Another Inconvenient Truth

This week there have been many eloquent and moving eulogies and articles written about Steve Jobs, his life, work, and genius. Many articles noted the place Jobs came to occupy as a visionary who changed the way we live and work. I am among his many admirers and a user of quite a few of his company’s products, and I agree with much of what has been said about Steve Jobs in the days following his untimely death.

But something about the overwhelming celebration of Jobs’ genius, the many stories about his unwavering and unusual approach to the things he was passionate about have given me pause. Not because they weren’t true—no, it is more the gaping discrepancy they expose between how we celebrate him now versus how he and others like him are treated when they are younger. Because when we call a mega-successful man like Steve Jobs a visionary genius–despite his famously “difficult” and “flawed” personality—we can safely celebrate his quirkiness and uniqueness and break-the-mold attitude. But when that same Steve Jobs is a kid, let’s say, or a difficult pre-teen or teenager, how does our educational system typically treat him? In most cases, not too well.

By now it’s something of a mantra that the likes of Steve Jobs and Bill Gates and other “geniuses” dropped out of college or had great difficulty even completing high school. The fact is, many of these (now) visionaries were “square pegs in round holes,” who were unable—and often unwilling–to “go with the program.” And often they have a miserable experience in school, where the way they learn best is not accepted or tolerated, and they are generally viewed as a big pain in the butt and a daily challenge to accepted (easier) ways of doing things. While these kids are frequently acknowledged to be smart, they may not perform especially well on tests and they don’t always follow convention. In short, kids like this are often viewed as more trouble than they’re worth—and unless we are lucky, that genius is squashed.

Steve Jobs was said to be a “turbulent” child who didn’t care much for school. In 4th grade he had a teacher who saw something special about him and bribed him with candy and her own money to encourage him to learn math. He excelled, and actually skipped the 5th grade, entering 6th grade in a new middle school. In this new school he was bullied. Steve Jobs came home and told his parents he was going to stop going to school completely unless he was sent to a new school. His parents apparently agreed, and had to move to another city to find a school he could attend. That city was Cupertino, which we know was an incredible bit of fortune for Steve Jobs, and for all of us.

In Steve Jobs’ commencement speech to the 2005 graduating class of Stanford, he explains why he dropped out of Reed College after a short time, but then hung around the campus for another year and a half, sleeping on friends’ floors and couches so he could audit classes that interested him—at least one of which (calligraphy) he said had a tremendous impact on him and the later development of the Mac. What drove him from Reed was the rigid system of required core courses—which students must in many cases “get through” in order to graduate. I’m not going to debate the wisdom of a core curriculum here, but I do think that the rigid structures of some university core requirements, as well as the test-driven, requirement-laden educational system, are counterproductive for many who need a different approach. There’s a difference between exposing students to different areas of learning and imposing an often-arbitrary set of courses believed to be enriching and “necessary” for a “well-educated” person. Moreover, many times alternative courses or paths in high school are discouraged in favor of a college-bound curriculum that can be measured and standardized.

A few years ago I read a fascinating article in the Wall Street Journal about the young Bill Gates, and his difficult path through adolescence and high school. His intellect had taken off around age 11; he read the entire encyclopedia on his own, and became very interested in international politics, business, and the nature of life. However, he resisted control and needed a great deal of freedom to follow his interests, and he was a trial to his parents. Eventually, however, they realized that the status quo wasn’t working, and enrolled Bill in a private high school that allowed him much more freedom, and where he coincidentally discovered computers. Bill was allowed to take some school nights off to enjoy use of computers at the nearby University of Washington, and during his senior year of high school he took a break during the year to work as a programmer at a power plant in the southern part of the state. Gates thrived on the freedom he had been given.

Now we find these men, their passion, their drive, their individualism, remarkable, but they’ve already been successful, so it’s an easy leap to make. However, there are countless kids like Bill Gates or Steve Jobs, growing up right now, who may have a similar potential but who aren’t lucky enough to find themselves in places where they have a chance to become the next remarkable visionary.

