Guest Post by my brother, Richard R. Schulze, Jr., M. Phil. (Oxon), M.D.

My Family’s Journey Through Medicine: Four Generations Across Three Centuries

Paper delivered to The Cosmos Club, a men’s social and intellectual club in Savannah, Georgia, founded in 1916.

Paper delivered March 27, 2014

My father had a fascinating career.  He was born in Charlottesville, Virginia and attended prep school at St. Andrews in Middletown, Delaware, claiming to have the lowest grades in the history of school.  But a biology teacher at St. Andrews saw something special in my dad, and with his encouragement, my father became a brilliant student.  Dad graduated cum laude with a degree in biology from Princeton in 1957 prior to attending medical school at Johns Hopkins.

After graduation, dad decided to pursue a career in ophthalmology, and was was fortunate enough to be one of only four residents at the Wilmer Institute chosen from over 200 applicants.  The Wilmer Eye Institute at Johns Hopkins was—and still is–the premier training program for ophthalmology in the world, and this provided the springboard for a fabulous career.

My Father, Dr. Richard Schulze Sr.

After residency, he decided to pursue fellowship training, which was rare for the time.  So when I was only three years old, we moved to London in 1965 while my father worked for a year at Moorfields Eye Hospital, the oldest eye hospital in the world (founded in 1805), and the only institution in the world to rival the Wilmer Institute at Johns Hopkins for academic prestige.

When he finished his fellowship in ocular pathology, my father’s training and expertise were truly world-class, lending him the luxury of choosing any place in the world to practice.  But he knew he wanted to be in the South, and he knew he wanted to be close to the water, so for all intents and purposes, that left Charleston and Savannah.  He chose Savannah because he felt that, as an outsider, Savannah had a reputation for being more welcoming to newcomers and as such, was less of a closed society compared to Charleston.

Practically on the day my father finished his residency at Hopkins, President Lyndon Baines Johnson signed into law the Mills Bill, HR 6675, popularly known as Medicare.  It was 1965, and the critics saw Medicare as the beginning of socialized medicine.  Yet Medicare filled a glaring need for care for the elderly, ultimately becoming one of the most popular of all government programs.

In spite of dire predictions about Medicare wrecking the private practice of medicine, it is largely because of Medicare that my father became a wealthy man.  But it wasn’t just luck that drove my father’s career.  In his era, where you trained truly made a huge difference, given that there was no internet to facilitate the rapid sharing of ideas and techniques, and his surgical skills were well beyond those of his peers.  In addition to his clinical acumen, however, he was forward thinking in his embrace of new technologies in cataract surgery such as the use of phacoemulsification to remove cataracts through small incisions without stitches and the use of intraocular lenses to rehabilitate vision for cataract patients.  To my knowledge, he was the first surgeon in Georgia to perform phacoemulsification—a technique that uses ultrasound to remove the cataract with minimal trauma to the eye—as well as the first surgeon to implant an intraocular lens.  Both of these technologies were in the early days considered quite risky and were extremely controversial.  History proved him right, however, and his practice grew tremendously, for he had the fortuitous combination of being the right man with the right set of skills in the right place at the right time.

The heyday of my father’s career extended from the mid-1970’s to the 1990’s.  At its peak, his salary rivaled the average CEO of the time, allowing him to live a lavish lifestyle:  flying to Europe on the Concorde, purchasing bespoke suits from Savile Row in London, amassing a collection of sports and vintage race cars with multiple Ferraris and Aston Martins, and purchasing not one but two plantations in the Carolina low country.  Apart from his extraordinary career as a surgeon, he will likely best be remembered for re-introducing Carolina Gold rice in the mid-1980’s, a feat which was recorded in the New York Times, the Princeton Alumni Weekly, and countless other publications.

My father retired from surgery at the age of 70, but continued to see patients in clinic for another five years before retiring completely at the age of 75.  He still sees patients as a volunteer for a free clinic in Hilton Head and continues to enjoy hunting and fishing.

So why did I go into medicine?  The simple answer to the question is that I wanted to emulate my father.  As a child, my mother never spoke to me about her father or her grandfather, so I was unaware of the history of medicine on her side of the family.  But my dad was the happiest person I knew, and naturally I wanted to pursue a career that would lead to the same kind of success that he enjoyed.  Like most kids everywhere, I suspect, I took my circumstances for granted:  not knowing any different, I simply took it as normal that I would learn how to drive in a Ferrari and attend an Ivy League school without any financial hardships on my part.  Only later in life did I begin to appreciate how truly fortunate I have been.

