Mark H. Goldgeier, MDf 585-442-4767
Karen M. Landt, RN-C, MS,NP
919 Westfall Rd
Bldg A Suite 200
Rochester, NY 14618
A Message from Dr. Goldgeier about Friends of the Practice
I need to tell you why I have taken my practice and dedicated it to a new model of health care ….. and what it means for you and for your family. This is an unrehearsed statement, unpolished, from me to you. I will do away with tight organization, grammatical rigor, and certainly linearity and parsimony. I hope to tell you what I bring to the office and why I must rededicate myself to your care.
I grew up in the “projects” of New York City in a lower income blue-collar family. A chubby kid with absent athletic ability, diplopia, and some hints of future eccentricity, I was really only good at one thing. I was smart. I could out think, out learn, and out test pretty much anyone around me. While other children were interested in normal kid stuff, I wondered about encyclopedias, religion, global politics, science, and medicine. I dreaded gym class, bowling alleys, and softball. I still get palpitations when I go to my grandkids’ baseball practice.
I adored my grandparents. As a preteen I would compete with my grandfather in mathematical games. I would try to beat him at calculations ….. he with a “slide rule” and me with my head. My grandmothers were generous beyond belief. One of them was dirt poor. She would literally collect rubber bands and tin foil from the streets of New York and fashion them into homemade toys for me. The other grandmother developed Parkinson’s disease after the worldwide Influenza pandemic of 1918. Recognizing my Gd given gifts for intelligence, critical thought, and caring (yes, I am talking about an eight year old) they would say ….. “Mark, become a doctor and find a cure for Grandma”. I watched my grandfather devotedly care for my grandmother through her years of relentless decline to her ultimate demise from advanced Parkinson’s. In my very late teens and early twenties I assisted my own father in caring for my grandfather through his repeated strokes. I learned about the intersection of intellect, discipline, knowledge, and compassion.
At sixteen I entered college with emphasis on physics, mathematics, and biology. As my fellow students did “college” stuff ….. I really had nowhere to go but the library. I was young, socially inept, in hoc up to my eyeballs, and athletically challenged. When they would invite me to go out for a 35 cent slice of pizza and a coke ….. I literally could not afford to. I hid in the “stacks” studying, learning, wondering, analyzing, compiling. I graduated at twenty summa cum laude with multiple degrees. I wanted to be a world famous mathematician but I was not good enough at advanced algebra to meet my own standards for success. Pretty much as a lark, I applied to five medical schools. I was accepted at six! I chose the most difficult, most rigorously scientific, best regarded school ….. Cornell University Medical College. Wow, I studied night and day. The brightest faculty and students anywhere surrounded me. They filled my head with a thirst for knowledge and experience that was insatiable. I learned how to learn. I dedicated myself to a lifetime of exacting self-improvement for the care of patients. I did everything. I was everywhere. From diabetic comas, to gunshot wounds, to every emergency procedure known to man ….. I was a member of the team that could do it all.
With great clarity, I remember so many moments from medical school. I remember the first time I put a white coat on and walked from New York Hospital across the street to Memorial Sloan Kettering. Strangers (New Yorkers nonetheless) made eye contact with me (I had long curly hair and even longer sideburns) and smiled at "the doctor". I remember the first time I walked the hallways of Memorial Sloan Kettering Hospital. I felt I was impersonating a doctor because I could not do the things that “attending doctors” could do. I would work long, long days and nights ….. oftentimes around the clock ….. to acquire knowledge, experience, skill, polish. I became friends and colleagues with the giants of medicine. I took care of people. I loved my patients. I ignored the advice to stay remote …. I took it very, very personally when they suffered. I could “feel” their illnesses. I developed an empathic and intellectual link with patients. Despite this connection, I wore the white coats and the masks of academic discipline. My instincts have very rarely failed me. I won virtually every prize for academic and clinical excellence, leadership, compassion, and honor there was.
When it came time for residency training, I chose Yale. Wow, I loved every second of being at the world’s best Internal Medicine and Dermatology training programs. I hated every second of my internship. My first born was less than one week old when I began my internship. I cried every morning that I left her ….. I left the house at 0600 and knew I would not return home until the next evening at about 1900….. that's thirty seven hours of straight on your feet, intense physical, mental, and emotional work. The hours were brutal (literally 115 hours every week). The working conditions horrible. The toll on your emotions, on your body, on your friends, on your family absolutely dreadful.
But the payoff was becoming an elite physician. A healer. I could take care of anyone and any set of conditions with incredible focus, constant attention, star wars science, and transcendent thought. I was part of a team of likeminded individuals ….. the world’s best doctors, nurses, unit staff, transport staff, technicians ….. it was incredible.
