• Rebekah Bernard

What's driving physicians into early retirement?

There are so many challenges in healthcare today, and it’s becoming ever more difficult to practice medicine. In fact, many physicians that could continue to work well into their golden years are retiring as soon as they can because the struggle of practicing medicine is just no longer worth it to them.

Today we are joined by an amazing physician who has experienced his share of heartache within our healthcare system. Dr. Mark Lopatin is a rheumatologist who has written extensively about his experiences, and he joins to share his insights and thoughts about how we can improve our broken healthcare system. Get the book!

Podcast HERE or wherever you listen to podcasts

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Dr. Lopatin's writing: "I knew she was trouble" - "The facts did not matter" = "This physician is retiring: here is his most valuable lesson" =


Rebekah Bernard MD 00:07

Welcome to 'Patients at risk,' a discussion of the dangers that patients face when physicians are replaced with nonphysician practitioners. I'm your host, Dr. Rebekah Bernard, and I'm joined by my co-host and the co-author of our book 'patients at risk, the rise of the nurse practitioner and physician assistant in healthcare.' Dr. Niran Al-Agba.

Niran Al-Agba MD 00:25

Hi, good evening.

Rebekah Bernard MD 00:27

There are so many challenges in healthcare today, and it's becoming even more difficult to practice medicine. In fact, many physicians that could continue to work well into their golden years are retiring as soon as they can, because the struggle of practicing medicine is no longer worth it to them. Today we are joined by an amazing physician who has experienced his share of heartache within our healthcare system. Dr. Mark Lopatin is a rheumatologist and he has written extensively about his experiences. He is joining us today to share his insights and thoughts about how we can improve a very broken healthcare system. Dr. Lopatin, welcome to the show.

Mark Lopatin MD 01:04

Thank you for having me.

Rebekah Bernard MD 01:06

Mark, you've been in practice for many years, and you recently made the difficult decision to retire from medical practice. Tell us about your journey and how you came to that decision.

Mark Lopatin MD 01:15

Well, the decision to retire was strictly focused on maintenance of certification. Maintenance of certification has evolved over the years, I was board certified in internal medicine in 1986; took a year off before starting my fellowship in Rheumatology. I finished that in 1989 and found out they didn't offer boards that year, I had to wait till 1990 to take my rheumatology boards that year was the first year that the American Board of Internal Medicine decided that board certification is no longer lifelong. It's only good for 10 years. So I took boards in 1992, 2000, 2010. I was due to take them again in 2020. But over the years, I became very disenchanted with what ABIM was doing. And I've written about this a lot. I spoke with ABMS about this. I've offered alternatives to what they have in place. But the main question I've asked him repeatedly is what exactly are you measuring with your 10-year exam? I've yet to get a satisfactory answer to that question. And I decided that, frankly, it was not worth the time, the effort, and the stress associated with preparing for the exam in 2020. It would have bought me another year or two before retiring anyway. And I wanted to make a statement that I'm not going to bow down to them in terms of this. So I opted to retire rather than take the boards again. Ironically, with COVID, they extended board certification for a year and then another year, so I'm still board certified in Rheumatology. Meanwhile, in internal medicine, I'm board-certified for life. I haven't done internal medicine in 30 years, but that which I do every day of my life at work, I'm no longer considered qualified to practice that area of expertise, unless I successfully passed another exam in 2020.

Rebekah Bernard MD 02:53

Mark, what you say resonates with me so much. We recently had a podcast with the National Board of Physicians and Surgeons - one of their legislative chairs Dr. Paul Matthew, and I shared my story of dropping my board certification and how frustrated I feel with not being able to call myself a Board Certified physician. Even though I graduated from residency, I was board certified in 2002. I recertified in 2009. But I did not want to do the whole maintenance of certification, and I felt bullied. And I did like just like you said, it became like sort of a matter of principle. And now I'm kind of having to make a decision about whether I want to go ahead and just do it so that I can take on some other opportunities that require board certification, and it's really sticking in my craw. I've got to tell you, so I want to thank you for what you're saying because sometimes I think 'Am I nuts? Am I just, you know, making too much of this?' But it really is the principle, isn't it?

