Despite an increasingly hostile practice environment, physicians can still find enjoyment and satisfaction in medicine. Meet six doctors who reveal what keeps them motivated and moving forward. Then, try a few tips to salve your soul.

Frustrated with penny-pinching payers, administrative demands and long hours, physician morale is currently at an all-time low. Seventy-five percent of California doctors have become less satisfied with medical practice in the past five years, according to a recent California Medical Association survey. Low reimbursement, managed care hassles and government regulation were cited as the greatest sources of dissatisfaction.

"Most of the physicians I talk to are burned out and overwhelmed," says Christina Puchalski, MD, director of the George Washington Institute of Spirituality and Health, Washington, D.C. "There is a real sense that doctors no longer have autonomy, preventing them from practicing like they used to and want to.

"When they were medical students, they were very idealistic. They wanted to serve, to make a difference and to help people. Now, physicians don't have enough time to spend with their patients to establish rapport and trust. They are running from one exam room to the next, trying to get things done and hoping that they didn't miss anything or make a mistake. I often hear physicians say, 'This is not why I became a doctor' and 'I am not being honest to my calling.'"

Still, in the face of these difficulties, there are doctors choosing to remain optimistic and inspired. Instead of getting angry or demoralized, they are taking action to focus on the heart of medicine: helping people. Southern California Physician spoke with six physicians who share their personal motivations.

Ralph Di Libero, MD
President of the Los Angeles County Medical Association
Orthopedic surgeon for more than 25 years, Los Angeles
Heart of Medicine: Conducting International Advocacy

Ralph Di Libero, MD, a Los Angeles orthopedic surgeon and the president of the Los Angeles County Medical Association, finds inspiration in leading the association's collaborative efforts with medical societies abroad. In November, Dr. Di Libero, accompanied by LACMA Treasurer Robert Bitonte, MD, JD, visited the Hiroshima Prefectural Medical Association in Japan to commemorate the 30th anniversary of the relationship between the associations.

"The purpose of the visit was to honor our longstanding relationship with the Hiroshima Prefectural Medical Association," Dr. Di Libero says, "but also to show continued support for a radiation study that the organizations have been collaborating on for the past 30 years."

In 1977, the Hiroshima Prefectural Medical Association and LACMA launched the biennial Radiation Effects Research Project, which performs screenings and medical examinations on first- and second-generation atomic bomb survivors living in Southern California. Every other year, the project is carried out in Los Angeles by a dozen physicians from Japan, under the supervision of LACMA doctors.

More than 60 years after atomic bombs scorched the Japanese cities of Hiroshima and Nagasaki, the scars of health problems and traumatic injuries to those exposed remain, Dr. Di Libero says. It's estimated that more than 300 survivors of the attacks live in the Los Angeles area.

In the 2001 study, the sister organizations found that area survivors are an average age of 69.5 years. The number of female examinees was twice that of male patients. The exam included an interview, a clinical and physical examination, an EKG, and blood, urine and stool tests. The results showed that hypertension was the most frequently diagnosed condition, found in 39.3 percent of patients.

More recently, local physicians helped Japanese doctors collect data on thyroid diseases in atomic bomb survivors for their Journal of the American Medical Association article published in March 2006.

At a special ceremony during his Hiroshima visit, Dr. Di Libero presented letters of commendation from the California State Senate, the Los Angeles County Board of Supervisors and the Los Angeles City Council to Shizuteru Usui, MD, president of the Hiroshima Prefectural Medical Association. Later, Dr. Di Libero had an opportunity to meet Tadatoshi Akiba, the mayor of Hiroshima.

Dr. Di Libero also attended the society's general assembly where he exchanged ideas with more than 200 Japanese physicians. For two days, he lectured on historical trends and future forecasts in the American healthcare delivery system.

"The work of the Hiroshima Prefectural Medical Association, an organization dedicated to documenting health hazards of nuclear weapons, has mobilized and influenced medical specialists throughout the world to join together in seeing to it that no one should ever suffer like those in Hiroshima," Dr. Di Libero says. "We physicians must continue to work toward the abolishment of nuclear weapons and disarmament. Our combined medical and political efforts will produce a better and more peaceful world where absolutely no role for nuclear weapons can exist."

Ken Bell, MD
Chief Medical Officer of CalOptima
Obstetrician/Gynecologist for more than 40 years, Orange
Heart of Medicine: Delivering Babies

Ken Bell, MD, an Orange obstetrician and gynecologist, grew up in the Bronx, the son of a Russian immigrant who became a dentist. His father's professional example made an impression on the boy.