The Adventures of Captain Dunsel

Stardate 2011.4

(Episode aired April 5, 2011)
Having received a request from Starfleet Command to voyage to the offices of a remote employment agency to follow up on previous online submissions of resume and personal data, our hero finds herself confronting a hostile life form, fellow voyagers, and a young account lieutenant with whom she must interpret the New Order.

A little background is called for. On March 8, 1968, the original Star Trek series aired an episode called “The Ultimate Computer,” in which a computer does a better job (at least temporarily) of running The U.S.S. Enterprise than Captain Kirk.
Captain Kirk is called “Dunsel” by a colleague and walks off the bridge fuming and hurt. “What in the blazes is Dunsel?” Bones demands. Spock explains, “Dunsel, Doctor, is a term used by midshipmen at Starfleet Academy. It refers to a part that serves no useful purpose.”

These last few months have been discouraging for me, confronting, as I am, the reality that within a 5-month period my three biggest and long-running freelance writing/editing jobs evaporated, one after the other. The first, and perhaps worst, blow was the demise of the women’s health magazine I’d been the managing editor of for the last 5 years. It was not only my main source of income, it was also a source of pride, a well-regarded publication among the physicians who read it, and in many ways, a part of my identity. It wasn’t the first women’s health magazine I’d worked on, but like the others before it, it was my focus and I loved working on it. I worked with scores of interesting people all over the world, and had a great working relationship with several virtual colleagues. I’ve met many of the authors and board members at the association’s annual meeting, and made some friends among the colleagues I saw every year.

The death of this journal can be blamed on many things: steadily declining revenues resulting from a lack of advertising from pharmaceutical companies, especially after the reversal of fortunes for hormone replacement therapy; the movement of drug ads from doctors’ journals to magazines for consumers; changes in the journal’s leadership; and, of course, the big shadow cast by the Internet’s dominance over the antediluvian bound and printed page. I had other ongoing projects, but over the last year, several ceased to be viable or no longer could support freelance workers.

In the previous several years I’d weathered the end of a series of journals that I worked on. Even when publications remained afloat, several were purchased by new owners who brought with them a new crew that did not want to use freelancers who had previously worked on the publications. In one instance, I was told that all freelancers “left by the old ones” (another Star Trek allusion, my apologies) were being put on notice that if they wanted to continue with the publication, they had to agree to work within a new rubric: no more “scientific-y” articles, they were now going to be based on interviews with patients and would be more “human interest-y.” I’d done many interviews before and figured I could weather the storm. And I thought I passed the test: my first story was on the cover. My second story was on page 2. But after that, I never heard from them again; my calls went unanswered and emails unreturned. The editors I worked with had left the company. I had worked for this publication for more than 6 years, and had lunch with its editors in New York. I found out much later that every single staffer who had been with the publication prior to the installation of a new executive was gone within months.

There were other ominous signs of the way things were going. When someone did want to give you work, it was at 1980 prices. I say 1980 specifically because that was the year I got my first job out of the college. So I’ve come full circle. I’m making the same hourly amount I did when I was 22.

Another trend has also emerged. Experience and a long resume is no longer a plus. You may be set in your ways and not fun to work with. Also, you might require a living wage. And you might get on the phone to discuss something because it will take half the time of sending 10,000 emails back and forth that only deepen the confusion. I can’t escape the feeling that some of the young people now in positions of account managers and editors, who I’m now looking to for work, are uncomfortable with the idea that I could be their …mom.

So by the end of December, things had reached a new low. I had hardly any work. Phone calls placed to former colleagues who once gave me work ended the same way. One friend with whom I’ve worked for 15 years on different projects in a variety of different companies said, “Do you want the full-length nauseating version or the shorter nauseating version?” The short version was bad enough. Not only did the long project I was to work on fall through, the editor had also essentially lost her job, was half-time now, and was doing the little available work herself, so there was no need for freelancers.

