A Week in the Life
On Physician Exceptionalism and Medical Narcissism
Wheels In — Intro + Opening Thoughts
Are doctors special? Many of us think so. We endure a lengthy process of costly education and demanding training. Including college, it took me 16 years to become a board-certified orthopedic surgeon.
Our day-to-day lives are quite different from most other professions. Most physicians feel the weight of expectations and demands that come with a medical career. Doctors are held to a higher standard and revered by society, or at least we used to be.
Are we special, or is this mindset a case of physician exceptionalism? Lots of jobs are unique. Plenty of other professionals work in high-stakes, high=pressure environments. Are we exceptional or simply medical narcissists given to self-protective coping mechanisms like “fantasies of omnipotence” and feelings of “specialness”?
Last year, OpenAI CEO Sam Altman opined that artificial general intelligence (AGI) will be the equivalent of a “median human” who could learn to be a doctor. (Mahek Shah’s take on this is worth reading). I don’t think the comment was made maliciously; it was given offhand in response to a broader question. I’m still trying to figure out if being a “median human” is a good thing or a bad thing.
However, the idea that we’re on the cusp of technology capable of rendering 16 years of struggle irrelevant strikes at the core of physician exceptionalism and medical narcissism. It’s an interesting window into how others view the doctor’s role in an ever-evolving healthcare system.
As physicians, we tend to get defensive about our ever diminished (but not diminishing) place in healthcare. Comments like Altman’s don’t help. Neither does feeling devalued by insurance companies, the government, and administrators. When it comes to healthcare innovation, kudos follow funding rounds and exits, not clinical impact. “Subject matter expert” feels like a pat on the head, not a seat at the table.
So, are we exceptional? My advice to docs is this: don’t think about it too hard. And don’t get defensive. In some ways, we’ve become too embittered and too easy to troll (I’m guilty here too). Perception, while important, is not reality. What we do is different and unique. I’m reminded of that every day. It’s in our best interests to educate, not argue.
To that end, this week’s edition of TSR presents a snapshot of my typical week as an orthopedic surgeon with several side gigs. You might call it indulging in physician exceptionalism or medical narcissism. I call it a week in my life.
Dem Dry Bones
From the EIC’s Desk
Monday
Pre-Dawn
True story: I haven’t set an alarm clock for more than 15 years. My internal clock goes off at 5 a.m., at which point I’m usually wide awake. Don’t get me wrong, I love sleep. But that’s when my body tells me it’s time to get up, and who am I to argue?
Monday mornings are Peloton mornings. I’m a Dennis/Christine/Sam kind of guy, probably because they’re closest to me in age and musical tastes. I’ll occasionally throw a Matt in there, too. Until a few years ago, I wasn’t a morning workout person, but I’ve come to enjoy it. It’s a fantastic way to start the day/week, feel energized, and clear my mind for the week ahead. As I’ve gotten older (now approaching the late 40s), I also appreciate the importance of aerobic exercise.
Post-ride, I spend a few minutes catching up on the headlines, email digests and sources like Rama On Healthcare, Bloomberg, Pitchbook, Becker’s, and various independent newsletters. I love staying informed, and this process often sparks a LinkedIn post or idea for a TSR article.
The Daily
Mondays are clinic days, and clinic days are like a box of chocolates: you never know what you’re going to get. But, you can prepare. On Friday or Sunday, I print out my schedule and go through the list of patients. Doing this gives me a preview of who’s coming in and a head start. I review old notes, external records, and anything that’s happened since the patient’s last visit.
Clinic starts at 8 a.m., but I’m at the office by 7 clearing my EMR inbox and reviewing surgical cases for the week. As a joint replacement surgeon, I perform a planning process called templating for all my hip and knee replacement surgeries. Templating involves using x-rays and a computer CAD program to determine the proper size, shape, and fit of the replacement parts I want to use for each surgery. It’s a critical step in surgical preparation. In a typical week, I template between 10-12 cases, which takes around 30-45 minutes total. I’ve done this routine—hidden, “uncompensated” work that helps my clinic and OR days proceed smoothly and efficiently—for years.
