EP 60: Bringing Joy Back to Medicine

Episode 60 of the Hope4Med podcast features Dr. Nicholas Fogelson, a surgeon in private practice in Portland, Oregon, focusing on pelvic pain and endometriosis. Dr. Fogelson shares his experiences in academic medicine that lead to burnout and unhappiness. He discusses how transitioning to private practice with a new practice model has helped him bring the joy back to practicing medicine and become a better doctor for his patients.

Connect with our guest:
Website: https://www.nwendometriosis.com/
Facebook: https://www.facebook.com/nicholas.fogelsonphysician


[00:00:00] Dr. JB: Welcome to Hope4Med.

[00:00:04] Hi everyone. Welcome back to the Hope4Med podcast. I am your host, Dr. JB, and today’s featured guest is Dr. Nicholas Fogelson. He is a surgeon in private practice in Portland, Oregon, and focuses on pelvic pain and endometriosis. Welcome to the show Dr. Fogelson.

[00:00:23] Dr. Fogelson: Thank you, dr. JB, thanks for inviting me. And I look forward to talking to you.

[00:00:27] Dr. JB: So let us start from the beginning, can you share with my audience your origin story?

[00:00:33] Dr. Fogelson: Well, I mean, I grew up in– my origin is Oregon, so I grew up in in Portland, Oregon, grew up in Eugene, Oregon, actually, we’re the home of the Oregon ducks, right, where, when I was a kid, they were a terrible football team and somehow they’ve become like good team over that period. Nike money. But anyway, so, I went to college in Eugene, Oregon, and then eventually– really wanted to be a physician from a very young age. My, my mother said I wanted to be a physician when I was a sperm. And I literally like from, always from a very young age, I always wanted to be a doctor. And eventually went to medical school and went to medical school actually in Oregon as well, and became enamored with, at that time, obstetrics and also surgery, but ended up deciding to do a residency in OB/GYN and had a great time. Enjoyed that work. I was very passionate about it. I mean, at one point I was, I was profoundly passionate about it and kind of had a career in academia for a while where I did a residency and then I did a academic stint at the University of Hawaii, and then ended up moving back to South Carolina.

[00:01:39] I was married at that time and for reasons of my marriage, ended up actually going to Hawaii cause she, my wife matched there for her residency, and then wanted to come back to South Carolina where I had been a resident. So I was a resident in actually in Charleston, South Carolina, Medical University of South Carolina. And then wanting to come back to South Carolina because she wanted to do a fellowship there, and so we came back there and then I was on faculty at a couple of other places, University of South Carolina. And then actually we ended up getting divorced, that relationship didn’t work out.

[00:02:09] And we, I did a fellowship at Emory University and then continued in academia there. And then for various reasons that we, would certainly be apropos to talk about, eventually decided to stop being an academic and focus on private practice. And now I have a very focused private practice in pelvic pain and endometriosis, the bane of every gynecologist, that the vast majority of gynecologists are like, I don’t want to see those patients, is that’s all I do. And what’s funny is that some people say like, oh my God, if I had to see pelvic pain patients everyday, I’d shoot myself. And I’m like, my God, that’s the only thing I want to do. It’s just fantastic.

[00:02:46] And so the question is, like, you know, how I got there, I guess, because now I have a practice that’s– I, for the first time in like the last three or four years, the first time in a long time, that I really enjoyed being a physician and I am actually rewarded. I have time for my family. I have not only that, but I have the time for professional development that I never had in academia to really pursue what I want to do. And so if I, if I had one message to give the listeners is that, if you’re a really smart, intelligent physician, don’t let anybody convince you that private practice is a waste. And that “you’re too smart to not be an academia” is the most stupid thing anyone’s ever said. It’s like, I cringe. I was told that so many times and I was like, yeah, I don’t believe it. Private practice is a noble and fulfilling pursuit, if done correctly.

[00:03:47] Dr. JB: Well, a couple of things, you are the, I guess your story, how do I say this? Decided to become a doctor from when you were sperm is the earliest I have ever heard somebody say that they decided becoming a physician. And this was predestined, are you from a family of physicians?

[00:04:15] Dr. Fogelson: No, no, my mother was a clinical psychologist, my father was an entrepreneur. I, I literally don’t ever remember, I mean, I had like a brief dalliance with wanting to be an astronaut and I had a fantasy of wanting to play golf on the PGA tour, and I took a brief– I was a decent golfer, I took a brief detour and actually took a year off of medicine to try to play golf professionally which was actually an interesting thing. It was an interesting thing that I did, but that didn’t work because I wasn’t good enough, but I found out which was why the, why the year was worthwhile.

[00:04:48] But, yeah, I mean, I like other than a couple of little brief detours, like it never occurred to me that I would ever want to be on anything else. And when I got to medical school, I was profoundly sure that it was right. I was on fire, like I absolutely just was in ecstasy of joy and fascination in what we were doing, and but they say that in order to burnout, you have to be on fire and that like people that have a middling existence in their career are far more likely to enjoy it at a middling level forever, whereas the person that absolutely is profoundly in love with what they do, is the one that is going to become disillusioned and fall out of it more likely. I think that’s true. Like I’ve had people tell me that, I’m like, yeah, I think that’s true.

