"The lack of due diligence in regard to the pursuit of
one’s intentional destination in life and medical career
eventually results in the surrender of your expectations
to the unrolling of unexpected circumstances that
chance presents you with."
For a large percentage of regular people who have a passion to do great things in their lives, their future becomes a series of personal and uninformed decisions based more on emotion than facts.
The problem is that those decisions are unaccompanied by a serious investigation into the essential elements required for the attainment of each step in your progress towards your original desired destination. Consequently, you arrive at a different destination than you expected. The suffering from this factor is a physician's nightmare.
For example, when you finally made a decision to become a doctor, did you research, visit, and interview at the various college and university premedical programs and curriculums that factually and predictably had a higher rate of acceptance of premed students into medical schools?
Did you choose that college or university based on some other personal reasons unrelated to your chances of getting into the medical school of your choice? Did you even have a medical school choice? I didn't, but I got lucky.
If you diligently did an investigation, you might have found that the medical school of your choice always made the selection of medical school applicants from certain premed programs and certain premed schools above all others. That would necessarily increase your chances of being selected to that choice of medical school.
Did you arrange to have your premed faculty member write a strong recommendation letter to the top few medical schools that you applied to? Did you make a personal visit to the medical school and meet with the recruitment team or manager of admissions?
Maybe you were so glad to get into any college premed program that you had no thoughts about any of those future decisions. In your last year of high school did you make any attempt to find a mentor who could have helped you plan the most advantageous steps to take that would have predictably guaranteed your career path? Didn't know there was one?
Most high school students have no idea that they would get great value from a mentor or career planner, or how would you even find that mentor who knew the ropes about medical career planning? It would take something akin to due diligence.
It’s likely that most premed students today are in a premed program at a college or university that they “heard” had a good premed program and never actually checked it out, to be sure.
You already know that there exists huge competition among premed schools to attract the best premed students. Well, have you (or did you) ever consider how that might affect your chances of being accepted to medical school later? Probably not.
Think about this realistically. You are in a premed group of 50 and you discover that the medical school you prefer to go to only accepts 2 students from your premed group. Another college’s premed group of 20 premeds who are applying to your chosen medical school for the same two spots. Which would offer you the best chance of being accepted into your chosen medical school?
You would have given yourself a much better chance of being accepted into your medical school choice. Oh yes, there are other such things to consider like premed advisor recommendations, if there is another doctor in your family, college grade average, among others. Who writes the recommendation is important because medical schools know how reliable that person’s recommendation is.
However, most premed students have only one goal… to just get into any medical school anywhere. You would benefit from the statistics about the number of premeds from each premed college program that are never accepted to medical school, even after reapplying several times. In my premed class, several were accepted to dental school as their back up plan.
In the long run, they may have done far better in careers than I did in medical practice. The introduction to dental implant procedures has made many dentists millionaires. Knowing that "Clear Choice" charges each dental patient about $35,000 for the full mouth dental implant procedure in one day, might change your mind about attending medical school.
Remember the story about the cardiac bypass surgeons who for several years were top in their profession. A few years later they had no more subspecialty, or patients, because of the interventional quasi-surgical procedure of stenting procedures of the coronaries by invasive cardiologists who make $600,000 a year. Stenting put the bypass procedures of the coronaries by surgeons out of business. Many became ER physicians as apposed to re-training.
What about due diligence in selecting the medical specialty you are best fitted for?
Now you’re in medical school and the elation and celebration of being in medical school makes you shift gears to the next goal. It’s probable that the old-fashioned general practitioner and the family doctor will be disappearing along with the demise of private medical practice in the
near future. You should be reminded that our government/politicians plan is to eliminate private medical practice all together so they can gain total control of American healthcare.
Internal medicine has already invaded the primary care arena. I expect that all primary care doctors will be required to become Internal Medicine specialists in the near future. If all healthcare is in total control of our government (Socialized Medicine) soon, as expected, then doctors will eventually be told what specialty to focus on and even geographically where to practice.