My recollection of the training process was as follows. With a solid foundation in science, anatomy, physiology, pharmacology, etc …… the medical student is introduced first to single system disease and then to multiple system disease. Upon moving on to residency training, the intern learns to take care of the most severe illnesses and the most complex presentations. Within one year of residency, you are an experienced resident doctor. In two years you are oftentimes the most senior physician in an entire hospital ….. with responsibility for hundreds of patients and a score of residents, interns, and students. Is it any wonder that, in order to fulfill these roles one needs a strong sense of self worth, an ability to perform under the most adverse conditions, and (yes, the "a" word) an arrogance that permits you to bring your relatively juvenile skills to the most strenuous of life situations. On any given thirteen to thirty seven hour shift you made countless life and death decisions.
My longest shift was sixty two hours straight in the blizzard of '77. I was one of very few doctors in the hospital and it was either I took care of scores of critically ill patients or they died. No one died on my watch. Indeed, everyone was extremely well taken care of.
With further study, the resident becomes a chief resident and experiences the application of all of his training, experience, G-d given abilities, and human dedication to solve the riddles of human afflictions. It is a feeling of power and ability that, if not for the continual exhaustion and short shrifting of one's outside life, would be positively intoxicating.
I was given the great privilege of doing everything in my power to heal people. There were no limits on the resources at my disposal. There was no limit to how far I would push my body and my mind in the service of others. No one, not the hospital administrator, nor the insurance company would or could interfere with my best judgment and my recommendations. This is not to imply that I was unsupervised.
Tested senior physicians, peers, wise nurses, and a host of other colleagues were quite aware of which of us was deserving of the trust and which not so much.
I can honestly say this was the golden age of medicine. Wonderful, integrated teams of professionals cared for families. It was truly patient centered, respectful, responsive, multidimensional treatment. We formed a strong bond with our patients and their families ….and they were grateful. I loved being an Internist. I showed great promise.
And then I met dermatologists. They were the smartest, most intellectually gifted, the most humorous, the happiest, the most clinically adept people I had ever known. The dermatology residency was the most coveted position in residency training. I changed track from Internal Medicine to Dermatology….. but not until after completing three rigorous years of training in Internal Medicine and ultimately becoming a board certified Internist. I worked three long years with my fellow residents in Internal Medicine in order to be fair to them (had I left prematurely, they would have had to “take up the slack”) and to broaden my experience. And then I started all over again. Most medical doctors had under two hours of formal training in Dermatology over the course of their entire seven years of medical training. I was back in medical kindergarten except this time, the giants in the field were even larger. I chose the absolute best Dermatology residency program in the world …… Yale!
The Dermatology residency was magical. Although a profound neophyte, I found I had an ability to “read the skin” that very few others in the world had. I was mentored by the best of the best. One world famous doctor scientist after another became my friends. I wanted to be like them. They saw great promise in me. I felt I could be a great Dermatologist if I brought my Internal Medicine work ethic to my Dermatology skills. I was close to standing shoulder to shoulder with the best in the field. I honed my observational skills, my critical thinking, and my technical surgical abilities to a very sharp edge. After another three years of training (three years for Medicine, three years for Dermatology), I looked for somewhere to be of greatest use ….. in teaching, in practice, in research, in raising a new family.
Enough of my story for now. I must get down to work and attend to my practice. I promise to continue each week to address the why, how, when, and what FOTP (Friends of the Practice) means to you . What I can tell you is that for many of you FOTP will be less expensive. For each of you, this will mean great care unfettered by your insurance company, your ACO, your PBM, your ABC …. I will bring the full resources of my experience and of this office to you. You will be better for being a friend of the practice. More to come…………..
I was in the elevator at Yale New Haven Hospital going up to the fifth floor in order to participate in Grand Rounds. "Grand Rounds" was an exercise in excoriation where one resident stood before the grand assemblage of the most knowledgeable, clear thinking, and respected doctors in the world ….. and presented a description of a patient, the differential diagnosis, the most likely diagnosis, the proper work up of the patient, and the likely treatment and outcome. At any rate, a resident one-year senior to me urged me to aim for a career in research and teaching. I decided then that I would be a physician, a scientist, and an educator!