Mark Lopatin MD 03:56

One of the things that ABMS has done is they've established themselves, they've self-appointed themselves as the enforcers of the medical profession. And one of the things that I've discussed with them in writing to them back and forth is the idea that this exam is not a voluntary exam as much as they claim that it is insurance companies required hospital potentially, committees require it. So it's not a voluntary thing. It used to be that the exam was used to distinguish the cream of the crop to find those who rose above the normal level. Now, taking the boards puts you at the normal level, and those who don't take it drop below. And ABMS leadership had failed repeatedly to recognize that point. So as they put their statements out there that this shows who excels and who doesn't. No, it doesn't. It simply measures who's able to pass an exam and what your knowledge is on one given day. It doesn't even tell what a physician knows Two weeks later, because much of the information is very esoteric. It's forgotten Two weeks later, if I wanted to play rheumatology Trivial Pursuit, I would play that - I don't have to take boards to do that.

Niran Al-Agba MD 04:50

Well, and meanwhile, my hometown of 300,000 people has one rheumatologist and I believe he's far older than you - he's got to be pushing mid-70s and beyond. So again, we are about to lose yet another rheumatologist. And for people who don't maybe know or understand the difference, you know, gastroenterology usually can be found more commonly or cardiology. But I think the point is really worthwhile making that rheumatology is a very specific specialty, we need them. They're very bright people. I mean, like all specialists, and primary care docs are, but my point is, it's rarer. So we're losing some of these really more rare specialties because of this MOC requirement, which is rheumatology. We're losing, you know, psychiatry, we're losing a lot of these specialists that we need. And when you need a rheumatologist and don't have one, it can be really a problem. So I think that's an important point not to miss,

Mark Lopatin MD 05:40

I made a list for ABIM in all the ways that their exam, their process is harmful, not to physicians, but to patients and physicians retiring is one of those mechanisms, spending three to six months studying for material that you don't see every day in practice is another example. And the frustrating part is I've put forth a fix to them, I put something, a proposal to them of something where they can have a product that can generate income, the product would provide value, it would distinguish physicians who are keeping up, it would demonstrate that physicians are showing due diligence in their practice, there's a way to do that. And I've pushed it repeatedly to them, and they reject it every single time.

Rebekah Bernard MD 06:22

But that's also where I get frustrated is because when they announced the maintenance of certification program, many physicians had concerns, expressed them, gave them alternative ideas. And the response was, 'we don't care; we're going to do what we're going to do.' And I think that's where, you know, we get so used to being told what we are going to do what we have to do, I think for me, it was just the final straw. And since I was going into direct primary care anyways, which Mark maybe after you spend a few years in retirement, you start getting a little bored, Maybe you hang that direct rheumatology care shingle. Keep that in the back of your mind, because maybe that'll call back to you. But I want to talk about some of the other challenges because really, Mark, you have been through some of the things that physicians fear greatly. And some of the reasons that doctors a lot of times don't want to practice medicine, you came through them well, but you faced a lot of adversity. And I want to talk first about the lawsuit, the frivolous lawsuit that you faced. And you wrote an amazing article that I'm going to share the link it was published in Medical Economics, and it was called, 'I knew she was trouble.' And talking about this patient that was difficult from the get-go, had all the red flags. Mark did everything right in taking care of her. And in fact, he took her back as a patient after she left him because of an insurance change. And then he tried to get her off of the medication that ultimately caused her harm. And yet he got named in the lawsuit and his attorneys basically persuaded him to settle. Mark, talk about how that experience impacted you.