[00:05:37] I see people who have kind of a reasonable– like it’s funny, you’re an ER physician, like, it seems to me that ER physicians are pretty happy people, like they have kind of like a middle existence in medicine because every ER doc I know, if I asked them to describe what is their core, the core of who they are, they’ll tell me they’re a drummer, or they’re a skier, or they’re a rock climber, or they’re a parent. I don’t ever hear them tell me their core existence is being an ER doc. Whereas most surgeons, if you asked them, you ask a surgeon what’s their core existence? And they say I’m a surgeon. And so I think that to some extent, like certain paths in medicine are very, uh, lend themselves towards seeing medicine as being your job and other paths in medicine lend themselves toward your, medicine being your core identity. And I think if you choose the path that requires medicine to be your core identity, you’re going to have moments of disillusionment and moments of crisis where you go, well, who the hell am I if I’m not a doctor? I was profoundly impacted by the song from Encanto– have you seen Encanto?

[00:06:47] Dr. JB: Yes, I have.

[00:06:49] Dr. Fogelson: Surface pressure, where the character Louisa has tremendous powers, she’s super strong, and yet the pressure of lifting heavy rocks her entire life is profound, even though they’re not heavy for her. And that, that being given a lot of power and the responsibility that comes with that, of course, the corollary is even Spider-Man, that with great power comes great responsibility. Like once you have a lot of ability that the expectation of society that we use those abilities for external benefit, not your own benefit, for the benefit of society, it becomes a tremendous pressure that over time can be quite overwhelming. And in medicine and what I do, like I have focused myself more and more and more into– remember how I mentioned that I do stuff that no one else wants to do? It’s like the reason why no one else wants to do it affects me too, and like I’ve focused my life in things that are very, very difficult, perhaps for my own psychological desire to be iconoclastic and different or something, and to conquer the things that other people don’t want to deal with, and yet at the same time, there’s a tremendous pressure. Like once you become good at doing something like that, that you better do it because no one else wants to do it. And so if you don’t do it, then now you’re letting the world down.

[00:08:19] And so that is, it is in my own path, became a difficult time in my, in the middle of my life, kind of when I was in academia to some extent, becoming very good at something but feeling this tremendous pressure to provide that for the world and, and then not being able to do it on the terms that I felt was acceptable. And that led to a sense of burnout of where one is, I’m trying to take care of patients that no one else wants to take care of because when the patient with pelvic pain comes in and says, oh, I’ve got this pain, you know that you have 15 or 30 minutes to talk to them, and like this is going to take hours to sort out and even then I may not fix it. So, then you feel like, oh my God, just get out of my office, I can’t deal with this, and yet that was the environment I was in. Like, I was trying to take care of those kinds of patients, I wanted to take care of them. I felt that personal desire to try to help them, and in the occasions where we really did help them, it was very gratifying to really help someone that, that other people hadn’t been able to help.

[00:09:20] And yet, yet the structural mechanics of academic medicine was such that no one was giving me the time to properly do it. And I think throughout medicine, people, I think that a lot of physicians who believe that they have fallen out of love with medicine, it’s not medicine they fell out of love with, it’s the way that they’re doing medicine. It’s the way that the medical system is forcing them to, forcing them to do what they do. And so if you’re trying to do something really complicated and they only give you 20 minutes to do it, it’s just like, forget it. Patient’s unhappy, the doctor’s unhappy. You probably don’t fix the patient. Patient feels like they’re not being listened to. And then they go online and write a complaint about you, “the doctor doesn’t listen to me.” Yeah, I tried, but I don’t have time, they don’t understand the other side of that. Of course, not that they should. But the reality is that, is that the system has not structurally given you the time and I really feel for the patient that has something that’s hard to figure out because patients, by and large, medicine want– the sort of the systematic, industrial way of practicing medicine doesn’t really give time to really think about things. Like you better know what to do immediately because no one’s giving you time to go and read a book or even just sit at a chair and think about it and have a little Einsteinian thought experiment about someone’s condition about can you really figure it out? There’s no time for that.

[00:10:44] And by the time, if you choose to do it at home, you’re ignoring your family. If you choose it at work, there’s no time at work. So some people have solved that by not having families. I know some people who are really talented physicians that basically don’t have families, they’re like warrior monks who basically have allowed medicine to eat their life and they’ve decided that that’s the way that they’re going to solve this problem, and at some level of satisfaction, I think, and also some level of sorrow over it. And everyone admires those people to some extent, like they’re the, they’re like the Gandhi of medicine, but I think internally they’re not as happy as they may appear to be. And, and so if you don’t want to do that, you either have to just give in to the mediocrity of what medicine demands of you, which is that yeah, you could be, you could be a really good doctor but the system’s not going to give you the time. And that’s where the burnout comes in and you say, okay, I’m either going to give in to this and kind of become a drone and just do it in order to keep your sanity and just do the best you can and realize that that sometimes its best isn’t good enough, the system’s not letting you. Or you just go crazy. If you can’t, if you don’t give into it, then you just lose it. I guess it depends on the personality of the person you are, but for me like that, that sense of like, man, I could do this job so much better if the system was structured in a different way and so eventually I just lost my, lost my desire to continue to do that.