Working in tandem, my PA and I see between 40-50 patients a day, going from 8 a.m. to around 4 or 5 p.m. with a break from noon to 1 p.m. for lunch. My goal for clinic is to be efficient and thorough without being hurried or distracted. I take pride in running on time while making sure patients feel listened to, informed, and engaged. I always sit down when I walk in and ask if there are any questions before I walk out.
This might come as a surprise to some, but most of my time isn’t spent trying to figure out a diagnosis. My practice is sub-specialty focused on hip and knee problems, and common things are common. As I like to say: it’s orthopaedics, not brain surgery. The top three causes of hip and knee pain account for around 90 percent of the problems I treat. Something else that might seem counterintuitive: often the longest, most difficult conversations I have involve recommending against surgery. You can’t click with every patient, but I’m a big believer in developing the doctor-patient relationship.
After Hours
I’m fortunate that the satellite clinic where I see patients on Monday is less than 10 minutes from home, a nice time saver. Getting home a little earlier helps me catch up on side gig stuff (emails, phone calls, video chats, second opinions, social media posts, etc.) before dinner.
We’re a family that eats together at the dinner table every night, something my wife and I both did with our families growing up. After dinner, it’s family time with an occasional evening meeting. I try to maintain a reasonable bedtime and have been known to fall asleep on the couch from time to time.
Tuesday
Pre-Dawn
Tuesday is an OR day, and once again I’m up around 5 a.m. I tend not to work out on days I operate. Joint replacement surgery is physical, including positioning the patient, hammering, sawing, and manipulating the leg. Surgeons burn around 340 calories per hour doing hip and knee replacements while experiencing increased heart and ventilation rates (still waiting for an “operating” workout on my Apple Watch). Joint replacement surgeons have one of the highest rates of occupational injuries of all doctors with more than 96 percent experiencing procedure-related musculoskeletal pain.
Instead of exercising, I use the extra time in the morning to enjoy a cup of coffee, peruse the day’s headlines, and mentally prepare for a day of operating. My first case rolls into the room around 7:30, but I’m at the hospital early, signing notes in the EMR, seeing the patient pre-op, and making sure the room is ready to go. Once again, the key to an efficient day is preparation—preparation and consistency.
The Daily
I fought for years for a dedicated OR team, including a PA, circulator, and scrub tech. It only took nine years, but I finally succeeded. (There’s ample evidence supporting the benefits of dedicated teams). More than almost any other procedure, joint replacements are about reproducibility. Planning the procedure (templating) then executing the plan intraoperatively. Constant refinement ensures continuous improvement. Flexibility and experience allow adaptation to the nuances of each case. A smooth, efficiently performed surgery is a beautiful thing.
I’m fortunate to have a talented, motivated team. They work hard for me and make life significantly easier. My end of the bargain is being consistent and dependable while treating them as respected, valuable members of the team. We’ve been working together long enough now that the connection is more personal; there’s a confident looseness that comes from subconscious synchronization. It’s our version of “being in the zone.”
In a given day, we typically perform four joint replacements in a single room. Like clinic, the goal is to be efficient without feeling rushed or hurried. My surgical times are consistent, but I never watch the clock. The case takes as long as it takes. While I’m not opposed to music in the OR, I have two rules: not too loud and no country.
I spend the time between cases (called “turnover time,” when the room is being cleaned and set up for the next case) to catch up on emails, work on side gig stuff, or finalize a post. Sometimes, I just regroup for the next procedure. I rarely eat lunch on OR days to avoid blood sugar spikes and crashes. My ritual is a cup of a ginger ale-cranberry juice cocktail with ice and two servings of peanut butter between cases two and three (“halftime”). The team is so consistent, I can usually time when the next patient is rolling into the room.
Dr. Schwartz’s OR Cocktail Recipe*:
1/2 cup ginger ale
1/2 cup cranberry juice
Lots of ice
*Pairs well with peanut butter
After Hours
Depending on the flow of the day, we’re typically done between 3-4 p.m. I’m usually mentally and physically tired at the end of a day of operating, but not exhausted. This is by design and the product of years of refining how to approach OR days in a way that works for how I want to practice.
On Tuesdays, I operate at a hospital that is also a short drive from the house. The evening routine is similar to Monday.