Mark Lopatin MD 07:51

Let me go back before that because there was another lawsuit that was right before that, where I saw a woman with musculoskeletal aches and pains. She had Fibromyalgia. As part of our routine intake, I asked her the question, 'Do you suffer from headaches?' She told me 'No.' I saw her four times. Her primary care doctor had started her on Elavil. And she did well with it. There was nothing I needed to do. And about a year and a half later I received a summons papers, suing me for failure to diagnose her meningioma. So I was basically sued for failure to diagnose an illness outside my realm of expertise by a patient who denied the cardinal symptom of that illness. Despite the fact that I specifically asked that question, that lingered on for two and a half years. That lawsuit was ultimately dropped. The ironic thing about that lawsuit is shortly after it was dropped, the Pennsylvania legislature put forth regulations that if they had been in place, the lawsuit would never have happened. And that's true with all my legal action, every single legal action that I've experienced, something happened after the case that if it had been in place at the time of the lawsuit, I would not have settled I would the case would not have gone through. The lawsuit you're talking about was again, another young woman who presented musculoskeletal aches and pains, diagnosed with fibromyalgia. I was a little leery of her. She was a nurse, she had a notebook full of records, she was a little bit sullen, and I describe all this in the article, but we established some semblance of rapport. And then at some point, she developed the loss of hearing, she went to see an ear, nose, and throat doctor who diagnosed her with autoimmune sensory neural hearing loss and started prednisone 60 milligrams. He referred her to another rheumatologist in Philadelphia. He only saw her once and then she came back to me because of insurance problems. I called her ENT doctor to verify the diagnosis and learned that - I was not very familiar with what it means sensory neural hearing loss. He said, 'steroids treat it. If you don't treat steroids, the threat exists for permanent loss of hearing.' So I had her on steroids and she began to complain of increased musculoskeletal aches and pains but she'd had aches and pains for 10 years difficult to determine. I began to wean her off the steroids and at one point she described specifically knee pain separate from the other aches and pains. I ordered an MRI of her knee and it revealed avascular necrosis, which is one of the side effects of steroids. To make a long story short, she saw an orthopedic surgeon, had multiple MRIs ordered, and was found to have avascular necrosis of multiple joints. She required surgeries. She required opioid treatment. And I was named in the suit simply because I was the treating physician who had weaned her off the steroids. It took me five months to wean her off steroids, which, as a comparison, if you think about temporal arteritis, which is a condition that affects vision in Rheumatology patients, usually we treat patients for a year to 18 months with steroids. So getting off steroids in five months was a remarkable achievement. She had no further loss of hearing her hearing recovered. But nonetheless, I was named in the suit. The two issues that affected this lawsuit were joint several liability and venue joint and several liability policy at that point dictated that if I was found to be at all responsible for any part of her problems, I could be liable for the entire sum of the damages, even if I was only 1% responsible for it. So that threatened my personal assets, my home, etc. That scared the bejesus out of me. The second thing that happened was the venue. Because the ear nose and throat doctor practiced in Philadelphia, the plaintiff's attorney took the case to Philadelphia, and my attorney informed me that I had done nothing wrong. My case was well documented. He said the case is going to Philadelphia throw it all out the window, because the Philadelphia jury Philadelphia, by the way, is one of the leading hellholes for lawsuits in the country. And what he informed me is that a jury in Philadelphia is much more inclined to look at the patient's symptoms, their suffering, and make a decision based on that, regardless of the facts. It was the first time that I learned that the facts did not matter. And then a later case, I use that as the title of the article that I wrote when I wrote about it. But in any case, I had to make a decision whether or not to settle this lawsuit, knowing that I had done nothing wrong, versus fighting it, recognizing that if I lose, I can lose big, I was young, I was naive, I was scared. And I opted to settle I knew nothing about the medical-legal environment, I got an education there. I've gotten further education since then, I would not settle the lawsuit if it happened today. But back then I settled. That was a problem because as I wrote, how do I look my children in the eye and tell them to fight for what's right, when I'm giving in? And I struggled terribly with that. And I required counseling to help me get through it. And it was an ordeal.