Having only one board certification under my belt (Internal Medicine) I was the junior of our residency group ….the other two had advanced certifications in Internal Medicine and Rheumatology, and in Pediatrics, Endocrinology, and Genetics. All told we possessed SIX board certifications before we even started our Dermatology residency. We were undoubtedly the most self confident, mature, iconoclastic, skilled, fresh three-some that Yale Dermatology had ever encountered. That was a heady time in my life. There was no competition among us …. only camaraderie, hard work, and relentless dedication to molding ourselves into compassionate ivy league trained physicians. We accomplished amazing things for our patients, for our students, and for our institution and specialty. There was a saying that went around Yale at the time among the medical residents. It went, if the intern can’t figure it out, ask the Medicine Resident, if the Medicine Resident can't figure it out, ask the Medicine Chief Resident, then the Medicine Attending …. and if no one can figure it out, ask the Dermatology Resident! We were at the vanguard of Dermatology practice, research, and education. Each of us became Chief Residents in Dermatology at Yale. Wow!!
Confidence and ADD have served me well in my career and in your service. I am eccentric, socially challenged, blunt, and …. unbelievably well trained, knowledgeable, confident, and dedicated to you. I am quite certain that I can diagnose things that few others can. I possess an intuition …. probably based on very subtle clues from you …. that I trust implicitly. I can literally “feel” illness. I have a discipline about physical examination, morphology, analysis, integration that has been drummed into me by the best of the best of the best. I believe that the difference between a good doctor and a great doctor is …. your health. I am continually tweaking my skill set. My diagnoses are crisp, my surgeries elegant, and my cosmetic procedures spot on. My confidence has been formed over four decades of dedication to my specialty and to you. I strive to be a “complete physician”. I pride myself on others calling me the “doctor’s doctor”. I am proud of my membership in the American College of Physicians. I am proud to be a Dermatologist and Dermatologic Surgeon.
Several years ago a young student at a nearby University visited me. He had a "mole" taken off from his skin by his local medical doctor. He said the doctor felt it was "nothing" and "to save money for his insurance company" he proceeded to "toss the specimen into the medical waste garbage". Our new patient was nineteen, handsome …. with an equally young and handsome girlfriend at his side. I examined him quite thoroughly and found a large lymph node in his armpit .... precisely where a "mole" would have traveled had it been, in fact, a melanoma. In my mind’s eye, I could see this young man's tumor under the skin, I could see the microscopy and the histology report, I could see the too familiar fate that awaited him. The nausea overcame me. I "hung crepe"…. explaining that this might be a metastasis and if that were the case, we would have some serious treatments ahead.
When the pathology report returned it read metastatic malignant melanoma. I called the young man up and asked him to bring his parents at the end of the day. We sat, the man, his girlfriend, his parents …. as I delivered the facts as clearly, honestly, humanely as I could. I gave them both reality and hope. I wanted to succumb to the horrible terror along with them. I wanted to leave the room and have this young man's fate not come to fruition. I wanted to be alone, apart, removed from the rawness of his disease. I wanted to protect my own emotional self. Instead, I was a strong, trustworthy, kind, and always available physician to them. They put their faith in me and in the team of experts that I assembled….the best doctors I could find in the region. With great speed we did everything humanly possible for this young man, his girlfriend, and his family. For a very short while, he was a happy college student in Rochester.
A few months later he returned for his regular check up. Although he hadn’t noticed them, he was riddled with BB sized tumors all over his body. I could not hide my horror. I took a biopsy through the skin, and there it was … a sickening blue black metastatic nodule. This was the pigment that would sign his death warrant. A month or so later I was attending our annual convention in Washington DC. While on the frenetic convention floor I felt a terrible wave of dread come over me. I knew this young man had died. In my mind I saw him on his death bed at his home, with his girlfriend and parents at his side. I called my office ….. they asked how the family had called me so quickly since they just got off the phone with them. They called to say their son had passed.
The greatest certification test in a doctor's career is the dreaded "Board Examination". I had to fly to Chicago and take a sixteen-hour multifaceted test in order to become Board Certified and a Fellow of the American Academy of Dermatology. “Board” examinations were "proctored" by the world's most famous doctors. During the course of these sixteen hours, I got to be escorted to the men's room by virtually every luminary in the field of Dermatology. Some of them still chuckle when they see me!
And yet, I find myself now lacking the robes, the power, the influence of a Physician …. I have become a health care “provider” ….. a “performer” ….. and, worst of all, “leakage!” Somehow, over three decades, there has been a transfer of influence from the patient and the doctor to the insurance company, the political system, the affordable care organizations, the pharmacy benefits managers …… my role, and the role of every single other physician in this region, has changed. The physicians providing your care are no longer able to be the powerful advocates for your care. We can no longer assemble the finest colleagues for your care. Instead we are bound by hospital affiliations, ACO's, insurance companies, etc.. Physicians providing care no longer influence, much less decide, sound medical policies that hospitals, insurance companies, and politicians consider. We are no longer directing much of your care. We click on our computers, follow the rules, do our best within the system. The system is not your friend. The system worships control, big data, uniformity, mediocrity, sweeping rules and regulations. Where no good data exists, the system must act … and often without logic. Dreadful things happen when the doctor, the patient, and the family lose their voices. Allow me to tell some more stories that frustrate me, anger me, and break my heart. They explain why Friends of the Practice has come into existence.