But, at least for the next several years, most medical students will still have choices of type of practice, kind of specialty, and where to practice.
Diligence should come into the picture no later than at the beginning of medical school. Unfortunately, even then it seems far earlier than you want, to have to make any decisions about specialty, where to do residency/internship, or where to practice. The best opportunity you will ever have to change your mind about your prior intentions and desires is during the first year of medical school---second year at the latest.
Others believe that a medical student should have their third year of medical training (rotation through all of the specialties) before reaching a final decision about their medical career. By then a student has had an actual taste of each specialty and often have a chance to learn and feel what their medical skills actually are.
The problem here is that most medical students have very little idea where their talents, skills, and desires are best used, or even if they have some of those highly critical skills they have
never recognized.
As a general rule, most medical students require the first three years of medical school exposure to the various kinds of medical practice to even begin to have enough reasonable judgment about where their talents and interests should be invested.
How do you discover what talents and skills you already have? You may have already taken all the tests earlier that are supposed to point you in the right direction. I will tell you that nothing will reveal the truth to you other than direct experience practicing the various training segments of medical practice in medical school.
Even that process may confuse you. Each specialty clinic you rotate through usually indicates to you clearly about what you can or can’t spend the rest of your life practicing medicine in. So, you end up picking the top 5 ones that seem the most desirable and interesting, and then choose one
to go after.
I discovered that I could never tolerate sticking needles into the scalp veins of babies while they screamed, and while I imagined their extremely protective mother holding a baseball bat standing behind me, watching the procedure.
Coming to those decisions is not easy for any student. No one has yet devised a reliable system or method for making these choices.
My personal experience in medical school (1958-62) has undoubtedly changed considerably like everything else in medicine. But, I can’t ever remember any instructor, practitioner teaching us, or academic telling me what they could see my talents or skills as being best fitted for. So I was on my own to make those choices. I chose OB-Gyn.
Maybe I should tell you while i was in my rotation on cardiac surgery at Univ. of Pennsylvania Hospital, as a third year medical student, was kicked out of the operating room by the top cardiac surgeon, Julian Johnson, MD, because I could not name all the arteries supplying the lungs. He had told me to be able to name them the next day and I spent a late night memorizing those I could find the names of in Gray's Anatomy, but that wasn't satisfactory enough.
I chose my specialty because my thinking at the time was...
- If I didn’t like one of the areas of the specialty I chose, I’d quit doing it and and work on another area I liked the most and felt most comfortable confidence-wise. I'd need to choose a specialty that was made up of several areas that could become a subspecialty.
- The specialty had to include both surgical and medical areas of medical practice and left me options for changing my focus of choice within the specialty later.
- I discovered that in either side of the OBG specialty I would get immediate gratification with what I did.
- I realized that I would get more gratification with solving a surgical problem than with the long process of diagnosing the medical problem and then following and treating a patient's medical problem for years to come. So it had to be a surgical specialty.
- Within the OBG specialty, there were many potential subspecialties that I could later focus on if need be, or if my talents seemed more compatible with... such as gyn endocrinology, infertility, gyn oncology, and radical pelvic surgery.
Consequently, later in my OBG medical career, the medical practice had changed radically, altering my original choices. It was something I had not anticipated and should have.
It's not that I couldn't make changes in my practice, but that the change would mean I'd have to shift my practice focus (like quitting OB and continuing with Gyn) when it takes years to develop a Gyn only practice (which I didn't consider) and earn enough to stay in practice. So I licked my wounds and continued with both.
A few of these alternatives that I was confronted with and was forced to make radical changes in my medical practice were...
Laparoscopy was introduced in the USA (the late 1970s-early 1980s) by Dr. Kurt Semm, who invented and developed the procedure in Germany. The thought that one could do large and variable amounts of surgery without doing a laparotomy intrigued me both as a surgical challenge and for patient safety and recovery speed.