Niran Al-Agba MD 12:29

You know, how did you feel essentially after? I mean, not afterward, I guess, but did it change your love of medicine? Because a very similar thing happened to my dad, and back then they didn't even have to get your permission to settle. To make matters worse, they didn't need the doctor's permission. And he was sued about a vaccination, actually, the oral polio vaccine. And I remember we appeared in the newspaper on the cover, and they split the page. And his defense was sort of like, 'look at my four kids, I gave them the same vaccine, I gave this other child'. And what happened is the woman had some neurologic, you know, difficulties and someone, the adult neurologist put down on the differential, it could be polio because you know, her child, whatever it was had, you know, just had the polio vaccine, it ended up not being polio, it ended up being MS. But she sued the hospital, she sued my dad, she sued the people who distributed the vaccine, and essentially they the insurance company settled the case with you didn't have to get the doctor's permission. So they just said, hey, it's gonna cost us $10,000 to defend it. Here you go take it or leave it, and she took it. And so I know he really struggled. And he number one, it changed the way he practiced medicine. Number two, this business of 'she was trouble' - or 'he was trouble,' I don't want to be biased in that regard. But he has said the same thing, something very similar to me about the moment those little hairs on your neck go up about a patient that is just something that doesn't make you comfortable. You need to just ask them to find a new doctor. It's not a good match. And I'd like to hear from you what you think about how it changed you.

Mark Lopatin MD 13:54

The first thing is, I began to play the what-if game 'What if something goes wrong with the next patient? What if this patient decides to sue me? What if they have an adverse reaction to a medicine?' And what happened was I began to look at patients as adversaries, as opposed to people that I was trying to help. And that's one of the reasons that I required counseling to get through it. Ironically, about a month or two after I saw this patient, I had another patient referred to me for autoimmune sensory neural hearing loss they wanted to and it was on steroids. They wanted an opinion regarding immunosuppressive agent, I saw her and I said, 'I'm very sorry, I can't take care of you with that diagnosis.' It was too emotionally draining for me. And I turned her what I refer to one of my partners, but it was mostly too troubling for me to have to take care of this patient strictly based on the diagnosis she had.

Rebekah Bernard MD 14:43

Wow, you know, I want our listeners that are out there hearing this. First of all, Mark gave us some really important advice which is get help - get counseling. The reality is that most of us will face a lawsuit at some point in our career, and it is emotionally draining. And I think Mark, didn't you feel like you were the only one that ever happened to you? Did you feel very isolated and alone?

Mark Lopatin MD 15:06

Oh, that's a very common feeling, because you're not allowed to talk about it. All my partners knew was that I was getting sued, I couldn't share the case with them. You know, you can't get comfort from anybody else on it, you can't share the burden. And one of the things I did this is what spurred me on to become political in the first place. Ultimately, I conducted a survey across the state of Pennsylvania, of over 1000 physicians, and I learned that over 70% of physicians in the state have been sued. And at the time of the survey, more than 50% had a lawsuit within the last five years, and one in three had an active lawsuit. And the message that I learned from this is, you're not alone when this goes on, and you've got to talk about it. And you've got to get help. And the only way we combat this is by publicizing what happens and that's why I wrote about this case. And that's why I wrote about a later case, to share what actually happens and what you go through, I still have remnants of PTSD and if I actually MTSS malpractice stress syndrome, not quite the abbreviations, but specifically related to malpractice lawsuits. Even now, if I talk about this or write about it, there are times when I'm tremulous about this, as I talk about it, I tremble a little bit as we're speaking about this right now. It's been 20 years.

Rebekah Bernard MD 16:19

Well, what you're saying is so important. And I think we need to start talking about this way earlier, even as far back as medical school, and not in the way that I was talked to about it, which is, 'oh, you better make sure you document,' 'what would a jury say about this?' instead of saying, 'you know what, there may very well most likely be a time in which you'll face a lawsuit in which you didn't do anything wrong, or there wasn't anything that you could have done differently. Or maybe you did make a mistake. And that is likely to happen. And here's what you should know about it. And you should realize you're not alone. And it's not a shameful thing. It is it's the way our system is set up.' So that when it happens to us because it will we need to be psychologically prepared, because if you talk to the lawyers there, you know, this is what they do. They say, Well, yeah, I mean settling, that's the cost of doing business. My husband's an immigration lawyer, and he tells me a story of how early in his career, he was sued for malpractice, and he didn't do anything wrong, and he had to settle and it was a case that wasn't winnable, and it hurt him too. But he also accepted it more like 'Well, yeah, a lot of lawyers get sued, and it is what it is.' But as doctors, we don't look at it that way we look at it as a personal attack and an insult and, and just it ruins the way we think about ourselves.

