My new cyber-friend, Dr. Ryan Gray, invited me to submit a guest post to his blog and podcast site: www.medicalschoolhq.net. It’s a great resource for premed students who are trying to navigate the pathway to medical school. Ryan asked me to write a guest post on burnout geared toward premed and med students. You can find it here. Thanks for checking it out!
My apologies for falling off the face of the earth for the last few months. Work has been very busy (hooray!), and quite a bit has happened. Perhaps most importantly, 2 1/2 years after leaving a career in clinical medicine, I find myself dipping my foot back into the pool to test the medical practice waters. (WHAAAAAAT????) This actually comes as quite a bit of a surprise to me as much as anyone else. Since I left clinical medicine, I have found more happiness and job satisfaction than I ever thought possible. I had virtually zero intention of getting back into any sort of clinical practice.
So here I am, wondering what happened as I sit filling out a credentialing packet for a major academic medical center that is thicker than War and Peace, and am tentatively scheduled to start seeing patients in a few months. Like the rest of this career process I’ve been through, I thought it would be helpful to really reflect on what has taken place over the past few months and break it down academically.
First, let me say right off the bat, I am in NO WAY leaving my current career track to suddenly shift back into clinical medicine full-time. I seriously doubt I will ever let that happen. I am going to start one day a week, and simply see where it goes. I cannot tell you how many people have asked me if I’ll be going back to clinical medicine full-time when they find out about my new job. It’s funny what a reflex assumption that seems to be for everyone. People, I have drunk the freelance Koolaid, and there is no going back to turning over my schedule to someone else.
Here’s what I came up with when I really looked at what has tempted me back into the world of clinical practice:
1. This is the right department – even though I am trained as a generalist, I’ve actually been hired by a surgical department to function as a consultation specialist with a specific group of patients that I have quite a bit of experience with. This so far appears to be a much better fit for me than trying to cram my work profile into a general pediatrics department. I am thrilled at the prospect of leaving the primary care stuff up to my peers (who enjoy it and therefore probably do a much better job of it than I would anyway), so I can focus strictly on the specialist issues.
2. This is the right place - when my husband and I arrived here 2 1/2 years ago, we moved into a neighborhood that just happened to be located almost exactly halfway between two major cities, both with very strong academic medical centers. I certainly couldn’t tell one from the other when I arrived. Having worked in both communities over the past 2+ years, it’s become extremely clear which center my philosophies and ethics align with better. Lucky for me, the one I’m going to be working for is a little closer and has a much better traffic pattern, among other things. :)
3. This is the right time – I’ve had over two years to establish myself and build my reputation in the community, as well as make strong connections with other resources. This job is a natural segue into continuing to build on those connections, and establishing a bridge between the center and the community that currently doesn’t currently exist. I’ve also had time to recover from the worst aspects of my previous job, and actually miss what I did love about practicing medicine. This opportunity really arose very organically – I certainly didn’t force the issue when the time wasn’t right.
4. These are the right people – I suspect that this may be the most important factor of all. The people who have hired me already had an interest in starting up a program, and just didn’t have the right manpower on hand to do it. They clearly want this to work. They recruited me (nice dinner with wine included), met all the requests in my proposal, and have already designated support including a dedicated coordinator, dedicated nurse, designated exam room, and corner window office, despite the fact that I have yet to sign my contract. And just for the record, I signed on for 40% more than I was making at my previous hospital. I realize it’s not exactly an “apples to apples” comparison since my job description will be radically different, but in the end it’s still me bringing home a paycheck that’s a lot less anemic than before. My chairman is also very laid back – he’s the kind of guy who hires talented people to do their job and then backs off and lets them do it. So far everyone I’ve met in the department is a clear testament to this, and have been nothing but lovely.
Of course, it’s still the honeymoon period – we’ll see how I feel when I’ve actually been working for a few months. But it’s certainly a very healthy start.
More to come…..
It has been several weeks since I posted Part I of this blog – I have been traveling on business quite a bit, and have finally gotten the chance to stop and catch my breath. And see my husband. And go to the gym. No complaining here: I love the work I’m doing now, but I will admit that sometimes is it a bit of a roller coaster, and it’s nice to get off once in a while and just sit on the bench nearby with a sno-cone.