I got a call in late March from another underemployed freelancer, who suggested that I join LinkedIn. She said she’d gotten one job out of it because a colleague from years ago saw her there and called her. So I did join LinkedIn, but the very first day three of my new connections wrote to tell me they were out of work, too; not too good for networking, but we did have fun talking again.

A couple of weeks ago I finished up a writing project, the last thing that would be contributing to my bank account for some time to come, and a few days after I sent it in, I got some really nice feedback from the client, very complimentary and very hopeful about future work. It was a much-needed boost. I was telling my husband that the article was well received and that it might turn into more. “That’s great!” he said. “I think you were feeling like Captain Dunsel.”

A disclaimer: I am not one of those Trekkies who goes to conventions and collects Captain Kirk dolls or wears Spock ears. But I did and do still love the original Star Trek series. I love the campy, over-the-top, preachy themes and the egalitarian and world-oriented depiction of the future –as it was imagined in 1968. In 1968, I was 10 years old, and my parents only let me watch 30 minutes of TV on certain nights. But if my brother and I watched the same 1-hour show, we could pool our time. Besides, my parents liked Star Trek, too. My brother and I looked forward to the night the show was on, enjoying all the famously low-budget aliens and the hokey transporter beam. (Well, maybe my brother was waiting for Yeoman Rand and her micro-mini skirts, but I was waiting for the Captain and Spock.) But I forgot who Captain Dunsel was! My husband feigned shock and was smug about his superior knowledge of Star Trek. He reminded me about the episode with the M5 computer, and it all came back to me.

So, in short, Yes, I have been feeling like Captain Dunsel!

The week before the Captain Dunsel epiphany, I registered with a temp agency on the advice of another of my unemployed publishing friends. I did most of the registration online and attached my resume and waited to see what happened. I got a call asking me to come in for an interview. That’s where this blog began.

Stardate 2011.4
(Episode aired April 5, 2011)
Having received a request from Starfleet Command to voyage to the offices of a remote employment agency to follow up on previous online submissions of resume and personal data, our hero finds herself confronting a hostile life form, fellow voyagers, and a young account lieutenant with whom she must interpret the New Order.

Sitting in the waiting room where the hostile life form (receptionist) did a great job of further deflating any self-esteem remaining among the group of hopeful job candidates, I had a chance to do some self-assessment of my externals. I came up short: hair (no style), nails (not painted), brows (not shaped), clothes (old), age (not young). The young woman who interviewed me was very nice, upbeat, and high energy, but I was out of practice:
• Was I a writer or an editor? (I was pressed to pick.)
• Have I written email blasts? Web banners?
I guess I survived, because she’s given me a good lead and some work has resulted from it. But I felt very Dunselish—only I was still a week away from realizing that it was Dunsel I was channeling. Driving home, I took a detour for a cappuccino at my favorite coffee shop. I needed fortitude. It is a good place to go when you need to see a middle-aged, style-challenged person or two.
When I got home, I checked my email. There was an email from MediaBistro, which sends job listings in media. They also advertise their online seminars and courses. This one caught my eye:

“Reinventing Print Content for the Web: This class …will help you stay current with demanding online audiences. You’ll learn how to WEBIFY magazine articles…[the] instructor was ‘rich media ninja’ [in a previous company]…”

And here’s the important part:
“This course is an eye-opener for anyone who has been preserved in the amber of the print world.”

Oh, wow, that spoke to me! I AM THAT PERSON! I emailed a few of my friends to let them know I had just found out what my problem is, or how the world saw my kind.
A relic from the Jurassic, preserved in amber, like an unfortunate trapped fly of millennia past. “Is the young stuff so much better than print amber?” asked my friend Bob. “Is a rich narrative no longer the ticket?”
I can’t answer that. Maybe down the road, at a future stardate. In a different installment of The Adventures of Captain Dunsel.