Niran Al-Agba MD 17:34

I think the idea that we did harm to someone is really hard for all of us to swallow because I think we all go into this field never to harm someone knowing full well that we may bring harm to someone. And that's the hard part about this. And I think it's just something we like you said it helps to talk about it. And you know, Mark, it's interesting, I think that tremulousness. And most people know I was involved in this terrible defamation case that I ended up winning. I know I've talked about it a lot. Yeah, just last week, the doctor's wife in our town who started the whole thing was on a tennis court next to me, and I was shaking. And every time the ball came over, finally I told the lady who kept saying my name, I was like, 'please stop talking to me. Could you - I'll get your balls, please stop talking to me. Do not talk to me. Just play your stuff, please.' And I and I was like almost crying. And I don't even know it's been two years since it's settled. And it's like, I couldn't stop the shaking. It was involuntary. And people miss, they misunderstand. They don't really say let it go. And the thing is, I've let it go. It's over. But I couldn't stop this involuntary reaction. So my heart goes out to you. Because it's just, it's hard.

Mark Lopatin MD 18:44

Yeah, a couple of comments on that. Or there's a reason for that some time. A number of years after this. I received a summons in the mail. And I had to go to the post office to get it. It was on a Saturday and I knew immediately it was a lawsuit. And I was a basket case all weekend. And when Monday rolled around and they went to the post office, I found that I was indeed being sued for a car accident, a fender bender, and I jumped for joy. And I gave it a great deal of thought I thought about why is that when you meet somebody at a party, you judge them, just looking at them. proximate age, you judge their gender. Some of the first questions you ask her are, Are you married? Do you have kids? One of the first questions you ask is what do you do for a living? It is part of our identity is our core identity. What we do, I don't identify myself as a driver. I do identify myself as a doctor. So when someone attacks me in that arena, that's the reason that it's so personal and so heart-rending to be sued. There was a study done in Cook County, Illinois, looking at 220 physicians who got sued, and the findings were impressive. 50% of them changed the way they practice medicine 90% of reported emotional trauma, depression, etc. But the amazing thing was 10% of them contemplated suicide and this was four cases that day, I spoke with one of my colleagues who was involved in a lawsuit and I congratulated him because he won the lawsuit and he turned to me and said, 'Mark, I spent the last two years anxiety-ridden. I've missed time for my practice. I've had to meet with lawyers, I've had to review the chart, tell me exactly what I've won?' And one of the things that I realized is that as a physician, you lose a lawsuit. Once you're named in a lawsuit, no matter what the verdict is,

Niran Al-Agba MD 20:27

I couldn't agree more, you completely classified it. I talk about that a lot. There were times I just wished I wasn't here. And that I could just and it wasn't even about malpractice. And it just it was it's so so horrifying. And I'm so sorry, it's happened to you.