[00:12:20] And also kind of an interesting, interesting dichotomy in academic medicine between like, what is our role in teaching young physicians to be better doctors and what is our role in actually taking care of our patients, because academia has really pushed to where academicians basically have to be in private practice now, like you’re expected to make the money and produce your salary. There’s no, you’re not getting paid to teach, you better be a doctor and bring in the money that pays your salary, in addition to some massive tax to the Dean of the med school and all this kind of stuff. And yet, then you’re expected to teach young physicians how to be doctors at the same time. And it’s a tremendous, like dichotomy of goals, particularly when you’re trying to do things that are really difficult. You know, the kind of things I do in pelvic pain and endometriosis are technically very, very difficult surgeries, like they are way above the head of some second- or third-year resident, and so at that time in academia, like I was trying to push myself and teach myself how to do this stuff. Like I did a fellowship in cancer surgery, but no one ever taught me how to do endometriosis surgery. I taught myself from YouTube honestly. And I mean, it’s kind of a joke, like people say, where’d you learn to do that? I say I learned it off of YouTube. And–

[00:13:36] Dr. JB: You know, patients don’t realize how much you, how much physicians learn and review these videos right before they go in and do these procedures for the first time.

[00:13:46] Dr. Fogelson: Right? I mean, but the thing is that it’s a totally new world. I mean, laparoscopic surgery, it’s all recorded, and so then you can watch someone else’s surgery and someone says, well, it’s crazy you’re learning it online. Honestly, I probably get more out of watching someone else’s surgery than I would having them in the OR like telling me what to do. Like, like once you reach a certain point as a surgeon, of knowing anatomy and knowing surgical technique, once you understand those things, then you just have to understand, like, what are you trying to accomplish? And if you understand that, then you can really go do it, and the first time you do it, isn’t really the first time, like you’ve been through all of the, the mechanics of how it gets done, and then you can pretty much just do it. And you’ll refine it and make it better over time, but we’ve moved past where you have to have a mentor physically in the room telling you how to do something. Like you can study and learn but, but that takes it– I mean, we’re kind of getting off path here– but I mean, that takes a certain personality that I guess I have, I’m not sure that everyone does, of being willing to go and actually operate on someone and do something that you’ve kind of never done before. But, but having enough study of the system and enough study of what, of like the anatomy and the technique and willing to watch videos and really kind of maybe even go operate on some cadavers. I’ve done cadaver surgeries before where I’ve literally rehearsed a surgery I was going to do. And that that’s a certain personality that not everybody has.

[00:15:10] But at the same time, like this is an example, like I had a surgery, the first time I ever did a pudendal nerve decompression, which is a surgery I do that like three people in the country know how to do, maybe more, maybe 10, I don’t know, but very, very few people. And I, and I think only two or three people in the country do actively will do a laparoscopic pudendal nerve decompression, which I will do. Like, I never in a million years would have been able to do that in academia. Somebody would have told me you’re not allowed to do it, you don’t know how to do that. What qualifications do you have to do that? What credentialing do you have to do that? Like, none, like whatever, whatever official system that would be to allow me to do something that no one had done in that hospital, I never could overcome. But what that means is that in that environment, no one will ever be able to push forward in an event a new surgical procedure or push forward and do something that maybe they experimented with in Europe and they’re not doing the US, in this case, that is the case. It was impossible. Like the bureaucracy of doing creative things for patients, like the system would rather tell a patient, I’m sorry, no one can help you, than say, okay, we’re going to let our doctor who’s willing to try to help you with something that may or may not work and we’re going to let them try. And instead they would say no.

[00:16:26] Dr. JB: Real quick, when you talk about the system, what are you talking about? Are you talking about like life in academic, academia or…?

[00:16:33] Dr. Fogelson: Yeah, I think mostly in academia because I haven’t really experienced it in private practice. Like I think the hospital mostly cares about the fact that– like a lot of the restrictions I had on myself in academia– Like, for example, let’s just take this example of doing a pudendal nerve decompression surgery. If I had tried to post that surgery as an academic at Emory University, I think that somebody would have asked me what, would have said I don’t have credentials to do that. And I wouldn’t have been able to do it because they would have said, oh, you’re going to need to go and you’re going to need to get an IRB approval because it’s an experimental procedure, we need to do this under the IRB. We need to… we need to get some lawyers together. We need to do this, it just would be like, and then at certain point you just go, “forget it.” Like the inertia, the slogging, would be ungodly, and then you just go “forget it.” Like I can’t, I can’t do it. It’s too much.

[00:17:25] Whereas in private practice, the first time I ever did a laparoscopic pudendal nerve decompression, I mean, I actually practiced it on cadavers few times and then I went and did it. I had a patient with endometriosis, I posted that it’s an endometriosis surgery, and then I just moved my robot over to the side and did what I wanted to do. Nobody told me I couldn’t do it. Now, maybe that’s a little cavalier, but the reality is just that I’ve developed a reputation in this country for being willing to try to do things that very few people are willing to try to do, and I have patients that fly to see me from all over the country for that reason, and that makes me feel good. Like I have patients who today say that I changed their life for the positive who are really, really appreciative of what they did, of what I did. But I guarantee I would not have been able to do if I stayed at Emory University. Now I’m not talking specifically to Emory, I think Emory is a fantastic institution and I’m not being critical of that specific institution, but like I never would’ve been able to do it in academia.