Last I checked in, I had just called my husband to tell him I could not take work one minute longer. I didn’t want to get into details with him on the phone, as I still had a full afternoon of patients left to see and I didn’t relish the idea of being an emotional wreck for the rest of the day. I simply said that I really needed to talk to him that evening, so if he could dodge the Friday happy hour at his firm and come home, that would be great.
I thought long and hard on the drive home exactly how I was going to put this to him. It was no secret that I had been becoming steadily more unhappy over the past few years. But thinking about quitting your job and actually doing it are two completely different things. By the time he arrived home, I had a fairly well-rehearsed speech ready for him.
He walked in the door, took one look at me, and said, “I don’t know what kind of song-and-dance you had prepared to share with me tonight, but if you need to get the f**k out of that place, then just quit.”
This is why I married my husband. He knows me almost better than I know myself. He is a gift, and I am thankful for him every day.
I talked with him about giving my department three months notice, even though I was technically only part-time faculty, since it would give them the most time to create a smooth transition for my patients.
Ever the pragmatist, my husband looked at me narrowly and said, “You won’t make it three more months without frying. Give them two.”
And he was right. Getting through the final two months once I had given my notice was nothing but an exercise in exquisite torture. My meeting with my chairman was nothing too terrible. Perhaps sad and somewhat pitiful, yes. My chairman was sad to see me go, but knew that he didn’t really have anything to offer me that would convince me to stay (and certainly not any additional money), and he didn’t even try. it was more of a formality than anything.
No, the worst part was seeing my patients over the next two months and have each one of them react to the news of my leaving. There was disbelief, tears, and even some anger at the department (which I of course did not encourage but admittedly took some small delight in). Every day was a soap opera, and it became exhausting. But eventually, I did get there. My last day of work, the department threw an anticlimactic little cake and cookie social in the resident lecture room. I was happy at least to see it was well-attended.
I essentially took the next 6 months off. Mostly because I could. My pitiful salary, while welcome, wasn’t exactly dictating our standard of living, and so it wasn’t missed much. Which is why I wasn’t in a desperate rush to run right out and find another job. I slept. I worked out. I slept some more. I had sex with my husband. I planted some flowers in front of the house. It was glorious.
The funny thing is that once you give yourself permission to do something absolutely crazy, like quit your academic physician position after 11 years with absolutely nothing lined up to do after, it creates a bit of a domino effect. I later learned that four other faculty left my department in the six months after I resigned.
It can also affect your loved ones. My husband has also been fairly miserable at his big-city firm. He had a wonderful run there, but had specialized in a part of the law that his firm didn’t really support. He was respected, but his work was being de-valued, and he felt like he was going through the motions to pull in a paycheck. He had also been mildly entertaining the idea of joining a small company in the south that had been trying to recruit him for several years.
We were talking one night at dinner. Having gotten ten hours of sleep and a two-hour workout in, I felt like a goddess. My husband felt like a doormat. We talked about how fed up were were having lived in an East Coast big city all our lives, and wouldn’t a change be great?
I looked him dead in the eye and, almost without even thinking, said, “Well, how about that company that’s been trying to recruit you? We could go there.”
Just like that. Clearly, I am not a change-adverse person. Plus, we had entertained the idea several times before, just not seriously. I was thrilled at the possibility of seeing another part of the country, and even happier at the prospect of moving to a place where winter doesn’t really exist. I could never see another snowflake in my life and be just fine with that, thank you very much.
And within three weeks, my husband had given his notice, let the new company know he was coming, put our house was on the market, and found a house about 15 minutes from his new job. Just like that.
The move was even easier. We sold one of our cars, packed the other with as much of our stuff as it would hold, hired a moving service for the rest, and drove the 1,497 miles to our new life. We pulled up to our new house the evening of the third day, and were immediately greeted by our next door neighbor, who brought us over homemade dinner. Welcome to the South.
Within two months of our arrival, just when I had started getting the itch to go back to work, I got a position as a medical consultant doing peer education and policy development in outreach communities all across the state. It was uncanny.