Mark Lopatin MD 20:42

I never got that bad. You know that I contemplated suicide. But I will tell you, the third case rocked me to my core worse than either of these two. And that was a case, an opioid case where the State Board of medicine. This was not a lawsuit. But the State Board of medicine was looking to set an example for indiscriminate prescribing of opioids. I had a patient again with fibromyalgia - must be something about fibromyalgia patients, chronic pain - who I titrated the dose of her OxyContin up exactly as was recommended at the time, she was on a very high dosage. She was admitted to another hospital. And the doctors there objected to the high dosage and told the husband that this was inappropriate. And he reported me to the State Board of medicine. The State Board of medicine, wanting to set an example for me, hired an expert witness who gave fraudulent testimony. And this expert witness had one year of family practice residency, an internship in the 60s, no residency, no training in rheumatology and he made his living by giving expert testimony. I put the word expert in quotes. There was legislation that was put forth in 2002, before this, that required certain criteria for expert witnesses. The State Board of medicine declined to follow those guidelines. Had they followed those guidelines, this person would not have been eligible to testify. He made at least 25 errors of fact. Now you can argue about opinions about whether this medicine or that medicine is the right medicine to use in this case and what the right dosage is when we make the statement that I was wrong because I started the dosage of 50 milligrams instead of the 10 milligrams that it should have been started. And I look at my chart, and I did start them on 10 milligrams. That's an error of fact, that's not an opinion. There are at least 25 errors of fact, this person was not qualified to testify. He gave blatantly fraudulent testimony, which can only be described as stunning and the State Board of medicine did not care. In this case, it was not a malpractice verdict that was at stake. This is my career because if they found me guilty, they would have pulled my license to practice, my malpractice carrier did not cover it, I paid for this coverage out of pocket to the tune of $30,000 against a state board that was not interested in the facts. And when I wrote about this case, in the Journal of medical practice management, the article isn't perfectly entitled, 'The facts did not matter.' Because my chart was very well documented, I got off with just a slap on the wrist. But this could have been so much worse. And again, This was much more devastating to me than the first two cases in this required much more extensive counseling to get through it. ,

Niran Al-Agba MD 23:15

And I think now as I talk about this right, and I think listeners should know that state medical boards are famous for this Washington State is right up there with Pennsylvania as well. The experts they hire do not have to have any criteria to meet expertise. And we call them kangaroo courts, right? So it's not a real court of law. And that's something I'm sure you experienced the same thing. You can't call witnesses. You can't get the other person's records. So patient records are not available to us. It happened again to my dad, the person involved had had this long psychiatric history for 20 years and we couldn't obtain any of it. And so if they have lied at any point if they were dishonest at any point, in this case, they were in his case and there was nothing you could do it was simply they were against you and the court system was really interesting because it isn't a court of law that we that the rest of the country gets physicians do not get that court system they get the kangaroo system which has none of the rules about protecting the victim none of the rules about protecting the physician no discovery rules so I really want that clear to people that that is one of the most terrifying things is they do not have a court of law for physicians we are simply tagged sealed and you know taped across our mouths and slapped with things whether or not we did anything wrong. So again, I'm so sorry, it feels like you've been on every stop on the train to hell.

Rebekah Bernard MD 24:40

That's why Mark is going to be writing a book about his experiences which has been accepted for publication. And so he's - I think one of the small silver linings to all this is that you are able to so eloquently and beautifully share your story so that other people can learn and I know you have a lot of ideas for healthcare reform. And so I guess I would say that some of these experiences have really galvanized you. And you have been writing, and you have been talking to people in power. And some of the things you've been working on, you mentioned maintenance of certification. And the other things are, you've been talking about pharmacy benefit managers and writing about that, and talk about some of the other things that you're interested in working on in healthcare.

Mark Lopatin MD 25:24

Well, one that I'm sure is near and dear to both of you is scope of practice. And I've written extensively about that, not as eloquently as you two have. But nonetheless, I've written about that. And, you know, the book you wrote, has all kinds of data, and so forth, and so on. And it looks at the data that nurse practitioners have written as to why they're equivalent to physicians, and you explain why that data is not valid, and so forth, and so on. And my response is to throw all that out the window because this is simply a common-sense issue. 15,000 hours of medical training does not equal 500 to 1500 hours of nursing training. And that's it in a nutshell, I like to make analogies, one of the analogies I made in the book is that looking at a medical practice is like looking at how well shortstop fields. And if you want to know how well shortstop fields, you can't measure it by simply whether or not they catch the balls that are hit directly at them, you have to understand where they catch the balls and take a bad hop, how far they're left, can they go? How far to the right can they go? Do they make good throws? And a lot of the data with nurse practitioners, you know, a lot of the argument is we catch the balls that are hit us, but they don't catch the balls that are hit to their left or to the right. And a lot of this stuff looks at things like checking hemoglobin A1cs, a nurse practitioner is very qualified to check hemoglobin A1c. A patient is diagnosed with diabetes, they're very appropriate - in fact, they excel at looking at preventive measures. I mean, their nursing training is different than ours. And they excel at that they do things in that regard better than we do. But that's different than making diagnoses. And knowing the proper treatment. Nursing training is different than medical training. So you know, that's the analogy that I use. I've had nurse practitioners tell me they can do 85% of what a physician can do. I say, 'Great, let's take it up to 90%, you can do 90% of what I do. Let's see, I see 100 patients a week, that's 10 patients a week that you can't take care of as well as I can and there's let's just round it up to 50 weeks a year. That's 500 patients a year that you're not taking care of as well as I can. And let's see, I'm in a 12-man rheumatology practice. So that's 12 times 500 is 6000. And that's my practice alone. Is 6000 patients a year in my practice an acceptable rate? I don't think so.'