"I wanted to be a physician since the time I was born," says Dr. Bell, chief medical officer of CalOptima, Orange County's Medi-Cal managed care program. "I ended up doing the most gratifying thing that anybody can do: I became an obstetrician."

Dr. Bell received his medical training at the University at Buffalo in Buffalo, N.Y. He completed his internship in internal medicine and his residency in obstetrics and gynecology at King's County Hospital in New York. Nearly 10 years later, Dr. Bell was recruited by Kaiser Permanente Bellflower Medical Center to work as a staff obstetrician in sunny California.

"Delivering babies was such a thrill for me," Dr. Bell says. "When you deliver a baby and hand him to the mother that first time, it is such an incredible opportunity. The mother cries and it is the happiest moment of her life."

Dr. Bell eventually rose to the position of medical director of Kaiser Permanente Orange County Medical Center, where he worked for 14 years. However, when Dr. Bell became a full-time senior administrator, he continued to take call, because he didn't want to give up those happy moments. He has delivered more than 4,000 babies in his medical career.

Now an administrator at CalOptima, Dr. Bell advocates for Medi-Cal patients to ensure they have access to quality care. He no longer delivers babies. When asked, "When was the last time you delivered a baby?" he replies, "Five years, five months and 22 days ago to be exact, and I miss it tremendously."

Nirmala Murthy, MD
Vice President of Krishna and Nirmala Murthy, MD, Inc.
Pediatrician for more than 20 years, Apple Valley
Heart of Medicine: Healing Children, Finding Personal Peace

When Nirmala Murthy, MD, was growing up in Chennai, India, her fifth grade teacher asked the children the age-old question: "What do you want to be when you grow up?" While other kids were shouting things like "pilot" and "teacher," Dr. Murthy declared that she wanted to be a physician.

"That was the first time I realized that being a doctor was what I was supposed to do," Dr. Murthy says. "I don't know why I said that, because we didn't have anyone in our family who was a physician. My father was a civil engineer and my mother was a housewife."

Dr. Murthy completed her medical training and internship at the University of Madras in Chennai and performed her residency at Lincoln Medical Center in New York. During her pediatric rotation in medical school, she fell in love with kids.

"Children are so helpless when they are sick," Dr. Murthy says. "Often, they are not able to even say what is bothering them. When you see that, you can't help but want to take care of them and make them better. To make them feel comfortable is such a great feeling of fulfillment."

Today, Dr. Murthy is taking care of hundreds of children, as vice president of a small pediatric practice in Apple Valley. Her husband, Krishna Murthy, MD, a pediatric psychiatrist, serves as president. He works at Arrowhead Regional Medical Center in Colton and at health clinics in San Bernardino County.

To stay balanced and healthy, Dr. Murthy practices meditation and yoga exercises twice a day. She spends an hour and a half on her spiritual practice in the morning and 30 minutes in the evening. She says the discipline helps her meet medicine's daily challenges.

"My meditation and breathing help me see life from a different perspective, beyond all of the difficulties of maintaining a medical practice," Dr. Murthy says. "I don't worry or get stressed out about what payers or patients will pay. I do what I need to do: I write the Legislature and I write letters to the payers. Then, I leave it alone."

Her personal philosophy is built around loving life, she says. "The more complaining you do, the more down you get and the less you enjoy your job. I want to enjoy my job and love my life."

Robert Lum, MD
President and Owner of Renewed Hope Radiation Oncology
Radiation oncologist for nearly 20 years, Oxnard
Heart of Medicine: Practicing His Faith, Being Politically Active

Robert Lum, MD, an Oxnard radiation oncologist, went into medicine at the strict urging of his father.

"When I was growing up, my father said to my siblings and me, 'You're either going to be a doctor or you're going to be a bum,'" Dr. Lum says. "Then one of my brothers replied that he was going to be a race car driver. In response, my father kiddingly said, 'Then I guess you are going to be a bum.'"

Unfortunately, when Dr. Lum was 14 years old, his father died of cancer at the age of 52.

"In retrospect, I think [my father's death] had some influence on my decision to pursue oncology," Dr. Lum says. "I wanted a specialty where I could really make a difference. Oncology is a specialty where people are at a time of great need and great crisis."

After a long stint at Ventura County Radiation Oncology Medical Group Inc., he opened a medical practice called Renewed Hope Radiation Oncology in Oxnard, where he has served as president and owner for the past six years.