I took the first instruction class in the USA in Los Angeles given by Dr. Semm for laparoscopic surgery, which included live practice sessions using the special laparoscopic instruments.
After the battle of introducing a completely new type of surgery into our hospital surgery department and after creating the surgical privileges for the procedure were approved, the privileges conflict continued. The procedure was entirely new to American physicians
and hospitals.
Who said this procedure was safe and that the results would be a good upgrade for surgeons? Hospital privileges for new procedures required being mentored first. No one else had ever done the procedure, so we had to mentor ourselves for the first several months.
It was a smart move to lean on the operating room nurses for the monitoring primarily because they all had worked with me in many major surgical cases and would be the most reliable individuals to judge how I performed in the new procedures. The OR nurses work with all the staff surgeons and know the quality of surgery that each surgeon performs.
My friend and associate in practice (who had taken the same training in Germany a few months earlier) were forced to buy all the laparoscopic surgical equipment ourselves, and then train all the OR nurses about the procedure.
After tolerating the severe skepticism of all the surgeons and medical staff, and continuing to add new procedures to laparoscopic surgeries that we performed safely in increasing numbers, things slowly got better rather quickly.
Within the next 3 years the hospital bought the laparoscopic equipment from us and ordered more. By the end of the second year of doing laparoscopic surgeries a new young general surgeon arrived and started doing laparoscopic gall bladder removals, and the skepticism totally disappeared. The surgeons were the most critical specialists at first, but when they realized what they could do with the laparoscope, all the critics vanished.
As you might have guessed, it didn’t take long before he was overwhelmed with patients who needed gallbladder surgery (other surgeons lost those cases), and overnight all the other surgeons scampered to learn how to do it themselves.
I believe I was lucky and privileged to see the eventual value of laparoscopic surgery from the start, to survive the grind of implementation, and to have a forward-thinking associate who felt like I did. Advanced laparoscopic surgery became my primary practice focus and fulfillment in
my medical career.
The next massive change in OBG came with the battle over C-Sections.
Obstetric forceps deliveries were a critical and important skill taught during OBG residencies in the Philadelphia medical school's community in the late 1960s (my OBG residency 1967-70).
C-section rates were rising rapidly. Fetal monitoring was a daydream in those early days. I had become a sitting duck for malpractice suits in California later when the whole obstetrical specialty in California shifted to C-section rather than forceps use for childbirth problems, and I was still using forceps for delivery, which I had been taught by my residency Chief of Service, Dr. George Lewis, an OBG Board Examiner.
C-section rates skyrocketed as medical malpractice suits increased to millions of dollars in most complicated delivery cases. C-Section was accepted as much safer method of delivery of babies than forceps. Even "low forceps" use was avoided. At that time my C-Section delivery rate was 5-6%, and the rate for the 15 other OBGs on staff were from 20 to 50%.
I was smart enough to stop forcep deliveries and increase my C-Section rate--go with the flow. The medical malpractice risks drove the change in the OB deliveries. At the same time the OBs on the East Coast though we were nuts. And the ACOG continued to insist on lowering the
C-section rates.
I was forced to put away my forceps expertise, and increase my "reasons" for doing C-sections, completely contrary to my training. The move to increase C-sections was then subject to constant academic ACOG standards demanding reduction of C-section rates everywhere in the nation. It was a catch-22 situation that continues to today.
Notably, at that time C-Section deliveries in Brazil and South America was occurring "on patient demand" for prevention of future increase in urinary incontinence secondary to vaginal delivery stretching of pelvic structures.
Remember that we all are responsive to our mental fixations and experiences that directly affects our ultimate medical career destiny.
I had previously just spent five years as a Navy/Marine military physician and Flight Surgeon, then the next three years in a civilian teaching hospital residency program, then the next three years in California at a Kaiser HMO during which time malpractice was never a big issue.