I’ve thought a lot about why this move was so simple, when it scared the crap out of many people we knew. I think it’s because on the surface, it certainly appeared as though we had woken up one morning and had decided to abandon our lives and head for greener pastures. Certainly, for people who didn’t know us well, that’s exactly what it looked like. The reality is that it had been something we had been talking about and planning for here and there for years before. When it was the right time, all the pieces fell into place.
If I had to make a list of the things and resources that helped us along our way, I’d start with Kathy Caprino’s article in Forbes: The Five Biggest Mistakes That Career Changers Make. I actually didn’t find this article until after I relocated, but I had already addressed several of the things she mentions in the article, and I thought it was a nice summary of some of the common pitfalls of career change that are easy to get sucked into.
Here are some other important factors that played into our smooth transition:
1. We moved to a lower cost of living area. I cannot emphasize enough how awesome it was to move from an expensive city to a not-so-expensive one. For the money we got for our old house, we bought a house that was 1200 square feet bigger, complete with renovated kitchen and pool, and were able to furnish it too. Mind blowing.
2. We had no consumer debt. This certainly was a huge help in allowing me to take the time I needed to find a job I really wanted, instead of taking the first thing that was available that came my way and getting right back into Misery Part II.
3. I am not tied to career identity. This gets back to really, truly knowing yourself. I was never exclusively wed to the idea of being a clinical physician, so when another opportunity came up that was related to my field but was something new, I jumped at the chance. If you are one of those people whose career title is critical to your identity and self-worth, a sudden career change that you have not explored fully can feel like suicide.
4. I had multiple interests that I cultivated along the way. I did quite a bit of public speaking and advocacy/policy work during my academic tenure, and discovered that I liked them tremendously. I honed these skills, and was able to develop them into work. This is not something that happened overnight. I also was fortunate enough to grow up speaking a second language, and had done some informal interpreting her and there for many years. Part of the time I was between jobs I spent time working with an interpreting mentor and became nationally certified as an interpreter. I figured that it would be great transition work while I was looking for a new job. What I never counted on was how quickIy I would develop a tremendous passion for interpreting, and that it would become a significant part of my new working life.
5. I was (and am) willing to hustle. Functioning as a freelancer with multiple income streams, I have to be willing to work and to travel to do so. Luckily, this clicks very well with my life, my personality, and my marriage. If you need a steady income stream, or crave the reliability of a full-time single site job, this way of life is not for you.
The bottom line is that, while people may think we are career nomads floating wherever the wind takes us, my husband and I were very deliberate about the choices we made, and did a lot of work assessing ourselves and what we really wanted out of life.
Go get ‘em.
I’ve been thinking a lot about Kathy Caprino’s article that I mentioned in a prior blog post (“Guilt Is Not A Career Platform”). The issue of not knowing yourself really stuck with me. I was actually chatting about it with the hubby the other day, and he asked me, “Well who DO you know in medicine who is really happy with their career and really knows what they want??”
What an outstanding question.
I thought of course I’d immediately be able to come up with a bunch of colleagues that were satisfied and happy in their work. Sadly, as I ticked off the list in my head, I realized that it was much harder than I thought. Most of my friends from my old department were wrestling with a lot of the same things I was, and weren’t winning the battle either.
But finally, it happened.
I remembered the dean of the medical school where I used to work, Gary, who may have been one of the happiest people I have ever met on the planet. This guy literally whistled while he worked. So I asked myself, what was it exactly that he had going on that the rest of us were missing?
And the answer I came up with was that this man took nosce te ipsum to a whole new level.
Gary certainly was as busy as the rest of us, if not more so. In addition to being an extremely active and involved dean (with all of the administration and red tape that comes along with the job), he also still held clinic weekly and carried a regular patient load. Gary had every right to be cranky, put-upon, and unhappy. Except that he wasn’t.
I think Gary had simply found the absolute perfect career for himself.
Gary was the kind of dean who inspired even student he met. He loved to teach. He grabbed teaching moments every chance he got. He personally sponsored an annual award ceremony that acknowledged the best teaching residents in the hospital. Illuminating medical student’s lives was his passion. And he took it upon himself to truly know all of them, every year. They absolutely worshipped him, and he inspired them to become great doctors. But it didn’t stop with his students. He had the same effect on his colleagues. We all wanted to be better doctors because of the way he made us feel. His knowledge and his presence lit up a room.