"I chose that name because I wanted my practice to be a place where cancer patients, who did not have hope, could find some," Dr. Lum says. "I also happen to be a Christian, and the name was a way of incorporating my faith into my practice.

"Patients have a lot of fear at hearing the word cancer. And being able to put those fears to rest is something I value," Dr. Lum adds. "Also, it is a field where I have been able to see quite a few miracles. Patients who should not be cured are cured."

Like many physicians, Dr. Lum is bothered by the difficult healthcare environment. His response: get politically involved, put patients first and work for change. As president of the Ventura County Medical Association, Dr. Lum calls himself an optimist.

"I can see why physicians are getting frustrated and refusing to treat patients for free," Dr. Lum says. "Our profession is at a crossroads. But I still feel empowered. Healthcare in the United States does not work without physicians. We are still in control of our own destiny, and as long as we understand that, we can take the steps necessary to protect our profession and our patients."

Virginia Garrett, MD
Medical Director of Rehabilitation, HealthBridge Children's Hospital
Physical medicine and rehabilitation specialist for more than 20 years, Riverside
Heart of Medicine: "Fixing" People, Doing Cosmetic Procedures

At 18 years old, Virginia  Garrett, MD, was living in Santa Ana attending a local junior college. But she wanted more out of life. Her mother was a nurse, and she wanted to do something in healthcare, too.

Today, Dr. Garrett has a physical medicine and rehabilitation practice in Riverside and Orange. She is medical director of rehabilitation at HealthBridge Children's Hospital in Orange. She also serves on the trauma team at Riverside Community Hospital. Her special interests include brain injury, trauma, spinal cord injury, and scar and wound care.

Her philosophy of care addresses the whole patient as well as the parents and family, delivering a total therapeutic treatment plan. "I really like fixing people's wounds and injuries," Dr. Garrett says. "It is amazing after we fix people and they come in all dressed up and say, 'Hey, I want you to see how I turned out.' It is great to give people their lives back."

Since Dr. Garrett treats many trauma patients, she doesn't get paid for every patient she sees. So instead of complaining, she took matters into her own hands. In the late 1990s, she sought training to perform cosmetic procedures.

"In 2003, I expanded my rehabilitation services to include cosmetic procedures, which patients pay for by cash or credit card," she says. "That helps me see my trauma patients for free. I know I will never get paid for those patients. Payers reimburse podiatrists, orthopedic surgeons and trauma surgeons, but we are the last ones on the list."

Dr. Garrett's aesthetic medicine practice is 20 percent of her business. She offers Botox, chemical peels, tissue filler injections, photo rejuvenation and nonsurgical facelifts.

James Roach, MD
Former Chief of Staff at El Centro Regional Medical Center
Urologist for more than 35 years, El Centro
Heart of Medicine: Helping People

Although he lived in Southern California, James Roach, MD, spent a large part of his childhood visiting extended family in Burlington, Iowa. In particular, he spent a lot of time with his grandmother, a kind woman plagued by foot ailments.

"I used to take a pumice stone and rub it on my grandmother's feet to get rid of her corns and bunions," Dr. Roach says. "It made her feel so good, and I never felt so good as I did when I was helping her. It was a brief glimpse of my interest in helping people."

For years, that desire lead him along a path toward priesthood. Dr. Roach completed his bachelor's and master's degrees in philosophy from Gonzaga University in Seattle and studied theology at Woodstock College in Woodstock, Md.

While in the seminary, Dr. Roach volunteered in a hospital and decided that medicine was his passion, not the priesthood. So two months before he was to be ordained as a Catholic priest, he changed his course.

At the age of 32, Dr. Roach entered Marquette University Medical School in Milwaukee, after which he completed his internship at UCLA Medical Center and his residency at the University of Iowa.

Dr. Roach recalls why he chose the field of urology. "One of my first jobs as a medical student was transplanting kidneys in dogs all summer," Dr. Roach says. "My role was to decide what solution, pressure and temperature was needed to best perfuse the dog's kidney. I would take a kidney out of the dog, put it on a pump with different solutions, put it back in the dog, and then watch his kidney function. I fell in love with renal physiology and with kidney work."

As a physician in his 70s, Dr. Roach is incredibly aware of the drastic changes in medicine. However, he prefers to focus on taking care of his patients and refers business-related matters to his staff. "Even though I know the reimbursement for my patients is going down, I really haven't been worried about it," he says.

