The ultimate payoff.

A C S s I write this we are just entering the holiday season; you will e reading this in the midst of the holidays. This is traditionally time when thoughts become more philosophical than scienific. It often engenders contemplation of the actual importance f material things and what brings real happiness. I recently ad an interaction with a patient and his family that caused me o pause and consider the things in life that are of real value. It as particularly relevant in light of the current attention ocused on the issue of reimbursement. So I thought it might e an appropriate topic for this Editor’s Page. The patient was a career academic physician who had just etired to San Diego after developing health problems. He ad recently been diagnosed with heart failure due to an nfiltrative cardiomyopathy and had been started on conentional as well as investigational medications. He and his ife of many years were always together, in the clinic, the ospital, or outside. He was invariably in good spirits, an ngaging personality with a wry sense of humor. His pproach to his own disease was professional; some might ay that he intellectualized as a defense mechanism. He ould present his symptoms and signs almost as if presentng a case to an attending; his wife would interject any nformation that he might have “overlooked.” During his isits our conversation would often wander from medicine o family (his and mine), world situations, and life in eneral. I communicated often with his children, several of hom were physicians, themselves. We became friends. The patient had a tumultuous course. Over the next four ears he experienced a continuing onslaught of acute medcal events. He was hospitalized intermittently for recurrent eart failure and developed nasal tumors that caused suffiient symptoms to warrant surgical removal despite his ondition. We dealt with gastrointestinal bleeding, a sysemic embolus, and progressive renal failure. At one point, uring an acute myocardial infarction with severe hypotenion and failure, his wife asked me if this was finally the end. answered that I did not know, but the patient recovered. hen cataracts threatened to remove his last enjoyable ctivity—reading—we finally had them removed. One night e collapsed at home and died shortly thereafter. Several weeks after the patient died, I received a letter from is wife. She wrote to thank me for the care he received, and o be sure I knew how much they both valued it. She indicated hat before relocating to San Diego, they had been told by hysicians at a highly regarded institution that he would not ive a year. They naively credited me with the fact that he had a urvived for four years. During those years they had shared any wonderful moments, alone and with their children, and heir entire family extended their sincere appreciation. I read he letter several times and then filed it in a special folder in hich I place things of great personal value. If I were to atalogue my perceived accomplishments over the past several ears, this would certainly rank near number one in satisfaction. Reimbursement issues have gradually become center tage for cardiovascular specialists. Driven by rising health osts and a budget deficit, the government has sought to ontrol health care expenditures and reimbursement. A day arely goes by without reference to relative work units, ractice expense, managed care, capitation, and so on. rofessional societies have initiated aggressive advocacy rograms, in large measure to insure that physician services re adequately compensated. Salary considerations are said o be a major driver of the choice of physician specialty. There is no question that medical services should be dequately compensated. The training, work, and responsiility involved in providing clinical care ranks with the most emanding vocations. In fact, physician salaries are invaribly near the top of wage earners in society. However, no mount of money can equal the tremendous satisfaction and ratification that comes from the thanks of a grateful patient r their family. We as physicians are relatively unique in this egard. Just as there is no greater gift that one can receive han their health, there are few other services that can ngender the level of gratitude as can clinical care. Just etting to deal with something as precious as a person’s ealth is a real privilege. I often tell family and friends that would go to work if I was not paid, and not many in our ociety can make that statement. So, we physicians are a lucky lot. Our incomes are among he highest in society, we are generally granted a position of steem in our communities, and we have an intellectually nteresting and challenging occupation. But as we approach the oliday season, I cannot help but think that the ultimate payoff or our efforts is the gratitude of our patients. Whether eimbursement increases or decreases, we will always be genrously compensated by the privilege of serving and the eartfelt thanks of our grateful patients for the care we deliver.