[00:18:25] I mean, and not to mention the fact, I never would have had a surgical assistant. Like I would have had a second-year resident assisting me on something that they have no idea about, the anatomy that I’m trying to deal with. I have a great assistant now who, who studies with me and is going to do whatever I say and I don’t need to worry about teaching her. I need to worry about teaching her job of assisting me, I don’t need to worry about trying to teach her how to do the surgery because that’s not her life path– and unless she decides that she wants it to be, in which case I’d support her going to medical school. But like it’s really, really hard to do difficult, complex stuff that is pushing the boundaries when you’re trying to teach a second year resident how to hold a laparoscope. It’s just brutal. And again, it kind of just, at the very least, it holds you back, and at the very worst, sometimes at least the complications in surgery.

[00:19:14] And in the end as a, I had some complications in surgery as an academic physician that in the end were my responsibility because I was teaching, but I didn’t do them. My trainees did them, or like trainees were the direct cause of the complications, and I was the indirect cause because of a poor– being a bad teacher. And that, that weighs on you. It’s like when you realize like, okay, if my pathway is to try to do this really complex, unusual stuff that no one else wants to do, I am getting burned out and I am getting really, really unhappy in trying to satisfy both of these roles at the same time where I’m trying to teach young physicians how to basic do basic surgery while I do things that are extraordinarily complex and there’s no fellowship structure that would have put a fellow under me, really. Like now I have a minimally invasive surgery fellow, like an AAGL fellow, which is a higher level of gynecologic surgery training, that works with me. And even then, that person may or may not do these things I’m doing, I maybe teaching them, I may not be letting them do all this stuff that I do.

[00:20:19] So, to some extent like the structural weight of all the huge academic system was making me not able to do what I wanted to do professionally and it was making me unhappy and not giving me the time to do what I wanted to do with my patients. It was not paying me that well, like I felt like I was trying to do sort of extraordinary things that no one else wanted to do, but those things had no financial value. Like I was being told I was working my ass off, getting up at five in the morning, six in the morning, going home at six or seven at night, and not even getting paid really, particularly well for that. And, and then I had a child too. I, I was remarried and I had a daughter and like in the first six months of my daughter’s life, I was like hardly home. I mean, I was like working my ass off and there was no end in sight. Like there was no time where I’m like, oh yeah, one day I’ll be able to go to my daughter’s soccer game. It’s like, no, not really. I mean my current job is never going to allow that, and so finally just like a coalition of things happened where I was just like, this is like intolerable and so then I decided to leave academia. And I honestly have never, I felt like I left a cult of sorts. It’s like– I mean, that’s a little strong, but like everybody in academia is so certain that the academic life is like pinnacle of medicine. And I am so much of a better doctor now than I was when I was in academia.

[00:21:57] Dr. JB: What do you mean by you’re a better doctor now than when you were in academia?

[00:22:02] Dr. Fogelson: I am so much more able to give the patients what they need and I’m so much more able to give them the time. I’m able to pick up a book and read and go read some articles to try to help my patient, try to figure out something unusual. I’m able to pursue paths that are not in a little silo that the institution says I have to be in. They say you’re a gynecologist, that issue with the bladder, go send it to the urologist, or okay that– like, so I went to a practice, study with a group in Switzerland, they became certified in neuropelviology, which is like pelvic neurosurgery. That would have been really difficult to do in academia, but then the stuff I was doing, like I’m able to pursue this interesting stuff that is helping some patients that would be so hard. Like to me, that is being a good doctor, like really rekindling that passion I had for medicine and actually pursuing something that fascinates me, and then able to actually put that into action to try to help my patients. Like that was not going to happen in academia. The overhead would just be ungodly. I mean, it’s not that you couldn’t, but it would be like, it would be like, like the Spartan race, like running over obstacles and under barbed wire and machine guns, and when maybe at the other end you’d be, you’d be able to do it.

[00:23:24] And then at the end, they still wouldn’t pay you for it. It would just be like this ungodly– maybe they give you a medal, maybe they call you an associate professor. What a grand, what a grand reward that would be, God forbid they call you a full professor. I mean, I mean, literally like that was the brass ring. You work hard enough, we’re going to make you an associate professor. Will you get paid any more? No. Will you have more responsibilities and be required to go to more meetings? Yes, probably. It’s like, and so, I feel good about what I do now, like I enjoy my work. I have time to talk to you. Would I have had a time, would I have been able to break out an hour of my day in the middle of a Wednesday to talk to you in academia? Probably not. I mean, I do my own podcast, I do my own social media stuff, I do whatever I want to do. The point is I do whatever I want to do. Nobody’s telling me what I can do. I mean, I push the limits a little bit, occasionally tell me, people will say, hey, pull back a little bit, but um, not usually. And so that’s made me a better doctor and it’s made me a happier doctor.