Still, he has had to step up the pace to compensate. Dr. Roach must see at least 30 patients a day to keep his rural practice going. "I consider it a privilege to talk to 30 different people every day," he says. "I think helping people is the most rewarding thing in the world. I don't know what I'd do if I retired."

FEATURE ARTICLE SIDEBARS

INSPIRING WORDS: DON'T FORGET THE FIGHT IS WORTH IT

By William G. Plested, III, MD, president of the American Medical Association

I am pleased to have this opportunity to write about the reasons why it is important for physicians not to become disenchanted with the practice of medicine. Unfortunately, there is widespread demoralization among today's physicians, which is leading far too many of us to consider giving up--our specialties, our practices or even participation in clinical medicine.

In the heat of battle, particularly when the going gets rough, it can sometimes seem best to abandon the fight and pursue something else. But the most important thing to do at those times is stop and review the reasons why we are fighting, and determine whether what we are fighting for really deserves the effort. My answers to these questions guide my thinking on this critical subject.

Why we are fighting is to preserve the profession of medicine and to return control of our profession to physicians. It is my firm belief that most, if not all, of the problems we see destroying the practice of medicine are caused by outside parties usurping the professional prerogatives of physicians. We have Legislatures mandating topics to be included in the curricula of our teaching institutions. Insurers, trial lawyers and others are setting standards of practice. Courts are trying to set principles of medical ethics. And everyone else is determining the value of our services. Clearly, all are daunting and depressing problems. However, none are beyond our ability to correct--if we truly believe that the fight is worth our effort.

Here is where I must make my case as powerfully as I possibly can. I would encourage anyone who questions whether the fight for our profession is worth the effort to think back to the years when we were striving to become physicians. We were committed to becoming physicians for all of the right reasons and these reasons have not changed. Physicians are truly blessed to be able to ease suffering and to prolong life. If protecting this ability means we must endure temporary hardships, then so be it.

Our legacy to future generations must be our commitment to returning the practice of medicine to the physicians of America.


SUPPORT GROUPS: CONNECT WITH OTHER DOCTORS TO SALVE YOUR SOUL

Demoralized physicians nationwide are discovering Finding Meaning in Medicine, support groups for doctors who want to regain professional satisfaction. FMM facilitates physicians listening to one another, rediscovering the joy of their work and receiving healing through genuine community.

Under the direction of Rachel Naomi Remen, MD, FMM was established in 2000 by the Institute for the Study of Health and Illness at Commonweal in Bolinas, Calif., an education and training center for physicians who wish to renew their commitment to service.

FMM support groups of between 6 and 12 physicians meet in a living room one evening a month for two to three hours. The group selects a topic central to the work of physicians, such as compassion, listening, mistakes, forgiveness, grieving and healing. Each physician shares a story from his or her personal or professional life.

If you're interested in joining an FMM group, register at www.meaninginmedicine.org or call 415/868-2642. There are currently groups in Pasadena and San Diego. Pasadena Contact: Marsha Pagenkopp, PhD, 714/539-4164. (This group includes physicians from Los Angeles and Orange Counties.) San Diego Contact: Betty Joan Maly, MD, 858/450-1122.

If you want to create your own FMM group, registered physicians can access a free FMM Resource Guide with information on forming a group. Online FMM groups and discussions are also available.


PRACTICAL ADVICE: 15 WAYS TO BOOST YOUR MORALE ABOUT MEDICINE

Christina Puchalski, MD, director of the George Washington Institute for Spirituality and Health in Washington, D.C., offers physicians 15 ways to reduce stress levels and restore motivation in medicine. The institute develops educational and clinical programs for physicians on the role of spirituality and health in medicine.

1. Forget about the bad healthcare system and leave your frustrations at the door.

2. Before you start work, remember why you became a doctor.

3. Do the best job you can and be attentive to each patient.

4. Make your practice schedule as manageable as possible.

5. Balance the intensity of patient care throughout the day. For example, follow hour-long exams with quick, routine visits.

6. Stay in tune with yourself and your needs during the day.

7. Adopt a spiritual practice and perform it twice a day. Try meditation, prayer or yoga.

8. Eat a healthy diet and exercise regularly.

9. Join a local support group of physicians.

10. Be a political activist and write your local and state legislators.

11. Don't hesitate to cry when you need to.

12. Spend time with your family, friends and pets.

13. Take a bubble bath.

14. Get a massage.

15. Feel free to laugh.