And, in the HMO arena, almost forgotten about. Malpractice cases occurred but it was always silently "taken care of" by the institution employer's attorneys---paid patients to drop the case.
My next step deeper into the quicksand was to begin my medical practice as a Kaiser Permanente physician in California with at least two tripwires.
First, the doctor environment in California was and still is first in accepting new medical treatments and changes that advance medical care.
Second, California was and still is a fruitful bed of aggressive medical malpractice plaintiff attorneys.
Because of the many and increasing numbers of huge malpractice case verdicts in the mid 1970s, all medical malpractice companies quit offering medical malpractice insurance in California.
During the next two years or so physicians either elected to practice "bare", use "arbitration" contracts", or move out of California. Several medical groups created their own insurance companies to cover doctors during that time. I joined CAP-MPT, Cooperative of American Physicians---Mutual Protection Trust.
After California passed a law putting a cap on the jury verdicts payouts, the medical malpractice insurance companies offered policies again. About six other states saw what happened in California and legally capped medical malpractice jury verdicts as well.
Once I began solo OBG medical practice, my mind was on many other more important things than potential malpractice actions and practicing in a defensive mode right from day-one.
A prominent malpractice attorney told me that an OBG practicing in California at that time had a risk of a medical malpractice suit every three years on average.
By this time the American College of Obstetrics and Gynecology was continuously publishing articles and practice protocols insisting on reduction of the rapidly rising C-section rates (a common defensive way to avoid obstetrical delivery hazards and malpractice risks).
My primary practice hospital and many others hospitals where I was on staff, pushed for less C-Sections. Hospital OBG departments published the C-section rates of every OBG and Primary Care doctors doing deliveries.
Of importance here is that an OB's risk tolerance level determined not only the "reasons" for C-sections but also the C-section rates each physician had. My associate that had a 50% C-section rate was never challenged legally or by the hospital surgical committee, or by our ethics committee... was given a free pass. But it did make me decide to do my own OB deliveries when he was "on call".
At that time the C-section rate at our hospital ranged from 20% to 50% among 15 doctors. Nothing adversely ever happened to the one 50% C-section physician, other than a little embarrassment at the time the statistics were released each month OBG department meeting.
Feeling confident about forceps deliveries enabled me to remain at the low end of the C-section rates which drew much criticism from the other OB doctors. These other OBG doctors were younger and had very little forceps delivery training, so delivery by C-section indications was easily over-stretched, judging by how I had been trained on the East Coast.
I had great belief and trust in the training that I received from my professor, board examiner, and Chief of OBG at the teaching hospital in Philadelphia. Avoiding C-sections by the use of forceps when indicated seemed well supported by ACOG and the medical literature at that time.
I had done the right thing by official guidelines but had violated the unwritten law about avoiding malpractice risk regardless of consequences that still permeates the specialty today.
This catch-22 situation will persist until the government takes complete control of medical practice, as we now expect to happen. The chances that our US Congress will legally provide laws to protect medical doctors from outrageous malpractice verdicts is a pipe-dream.
I’m sure that you can relate to many of these factors here that were caused by my lack of due diligence in my profession. I failed to seriously research, consider, and evaluate each step I took along the way. I failed to see the wider view of my options and alternatives until forced to comply.
Due diligence is an intelligent way to avoid these hazards.
Stop doing obstetrics and spend full time on gyn is another trap most OBG doctors get caught in. Contrary to my medical school thinking about this issue, later in my private practice I made a decision to quit OB and just work in Gyn. I reversed that idea quickly.
It made sense in view of the highest malpractice risks associated with any medical specialty in California. It is still true over many areas of our country today. Essentially, it seriously compromised me because of my lack of due diligence.
Starting a separate category of medical practice, like my doing only Gyn, in my opinion is a major mistake. At least for my specialty, the reasons for knowing
that, are…
1. The major money earner (about 70%) for OBGs is obstetrics. Quit obstetrics and you leave well over half of your practice money on the table.