“Ultimate Computer” on Wikipedia

The Great Depression: An Oral History

About 10 years ago a teacher at my sons’ school asked the students in his class to ask their older relatives if they had lived through the Great Depression and were able to tell the class what it was like to be a child during that period of US history. My father, who has always been an enthusiastic student of history, was a boy in New York City during those years, and he volunteered to make a tape about his experience. My sons’ friend, Juan, is the boy who had this assignment, and as he had not been born in the US, and none of his relatives spoke English, my father volunteered to make a tape about his experiences for Juan to use.

At the time of this recording, Juan was 12 years old. Now he is 22 years old and serving in the US military. My father is now 83, and still has vivid memories of the Great Depression. Given the current economic situation and some of the recent discussions about social programs like Social Security and Medicare, which were created in response to the Great Depression, I thought it was interesting to listen once again to my father’s recollections so we might remember how difficult things were when there was no “safety net.”

The recollection is quite long, but worth listening to. For those who need to limit their listening time, it might help to know that at around the 19 minute mark, the discussion shifts from a general discussion of what life was like in those years to one that is more specific to his experience during the Great Depression.

Here’s a downloadable link: The Great Depression

Welcome to Wealth Care

"When I grow up, I want to go into medicine and help people who can pay out of pocket."
“When I grow up, I want to go into medicine and help people who can pay out of pocket.”

Last summer my family doctor sent all his patients a letter saying that he was sponsoring a telephone-administered questionnaire, and asked if we would answer the survey questions should we receive the call. His letter said that the answers we gave to the questions would be used to help him improve his practice. What we did not understand at the time was that the practice would improve—but only for the doctor and about 25% of his patients. The other 75% of us would be “fired” because we couldn’t, or wouldn’t, pay a high yearly fee to “join” what would become his new practice.

Welcome to “concierge medicine.”

We didn’t realize it at the time, but the survey was a tool that would be used to create a problem that could then justify a radical repair. The next letter we received from our doctor stated that the results from the telephone survey of his patients confirmed exactly what he suspected: that patients felt rushed, they wanted more advice about preventive health care, and they really didn’t like to wait in the waiting room. I don’t recall the letter stating how many patients were actually questioned and what percentage of them said there were problems. No need for specifics, we were just to take it on faith: There was a problem.

 

Reality Check

In fact, we had never waited long in our doctor’s waiting room or for an appointment or felt rushed. I rather liked the fact that the waiting room hadn’t been redone in at least 10 years—it showed that the doctor had the right priorities.  We had what seemed like relaxed, unhurried annual physicals and visits. The doctor talked to us at length, and discussed individualized preventive health care and lifestyle changes. We always felt that our doctor was accessible. He called us personally to discuss test results or answer questions. The only complaints I ever had involved members of his front office staff, but they were minor.

Maybe we had low expectations for our health care. So I asked a friend who had been seeing this same doctor for many years, and he too felt that none of the problems applied to his family’s care. So it was news to us when the doctor announced that he needed to make changes in his practice in order to be able to provide…exactly what he was already providing.

 

Members Only

The letter informed us that as of January 2011, our doctor would be changing his practice so that these “problems” were no longer an impediment to the health care we deserved–and that he wanted to practice. He was going to be joining a larger practice called MDVIP, and would be “limiting” his practice to the first 500 of his current 2000+ patients to sign up and “join” the practice. Patients who joined were promised greater accessibility to the doctor, more individualized preventive care, same-day appointments, no time spent in the waiting room, and appointments that lasted a minimum of 30 minutes.

I read the letter over a few times. There had to be a catch—money, fees, something. The letter referred me to the MDVIP website. The website was filled with smiling, happy people who were bursting to tell you why they switched to MDVIP, and how pleased they were to have done so. I was invited to click on the kind of patient I am: a frequent user of health care? A once-a-year type? Someone who needs to go more often?  Hear their stories and you’ll recognize yourself, and better yet, imagine yourself with MDVIP! Still, all I was hunting for was the answer to one question: how much money was this going to cost?