[00:24:27] Now what’s the other side of this that everybody should know? I don’t take insurance, like I got specialized enough in what I do that the insurance companies have no concept of what I do that values it at the level that I value it at, or that my patients value it at. Right? I can’t, if I do a surgery that takes five hours and the insurance company, if I were to code it with Blue Cross Blue Shield and they’d pay me $1,200, it’s impossible. Like I can’t do it. It doesn’t make enough money to pay the bills and enough money for me to, even if it paid the bills, I’d be making very little money to take home to my family that I would feel good about my job. And I was told something when I was a medical student that I will reiterate. I was told by a gentleman named Michael Wheeler, who was a plastic surgeon at the VA, was a mentor of mine, taught me a lot of surgery. And he said, Nick, if you don’t feel adequately compensated for what you do, you’ll never be happy. And he’s right.

[00:25:28] Like not necessarily in a global sense. I mean, like happiness doesn’t come from money, but you will be dissatisfied if you, if you feel like you’re really underpaid for what, the kind of effort that you put into your job, that will always be a level of dissatisfaction. And I don’t, like I feel more satisfied with my job now because I do what I want to do. My patients are appreciative. I’m able to pursue what I want to pursue. And I’ve decided that, you know what? I think my work is worth more than what Blue Cross Blue Shield thinks it’s worth. And so I’m going to, I’m going to decide that I’m not going to contract with any insurance companies anymore.

[00:26:04] And I had people, like when I left academia, I contracted with the insurance companies for three years, but eventually as I focused myself in all this, I developed my reputation enough, which is now international– I mean, I get calls from all over the world– that I clearly have enough demand for my services that I can support a practice without taking insurance. Eventually developed enough demand for my services that I decided not to. And I had people tell me, Nick, you’ll fail. It’ll never work. Patients will never want to come see you if you don’t take insurance. Just hasn’t been true. All I can tell you is that hasn’t been true. I’ve had no problems. And interestingly, I’ve had a couple of colleagues that are kind of on a similar career path in mind that kind of took my advice to drop their insurance carriers and they’ve all been successful, like I have yet to hear of someone who didn’t succeed at doing that. Now, the people that I’m talking about are really, really high-quality physicians who have demand and they’re doing something really– I mean, every, whatever one isn’t important but like they have a real narrow niche. It would be hard, like if you don’t take insurance, you better provide something that other doctors don’t provide. Either you provide a very specific expertise that other people don’t or you provide a level of service that other people don’t provide.

[00:27:22] And so some like primary care practices that are concierge practices provide a higher level of service, and that’s what they in turn are charging their patients for. Hopefully they’re good doctors also, but like patients can call me on the phone, I’ll call them back. There’s been very little barrier between patients and myself. And I provide, uh, I have a lot of time, like I don’t have to be running on the treadmill all the time so I can call patients before surgery and say, if you have any questions before tomorrow, and call them after surgery, I can visit them in the hospital. I can, I can even send them flowers if I want to, But I don’t do all the time, but occasionally do for one reason or another, someone that’s struggling with some thing, so maybe I’ll do something that’d make them feel a little better. It’s like, so my practice will send them some flowers. Why not? It’s just nice. And it’s, it just starts to become a kind of like, it starts to feel a little bit more like humanity, like a person’s coming to me, not to the machine that is Dr. Fogelson and his practice, is coming to the person, Nick Fogelson, saying, can you help me? And I’m saying, well, let me see. Maybe, let me, let me talk to you about this problem and maybe we can help. I don’t sell my services as being a, that I’m the magic wizard of Oz. Like these people have some, most of my patients have really difficult problems and sometimes they fit into this category. I’m like, oh yeah, I definitely can help with that. Sometimes they’d be in the category I’m like, well, this is an interesting problem. Let me think about it. The next, sometimes I come up with an idea and then sometimes I go, you know what? I don’t think I can help with this.

[00:28:35] I just talked to a patient on the phone that she had a neuro– has this really horrible neuro, neuropathic pain in her legs and I’m pretty sure it was caused by her neurosurgery. And I’m like, yeah, I can’t, I’m not a spinal surgeon, like I can’t help with that, but I did give her a few resources, like, well, I think that this would probably be best handled with an interventional pain management doctor doing a neurostimulator because of what I know about the nerve, I’ve learned a lot about the nervous system in my studies and I think about the pain she called me about and I said, well, I can’t help with this but here’s a path that would probably be the best. Did I charge her for my advice? No, she just called me on the phone and I talked to her, and I’m happy with that. Like, I’m like if I helped her, then great. If I provided some little help, then good. How many doctors take free phone calls from random people that asking for your help without like making a point?

[00:29:29] Dr. JB: The question that I had, you mentioned a lot about time constraints and not being able to have the time to be able to spend with the patients, but also to cover the time that you spent exploring and reading and researching and things like that. So now that you have left the academic medicine and you are now doing private practice, how do you, do you bundle like the fees for all the extra research and studying that you do into the cost of your services, or how do you go about that?

