Contemplating the New Year: A private cardiology practitioner's resolve to stay the course

A few fleeting hours are all that separate the peace of a winter respite from the insanity of my daily work routine. I sit just outside the shadow of my family's temporarily abandoned beach tent, grasping at the sound of ocean waves, collecting them as they gently, rhythmically caress the beach. I try in vain to record the soothing sea song and the warmth of the December Florida sun so I can later conjure them on a cold damp day in Kentucky. I close my eyes and drink in the sun, happily recalling why I have always felt such love for the beach.

Cocoa Beach, FL is our favorite respite, where time melts like Salvador Dali's clocks, draping itself over palms and boardwalks. It spreads itself over gritty powder-white sand and lingers on comfortable worn flip-flops. The ocean, blue as the sky, gives up mounds of shells and is my constant companion on long morning walks and nighttime excursions. I love this beach. I long for it at times, but there has been no other time that I have been needier of this refuge than the last two years of my practice.

Like an old sea captain who reflects backward on his career, I took inventory this weekend of my time on the high seas of private practice. Although challenging, the first two decades of my career were smooth sailing and most rewarding, but there is truth in the saying "there is nothing more deceptive than the calm before the storm." An able and wise cocaptain stood beside me through rough waters and celebrated victory upon victory. He still stands beside me today. We still rise to every challenge but are both a bit battle-worn, not from physical demands so much as from the politics and change in our local medical climate.

We have learned much from two years of turmoil. We have toughened up with assaults from our own government, which has locked in private practitioners at the other end of the spyglass, cannons at the ready, to dismantle old practices that have served the multitudes. Private practitioners are scapegoats, with threats to decrease our reimbursement by one-quarter, a misguided attempt to correct the sins of mismanagement and waste, and for that portion of the population who drink, smoke, and eat us into financial oblivion, individuals who are always expecting the treasure chest of government funding to be ever at the ready. They have no thought of the efforts and sacrifices required to fill it. Our income and those in our employ who have also entrusted their future to us are ever vulnerable. Add to this the pain of loss of consortium of our former colleagues who have fallen victim to the more attractive cousin of socialized medicine, hospital acquisition, and the sting of abandonment by the very institutions we have helped to build and sustain. With the weight of disappointment of the immediate past and the reality of the consequences of the temporary definition of legal collusion, another year of disappointment of last year's magnitude is at first difficult to contemplate.

Despite my clothing heavy from the water coming into our ship, I am miraculously now more optimistic. In part, I owe it to the lessons I have learned from nature on how best to cope with the adversities of a hostile practice environment. I have learned that sharks do not adapt to their environment but rather adapt all that is around them to theirs. I either must steer clear or outsmart their tiny brains, which understand only pain and hungry greed. I will sustain by being as reliable as the ocean tides and as truthful as the promise of a rising moon. I will give up the dead yearnings of yesteryear much like the sea spits out its dead each morning on every shoreline that edges its mother earth. I will accept the need to endure occasional raging winds but will still enjoy the warmth and comfort of calm waters. I will be a survivor and will hang onto whatever driftwood, plank, or passing ship that might lend itself in times when there is need of rescue, as long as it is a vessel with honorable intention. If the intentions are ever otherwise, I would rather let go and sink slowly to where the waters become murky and dark. For a brief moment, interrupted only by the sounds of sea birds, I once again, and hopefully for the last time, allow myself to sink, free falling into that small corner of my imagination to that unthinkable place. My toes first sense the cool depths of resignation, then my legs and my face, immersed and though hungry and panicking for air, a comfort compared to a life of piracy chosen by a few and a life fully mapped with few choices for others. I see in the distance other ships passing above me and contemplate their offers of assistance but stay submerged until that dreadful chapter of my imagination is finished.

I open my eyes and step back into reality. I feel the sand beneath my feet, the sounds of children playing in the waves. I stand to walk back toward home accompanied by a hint of dread at the thought of the beginning of another year. It will be a year of strategy, some certain disappointments, surviving . . . but then I abandon those negative feelings for a ship that passes with flags flying, sails full of wind, the ocean spray peeling off the bow as it parts whatever waters that lay before it. I am the proud captain of my ship. I author the manifest, the ports of call, and with the help of God, the destination. I realize that I have a beautiful family, a warm home, and a great life partner that welcome me at the end of every day's journey. I have tens of thousands of patients who are treading those murky waters of uncertainty who view me as their life preserver, their anchor, and their guide. They are adrift in a far more unsettling sea than what we as medical professionals will ever perceive.

As I reach my destination, I realize the sun that so gently caressed my skin this last hour, while now setting on a crimson horizon with the fingers of night dangling toward earth will rise over a glorious first new day of 2012. The subconscious scales that weighed my future are now tipped toward the positive. I have willed myself in the space of this hour to believe with every fiber of my being that right will triumph over might. I am resolved that I will be productive and happy. I will approach the year with a clear focus on each patient and each decision before me. My calm resolve perceived as weakness by some will be my navigation tool and my greatest strength.

My New Year's wish for all of you is that 2012 will bring you prosperity, happiness, health, and, most of all, peace in a future that often times is what we make it. May you always be your own captain. 