Rebekah Bernard MD 27:34

Wow, Mark, I never thought about it in those terms. That's really amazing way to think about it. I'd like to also address nurse practitioners practicing specialties and there's one I'm thinking of in particular who's hung a shingle and is calling herself a rheumatologist because she took some courses by the American College of Rheumatology. Now I can't call myself a rheumatologist. I'm a family physician. I do practice I have to see patients with neurological conditions. They don't have insurance. So sometimes I say I play rheumatologists. But I could never call myself one. What are your thoughts on that?

Mark Lopatin MD 28:07

Well, first of all, you look at the 15,000 hours of training that doesn't include the two years of Rheumatology training on top of that. But we have nurse practitioners in our practice, we utilize them, we use physician assistants, and we train them ourselves and we supervise them. They see new patients and every new patient, after they see them, they get the information is presented to an attending and the attending goes into the room and sees the patient with the nurse practitioner. We'll figure out what strategies we want to take, the nurse practitioner will order the labs, under our supervision, order the X-rays, order the meds, write the scripts, it's all supervised. It works beautifully. nurse practitioners are a valuable asset if they're used properly. Now, these nurse practitioners that we use, we train them for six months under our direct eye, and they take your course through the ACR. And because we train them, we know what they can do. And what they can't. I've had nurse practitioners who are superb in my practice. I've had other nurse practitioners in my practice that I would not like to see my patients if I'm not there. I know who they are. I know how they work. So that's supervision. And that's one of the messages that I hear with regard to scope of practice that I object to is the idea that nurse practitioners are worthless nurse practitioners serve no purpose. That is absolutely not true. They play a very vital role if they're used properly. And they can provide some things that I actually can't provide because they look at maintenance and prevention a little bit better than I do. But they are not rheumatologists and for someone to hang out a shingle after taking a course to the ACR. I mean, that's dangerous to their patients. rheumatology is a very complicated field.

Rebekah Bernard MD 29:39

Yeah, and I think it's insulting to you because like you said, rheumatology is an incredibly complicated field. And like many of the cognitive specialties, it's under reimbursed, it's undervalued, but yet you had to go to school for a lot of years to know how to do what you do to do it well, and so it just doesn't make sense again, that someone could just hang a shingle and just call themselves That, and that patients, our patients don't know any better. So that's one of the things that we're trying to do. And like you said, studies show over and over again that when nurse practitioners and physician assistants work with physician supervision, patients get exceptional care. However, that's never been demonstrated when there is no physician involvement. So we are not opposed to nurse practitioners or PAs, but we are completely opposed to independent practice by those professionals.

Mark Lopatin MD 30:27

One other question to think about is if you want to argue that nurse practitioners provide equivalent care, how would you measure that? What outcome would you use - the number of patients who die? The number of patients admitted to the hospital patient reports? What is an accurate measure of care? Patient reports are not a good measure, because patients oftentimes don't recognize them. Outcomes may not be I tell the story in the book about two patients who both had lupus, one of them followed what I did to the letter, and one, refuse to do what I said, saying God will save me. And the patient that I took care of died, the other patient left the hospital, and I didn't do anything wrong, I gave him proper care. To the point, there's a lot of variables beyond the care you provide that come into play. So you can't just look at outcomes in this. You can't rely on patients. What do you measure? How do you determine that? It's not measurable. You got to rely on common sense. 500 does not equal 15,000.