[00:30:01] Dr. Fogelson: Yeah. Yeah. Not like an attorney. It’s not like billable hours. I mean, we just said, it said fees on what we do. I mean, like my office fees are just sort of ordinary office fees. There’s nothing particularly high. My surgical fees are definitely higher than what most insurance companies would pay, but I don’t know. I don’t charge a patient for research in their case or thinking about it. My attorney does that to me. But no, I don’t do that. But I generally think of like any time, and to some extent, any money spent to improve myself as a physician is time and money well spent. Like if I do research to help one patient, it’s going to help another patient. And if I spend $3,000 to get a cadaver once every six months and go do a dissection at the laparoscopy lab, I buy the cadaver.

[00:30:48] Like that’s money well spent. Most people wouldn’t do that. Most people would say, well, I don’t have any more CME money, I don’t want to do that. I’m like, well, actually I can convert my expertise into money at any time. I don’t, I know that because I decided to set my prices, the better of a physician I get, the more demand there will be for my services. And the thing is, is that that does have a certain ethical responsibility to charge reasonable prices. I actually have competitors, colleagues/competitors kind of, in this space who charge three times what I do. And I don’t think they’re any better at what, I don’t think they’re any better than I am. They might not, maybe not even as good. I don’t know. But they just choose to. And it’s like, when you deal with the market of patients who are desperate, you have an ethical responsibility to not. It is reasonable to charge someone a $5,000 for surgery, like that may be, they choose to have a surgery rather than taking a vacation to Hawaii. Like that that is okay. It is not reasonable to make them mortgage their home to have surgery. Like in my, everyone has different opinions about the, like that comes all down to the concepts of capitalism and the concepts of socialism and all kinds of things and justice and so forth. I will say that, like, I really want to help my patients.

[00:32:12] If I have a patient that needs to pay reduced fees, we will often do that or develop a payment plan or reduce things or whatever. And like, in my life, I’ve never sent a patient to collections. I think collections agencies are evil and it’s just not worth it. Like, why would you, why would you let some dog that’s going to send some, like some sort of ravenous dog chasing after someone’s wallet? It’s just, it’s like, move on, help the next. Again, that’s the impersonalization of medicine that would say that. I’m going to think of you as a debt but I’m going to send some machine after you, this machine, that’s going to do horrible things to try to collect $1,200 or whatever the hell it is. So I would never do that. And at the same time, like I had a patient–when you don’t contract with insurance, you can do all kinds of creative things– I have a patient who’s commercial fisher person in Alaska, and she’s doesn’t have any insurance because a lot of times the people that kind of do the work, they don’t have health insurance. She need a surgery, I thought I really could help her, a very high probability I’d be able to help her, and we arranged her surgery at an outpatient surgery center where I have a reduced cash rate or the, the facility fees are not super high. And then my surgery, she paid about half the fees in cash and she paid the other half in fish.

[00:33:30] Yeah. And I’m serious. Like she’s she is an expert in fishing, I am an expert in surgery, like let’s trade our expertise. Like I like fish, you know, and I gave her top dollar for her fish. Like her fish, it is excellent. It was like right out of the ocean in Alaska and frozen on the boat. If I were to get that at Whole Foods, it would have been like $30 a pound, it was like really, really nice fish. And so, I gave her top dollar for her fish and, and she, I have enough fish in my freezer that probably my family will be able to eat delicious fish for a couple years, and I guess depends on how often we eat fish, but the point is like, I feel better about that than I would about the couple thousand dollars or whatever it was, and she feels good about it too, in that like, It’s not even about the money, like it’s the humanity of it. It’s the, it’s the value, it’s like, she feels good about that. And she was shocked when I said, hey, why don’t you pay for half your fees in fish? Like, you have a lot of fish, right? And she’s like, really? I’m like, yeah, because like, I love fish. You’re going to have great fish. It’s going to be great. And I’ll feel good about it. You’ll feel good about it. My wife and family will have– and would I take that money and buy the fish if it were money? No, of course not. I might buy a little bit, but I’m not going to buy like freezer full of fish, but we’ll, it’s just like, I don’t know, it’s the barter system, right?

[00:35:05] So it has a certain value to it. It’s not just financial, it’s also it has this humanity to it that you can’t do in private– you can’t do if you take insurance, like you’re contractually bound that if you charge one insurance company fish, you’re going to have to charge all insurance companies in fish. I’m kind of joking, but you follow. The point is, is that there’s all kinds of legalities, like you’ve got to treat everybody the same. So, yeah, there’s this, it’s this different, like when you decide to free yourself from the bonds of being contracted with all insurance companies that opens up a lot of flexibility and you stop feeling like you’re some slave to the system. Like I felt like when you’re trying to do complicated work and they’re not paying you, they’re sort of saying you can only get paid what we say you can get paid and I’m like, what does that, I mean, it’s almost like indentured servitude of sorts. And I think a lot of physicians, physicians are fundamentally altruistic and I, and I’m very altruistic, but I do feel like the systematic, that the industrialization of medicine kind of predates on that altruism of physicians because anytime a physician complains about the fall– about their work life, about anything, a lot of times it comes down to like, you’re privileged to be a doctor. You should be, you should be very, I don’t know, like every part of the medical system is all about making money.