The answer shocked me: $1500 per year, per person. So that would be $3000 per year for my husband and me.  And that fee doesn’t mean I get to stop paying for health insurance, because although $1500 covers all the preventive care I’d need in a year, if we get sick, that’s not typically covered, nor are hospital costs or medications. Not to mention our children, who are not covered by MDVIP at all.

Five hundred patients multiplied by $1500 per year adds up to a nice bottom line start to the year for the doctor: $750,000 … minus whatever percentage MDVIP takes off the top.

 

What is MDVIP?

MDVIP is a Florida-based, for-profit provider of “concierge” (also called “boutique,” or “retainer”) medicine that was founded in 2000 and acquired by Procter & Gamble in 2009.1 MDVIP is the largest of the concierge medicine providers. As of October 2010, there were over 430 MDVIP-affiliated physicians in the United States. MDVIP has grown by more than 40% since 2008.2

The cornerstone of the MDVIP program is the annual comprehensive “executive-style” physical and a detailed, customized wellness plan.2 MDVIP also restricts which doctors are allowed to join their provider group. According to MDVIP, affiliated physicians are “carefully chosen through a rigorous screening process.”2 They must score highly on the company’s patient questionnaire to be considered in the first place. So that phone questionnaire gets you coming–and going—or should I say “leaving.” You, the patient, say how much you like your doc, and then he or she can qualify for MDVIP, and dump you when you can’t afford their membership fee. It reminds me of the Seinfeld episode when Elaine’s boyfriend, a medical student, breaks up with her:

Elaine: What? You’re breaking up with me? But I sacrificed and supported you while you struggled. What about my dream of dating a doctor?

Ben: I’m sorry, Elaine. I always knew that after I became a doctor, I would dump whoever I was with and find someone better. That’s the dream of becoming a doctor.

I went to the section of the MDVIP website dedicated to my doctor’s nascent MDVIP practice. There was a place to respond whether or not you were interested in signing up to the new practice. I wrote that I certainly was not signing up because of the high fee and added that I was really disappointed to see my doctor, who I had liked very much, going this route, effectively jettisoning all his middle-class patients.

Less than 10 minutes after hitting the send button, I got a phone call from an MDVIP operator, who essentially said, “Don’t let the door hit your ass on your way out.” He checked us off his list.

Next, I wrote a letter to my doctor explaining why we were not staying in his practice and expressing disappointment in his decision to join MDVIP. A few days later, he called. Our conversation was not rancorous, but neither of us ceded ground to the other. He stuck to his talking points. (I now know they are talking points because the more I read about MDVIP, the more I see the same statements, over and over. “It’s about making your health a priority.” “It’s just $4 per day. That’s the same as what you probably spend at Starbucks.” My doctor improvised, changing Starbucks to Dunkin’ Donuts in our conversation. My town is more of a Dunkin’ kind of place. Still, his comments about Dunkin’ Donuts irritated me because they so trivialized our (and so many others’) situation.

I told my doctor that we had already made health care a priority, and spent a great deal of money to pay for health insurance, deductibles, and our many uncovered or out-of-network costs and medications. He countered that his $3000 fee could be covered by a flexible spending account. I told him that we already deplete our account every year paying for our many uncovered expenses. (We no longer have this benefit anyway.) “Should I stop paying our tuition bills in order to join your practice?” I asked.  He didn’t answer.

“I’m not doing this for money,” he said. “This change won’t mean more money for me.” I hadn’t suggested it. Okay, I thought it. I still think it.

Coming Soon, to a Doctor Near You?

Concierge medicine currently affects only a small percentage of Americans. We are just lucky, I guess. Nationwide there are estimated to be 3,500 concierge doctors treating 1 million patients.3 In my state, New Jersey, it is estimated that there are 100 physicians practicing concierge medicine.3 In some areas of the country, primarily urban areas, concierge medicine is more prevalent.