Two children were referred by their pediatrician to see me for their atypical moles. Their pediatrician and their parents entrusted me with their care. They called me Dr. Grandpa! At each visit I asked to see their mother and their father because atypical moles are familial…. and they carry the very real risk of malignant melanoma. Each year, mom would tell me that although she and her husband felt a visit was needed, although her doctor felt it was recommended, the HMO would not "allow" a referral. One day, years later ….. she presented to the office; her hairdresser had found a bloody, non healing spot on her scalp. I was so relieved to finally see her in the office. This turned to terror when I realized she had a huge mass on the left side of her neck. A rock hard lymph node. So large, in fact, that she had trouble turning her head fully to the left.
When I examined her I found abundant evidence for the dysplastic nevus syndrome (familial atypical mole syndrome) with its attendant risk of melanoma. Checking her scalp, I became nauseated and slightly tremulous. There was a huge, advanced melanoma eating away at her scalp. It had already widely metastasized. I knew this in an instant, in a glance borne of decades of experience. I knew this because the insurance company finally issued a “referral”. The young mother and business executive lost weight. She developed metastatic tumors. We did everything we could for her. She died. Her family was filled with sorrow. I was shaken. For many, many days and nights I struggled with my anger and my frustration at the lack of an opportunity to save this woman's life. The reason for my failure was not a lack of education, resources, or treatments. This woman died because she could not get a referral. I said to myself that I did everything I could. The family said they had lost a wonderful wife and mother. The insurance company said “no referral.” Did they hold any liability? No.
I doubled up on examining the rest of the family. I assured them this would not happen to them as long as I continued to see them (not entirely true, but essential to mitigate their nightmares and their fear). I promised them there was nothing they could get that I could not cure (almost true). I was always available to them, always counseling them, always confident in their care. I made certain that they and we did everything we could to minimize their very real risk of melanoma. We have been successful.
A few years after the young mother's death, her daughter told me she loves to run as fast as she can. It was one of the first times I had seen her light hearted and free of sadness. I asked her why she loves to run as fast as she can. She said "because when I run fast I don't think of mommy". Sometimes I believe I run this fast for the same reason.
Despite my many attempts to hold the insurance companies accountable for their actions there was nothing to be done. Despite my efforts to wrest control back from the bureaucracy, I was impotent. The situation is far worse now. The system is not working for you. The diversion of resources away from your care has passed a critical point. The health care system itself dangles on life support.
The concept of an HMO was ill reputed prior to 1973. Before the government embraced the HMO, it outlawed it …. as a clear danger to patients’ well being. The HMO was a negative reimbursement kickback scheme …the less care delivered, the greater the profits
for these “non profits” …. you know, the ones with naming rights and promotions all over town. At first, the HMO struggled to survive …. on newly minted resident manpower and with the backing of the giant insurers. They concocted the five dollar copay, referrals, prior authorizations, tiered prescription coverage, step therapy, mandatory waits for mri’s and ct scans. They "branded" themselves, bought naming rights, signs, advertisements, and doctors. More insidiously, they virtually eliminated working physicians from input into policies and restrictions that directly affect your care. They have buried physicians under a deluge of “requirements”, rules, “steps”, and "thou shalt nots" …that distract the doctor, reduce the range of care the doctor can bring to your family, and lead to physician burnout. What I seek is a healthy physician …. a complete physician, an elite physician …. one who has the determination, the resources, the emotional energy, the freedom to take the very best care of me.
I am preparing the final portion of this blog. I will answer your questions as clearly as I can. I envision a welcoming office, a respectful and open doctor visit, and results. I am so pleased to have the opportunity to greatly improve your care.
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Karen Landt and Dr. Goldgeier together have over 60 years of experience as caring medical professionals. Our colleagues are some of the most highly trained medical assistants in health care today. We feature comfortable, state of the art facilities and easy access, no matter where you live or work. We have a reputation for skillful diagnosis, artful facilities, and exceptional patient satisfaction. We have a holistic approach to health care. We integrate your dermatologic care with other disciplines, and customize your care for you. Some of the most prominent doctors in Rochester refer their patients and their families to us.
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