But medicine was not Gary’s entire existence. He was apparently a real fishing enthusiast too. The only reason I even knew this was because of a random encounter I had with him at the hospital.
I was still a resident, and I had been on call Friday night in the ICU. It had been a really intense call night, and my head had not even come close to touching a pillow. When I was finally free to go home on Saturday afternoon, I stumbled out to the parking garage, squinting in the bright sunlight, to find that my car was gone.
It took me a few minutes in my post-call fog to figure out what had happened, but I finally remembered that I had been forced to valet my car on Friday because the garage had been so packed (this was unfortunately a common occurrence). Over the weekend, that particular garage wasn’t manned, so the valets moved all of the cars over to a central garage where an actual person was working.
I realized I was clear on the wrong side of campus, and started exhaustedly trudging back the way I came, hoping that my car would indeed be in the main campus garage. As I dragged myself back up the hill and passed the Medical School, who should come bopping out but Gary. In full-on fly fishing vest, waders, and floppy hat complete with pinned-on lures.
“Hey Lumi! Where you headed?”
I said I should ask him the same thing.
“Oh, I’m off to go fishing – I go pretty much every Saturday. It’s great just being out there, even if you don’t catch anything!” Truly, the man’s optimism was mildly nauseating.
I asked him what he was doing at the medical school.
“Oh, I like to come in on Saturday mornings if I can, just to get some stuff done. It’s nice and quiet.” (So the man voluntarily comes in on his day off just to catch up on “stuff”.) “So where are you headed? Are you getting out of here?”
I said I was trying, but I hadn’t exactly located my car yet. I told him about the valet situation.
“Yeah, it probably is in the other garage. Hopefully you’ll get home soon – you must be exhausted! But listen, if for some bizarre reason it’s not there, here’s my cell number. Just give me a call and I’ll make sure you get home.”
This is how Gary was every single day. He loved his job. He loved stuff other than his job. And he knew himself. You can’t fake that kind of enthusiasm and kindness for very long without going completely insane.
I drove home from work yesterday after a very long, hard day, and was smiling because I felt so good about my job. For a long time I didn’t realize that you can actually enjoy those really tough, draining days. And maybe you should be able to enjoy some of them. I am knowing myself better every day.
I hope Gary would be proud.
Since I started this blog, I’ve been doing a lot of thinking. A LOT. Which has been wonderful, although my brain has decided that it is perfectly acceptable to wake me up like clockwork at 3:30 a.m. so I can sit at my computer and get more thoughts out into cyberspace. This would be no problem if I wrote for a living and didn’t actually have to get up and work in the morning.
Not that I’m complaining though. For the first time in a very long time, I can honestly say that I love my job. Or make that jobs. Actually, looking at my life from the outside, one could argue that it has become somewhat messy.
Two years ago, I essentially walked away from my previous life. In all fairness, my husband and I both took a massive leap of faith together. On paper, we had supposedly been living the American dream. He was a big-city, big-firm lawyer, and I was an academic physician at a well-known university hospital. We had the dream house, three cars, and pulled in a half million dollars a year between the two of us.
And we were f**king miserable.
We both hated being smothered by the systems we worked for and had no voice in fixing. We ended up resenting our clients, who were the reason we were employed in the first place. We grew to loath the suburban Garden of Eden we had bought into. We drank too much. We lived to get away for vacation, and then were even more miserable when we came back and it took us a month just to dig out from under the stack of work, charts, and emails that had been slowly breeding while we were gone.
But it took us years to actually figure out that we just really didn’t like how we were living.
We had naturally assumed that we had everything we were supposed to want in life, and something just must have been wrong with us. Though we’re not quite sure exactly how it happened, eventually we both realized that the things that are supposed to make us happy in life simply didn’t. We are just not those kind of people.
And then miraculously (you could almost hear the stars lining up in the sky,) in this crappy, terrifying economy, my husband got an invitation to join a small boutique law firm in the south. Far, far away from our Yankee roots, not to mention both our extended families and life-long friends. It would mean cutting almost every tie we had, and leaving the place we had grown up and lived in virtually all our lives. It would mean leaving behind careers and reputations we had spent decades building.