Once I got to Princeton, I was determined from the beginning to go into medicine, but it seemed a shame to me to narrow my focus to the sciences early in life when there were so many other things to learn in the humanities.  If I became a doctor, I reasoned, I’d be studying science for the rest of my life.  Thus I decided early on to be an English major, but planned all of my elective courses as science courses to satisfy all of the pre-med requirements.  It was hard work, given the heavy reading I had to do to satisfy my major, while at the same time, I had to excel in the sciences if I were to have any chance of getting into medical school.  Arguably I spread myself a bit too thin.  I rowed on the Freshmen Crew, played club sports such as rugby, and represented the Sailing Team in windsurfing regattas along the East Coast.

In my senior year, after I was accepted into medical school at the University of Virginia, I decided to take a flyer and apply to Oxford. My grades in English were good, and my thesis advisor, A. Walton Litz, was the world’s expert on James Joyce and William Faulkner, on whom I had written my junior papers and senior thesis, respectively.  So I applied to Oxford with good support from Professor Litz, and much to my pleasant surprise, I was accepted. Thus began one of the happiest periods of my life, from 1984 – 1986:  a two year interlude of serious study combined with serious fun, surrounded by an international group of brilliant students.  I was fortunate that my parents valued education and were happy to support me in my endeavors.

While at Oxford, as a hobby I raced my father’s vintage Aston Martin Ulster.  Built in 1935, the car was nearly bullet proof, a quality that stood me in good stead when I had the misfortune (or was it just plain bad judgment on my part?) to put it into a wall at 90 mph at Silverstone in my last race in England.   I was fortunate to row on the first eight for Trinity College for two years, allowing me to use sports to break through the notorious stuffy English reserve and make friends.  My master’s thesis was written on the novels of Walker Percy.

After Oxford, my recollections of life in medical school in Virginia are something of a blur.  Needless to say, going from an idyllic life of (relative) leisure characterized by civilized discussions about books and ideas, weekends of racing at the track, and croquet and Pimms on the Trinity College lawn, to the hard paced, fatiguing grind of medical school was quite a shock.  I was humbled, and deservedly so.

The years of medical school, internship, residency, and fellowship flew by, filled with nearly non-stop study and work, little sleep, and little opportunity for socializing.  The doctors here tonight, I’m sure, understand what I’m talking about.  I moved home in 1995 to join my father in practice.  Quite generously, my father gave me one of his plantations, Turnbridge, to have a place to live, knowing that I would do my best to take care of it and to carry on his legacy of rice planting.

The two of us had long recognized that the niche field of ophthalmology required increasing efficiencies to remain competitive, and that these efficiencies could not be achieved in the hospital setting.  So we immediately began to plan the construction of an ambulatory surgery center to perform our surgery in our own facility without having to go to a hospital.  This proved to be the best decision of our careers, and gave us the flexibility to make our own decisions about surgical equipment and personnel.  The Schulze Surgery Center was constructed adjacent to our practice, the Schulze Eye Center, in 1996, and our first surgeries were performed in 1997. Our facility allows us to perform eye surgery at a fraction of the costs charged to the patient by the hospitals, all the while offering the patient a higher level of service than is typically found in the larger bureaucracy of a hospital.  Typically we perform about 1600 procedures per year in the center.

The beginning of my career happened to coincide with an era of rapid decline in physician reimbursement from Medicare for physician fees.  As an aside, the bulk of an ophthalmic surgical practice is comprised of cataract surgery.  Since it is people over the age of 65 who tend to get cataracts, and since it is this same age group that has Medicare, we as eye surgeons are de facto government employees with almost 90% of our practice being Medicare.  A recent study in the journal Ophthalmology  looked at reimbursement rates for cataract surgery in terms of inflation adjusted dollars at two points in time:  1985 and 2012.  Interestingly, in 1985, my father was 51 years of age; in 2012, likewise, I was 51, so the study happens to look at data points at identical stages of our respective careers.  Over that time period, Medicare reimbursement for cataract surgery has declined from approximately $2000 per case in 1985 to approximately $650 in 2012.