But it is a movement that is growing. In my area, seven doctors recently switched to concierge medical practices, forcing thousands of patients like my husband and me to find another family practitioner.3 It’s not as simple as it sounds because some practices are closed to new patients and there are always questions about which doctors take your insurance. And now there are at least 1,500 more patients from my doctor’s former practice who are, like us, searching for a new primary care doctor.

Implications

Doctors who join concierge practices undoubtedly like their new practices. What’s not to like–500 patients underwrite a several-hundred-thousand dollar base each year, and they tend to be more health-conscious patients who are also healthier to begin with. The only national survey of concierge practices, done in 2005, found that these patients have lower rates of diabetes, heart disease, and high blood pressure than the general population of patients.4

For the patients who can afford to belong to a concierge practice, it’s a nice arrangement: instant medical gratification–and no waiting rooms. While there is very little evidence as to whether concierge patients have better long-term health outcomes than those in traditional medical practices, concierge practices advertise this to be the case. MDVIP’s 10th anniversary press release states, “We are satisfying the demands of our patients who want to prevent disease and live healthier, happier lives.”2 And now for the naked ambition part: “As a result, we expect our double-digit growth to continue for the next decade.”

I guess it’s understandable why patients who can afford to do so sign up for concierge medicine. But is it ethical for doctors to be (as a headline in my local paper put it) “putting some patients at the head of the treatment line” because they paid for the privilege?1

Writing in the Annals of Internal Medicine last year, Michael Stillman, MD, a self-described “regular” physician, notes that while he understands why patients are attracted to concierge medicine, he’s less charitable about the physicians who offer it.5 “Each of us has vowed to ‘treat without exception all who seek [our] ministrations,’ and limiting one’s practice to several hundred wealthy patents undermines this tenet of our profession.Even though economic realities and scheduling limitations dictate that some physicians maintain a certain payer mix…I am certain that the legendary physicians of our profession would be embarrassed by the criteria some of our colleagues have used in selecting which patients they will and will not see [emphasis mine].”6

Critics of concierge medicine say it is less ethnically and economically diverse than the general population, with fewer African American, Hispanic, and Medicaid patients,4 and that such practices cherry-pick the wealthiest and healthiest patients, “leaving behind a comparatively sick population to be absorbed by others in the community.”6 Concierge medicine not only creates (or, some would argue, worsens) a two-tiered medical care system, it makes it more likely that the rest of us have less access to care. Because each time a medical practice “goes concierge,” there are more than a thousand patients who flood other primary care practices, already overloaded as they are.

No one is saying that traditional medical practices are perfect. We’ve all likely had less than wonderful experiences and we do have to be vigilant about our loved ones’ (and our own) care. But nothing is going to improve if a segment of patients can pay their way out of the system, either.

I’ll end with a quote from Dr Stillman’s excellent article:

“Physicians who opt out of the current system by expending their energies catering to “patron patients” rather than helping reform a flawed health care system or energizing a beleaguered professional community should re-enter the fray. There are patients to be cared for, both wealthy and underprivileged; ideas to be proposed and exchanged; and policymakers to be educated and persuaded. These difficult times call for engagement, not isolation and retreat.”

REFERENCES

1.  Greene A. Programs put some local patients at the head of the treatment line. Trenton Times. September 4, 2010.

 

2.  MDVIP continues double digit growth and hits consumer milestones during its 10-year anniversary [press release]

3.  Augenstein S. More N.J. doctors deliver round-the-clock care, for a price. The Star Ledger. November 20, 2010.

4.  Alexander GC, Kurlander J, Wynia MK. Physicians in retainer (“concierge”) practice. A national survey of physician, patient, and practice characteristics. Journal of  General Internal Medicine. 2005;20:1079-1083.

5. Stillman M. Concierge medicine: A “regular” physician’s perspective. Annals of Internal Medicine. 2010:152:391-392.

6. Carnahan SJ. Concierge medicine: legal and ethical issues. Journal of Law and Medical Ethics. 2007:35:211-215.