I tendered my resignation immediately.
Some of my colleagues, of course, were horrified. After all, I was a successful (at least by their terms) physician with a good reputation and a solid academic position. How could I possibly ditch all that? And to rub salt into the wound, I had absolutely no job lined up for after we moved. Terrifying, right?
I actually found it to be incredibly exhilarating.
I have never been defined by my job. I certainly am not criticizing those who are. I am just not one of those people who takes a lot of stock in making my M.D. part of my identity. I am the last person at a party who is going to introduce themselves as “Dr. St. Claire” (especially since people are so uninhibited about asking you grotesquely inappropriate medical advice after they have had some hors d’oeuvres and slugged down a couple of glasses of wine.) My good friend once described me as “the most reluctant pediatrician I have ever met.”
So for me, I didn’t really view this as a period of mourning. I had a great run. I was leaving on a high note. And I couldn’t wait to see how things settled out for me in our new life. Perhaps I was totally naive (actually, I’m sure I was.) But honestly, I think it really worked in my favor. I have discovered several important things in the process of relocating my life:
1. After eleven years in the field, I finally figured out that I just don’t like primary care medicine that much. I am much better as a specialist and a consultant.
2. I absolutely, positively, love being my own boss. And my own scheduler. Although I have on occasion been overheard complaining that I need to fire my scheduler when I’ve really overextended myself. Thankfully, it doesn’t happen very often.
3. After 37 years of living just outside a northeastern urban metropolis, I have discovered that I really do not like living just outside a northeastern urban metropolis.
4. I like my life messy.
Let me clear – messy does not mean chaotic. My life is unbelievably scheduled. I have a speaking engagement I just put on the calendar for April….of 2013. But this discipline and organization has ironically afforded me the chance to be spontaneous much more than before. For one, I don’t take call anymore. I also rarely schedule anything over a weekend. You can imagine after eleven years of being tethered to a pager and spending a good number of weekends on call or in the hospital, how this has blown open my life in terms of new opportunities. For the love of all that is holy, I learned to cook after we moved.
For me, messy just means unbound. I am always open to new ideas, especially when it comes to work. I was just offered some consulting work in an area that is closely related to my field, but is something I haven’t had the time to focus on until now. I snapped it up like a bear standing in a river during a salmon spawn.
Sure, it’s unpredictable. But for me, that’s what keeps it intriguing. Yes, there are times where money is tight, and then times where I can hardly breathe I have so much work. It keeps me honest and prevents me from taking my successes for granted. In my case, leaving clinical medicine simply allowed me to pursue other avenues in life that bring me joy.
Sheryl Sandberg, the current COO of Facebook, said that the best advice she ever got was from Eric Schmidt at Google. When she was considering turning down an offer she received to be Google’s general manager, Eric told her, “Stop being an idiot; all that matters is growth.”
My life is full of growth. My life is messy. I wouldn’t have it any other way.
Over the past few years, I have realized that I have come to resent the word “just.” Certainly not in the civil sense of the word: social justice is the driving force behind virtually all the work I do these days. I am talking about using “just” as a qualifier. As in, “Oh, I’m just the medical student,” or, “He’s just a nurse.” We use it blatantly as an offense against others, and more overtly to undermine how we feel about ourselves. That word has come to mean that in some way, you are not educated enough, not qualified enough, or not worthy enough.
It has been really interesting for me in the two years since I left clinical medicine to pursue a decidedly non-traditional career path. I mean, who finishes high school, college, medical school, and clinical residency and then eventually leaves the job they actually trained to do? Here’s the secret about all that: your life experience is critical NO MATTER what road you take. I have been extremely successful so far in developing my new career, and I would not be doing nearly as well as I am and getting the high-profile work I am without my past clinical experience. It gives me credibility, knowledge, and perspective that make what I have to offer unique.
What I have quickly come to realize though, is that while I am extremely comfortable with having taken on a new job identity, a lot of my colleagues are not. The “just” word gets batted around constantly.
