Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
Joined Mountain View
Medical & Surgical Associates
of Madras, Oregon July 2008

Good day to all in the podiatric community. It is my pleasure to introduce a new relationship between two of our profession's most influential and beneficial sources of information. PRESENT e-Learning Systems and Podiatry Management Magazine have agreed to publish a printed version of the ezine formerly known as, “New Docs on the Block.” For three and a half years, I have attempted to describe as honestly as possible, the life and concerns of a podiatrist newly in practice. The ezine has grown into a forum in which many practicing podiatrists, residents, and students have expressed their wide ranging opinions. We’ve had some heated conversations ranging from physician salaries to biomechanics to universal healthcare—with the goal of providing a useful and interesting resource. It has been my privilege and honor to be the moderator of these discussions.

Now, with this new relationship with Podiatry Management magazine, we hope to bring these resources to the rest of the podiatric community. To mark the occasion, PRESENT e-Learning Systems and Podiatry Management magazine have formed a perpetual educational partnership fund. Their combined generosity and leadership will only further benefit our profession. I thank these two leading publications for their vision and look forward to reader participation and opinions.

Over these three years of writing "New Doc's on the Block" for Present e-Learning Systems, I've gone from being a resident at Botsford General Hospital in Farmington Hills, Michigan to a new associate in Lansing, Michigan—and finally to a hospital-based multispecialty practice in a rural community in Madras, Oregon. Along the way I became a father and have struggled with the demands of my profession and my family. I'm no longer the "New Doc," but each day I learn something new to improve my skills and help my patients, and it is in that spirit in which "New Docs on the Block" has been renamed to "Practice Perfect." The name may be different, but the spirit is the same: a frank dialogue in a new larger forum. I look forward to our conversations.

Our “Class” System

The other day, I was talking with my medical assistant when she made an interesting comment: "I would never sit down with Dr ----- at lunch." I asked the obvious question: "Why not?" She answered as if I were an idiot: "Because he's a doctor!" This interchange started me thinking about the nature of the relationships we physicians have with each other and with our subordinates, even the nature of our relationships in general. I've noticed through my 36 years of life — now more so than since beginning a career in medicine — the “grouping” behavior in which people tend to participate. We tend very much to stay with "our own."

From a historical standpoint, this part of human nature is obvious. Think about the early 1900's when immigrants from Europe and Asia came to America. Did they live in heterogeneous, multicultural neighborhoods? Not a chance. New York City, for example, harbored distinct cultural neighborhoods of Italians, Jews, Poles, and African Americans, among others. It was only much later that these enclaves became more diversified. Even today, this phenomenon exists.

What about the medical community? I don't think we behave any differently from any other group. As residents, we never would have thought to socialize with our attendings. In fact, residents of a particular year tend to socialize with each other, more often than with lower or upper year residents. Of course, as in everything, there were exceptions. We've all heard about relationships forming between residents or interns of different years and specialties. We're all aware, for example, of that classic doctor-marrying-nurse story.

Today, as an attending physician, I see a similar divide between medical "classes" (castes?). From medical assistants, front office staff, nurse assistants, nurses, technicians, and cafeteria workers to physicians, we all seem to flow naturally into our "cliques". This is most evidently displayed in the hospital cafeteria at lunch time. At separate but equal tables, you'll see physicians eating together, nurses chatting, physical therapists at a corner table, etc.

The divisions seem to go even deeper, though. In my office, age is a discriminator. The older ladies in the office have lunch together, while the younger staff — in spite of their different office positions — commingle. I've seen it among doctors as well. Older physicians, whether of the same or different specialties, appear to feel more comfortable with their age-peers than their younger colleagues. Medicine and people have changed...and we gravitate toward the familiar. I'm likely, for instance, to have more to talk about with another podiatrist than I would be with an internist. The same may be true with a doctor-nurse or young-older comparison. Within a certain group we have shared experience and a similar perspective that provides a comfortable framework for social relationships.

Of course, for every example, there's an exception, a case of the person who seems to transcend these self-imposed caste restrictions. My former residency director was quite comfortable in various social situations. My wife and I had dinner with him on various occasions, and I even went to a ballgame once with him. Our relationship was very much, though, as mentor/father-figure. I would never have dreamed of calling him anything other than “Doctor.” Even after three years and his request to be called by first name, I'm still a bit uncomfortable using the familiar. This is my own self-imposed limitation. During med school, we had a teacher who invited students to his house for a yearly party. Perhaps this was his way to break through those boundaries. Perhaps we students had more to learn from him than human pathophysiology.

Now, I'm not so naive as to think there's no reason behind this behavior. Let's take the doctor/nurse relationship. As physicians, we are the top of the medical food chain. As such, a certain distance may be required to maintain control in certain situations and ensure successful patient care. Take the operating room, for example. If a complication occurs in the OR, it's my responsibility. The OR is not run by committee; by necessity it's an authoritarian power structure to a great extent. Captain of the ship and the buck stops here are both true legally and professionally. Hence, I'm going to maintain a certain authority and, in some cases, a professional distance. We live in a world of power differentials, and it's very easy to buck the hierarchy. How many of us have been roughly and inappropriately treated by an attending physician without saying anything in response? I've seen the same poor behavior by doctors who treat nurses in verbally abusive manners. Luckily, this is changing, as organizations increasingly recognize the innate equality of people.

As much a part of human nature as this behavior may be, I find it a shame. I imagine myself having rich informative exchanges with people of varied backgrounds and experiences. I find myself working hard in certain conversations to make those in subordinate positions comfortable enough to open up and engage in real dialogue. I try to convince my office staff, for instance, to call me by first name, unless we're in front of patients. Yet they're still clearly uncomfortable with anything other than “Dr Shapiro.” I'll keep trying to break through our social caste system, and until then, I'll have to settle for a little more distance than I'd like.

Keep writing in with your thoughts and comments...we'll see you next week. Best wishes!

Jarrod Shapiro, DPM
PRESENT New Docs Editor
[email protected]