If only Steve Jobs was a medical doctor.

April 1, 2012

We clearly lost Steve Jobs too soon. He is the only person I can think of that may have reformed the health care profession the way he reformed the personal computer industry, the animation industry, the music industry, the phone industry, the photography industry, the book industry, and eventually the TV industry. He was a visionary which is something completely lacking in all the health care debate that has been going on as long as I can remember.

Steve Jobs biography by Walter Isaacson

Steve Jobs biography by Walter Isaacson

I know there are some good ideas out there. In fact there are probably some great ideas out there. But what we need is someone who can move the ball forward on the playing field, not just come up with new plays. We have lot’s of coaches, but very few players who excel on the health care field.

As the Supreme Court toys with the idea of scrapping healthcare reform altogether, I can not get too upset about it. The only thing I really liked about it was the fact that young adults could be covered up to age 26. Not that the coverage is good but since medical school students do not graduate until age 25 at the earliest, this meant we were dropping our future doctors from having health coverage while asking them to run up six figure education bills so they can take care of us. And then we want them to be kind and considerate to us and not about the money when we won’t even provide them with healthcare during their training?

But other than increasing the age of coverage, I can’t really see anything in healthcare reform I would miss. Most of the reform just mandates more people be covered by an already existing terrible healthcare system. That’s not reform, that’s just expansion.

And as far as electronic health records which we hear so much about, they were coming with or without reform. But the fact is that the currently available software for health records is as bad as software gets. Most of these systems have been around for years and resold several times to bigger and bigger companies that just want more market share without looking to improve the product. While some of these products have been written for Apple computers they clearly got a free pass on quality that is normally Apple’s trademark. If Steve Jobs looked at any of these systems he would have one of his classic fits and call them what they are ” a piece of s**t”. But he never got around to healthcare software and so we are left the dregs of the software pot so to speak.

Really, ask any doctor you know how he likes his electronic medical record and you will never see even a flicker of excitement in their eyes. But ask them about their iPhone or iPad and ….. well, you better have a few moments to kill while they go wild with enthusiasm. There’s no reason we can’t bring that to electronic medical records too. We just need a leader.

Steve, if only you had gone to medical school we could have real healthcare reform. I know you could have done it. Who will it be now?

Sal Imperiale, MD

Calling all primary care doctors

March 22, 2012

IN 1948 the eminent photographer Eugene Smith went to the rural town of Kremmling, Colorado and meticulously documented three weeks in the life of Dr. Earnest Ceriani, the general practictioner of the town. The photographs Smith took are amazing and defined the photojournalist style for years to come and can be viewed (here). The orginal article printed in Life magazine can also be found on-line and tells the story behind Dr. Ceriani and the photographs (here).

Dr. Ceriani, 1948 (photography by Eugene Smith)

Dr. Ernest Ceriani by Eugene Smith

I first came across this article in the 1980’s when I was a medical student and someone had arranged for a Eugene Smith exhibit at our medical school which included the photographs of Dr. Ceriani, Dr. Albert Schwitzer, and an incredible nurse mid-wife named Maude Callen. I believe these photographs had no small effect on my decision to become a family physician which I still practice today.

But in re-reading the article today I am struck by how little has changed for primary care doctors in the 64 years since the essay first appeared. The article describes the challenges Dr. Ceriani faces as a primary care doctor in a rural town in 1948. Specifically, long hours, low pay (compared with the specialists in the big cities), difficulty getting equipment, and no time off just to name a few. In fact, so little has changed for primary care doctors in the past 64 years you could republish this article with a few name changes (and without the photographs) and I doubt anyone would notice it was about someone practicing medicine 64 years ago.

Muade Callen, Nurse Mid-wife by Eugene Smith

But if the lifestyle and workstyle for primary care doctors has not changed since then, many other things have. In 1950, the average length of stay in a hospital was 8.5 days. In 2009, it was only 5.4 days(here). Good news you say? For insurance companies perhaps, but for primary care doctors who must take care of these patients when they get home, it means we are caring for sicker patients in our offices than we have in the past. Patients are sent home with urinary catheters, wound dressings, IV antibiotics, and many other health needs that were previously provided in the hospital. As a medical student, we called premature discharges from the hospital “dumping”. Today, insurance companies call it “home health care”.

In 1950 the percentage of primary care and specialist doctors in the US was 69% vs 31%. Today the percentages are 36% primary care and 64% specialists(here). An almost complete inversion of the ratio. The result is simply that there are not enough primary care doctors available and too many specialist so patients seek out the more expensive option due to availbility. Did some one say budget deficit?

The culture of doctors has changed as well. There are no more Dr. Cerianis who are willing to sacrifice their own life (and health) in the unending effort to care for a small town that has no other doctors. Today’s primary care doctors practice what they preach. They want quality of life which means more time with family and friends, time to exersise, pursue hobbies and avoid “burn out”.

As I like to tell medical students who rotate through my office, it’s a marathon, not a sprint – so pace yourself. Specialists figured that out a long time ago. Primary care doctors are just late to the party.

Maude Callen from Life Magazine by Eugene Smith

And finally, we have managed to make medical school enormously expensive and therefore primary care an untenable option to someone who may have as much as $200,000  of debt on graduation. These are smart people. They do not want to be indentured servants to the bank for 20 years. When I was a first year medical student in the 80’s, the tuition my freshman year was $5,000. When I graduated four years later it was up to  $9,500 a year. It took me 10 years to pay off my medical school debt and the student loan payments were higher than my first mortgage. Why would anyone NOT become a radiologist who can make $300,000 the first year in practice vs making half that salary and working longer hours?

Maude Callen by Eugene Smith

So how did we not see this coming? We had at least 64 years to plan for this shortage of primary care doctors. It was there in black and white in Life magazine, beautifully documented and we know everyone read Life magazine in the 40s., 50’s and 60’s. Maybe we just believed there would always be a Dr. Ceriani out there who would miraculously show up just in time as he had in Kremmling. But that is not happening in many places because there are fewer and fewer Dr. Ceriani’s out there and the number is decreasing all the time

Well, at least the next time you see see your primary care doctor, you might understand why you’re waiting a little longer than usual. Frankly, there’s just not enough of them to go around.

Sal Imperiale, MD

All photographs in this blog are by Eugene Smith.

from the New Oxford American Dictionary

March 10, 2012


  • adjective  – accompanying but not a major part of something : for the fieldworker who deals with real problems, paperwork is incidental
  •  predicate  –  ( incidental to)  liable to happen as a consequence of (an activity) : the ordinary risks incidental to a fireman’s job
  • ORIGIN early 17th cent.: originally from medieval Latin incidentalis, from Latin incident- ‘falling upon, happening to’ (from the verb incidere).

For his groundbreaking 1948 LIFE magazine photo essay, “Country Doctor” photographer W. Eugene Smith spent 23 days in Kremmling, Colorado, chronicling the day-to-day challenges faced by an indefatigable general practitioner named Dr. Ernest Ceriani.

Blog by Sal Imperiale, MD