The only means of overcoming that is to have one hell of a referral system already set up. I never knew this at the time I made my emotional decision. If I had had a good business education, those facts would have been easily visible. I was business ignorant at the time.
2. If a doctor wants to retain certain options for later in his or her medical practice, you must create a plan to make ready for the change long before the change becomes necessary. If not, you will become a medical vagrant or railroad jockey.
The problem of changing the focus of your medical practice is much easier if you can persuade yourself to make the change within the first two years in private practice.
That means it should be done before you have fully established yourself in the local community, haven’t yet developed a reputation that might offend the medical community, and before you experience a medical malpractice problem.
Statistics and surveys have proven that about 60% of your new patients are a result of referrals from other physicians. Now you know the importance of what I just said above.
It’s smart to make the decision at the start of any kind of medical practice.
3. Patients do not like to be dumped. It happens when you shift the focus of your practice well into your career and in the same community. Change your practice focus and move to another location produces a much better result in some circumstances. By doing that you have time to find a place to practice where you can rapidly restart a new practice loaded with the necessary factors that guarantee your success.
What you need to know here is what you have to learn in a marketing and business education, unless you have a mentor. That’s another reason I advise that formal business and marketing education be provided while still in medical school.
This is another critical mistake doctors make in choosing a place to practice after their training is complete. The excitement and desperate need to get started often leads to an emotional decision, not a strategic decision.
When you learn that everything is constantly changing, you cannot rely on old promises made to you about, “Come practice with me.”
The persistent rewards from the diligent investigation of every option you have done first will make you a happy doctor. Due diligence goes far beyond the usual remote access of
professional information.
Goggling the name of a town for practice info and talking to at least one doctor in the area you are considering practicing in without visiting the area personally, is a huge mistake.
Diligence is the process of obtaining the facts, not opinions.
Diligence is actually the process of proving to yourself that the facts and information you have recently accumulated are undeniably true and have all come from known reliable sources with
legitimate information.
There are many more important applications of using your due diligence during your medical career which I will dwell on in my...
Article #55, Title, "Due diligence Is The Tool Used To Organize Your Medical Career, without regrets"
Never underestimate the importance of using diligence in every aspect of your life. I believe the time you take to do this the more your decisions will accomplish for you in your profession
and life.
In this fast moving generation time becomes more important. When you delay, procrastinate, and avoid those decisions while wasting time, you create more barriers than your may think or even recognize. Avoiding doing your due diligence, frequently is not the most productive way to live, and it certainly hinders your speed for keeping up with those in competition with you.
I believe Lee Iacocca, former general manager of Ford Motor Company hit the nail on the head when he said…
“The trick is to make sure you don’t die
waiting for prosperity to come.”
----Lee Iacocca
Due diligence is also a critical factor in medical practice business management and practice marketing...
Requirements for maximizing your medical practice income
1. Good knowledge of medical practice management
2. Having the energy for continuous medical practice marketing
3. Medical practice business planning is important.
4. Marketing for physicians and their office staff is a winning set up.
5. Learn what makes a medical practice business successful.
6. Your medical practice business system is essential.
7. Bothe practice marketing and physician marketing is rewarding.
8. Business success is the objective of all physicians in private medical practice.
9. My business website—www.marketingamedicalpractice.com
----Professional Probe----
"Parachuting into a crocodile pond is as serious
as insulting a group of plaintiff medical
malpractice attorneys."
Here is a very focused example of what happens to physicians who fail to use due diligence throughout their medical careers. There are unintended landings in dangerous territories with great risk to your medical career. Using due diligence is a tool that will reduce the risk of injury from every decision you make in your life and profession.
Learning to approach every significant and important medical practice issue with adequate diligence ensures that you won't fall into the traps often caused by emotional rapid decisions. Get used to applying that tool before decisions are made and your career will be far more fulfilling and satisfying.
Articles © 2013-2022/CGG INVESTMENTS LLC. All rights reserved. #54, 3-16-22