[00:36:39] And then they, they ask the physicians to be incredibly altruistic and not to care, not to care about the quality of life, not to care about what they’re paid. And it’s bullshit. It’s bullshit. It’s just, it’s kind of abusive. It can be. And the truth of the matter is that physicians are being harmed by this, right? And you think about the mental health of physicians and think about suicide amongst physicians and how, 300 to 400 of physicians die every year due to suicide, I don’t know. And I think that unfortunately, people come to think they hate being a doctor and I’m like, no, I don’t think you do. Like you went to medical school for a reason. Like, I mean, there are some people that were ill-suited for medical school, but mostly people hate– like the system has driven the joy of medicine out of them because it’s just not allowing them to enjoy it. I mean, what I’ve chosen is not for everyone. I mean, I think it would be much more difficult to do what I do if I were a general, GP or something, but not impossible.

[00:37:45] I mean, again, I think that, that you just have to provide something to patients. And it may not be that you know how to fix some rare disease. It’s just that maybe you’re available on the phone or maybe you’re, I don’t know, that’s what concierge practice is. And then, even this sort of predating on the altruism of physicians, they’ll try to give a guilt trip to someone like me, which I don’t even accept, but people would try– or to someone who’s chosen a concierge practice and say, oh my gosh, you’re just taking care of rich people. You’re, you’re just out for yourself, blah, blah, blah, blah, blah. And I’m like, it’s a bunch of nonsense. Like, no, you’re just deciding to value yourself. You’re deciding to say that the system is not valuing me in the way that I value myself and I don’t want to participate in any of that. And you can continue to provide care for people that can’t afford your normal rates when you don’t insure, insurance. So you can do whatever you want. You can work for fish, you can work for chickens, you can work $5, you can do whatever you choose and I mean, it’s almost the opposite when I was in academia.

[00:37:58] Like one of the things that made me quit, I’ll tell you a funny story, is that I had a patient that had the largest fibroid uterus I’ve ever seen. It was like she was full-term triplets with her huge, huge abdomen, this young well middle-aged African-American woman, low socioeconomic situation that’s a daycare attendant at a fancy athletic club. So rich people who went to this club drop off their kids with her and go work out and that was her life. She came into the clinic at Grady, which is the public hospital where I was working and she had this just unbelievable largest fibroid uterus I’ve ever seen in my life. And I’m like, oh my God, like she’s saying, I have pain. I’m like, of course you have pain. You’re walking around with like 30 pounds of tumor in your belly. And I said, please let us do a hysterectomy. We can fix this. And she says, you know what, they’ve been saying that for years, but I can’t afford to take four to six weeks off of work. Like I can’t afford it. I’ll get kicked out of my apartment. Like she lives paycheck to paycheck, and she lives in a shitty tenement or something where the landlord is going to kick her out the instance she doesn’t pay rent. And, and I felt terrible. And at that point I had developed a pretty significant presence on social media through a variety of things that I did, that I always enjoyed, that also the institution didn’t like, which was crazy, but they didn’t like that. And, and I said, oh, this is bullshit. And I asked her a question. I said, how much money would you need for us to do the surgery and you to support yourself while you’re recovering? There’s got to be a number. And she says, I don’t know, like $2,000. I said, okay, get the surgery, I’ll get you $2,000.

[00:40:33] And I went online and I told her story. I took a picture of her in my Emory jacket, which was maybe stupid, and I made a little video. I went online. I broadcast to like the 10,000 people that follow my Facebook profile and I said, would anybody like to give $5 to this woman? Or $10 or whatever. I raised, like, I don’t know, $3,500 in 20 minutes or two hours, or I don’t even, whatever it was, it was less than 24 hours. I got the cash, I put it in her hands. I booked her surgery, gave her the money and I almost got fired. And I was called before the chair. The chair was actually out of town. So, I got called before the vice chair, which was kind of bad because the chair and I were good, much better relationship than I had with the vice chair, I mean, I didn’t have a bad relationship with the vice chair, I didn’t have any relationship with her really. And basically I was forced to bare my throat or get fired. And I was told that I had broken rules about fundraising. I was told that I was breaking insurance laws because I was going to treat one patient differently than I treated another. I was told that all kinds of just horse shit and maybe in the legality of all of it, maybe they were right. But if I had asked, “can I do this?” Of course they would have said no, I mean, what’s the chance they would have said yes? 0% chance, and, I felt like, wait, there’s this woman with this horrible problem and I can fix her problem. I have the power to fix it. And I guarantee I can raise this money. So, I just raised it and I fixed it and we posted her surgery too.

[00:41:58] And I was so pissed off that they were angry about it cause I was so happy about it. I felt like I was, like this was one of the best things I’ve ever done as a physician. I felt great about it. I was like, you know what? I really did something good here. And they were telling me I did something bad. And even to this day, I don’t think the chair realizes what he lost by firing me. I mean, they didn’t fire me, but I, I left. And maybe they don’t even know this, like, this is why I last like, well, it was the straw that broke the camel’s back, I guess you would say. And, but they would have fired me, like if it wasn’t for the fact that I basically laid down with my throat bare and said “I’m sorry,” that they would have fired me. And part of me said like, man, you could have a fantastic story in the news about a physician who did this great thing for a patient, and it could be a wonderful piece of positive press for Emory University, or you could have a story about wrongful termination lawsuit for firing a doctor for raising money for his patient. Like which one would you want? And there was a part of me that said, go fire me. This is going to be awesome. I’m going to sue your university to death, but I just said forget it, I just quit.

