Interviews - Elizabeth Chase, MD, Interview, Life in the Fast Ob-Gyn Fast Lane

“Women are much less likely than men to transfer their enormous intellectual capital into career capital. This is not a woman’s issue. The future of medicine is inextricably linked to women physicians realizing their potential as leaders.”

Toni Martin, Book Review, New England Journal of Medicine, January 8, 2008, When The Personal Was Political: Five Women Physicians Look Back (iUniverse, 2008)
Background

Q: Dr. Chase, the purpose of this interview is to give insight into the trials, tribulations and joys of being a woman physician in a transformed health system. Why don’t we begin at the beginning. When did you graduate from medical school, and how old are you?

A: I graduated from Tufts School of Medicine in 1992, and I am 46 years old.
Q: What is your specialty, where did you do your postgraduate training, and how long have you been in practice?

A: Obstetrics and Gynecology. Women and Infants in Rhode Island. I’ve practiced for 12 years.

Joys

Q: In those 12 years, has your career lived up to your expectations? Has anything surprised you?

A: From the standpoint of the joys of being part of patients’ lives, listening to their stories, and the pleasure of doing surgery, it has lived up to my expectations.

Q; So you enjoy surgery?

A: Yes, I do a lot of gynecological surgery for prolapsed and urinary incontinence.

Disappointments

Q: And what have been your disappointments?

A: The hardest part in my early years of practice in Pennsylvania was a combination of things – the shock of low reimbursements paying me half of what I expected to make and inadequate amount of time I had to spend with patients to make up the difference. I just could not justify spending so little time with patients.

Q: Was that low reimbursement due to aggressive HMOs in Pennsylvania?

A; Yes, U.S. Healthcare, and Anthem were the main players. They functioned like a monopoly to reduce reimbursement. That, in combination with malpractice premiums that increased significantly when I was there and even worse after I left, made practice life miserable.

A glut of lawyers exists in the greater Philadelphia area, and there was a lot of trolling on the part of the bottom dwelling lawyers.

There was a shotgun approach to lawsuits, naming everybody in the practice, even if you weren’t present for a delivery or any other aspect of the patient’s care . That happened to me several times when I was in Pennsylvania, and I was only there four years.

It was really a negative practice environment, and you had the sense every patient had a lawyer in their back pocket. It was frightening to practice and increased my anxiety level. Another thing in Pennsylvania was absence of tort reform. When I started, I paid $54,000 for an occurence policy. By the time I left, it was $70,000, and now, I understand, it’s close to $120,000.

Exodus

I was part of an exodus of doctors from Pennsylvania. I recall a full-page ad in the Philadelplia Inquirer, listing all the doctors who had fled Pennsylvania. I fled to Dover, New Hampshire, a suburb of Providence.

Q: Any other comments?

A: I’ve adjusted to managed care’s realities. It’s the only business in the world where you don’t get paid what you charge. The malpractice environment is definitely better here. It’s less urban and less litigious. By and large, patients here like and trust their doctors. Here we succeeded in starting a tribunal system for pre-review of claims so only meritorious cases move on. We may have a decrease in rates this year, and we have a malpractice firm courting us.

Context of Practice

Q: Give us some context of the community you’re in, the hospital you use, and your practice setting.

A: I practice in a community hospital with a level 2 nursery. We do about 900 births a year. Dover has 50,000 people, and its primary industries include the headquarter of Liberty Mutual insurance company and we have some high tech firms. The hospital employs a lot of people. We have a private practice, five doctors, all women.

Q; You’re part of the gender revolution.

A; Yes, but Tufts was one of the first medical schools to accept women, and my class had 50% women. And Ob/GYN at this point is something like 80/20 women.

Q; That changes medical practice dynamics. Women require pregnancy leaves, spend more time with family, are more likely to be employees, and sometimes women doctors are working and the husbands are not. How many women in your practice have “house husbands?”

A; At one time or another, three of us, including myself, have a “house husband.” It gets a little hectic, but we manage very well. We’re on call every third night, but we make our call easier by working with midwives. The midwives call in if there’s a problem or a need for a C-section. About half of our time is backup call, rather than having to be there.

Our practice is close to European model, with the physicians coming in only for complex cases. Personally, I enjoy the surgical and more high risk cases more than the day-to-day care. The C-section rate has increased because fewer women are given the option of vaginal birth after C-section. Uterine rupture occurs in about 1 of 1000 attempted vaginal deliveries after C-section. This high rate of sections is largely driven by hospitals and malpractice carriers. Also more women are asking for C-section. It’s called Cesarean section by maternal request. This can be because of a desire to avoid prolapse, fear of labor, but often it’s simply the convenience of a planned birth. The national first time C-section rate is about 25%. Our rate is about 12%.

Hospital Physician Environment

Q: Describe to me the hospital –physician practice environment. As you know, hospitals are hiring more and more primary care doctors these days and even specialists. How large is your hospital?

A: We have 155 beds and 10 Operating room suites.

All primary care practices are “owned.” There are no independent generalists working out of our hospital. We have a fully staffed hospitalist program. And all practices participate in the hospitalist program. We have 13 hospitalists on staff at this point. We have 24 hour ICU coverage by hospital-employed doctors. None of the surgical practices or sub-specialty practices are owned. There appear to be some collaborative agreements with plastic surgeons.

Hospitals like to own the physicians because they can control them. We are not owned, but the hospital has often suggested to us the only solution to any financial problem we might have is to be owned.

We feel much more comfortable with owning ourselves. We prefer the independence we have. We’re making it financially. We’re 5 women, and 4 of us have kids. All oour midwives have children.

We call ourselves a “lifestyle practice,” and we try to blend being mothers with a sustainable way of being a doctor. We give ourselves 5 weeks of vacation a year, and we give ourselves 2 weeks of CME. We don not believe in working 24 hours a day, 365 days a year. Our salaries are not as high as the national average, but we are happy this way. We look after other and we collaborate and cooperate with the town’s othe OB/GYN practice.

Q: Is there anything that keeps you awake at night?

A; We do not believe in a fear-based practice I try to have the most honest based conversations with my partners and my patients.

Q; So you are now a grown up girl?

A: Yes, I’ve learned how to deal with adversity, and not make it kill me. I like medicine too much to stop. We truly love our patients, and try to develop positive relationships with them.

A Last Questioon

Q: Last question. We have just elected a president who promises sweeping health care reform. What are your expectations, and what would you like to be done to change the system?

A; I am cautiously optimistic, The Republican party has lost its way in taking care of physicians and responding to the needs of the public. They have lost their moral compass by favoring corporate self-interests. When the Republicans favored the 10% cut in Medicare rates, they lost sight of the fact that current Medicare rates don’t even turn on your lights.

And Republicans offered no solutions to meet the needs of the 47 million uninsured. The vision of someone to provide health care for everybody at least has a noble goal. I feel insurance companies have long outlived their utility. They simply add costs to the system. They make things difficult for everybody- patients, physicians, and hospitals.

On the other hand, having seen how Medicare and Medicaid don’t work, I have little confidence our government can run a sustainable system.

Q; What about Medicare-for-all at current rates?

A: It would put us all under.

Q; Any concluding comments?

A; I still think taking care of people is an honor and a privilege, and I love it.