“But aren’t you bored being just a consultant?”
“Isn’t it weird being just an interpreter instead of a doctor?”
First of all, I never stopped being a doctor. There are thousands of us who have completed medical school and earned our MD degree (and many who finished clinical residency) who have taken detours to explore other areas of work. Usually they are related in some way to medicine, but don’t necessarily involve direct patient care. And guess what? The M.D. Police have still not shown up at my door to take away my degree. The last time I checked my business card, those two little letters after my name were still there.
Secondly, and perhaps this is the social justice beast in me rearing its ugly head, I can’t think of a single meaningful job that I would ever feel comfortable putting the word “just” in front of. Think about what the act of gainful employment provides for us as individuals. It gives us a sense of worth and need. It puts food on the table. For some of us who are struggling with temptation, it keeps us honest and clean and helps us resist activities that might lead us to a place of total self-destruction. Doctors would be nothing without nurses to actually put their plans into real action and physically take care of patients. And just because you don’t like someone’s job or think that it is particularly challenging, imagine what your life would be like if the trash collector simply stopped coming to your house. Not pretty.
I’ve been thinking a lot about “just” in the past couple of years since I switched my career horses in midstream. Not because I’ve had to wrestle with it at all on a personal level. I have more peace and joy in my career now than I can remember over the last decade. It’s really more about the reaction it draws out of other people. Usually it’s people who have made decisions for themselves that they don’t necessarily feel great about. But for whatever reason, they feel compelled to stick with their decisions. I tend to make these people really uncomfortable. I think it’s because my decision to follow an unorthodox path and find my career happiness again forces them to examine their own decisions more closely. And sometimes they don’t really like what they find. Sometimes they are truly stuck because of financial obligations, and are miserable but just don’t see a way out. I make them unhappy just by being me and feeling fulfilled and standing in the same room with them. Sometimes people are stuck out of fear, and my lack of fear and my willingness to embrace risk-taking makes them feel bad about their own paralysis. We are natural comparers as human beings. We are always looking at what the other guy is doing, and constantly trying to see if we measure up.
Mostly though, it’s other physicians who have the hardest time with my decision to leave clinical medicine. I think a lot of this has to do with the fact that there is a strong tradition of hard-won success in medicine. The educational road to becoming a practicing doctor is very long and very hard. For many people, there is also an enormous identity piece. Some people are doctors 24/7. I don’t mean that they live in their offices and never go home. I mean these are the people you will meet at a party (where there are no patients, no white coats, and everyone is drinking wine and eating little puffy hors d’oeuvres), and they will introduce themselves to you as “Dr. So-and-So”. I don’t have particularly strong opinions about whether this is appropriate or not, but it’s something I have never been able to relate to well. I did not come out of the womb knowing I was going to be a doctor. I am not one of those people who absolutely cannot imagine themselves doing any other profession. (Clearly – I have imagined myself right into another line of work.) For some people, being a doctor is the end-all of their identity, and they are not complete people without it and the respect and honor it (rightly) deserves. So these folks are the first ones to ask me how I can possibly be happy just being a consultant, when I could be a doctor?!?
I just came home from a conference where I had the opportunity to escape for lunch with a colleague who is a wonderful friend, and someone I don’t get to see as often as I would like. We were having a very energetic conversation about all the work that lay ahead of us and how motivated we were to be doing it with committed and passionate people. At one point, I was telling her about some of the new opportunities that had come up for me through the conference, as well as some exciting new job opportunities at home, and the fact that I also have been seriously committing time to writing, which has made me eternally happy. I must have looked like some blissed-out kid who had just eaten an entire box of Twinkies (before the vomiting started anyway). My friend looked at me for a long moment, paused, and simply said,
“My dear, clearly you were never meant to be just an MD.”
There it was, that “just” word again. Except this time it had a completely different meaning. It was obvious she hadn’t used it in the sense that being a physician is a lowly occupation, and I could certainly do something more quality with my life. No, she meant it in the purest form of the word. She was talking about scope and self-limitation. Why only be an MD? Why not use your skill set in new and unique ways to address issues of social injustice? It was such a pleasant shock for me to hear someone use that word in such a positive and fitting way, it was all I could do not to leap across the table and tackle her with a huge hug.