Your comments

	Contemplating the New Year: A private cardiology practitioner's resolve to stay the course
	# 1 of 8	January 6, 2012 12:48 (EST)
	Ken Lee	Dear Dr. Walton-Shirley, I have always enjoyed your eloquent essays, but this one captures the sentiment of so many of us who remain in private practice cardiology - even those of us here in the "belly of the beast" on K St in Washington, D.C.  Always interesting to see how many of the Capitol Hill gang who choose to come to private practitioners avoid the corporate structured offices for their personal care.  An interesting paradox. Those of us who have served in the Navy wish you "fair winds and following seas" on your voyage in 2012.  I hope that a new Admiral assumes command of the fleet in November.
	# 2 of 8	January 7, 2012 09:37 (EST)
	Melissa	Ken, You are too kind but thank you so much. I appreciate your post. If you have any political connections, :)  and I'm sure you do,  please FEEL FREE to pass these blogs along. I think Seth's last blog was right on. He always drills down on the topics so well.  Hope you have a great 2012. Though the changes in medicine threaten us all around, behaving honorably will always serve us and our patients well in the long run. Melissa
	# 3 of 8	January 9, 2012 10:48 (EST)
	Ed Fleegler	Dr. Walton-Shirley, I enjoyed your prose.  You are most certainly a physician who understands the importance of healing as well as the possibility of a cure.  Accurate empathy and compassion create healing as was written by Dr. Rachel Naomi Remen in a short story,  "The Starfish Story."  Dr. Remen, like myself, is an Internist. I no longer practice primary care medicine.  I started to feel many of your sentiments after the BBA of 1998, and left private practice to become a part of a large health care system in which I practiced clinical medicine until 2000.  I have spent 10+ years looking for answers regarding the creation of an efficient, aligned, collaborative health care system that places the patient in the center of care.  Physcians like you are a significant part of the answer. Thank you for your New Year's wish for 2012 regarding being one's own captain.  Wise understanding and good intentions can serve as a foundation for each of us.  Through wise and right actions, speech and the opportunity to earn a  reasonable livelihood there is an opportunity for restructuring of the mind.  A restructuring that requires effort, concentration and mindfulness.  Mindfulness is awareness of the present moment with acceptance. What does all of this mean?  Rather than each of us rale against the darkness of the night, we must shine a candle to be present as change occurs in health care.  We must  learn as physicians to hold ourselves gently with unconditional positive regard as we create a sustainable health care system for our fellow beings.  A health care system that creates the opportunity for cure as well as healing. Best to you and all of my physician colleagues.
	# 4 of 8	January 9, 2012 12:08 (EST)
	Kevin Finan	Dear Dr. Walton-Shirley: I manage a cardiology practice.  It is too bad that the American College of Cardiology has 'abandoned ship' at the first sign of rough water.  Guess the leadership of the ACC is setting themselves up for their next positions...with the government, etc.  Thanks for your blog, stumbled upon it by accident.  KF
	# 5 of 8	January 9, 2012 06:35 (EST)
	Joe Nuara	From another Navy veteran; I am starting my own solo private practice of Cardiology this month after leaving a large corperate practice at age 68. I am sure to have smooth sailing if we indeed get that new Admiral next November. Best wishes.
	# 6 of 8	January 17, 2012 11:24 (EST)
	Melissa	You are most welcome Kevin. Good luck with your practice management in the next year. May you find those most coveted calm waters! Melissa
	# 7 of 8	February 23, 2012 12:20 (EST)
	Saleem	Very well written post, Melissa! How can we in private practice of Cardiology be captains of our ships when the countless forces around us which include the Government( Medicare etc), the insurance companies, corporate bigwigs-- all are succeeding in killing the very institution of private practice. Cardiology as we have known and practiced it for the past 30 years, regrettably is teetering on the brink of extinction, I am afraid. Hospital administrators in general who ostensibly have revered us as bringers of patients to their facilities for years no longer consider us important since most of our cousins are their employees and hence very much beholden to them for their munificence. Cuts are looming in those salaries however in the next couple of years though and I see cardiologists and others chasing RVUs and fights breaking out in the doctor's lounges. Hospitals are in trouble and with looming 27 Billion dollar Medicare cuts to the hospitals, physicians salaries will go south. It is just a matter of time. Embarrasing it certainly is but cardiologists in private practice are having difficulties with cash flow with Medicare shutting off the spigot abruptly for weeks on end with no explanation whatsoever. No salaries for the physician partners. Never expected this and there is absolutely no recourse.  Glad I am near the tail end of my career. Few more years and I know they are going to be long ones, and I am ready to hang it up. I feel sadness and gloom about this exciting specialty which blossomed during my career and achieved amazing things for patient's benefits. The thrill, however, is gone!!
	# 8 of 8	March 1, 2012 10:52 (EST)
	Melissa	Saleem, There are so many angles and issues impacting us right now all across our country. I've said all along that I don't mind so much to work for a hospital. What I would never want to do is work for a hospital that does not share the same philosophy that we swore an oath to uphold. Is patient safety at the forefront? Will  actions that create harm and neglect in order to turn a buck be tolerated? Will outside entities be allowed to move into a "not for profit" hospital and split a community of close knit physicians in order to fuel a "for profit" arm? Will they shrink or take pensions and benefits from those they have hired,  then discuss bonuses for the CEO's who made those decisions? Will they offer pieces of silver as an incentive to change the long standing relationships patients have with their regular physicians?  Will older or sick workers be respected and accomodated without a hassle? Will nurses literally walk down a hall looking behind them for fear they will lose their job if they speak out? That hospital is not a hospital  that any good physician in a community spends 20-30 years building and after all that blood, sweat and tears, stays silent or becomes tolerant as it becomes a place from which the public fleas at every opportunity.  No amout of profit, or cash or advertising can fix that problem.  To regain the public trust for all venues, integrity, hard work, and a clear mission to profit the patient first and foremost will be necessary.  When that happens, a hospital will fill itself with grateful patients and physicians will take joy once again in being physicians.

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