Putting it another way, if you index those dollars to inflation, in 2012 I was paid only 10% of what my father was paid in 1985 for doing the same operation.  I’m hard pressed to find another industry that survives on 10% of its former revenues, but the optimist in me is mindful of the idea that most industries move in cycles, and that hopefully, our cottage industry is at the low point of a cycle that will soon rebound.  The fact that I own the center in which our surgery is performed softens the blow somewhat, since the center itself is moderately profitable.

But when I try to step out of the trees in which I practice and look at the forest of health care as a whole, it is harder to be an optimist for the remainder of my career.  Looking over my family’s history, from my great grandfather practicing as a country doctor with true fee for service medicine, to my grandfather’s practice during the advent of company sponsored health insurance in World War II, to my father’s practice during the golden years of Medicare, I struggle to divine my future.  I foresee that the era of the solo physician as rugged individualist, and the surgeon as hero, will rapidly be replaced by corporate medicine controlled by government decree.  While I live a very comfortable life, with a beautiful wife and family, and a beautiful home, my earning potential is nowhere near what it was in my father’s era.  Nobody’s going to feel sorry for me, nor do I want them to, since I have been blessed many times over.  But some days, when times are tough in the clinic, I think that perhaps, like my great grandfather before me, I should return to farming!

Having said that, I may be in the minority when I say that the Affordable Care Act (a.k.a., “Obamacare”) may ultimately be a good thing for medicine as a whole.  Not that I think that Obamacare in its current iteration will survive, far from it.  But I believe that the recent Obamacare debacle will serve to force us as a country to have a debate over a far more basic question:  is health care a right or a privilege?  Here’s a photo, courtesy of the Associated Press, showing the complete printout of the Obamacare legislation.

In most industrialized nations, health care has come to be seen as a right, but the United States is an outlier in that historically, health care here has been considered a privilege, with access rationed to some degree by one’s ability to pay, notwithstanding the tradition of doctors willing to work for free for the poor.

In my opinion, what we have in this country is not a health care crisis, but rather a health care financing crisis.  Ultimately I see our country moving inexorably towards a single payer solution, which may not be a bad thing if it can allow young people who have an unanticipated accident or illness to avoid bankruptcy, and others with pre-existing conditions to be able to change jobs without losing coverage, to name just a couple of examples.  But along with that social safety net, I would also like to see some element of free enterprise preserved, so that patients who want more advanced technologies can afford them, and so that physicians with higher levels of expertise can charge accordingly.  But the recent example of our dysfunctional democracy, as evidenced by the debacle accompanying the passage of Obamacare, is a reminder that my desire for a hybrid system of a government safety net with an element of free enterprise may be nothing more than wishful thinking.

In the meantime, I am grateful for the legacy of my forefathers in medicine, and hope to do the best I can for the patients in my practice.  I can only imagine what my great grandfather Stackhouse would say if he were alive today; but I would hope that he would be proud of what subsequent generations have accomplished.

Note from Catherine  Carrigan: My brother, Dr. Richard Schulze, Jr. , joined our father in practice in 1995. A magna cum laude graduate of Princeton University, he went on to study English literature at Oxford University, receiving his M. Phil. degree, before graduating with his M.D. from the University of Virginia in 1990. He performed his internship at Roanoke Memorial Hospital in Virginia before moving on to his residency in ophthalmology at the Ochsner Clinic in New Orleans. After a year of fellowship training in anterior segment surgery of the eye at the Kentucky Eye Institute, Dr. Schulze, Jr. returned home to Savannah in partnership with his father.

Dr. Schulze, Jr. is a member of the American Medical Association, the American Academy of Ophthalmology, the American Society of Cataract and Refractive Surgery, the International Society of Refractive Surgery, and the Medical Advisory Board of the Georgia Eye Bank.

Dr. Schulze, Jr. specializes in cataract and refractive surgery. Outside of ophthalmology, his interests include windsurfing, sailing, fishing, hunting, farming, and literature.

Further note from Catherine Carrigan: My middle name is Stackhouse. I carry the name of Dr. Wade Stackhouse, the great physician of South Carolina. In yoga, we talk about standing on the shoulders of giants. I have chosen the field of alternative healing but I include this article by my brother, a traditional medical doctor, and honor all the great healers in our family.

The Obamacare Document