Betty Friedan, the famous early feminist trailblazer and author of The Feminine Mystique, once spoke about how different our lives would be if we simply knew early on that we were going to have three or four different careers throughout our lives. If somehow that were the norm, how liberating it would be knowing that at any time, you could go ahead and start gaining the skills and education to do something new and exciting with your life.
I know just how she feels.
There are an awful lot of reasons that led up to my eventual resignation from an eleven year career in clinical medicine. I don’t know that any one of them is more important than the other (it really just depends on which day you ask me). One that stands out for me though as a universal problem shared by millions is Managed Health Care, and the imposition it has posed on physicians and patients alike is enormous. What happened to health care in this country anyway?
A BRIEF history of managed care:
The origins of the first managed care efforts in this country date back to the early 1900′s, when prepaid physician services started showing up in a few select industries and health care organizations. In 1947, the physician-run American Medical Association got walloped with an anti-trust violation conviction for their efforts to limit physician involvement with group health plans. The movement gained momentum and really got some teeth when the HMO Act of 1973 was signed into law by President Nixon (way to go, Dick), which used federal funds to promote the growth of Health Maintenance Organizations (HMOs). The backlash really caught up in the late 90′s, when US per capita spending started to rise again, despite the mission of managed care to reduce heath care costs. US healthcare expenses continue to eclipse the national income, and have been increasing approximately 2.4 percentage points faster than the annual GDP for the past 40+ years.
Ironically, while the whole point of managed care was to reduce healthcare expenses in this country, insurance company executives have continued to earn grossly exorbitant salaries. The top executives working at the country’s five biggest for-profit health insurance companies earned compensation of almost $200 million in 2009. Cigna insurance company paid its outgoing and incoming chief executives a combined $136.3 million that year.
So, you ask, what do we have to show for all this?
Booyah!!! We suck!!!
Now you have to layer on top of this healthcare cost crisis the fact that doctors have really had to change the way they practice medicine. Managed care means less time spent directly with patients, and more time spent on non-clinical activities (i.e. paperwork). The 2011 Medscape Physicians Compensation Report generated survey results from almost 16,000 physicians across 22 specialty areas regarding income and practice parameters. Primary care physicians have the shortest access time per patient, with a median visit time of 13-16 minutes per patient. (For the record, pediatricians averaged more patient visits per week than any other specialty.) 17% of primary care docs spent more than 20 hours a week on paperwork and other non-patient activities, and less than half of primary care physicians would choose to go into primary care again if they had the chance to do it all over again.
Quite honestly, this turns my stomach. And I already got out of clinical practice.
I remember my own horror stories quite vividly. Like the day I spent SIX HOURS on the phone with an insurance company trying to get one of my patients a badly needed MRI. It was my administrative day, and I realized that this company’s strategy was to walk you through a twenty-minute phone tree, and then conveniently “drop” the call a few minutes in once you finally connected with a live person. It became a point of pride that day. I put the speakerphone on, and did my charting and admin work for six hours while alternatingly listening to hold music and getting hung up on. Finally, in the end I wore them down and they relented and gave me an authorization code for the scan (the call being conveniently disconnected half way through my receiving the authorization number and necessitating yet another call back.) Apparently, they were quite nasty to our billing specialist who had to talk to them to get the final information, like I had somehow done something really, really selfish in getting my patient the procedure he needed. And just for the record, it was one of only two MRI’s I ever ordered as an attending physician, lest you think I was somehow ordering these tests willy-nilly and eating up all our healthcare dollars.
I also had one insurance company deny authorizing my patient an EpiPen. If you don’t have any experience with EpiPens, they are automatically injecting syringes pre-filled with epinephrine that patients carry with them who have life-threatening allergies to things like bee stings, peanuts, etc. They keep people from dying. I could not imagine on what planet and in what solar system an insurance company would have a sane reason for denying a severely allergic patient one of these. And the worst part was they absolutely had to talk directly to me about it. They couldn’t discuss it with one of our residents, our nurses, or our nurse practitioners. I had to take time out of my excruciating schedule to have a lively chat on the phone about why it was important for my patient not to croak.