[00:43:35] And so, I didn’t quit for about six months, but like, that was, that was the end, and it’s, it was so shortsighted of an institution to have a person who’s willing to creatively do something for a patient, to see that as a threat and see it as like, oh my gosh, this is, this is the, the head that’s sticking up that we need to hammer down, and I was like, and so like, it’s an interesting thing that, like, that’s what organized medicine wants to do. If you’re the doctor with your head up, they just want to put you down here and make sure everyone’s like this, and so not interesting to me anymore. And so, that was probably the, an interesting story in all this.

[00:44:22] Dr. JB: That’s so unfortunate now that that was the response and the patient is fine with this, right? Like it wasn’t like the patient didn’t want her picture taken or had any complaints?

[00:44:34] Dr. Fogelson: No, she was all over the moon that I wanted to help her. She was touched, she was crying. She was happy. If I had made this video without my Emory jacket on, maybe that would have been better. They were pissed that I was sort of like representing myself as a representation of Emory and not just of myself. Maybe I could have made the video without my jacket on. Would that have mattered? Probably not, but I guess, I guess that was the thing that bothered them the most. And it was like, I don’t know, it seems like that’s pretty good thing for your institution to me, but whatever, and so, you can’t fight against it. You either got to become, either got to get on the bus and go where that institution wants to go or like you can’t live your life fighting against it. It’s just brutal. And so if you’re not aligned with what they want to do, then you better just get out because you’re not going to, you’re not going to change it. Like these big institutions are too big. And if you want to wait until you’re the chair and you think you’re going to change it, when you’re the chair, you won’t like it.There’s still going to be a nurse or that you won’t have the power to fix. There was a point in time where I thought, well, eventually I’ll become the chair of this department or something or a department head, and I’ll do it my way. But even that kind of a, that’s a long time to wait to beat that. Also it’s probably naive, like the inertia and the pressure’s on you, still demand things of you that you won’t like.

[00:45:59] Dr. JB: So one last question, do you have any pearls of wisdom for my audience that you would like to leave?

[00:46:11] Dr. Fogelson: Everyone should have a therapist, including residents. I think that every residency program should have a mandatory psychotherapy once a month for all residents, nobody knows– I’ll say this to the residents, you have no idea who you are yet. You spent your entire life being this protodoctor. And now that you are a doctor for the first time, you still have no idea that you are because your entire life has been doctor-hood. And the biggest challenge that people experience, I believe, in medical training is the moment where they go like, well, who the hell am I? And when I’m not a doctor, or once they come out, come out from the difficulties of medical training and actually have a little bit of time to experience their own life, like what do I want to be other than a doctor? And I think that a lot of the unhappiness of residency and training could be better if people had a professional level outlet to figure that out. So that would be a piece of advice.

[00:47:28] The other piece of advice is just, if you love being a doctor, figure out how to be a doctor in the way that you want to do it. Society will value, like society respects and values doctors. You just have to, like if you’re really passionate about it, that will show through. If you wanna just be a doctor as a job and, and have it just not really be a core identity, then that’s fine, then probably you don’t want to do that. And there’s nothing wrong with that. That’s fine. But that you actually can choose to do it differently than other people tell you to do it. And what you have to provide is of value and people will pay you to do it. And if a hundred people tell you that you can’t do it, that’s just because they’re too afraid to try or they’re envious of your even attempt at doing that, and what’s the worst that happens? Like if you decide to try a non-standard practice in medicine, if there’s always a job for you, it’s not like you’re going to go and that you’re jumping off a cliff into spikes. You just find out that, Hey, it didn’t work. You go get a job. So it’s like taking birth control pills for your pelvic pain. Like it might work, it might not, but once you stop taking it, it’s out and you’re back where you started. So like, if you want to try a non-standard way of practicing medicine, if you want to go for Doctors Without Borders, you want to go and do whatever, like your doctorhood is your own. It’s your own superpower and don’t let the system teach you that you’re owned by them, cause you’re not. And the medical system can’t do what you do. They just turn what you do into, they kind of teaching you that you are like a spigot of medicine and they’re going to trade your water for money. But they’re going to handle all the business, like as long as you’re willing to, to get a little bit involved in the business of medicine, which is to me at least kind of fascinating, you can do whatever you want and if it doesn’t work out, you can always get a job. Or if you’re happy with what you’re doing great, but don’t be afraid to change if it if you’re not.

[00:49:15] But if anybody is compelled to contact me to discuss further, feel free. I’m on Facebook, my professional profile is Nicholas Fogelson physician, the other one’s my personal profile, I probably won’t answer you  on that one, but the physician one, I will answer you if you DM me. And my website is nwendometriosis.com, if anybody’s interested. And keep listening to this podcast, it’s cool.

[00:49:45] Dr. JB: Who says a doc can’t rap? D O C T O R J B. The greatest doctor to ever touch the mic. The greatest podcast ever broadcasted or prerecorded. Come learn some. Each one, teach one. I’m done.