HJAR Jul/Aug 2024

CHANGING THE CARE: PCOS 24 JUL / AUG 2024 I  HEALTHCARE JOURNAL OF ARKANSAS   for diagnosis and treatment of PCOS, and yet I can assure you that I was not diagnosing and treating PCOS in 10% of my female patients. Why not? The answer is complicated but linked to many of the themes being written about in this series of articles. My medical training took place throughout the 1990s, and I entered pri- vate practice in 2001, two years before the Rot- terdam criteria was published. I did not learn about PCOS during my medical training because formal criteria for its diagnosis had not yet even been brought into existence. And private practice in medicine could be all-consuming. Back then, I typically started my day at around 6:00 a.m. by rounding on patients in the hospital. I would typically see my first patient in the office at 8:30 a.m. with a goal of seeing around a dozen or so patients by noon. Noon is when I would usually go back to one of three hospitals to finish rounding or perform a consultation, sometimes squeezing in a quick 10- to 15-minute lunch before returning to the office for a 1:30 p.m. patient. The afternoon included seeing a dozen more outpatients to fin- ish up by around 5:00 p.m. or so to deal with messages, review labs, and make phone calls to patients about lab results or to answer questions — that is, if I didn’t have to go back to the hospital to admit a patient or see a consult that had arisen during the day. The goal was to try to get home by 7:00 or 7:30 p.m. to eat dinner with my family, spend some time with my daughters before they went to bed, and talk to my wife about household is- sues. So, I hope you will forgive me if I didn’t feel like reading the latest issue of the New England Journal of Medicine at the end of the day or learning about the new Rotterdam criteria for PCOS. Having said that, I now realize retrospectively that I started breaking my vow of staying up to date within the first two years of beginning practice. Furthermore, the way that I created and cap- tured financial value for myself and my partners was to see as many patients as possible dur- ing each day. Indeed, the only way to capture and create financial value was through these discrete transaction-based visits. Don’t get me wrong, I certainly tried my hardest to earn trust and create value for patients through longitu- dinal relationships and delivery of great care, ished high school and supported us through manual labor. I had the ignorant audacity to be jealous of my grade school and high school classmates who could afford tennis lessons or country club memberships, to whom I felt infe- rior while failing to appreciate how my own par- ents sacrificed to send me to the private high school in the town where I was raised. The vale- dictorian of the public school I would have at- tended flunked out of college, while 4 out of the 68 members of my graduating high school class went on to become doctors. Maybe that was just a coincidence, but I am forever grateful in winning the “lottery of life” and being raised by two parents who loved me enough to make financial sacrifices that would secure me the type of education that would eventually lead to a life in medicine. I may realize that now, but back at the start of my private practice years, I had residual feelings of inferiority and wanted more for my own daughters than I had growing up, and I really wanted to drive a nicer car than a Volkswagen bug. So, when it came to organizing my day, learning about the new Rotterdam criteria of PCOS received short shrift in terms of prioritization of what was quickly becom- ing my most valuable resource, my time. Adding insult to injury was that I was quickly realizing how medical “quack- ery” was rampant. I would often see patients who had been diagnosed by these “quacks” with “chronic Lyme dis- ease.” Chronic Lyme disease does not exist. Rather, there were licensed medical “doctors” who would open Lyme disease clinics and treat patients for vague and nonspecific complaints such as fatigue, malaise, or various aches and pains, of- ten prescribing antibiotics inappropriately while ordering obscure labs that had no basis in scientific evidence. I recall one such doctor who took several months to diagnose malaria through one of these obscure tests on a pa- tient who had never even traveled out of the country. Prior to embarking on that doctor’s recommended treatment regimen of non-ev- idence-based concoctions, that patient came to me for a second opinion. Unfortunately for him, his actual diagnosis was tumor fever from pancreatic cancer. We will never know if the delay in diagnosis cost him his life. So, when a clinic opened locally that was special- but no part of my compensation was linked to the quality of health outcomes that I pro- duced. Quality of health outcomes were not even measured, much less managed or incen- tivized; they were simply assumed. I remember one of my physician partners who “only” av- eraged seeing about 15 patients per day. His notes were incredibly detailed and thorough, his patients loved him, and he seemed to man- age a strong work-life balance, something that I failed miserably at doing. But he also drove a Volkswagen bug and was the least well com- pensated physician at our practice. He was widely respected by his physician colleagues, but the unspoken culture was that not all phy- sicians could practice that way, otherwise we would all be negatively financially impacted. Shamefully, I must admit that I wanted more than that for myself. My wonderful mother had a sixth-grade education and was a homemaker for our family, earning no income of her own. My incredibly hard-working father barely fin- “While being overweight or obese is common in PCOS, it also is not an essential criterion. Pathophysiology is complex, but insulin resistance plays a central role. Women can have tremendous difficulty succeeding with intentional weight loss even if they are modifying their dietary and exercise patterns.”