Niran Al-Agba MD 31:22

Yeah, I completely agree. I know I agree with Rebekah wholeheartedly that nurse practitioners have a lot of value in our system. And I just think that that needs the use of nonphysicians in the system needs to be really looked at closely and standardized. So I can't emphasize enough how much standardization is important. Tell us about your book.

Mark Lopatin MD 31:39

Well, in the book, I describe the evolution that you're hearing, I mean, basically, in the year 2000, I was before I was completely oblivious to healthcare, politics. I didn't know what a Democrat was. I didn't know what a Republican was. I didn't know what a liberal was. I didn't know what a conservative but I knew nothing about any of this. And getting sued caused me to become political. In the beginning. With regard to tort reform and defensive medicine. And I did a lot of stuff there. I actually got involved in organized medicine, through my County Medical Society and ultimately on the board of the state medical society to become very involved in that. And then some other issues began to pop up like maintenance of certification and prior authorization and pharmacy benefit managers and venue and surprise billing and lack of transparency and facility fees and hospital costs and so forth and so on. And slowly, I've evolved to become very active in grassroots as well as organized medicine, I, what I describe is I've got a foot firmly planted in both venues. But the book describes my journey from being someone who was totally involved in sports in their sports analogies in there. That was my focus, how I went through medical school, some of the stuff I learned in medical school that I would use later in residency, some of the things that happened to me in residency that was unfair, some of the stories there, I'm convinced that the only reason that the VA exists for residency is that so that you have stories to tell later on in life.

Rebekah Bernard MD 33:03

I think we all have those VA stories.

Mark Lopatin MD 33:05

And I do, and I describe my evolution and what happened, and then ultimately, getting to the end of the story is retirement. And the messages I learned as I reflect back on my career, and the main messages that medical care needs to be a human interaction between a physician and their patient, not a business or commercial transaction between a consumer and a provider. And by the way, I do get into the issue of the word provider, I talked about that extensively, including, including the issues with Nazi Germany, and I am Jewish, so I can speak to that. And my wife is a Holocaust scholar, I can very much speak to that issue. But how provider was used in Nazi Germany and how it is used currently, to devalue physicians. And I've written articles on the devaluation of physicians. But in the end, I realized that retirement that I've gotten a lot more from my patients, and they've gotten from me because they've allowed me to be with them. They've allowed me to share their lives with them. In the book, the House of God, which is one of my favorite books, Samuel Shem describes the art of medicine as the art of being with the patient of validating them and sharing their journey with them more so than writing the right prescription or making the right diagnosis. And I learned at the end of my career, as I retired, that my patients allowed me to do that. I tell the story of one patient who I met at 25, single working, she met a guy, she got engaged, got married, she had her first kid, she had her second kid, and I took care of her for 25 years, and shared her life with her I shared the joys, I shared the heartache that I was there with her. And that being with the patient is the art of medicine. And that's what I learned from my patients. And that's why I say I'm, I've gotten more from my patients, and I've given to them because I've gotten that realization. And if you can make a difference in one patient's life, it's as if you've saved the entire world and I've had the opportunity, fortunately, to do that many times in my career. So I feel very much blessed by my career.

Niran Al-Agba MD 34:55

I don't think we can say it any better than that.

Rebekah Bernard MD 34:58

Thank you so much for that - when your book is published, we absolutely want to invite you back. And thank you so much for being with us and sharing your story, we'll have some links to some different articles that you've written. And if you'd like to learn more about this topic, we encourage you to get our book. It's called 'patients at risk the rise of the nurse practitioner and physician assistant in healthcare.' It's available at and at Barnes and Noble, please subscribe to our podcasts and our YouTube channel. It's called Patients at Risk. And if you're a physician, and you'd like to advocate for physician-led care and truth and transparency among healthcare practitioners, please join our group physicians for patient protection. You can find us at our website Thanks so much and we'll see you on the next podcast.

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