Wednesday
Pre-Dawn
Wednesday is another OR day at a different hospital about a 35-minute drive from home. I’m up again at 5 but have less time to canoodle in the morning given the longer commute. Operating on back-to-back days increases the physical toll, so I usually skip morning workouts on Wednesdays, too. (On the occasional short OR day, I’ll hit the gym on the way home to lift weights). At 6’6, I recognize that my neck and back are at particular risk. But, when you’re operating, the body unconsciously twists and contorts to get the job done.
The Daily
My PA follows me to each facility, but the OR team is different. Luckily, I’ve also successfully pushed for a consistent OR team at this hospital too. It’s hard to explain, but each hospital and operating room has its own feel—subtle nuances that require slight adaptations to maintain efficiency. The day proceeds in the typical OR fashion. Turnover time is again used to work on side gig stuff and perform the clinic preparation ritual for Thursday.
After Hours
The commute home is used to reflect and decompress, a car meditation. It’s during this time that a lot of my thoughts and ideas around healthcare take shape. If my mind needs a break, I’ll queue up a podcast related to one of my three passions: healthcare (Relentless Health Value), technology (This Week in Tech), or business/investing (Prof G Markets).
By Wednesday night, my body is ready for some rest and another clinic day.
Car Meditation: Using the commute home to reflect and decompress
Thursday
Pre-Dawn
My Thursday commute to clinic is the same as my Wednesday commute to the hospital (the two buildings are about a mile apart). The gym is on the way to the office, so I usually get in an early morning weightlifting workout. I enjoy strength training but can’t lift like I used to. Turns out there’s some science behind this. (I turned forty-four during the pandemic when gyms were shut down and stopped lifting for a while). My workout mantra has become: “Something is better than nothing.” Such is middle age.
The Daily
Thursday clinic proceeds like Monday. I’m in by 7, clearing out EMR messages, signing notes, templating for Friday cases, and occasionally writing a LinkedIn post if something is top of mind. Another true story: in 15 years of practice, I’ve only missed a handful of days due to illness. This is not intended as a humblebrag. The pandemic made us reconsider what it means to show up to work sick. However, “playing hurt” is an unwritten part of medical culture, especially for surgeons.
There’s a practical side to the issue, too. Cancelling clinic or a day of OR cases at the last minute is a logistical nightmare. Patients (some of whom have been waiting weeks for an appointment or months for surgery) must be called and rescheduled, a burden to staff. There is a lot of work (and expense) that goes into getting joint replacement patients ready for surgery. These patients are in pain and are looking forward to their surgical day. My clinic and OR schedules are typically full for months. Finding new spots for patients isn’t easy. The work doesn’t go away—it gets shifted to a different (now busier) day. Some office visits can be seen by a PA or another doctor if necessary. The same isn’t true for operative cases.
After Hours
The Thursday drive home is time for more podcasts or phone call meetings on the drive home. Once or twice a month, I take call. I’m fortunate that, as a tenured partner of the practice, call is infrequent and usually not burdensome. However, there are occasional broken hips that need to be fixed. When on call, I’m responsible for addressing urgent after-hours issues for the entire practice. I don’t sleep well on call nights, even when it’s quiet. The next day, I’m tired.
Friday
Pre-Dawn
Friday is wild card day. Occasionally, I’m in the office or otherwise operating at one of two surgical centers. In total, I operate at four different facilities (a long story for a different post). Maintaining the same level of comfort and efficiency in all of them took some time, but I appreciate how hard the staff at all locations work to make my day smooth.
The Daily
Something I don’t believe in: pajama time. I work hard to avoid having clinic work spill over into the next week. The prep work done ahead of time allows me to stay on top of dictations during office hours. My philosophy is to document so anyone reading the chart easily understands what’s going on with the patient, including the treatment plan. I use curated templates with drop down menus for the physical exam section and dictate everything else using voice recognition software (we’re still evaluating ambient scribes). I dislike generic, cut-and-paste history and assessment/plan sections that say nothing while saying too much, an unfortunate byproduct of current EMRs. Thanks to years of process refinement, I can get through most busy clinic days without rushing, running behind, or staying late to dictate. It seems to be working.
After Hours
When possible, I try to finish a little early on Fridays and use the late afternoon to exercise (back on the bike), finish side gig projects, schedule meetings, or get a head start on the following week. It’s helpful that a lot of my side gig work is done asynchronously through Slack, emails, and texts with the occasional ad hoc meeting.
