injury that some call burnout in physicians, I have traveled to speak, written articles at night and on weekends, and I have had countless conversations with struggling physicians. I have always advised my mentees, my friends, my family, and my children to say yes to the things that bring joy and stir passion. So saying yes to all things related to this work has rolled over me like a Mack truck. My aha moment came from the podium. I began my talk with a disclosure that I have shifted to an edgy place. I’m not talking the wellness of yoga mats and organic vegan food. I spoke about the abyss that is growing between doctors and patients. About the loss of peer interaction. About the loss of respect for physicians, as evidenced by the #doctorsareassholes and #stayinyourlane viral movements. About the systemic challenges of the electronic medical record, sleep deprivation, loss of autonomy, and inability to have the support to function at the scope that we have trained so hard to achieve. And as I moved through my talk, I shifted from edgy to angry. Angry about what has happened to my beloved profession.
My kids go through their days at school and sports and friends and dance keeping it together, mostly as model citizens. Frequently they get home to me and lose it, with an ensuing hot mess of tears or rage. The sense of family, of warmth, of support, brings up the feelings they have bottled up all day long. This is what I felt as I came home to my POSNA family yesterday. I felt the support around me that enabled me to lose my veneer and show the crack in my armor.
I have left the beginner and intermediate slopes of this physician advocacy work I have assigned to myself. I feel like I am at the top of a steep and icy mogul field. There is no alternate route for me. I have committed, and I am pointing my skis down this mountain. I’m not sure if I will wipe out and fail or whether I will book down the mountain with good form and confidence. So stay tuned.
There are so many shifting tides in the practice of medicine in 2019. I have just learned of another milestone. For the first time, employed physicians outnumber physicians who are self-employed. This data is reported in a Policy Research Perspective from the American Medical Association by Carol K. Kane, PhD. She reports that younger doctors (under the age of 40) are more likely to be employed physicians. Women are also more likely to be employed physicians. I made the shift from an academic elite private practice to join a large multispecialty medical group at the age of 40, just as I was about to leave this demographic of “young woman.” And I continue to have so much to say about this shift.
I am an Orthopedic Surgeon. I have been a doctor for 2 decades now. I became a “surgeon” the year I turned 25, when I graduated from medical school and began internship. The year was 1997, and when I left New York City for Houston I wasn’t even sure what time zone I was entering. The humid southern climate was as foreign as the southern accents and the world renowned medical center called Baylor. My late father, who was also an orthopedic surgeon, moved me into my apartment and crushed the oversized bugs with his size 14 feet (mostly by accident).
I was confident in all of the wrong things, and was completely unprepared for the independence expected of an unsupervised intern in surgery. I survived year one, persevered year 2, learned in year 3, struggled in year 4, and finally hit my stride and thrived in years 5 and 6. I moved on to Los Angeles to one of the top pediatric orthopedic fellowships in the world. I entered the mecca of my specialty and surprised myself with my success. I was lifted by my mentors. I was brought into a fold that I never knew existed. I was asked to serve on the Board of Directors of the Pediatric Orthopedic Society. I believed that this honor came because of my academic hospital home.
I shocked myself in 2011 when I left the glory of Children’s Hospital Los Angeles and all of the accolades that went along with it. I assumed that I would no longer be embraced by the academic elite. But I had my 3 children to think of. I had sanity to consider. I had predictability to embrace. I was then elevated to the Board of Directors of the mother society of all orthopedic societies, the American Academy of Orthopedic Surgeons. I had underestimated myself, and I had underestimated Kaiser Permanente. My leadership experience from the orthopedic world grew. I was asked to mentor in an elite orthopedic program entitled “Leadership Fellows Program”. Applications are accepted for mentees in this program through age 45. I was 44 when I was invited to mentor. I was elevated to oversee the Communications Council of the Pediatric Orthopedic Society. I was appointed to the Board of Directors of the Ruth Jackson Society of women in orthopedics. My invitations to speak and lecture throughout the country did not slow down.
In the 8 years since joining Kaiser Permanente, I have worked hard clinically. I have become respected by my department and was promoted to the position of assistant chief the year after I became partner. I am the Regional Clinical Lead for Pediatric Orthopedics. I am part of the Clinician Patient Communication team, in which I get to do deep work with my partners about how to best connect with our patients with integrity and remain true to ourselves. I take great pride in this program that bolsters our physicians. I am part of the regional team that leads perioperative services, and my niche is in culture. Regional Perioperative Leader for People, Practices, and Systems. My long-term work on this team will focus on diversity and wellness among our surgeons and anesthesiologists. I do all of this while maintaining a full orthopaedic practice. And when I close the door to share a visit with a patient and their family, the room is absolutely no different than the one I inhabited in the mecca a few blocks away.
My 12-year-old daughter remembers the days when I rarely returned home in time for dinner, the days when I left for work before she woke up. But happily, my 9-year-old daughter and 7-year-old son do not remember these days. I am an active mother with full support and partnership from my husband of 15 years. I love being a busy surgeon physician, and I believe that whatever I have accomplished as a surgeon and a mother is enhanced by my shift. It is not for everyone. My ego is often checked at the door. But I wouldn’t have it any other way.