Commentary: An academic career: Bristle at the bureaucracy, rejoice about the resources

December 1, 2008

Last year, I gave up my private practice to return to a full-time academic position. I finalized my decision after making a list of pros that outnumbered the cons.

Key Points

Every day since then, as the director of a new division of dermatology within a department of pediatrics at a large urban children's hospital, I rejoice about the resources and bristle at the bureaucracy.

I have experienced the worlds of private practice and academic medicine and can assure anyone contemplating an academic career move that the pros greatly outweigh the cons. But managing bureaucracy is a daily challenge.

At my institution, I frequently find myself mired in bureaucracy-gone-awry. For example, I lost the medical assistant who served as my right arm after she agreed to join me as a university employee, because, without a nursing degree, she was not allowed to do anything in the Children's Hospital clinic other than weigh patients and put them in rooms.

She was allowed to trek three flights to the loading dock twice a day to fill the liquid nitrogen canister. This one-hour use of her time was required because hospital regulations did not allow storage of the tank in a secure, well-ventilated clinic space.

In order to address the long wait for an appointment, I organized an expanded clinic schedule, with the support of several dermatology residents. The residents offered to copy records of some patients' prior visits to the dermatology department clinic down the street and bring them to the children's hospital for the follow-up visits. This suggestion was vetoed by a nurse administrator, whose interpretation of HIPAA was, "You can get in a lot of trouble for copying records without written permission."

I was also cited for failing to preoperatively mark the "surgical site" for a patient who had at least 300 molluscum, another who had a facial port wine stain and a third, a developmentally delayed, combative, 9-year-old, immunosupressed, incontinent heart transplant patient with a history of HPV 16 giant condyloma and recurrent perianal lesions.

I knew these lesions required biopsy, but the only way I could adequately examine him and select the optimal biopsy site was with general anesthesia. This failing required a face-to-face meeting with my chairman and a written reply.

I was also forced to submit skin biopsy specimens to the hospital-based pediatric pathologist until I requested so many second opinions that they allowed direct submission to the dermatopathologist.

I am expected to submit an endless stream of detailed written evaluations of myself, colleagues, assistants, residents and medical students - including those I have only met briefly. And don't get me started on the prohibited, yet indispensable, "shadow chart" system.

Hospital resources

When the frustration mounts, I remind myself about hospital resources that have, without question, been devoted to a system for taking care of my young patients with severe skin disease and the many people who contribute.

This includes my dermatology nurse, physical therapist, child life specialist, a team of hospital volunteers, an outstanding team of pediatric pharmacists and social workers, who arrange home nursing visits for patients with limited resources and chaotic family lives.

We have a team of translators available for any language needed.

I have the privilege of working with residents and medical students who are interested and enthusiastic about learning and contributing; with pediatric cardiologists who helped devise a protocol for treating infants with propranolol for their alarming hemangiomas; with a pediatric toxicologist and a neonatologist who helped me design a safe system for administering narcotic pain control to infants with ulcerated hemangiomas; and with a pediatric oncologist who managed rituxumab infusions for an erythrodermic atopic girl.

Satisfaction

As an added benefit, I no longer have to meet with the accountant or fuss with billing and collecting, payroll, employee benefits, bills, office supplies or malpractice premiums.

There is no perfect job, but a career in academic medicine gives enormous satisfaction to physicians whose greatest rewards are acing the difficult diagnosis, finding the treatment that works, passing along the lessons learned from experience and nurturing a new generation of healers.

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