The Weekend
All Work and No Play…
Time for some much-needed rest and relaxation. While I’m usually awake by 5 on the weekend, I can usually drift back to sleep for another hour or so. Weekend mornings are low key (tying up loose ends, catching up on emails, reading, etc.) followed by a family trip to the gym (and more old guy strength training for me). After that, it’s various family activities like home projects, grilling or using the smoker, and day trips. In the late afternoon/early evening, I work on my weekly TSR post. At night, it’s TV/movie time with the wife (usually regretting the decision to watch another unnecessarily drawn-out Netflix documentary that could have been half as long!). Sunday night has a slightly melancholy feel, even for the kids during the school year. Dennis, Christine, Sam, and the start of another week awaits.
- Ben
Small Incisions
Quick Takes on Timely Topics
U.S. Employer Health Care Costs Projected to Increase 9 Percent Next Year (Aon)
As with many difficult problems, where some see challenges, others see opportunity. The continued spiraling of healthcare costs for employers will drive the need for alternative solutions. Those solutions will involve cutting out expensive middlemen and seeking direct care relationships with high-value providers. It’s a great time to be building and investing in such solutions.
Hospitals exhale after judge blocks FTC rule on non-compete agreements (Chief Healthcare Executive)
As some predicted, we might have spiked the ball a little too soon on the non-compete ban. In this case, a Texas judge ruled that the FTC overstepped its authority, a criticism immediately raised by non-compete stans (i.e., those who benefit from controlling doctor movements). Appeals will follow, more docs will leave medicine or consider unionizing. And maybe, the pendulum will swing back from employment to independence, provided there’s a better landing spot. It’s a great time to be building and investing in such solutions.
The Health Misinformation Monitor: AI Chatbots as Health Information Sources (KFF)
Most adults aren’t confident they could tell the difference between what’s true and what’s false when using AI chatbots. They’re also not confident that the information provided by AI bots is accurate. KFF suggests it’s good practice to fact-check chatbot answers and seek confirmatory information from multiple sources … Something the average person definitely does when getting information from the internet. Before we rush to splash chatbots everywhere, it’s important to engender trust, refine models, reduce biases/black boxes, and keep clinicians in the loop. It’s a great time to be building and investing in such solutions.
CMS and CMMI recognize the importance of quality data gathering, sharing, and analysis to achieve the goals of VBC. That’s a good thing. The process is currently hampered by the fact that EMRs and the billing/coding system are not optimized for meaningful data capture. Can VBC as a payment mechanism solve this issue by uncoupling reimbursement from the need to satisfy arbitrary documentation requirements (garbage in)? Streamlined, optimized electronic medical records and practice models that incorporate robust data capture mechanisms are the future. It’s a great time to be building and investing in such solutions.
The Light Box
Healthcare Visuals
From the Gallery
Amplifying Community Voices
Wheels Out
Signing Off and Looking Ahead
While the above might seem like medical hustle culture gone horribly awry, I can honestly say I rarely feel overwhelmed. I’m mindful of work-life harmony and the need to keep everything in balance. Family comes first. I’m extremely fortunate to have a spouse who’s my biggest advocate and supporter. I could not do this without her—an amazing woman, wife, and mother. ’m also a proud “girl dad” and couldn’t ask for two more inquisitive, empathetic, and responsible kids. When it comes to being needy, “I’m the problem, it’s me” (← T. Swift reference FTW!).
Professionally, my day job as an orthopedic surgeon takes precedence. My primary responsibility is to my patients. As a result, I sometimes turn down opportunities to avoid stretching myself too thin. (It’s also why I can’t schedule meetings in the middle of the day. Sorry to all the administrative assistants out there.)
As I’ve matured in my career, comfort with the clinical practice of medicine has freed up mental and physical resources for other things. During the transition from newcomer to seasoned veteran, the game has slowed down. I take pride in delivering high quality, engaging MSK care. Side gigs enhance that work by keeping me fresh and feeding my growth mindset.
After all, there’s only so many hours in a week.
Until next time,
Ben Schwartz, MD, MBA
Editor-in-Chief/Senior Clinical Fellow