Pardon my language, but this is a f**king crime. I did not pay a fortune and spend four years in medical school to be trained on how to deal with the insanity of managed care. And I don’t think my patients would have wanted me spending precious time learning how to appropriately fill out a prior authorization form, when I could be learning about medical disease processes. Yes, people are specifically trained to deal with managed care, but often enough the insurance companies make demands of us that they simply won’t accept from other staff. And if we don’t comply, our patients are the ones that pay the price. If I put my foot down and say it’s inappropriate for an insurance company to require I give a pharmacy my DEA number for a non-narcotic antibiotic prescription just for tracking purposes, my patients simply won’t get the medication they need.
Having recently retired myself from clinical practice, I will be the first to admit I miss my colleagues. I desperately miss my patients (well, most of them anyway). But I don’t miss this. Not for one solitary moment. My heart goes out to my colleagues who are still trying to practice actual medicine in the face of mounting adversity. Keep fighting the good fight.
So I was chatting with a friend of mine (also a doctor) today who has a lot more experience with blogging than I do. Actually, 97.2% of the free world probably has more experience blogging than I do, so that’s not really saying anything, but I value her opinion tremendously. She had read my blog, and gave me some great feedback and helpful hints. Then she hit me with something that was totally unexpected. She said, “I really like your blog, but your posts aren’t opinionated enough.” And in many respects, I have to agree with her. The last thing I want to do as a blogger is simply report what is already public information. Isn’t the whole point of doing this to get your opinion out there, and then put on your big girl pants and hear what the rest of the world has to say about it? This blog is for my friend Collette, and I make no excuses for shamelessly pilfering her fabulous title for my post.
One thing that I remember vividly from my days of primary care practice were the patients who made me cringe when I saw their names on my schedule for the day. Specifically speaking from a pediatric perspective, I’m talking about patient’s parents. Sometimes it was for obvious reasons – I mean, who likes chronically angry people? But sometimes the reasons were more subtle, but just as oppressive. Don’t get me wrong, there are plenty of jerk doctors out there too who think that their patients exist simply to make their lives miserable. But there are definitely some specific folks who elicit groans of actual pain when their doctors see their names on the patient list. After thinking long and hard about what it was exactly that made these people so excruciatingly difficult to deal with, I came up with a list of some of my favorites. You may love it, or hate it, or take the easy route and just assume I’m burned out and bitter. A few of you may see yourselves in these descriptions. And if you do, I hope it makes you very uncomfortable, because that means that you care about what I think and perhaps might even consider how you act the next time you visit your doctor.
1. The Entitled Professional: These folks are a lot of fun. They virtually always have a terminal degree, and the vast majority of the time, they are lawyers. They love to come into your office and make veiled threats by throwing important names around, and how they have so-and-so political figure on their speed dial. Their time is always more important that yours – they throw an absolute fit if they are not accommodated exactly at their scheduled time, but are perfectly content to show up 30 minutes later and still demand to be seen. They also like to come in with articles they have downloaded off the Internet and wave them in your face. I remember one mother who came in having printed out an 11 page article on sudden death risk in child athletes, expecting me to read it right there and have an in-depth journal club with her (while of course managing to do well checkups on both her kids in 30 minutes). I certainly didn’t object to her being a well-informed parent. In fact, I wish more of my patients had a decent sense of health literacy. No, what I objected to is that, while she had taken the time to kill three trees to print out the article, she hadn’t actually read it carefully for herself. Luckily, I already had, and was able to inform her that while the information was important, the study had been conducted entirely in Italy with a set of patients that had very different genetic and ethnic risk factors than American children, and that our standards of care had not changed.
I bet she’s also the same person that would throw the entire article in the trash, instead of recycling it.
2. The “1001 Questions” Patient: These folks come in with a list that is displayed ceremoniously at the beginning of the visit. It is usually brought out from a pocket or a bag with a flourish, and is often folded about seventy-two times, so there is a grand production of unfolding this piece of paper in preparation for a reading. Then there is usually some throat clearing or clothing adjustment, followed by a serious look and a proclamation of, “Well, I have quite a few questions for you today.” To this day, I still don’t know where the VIP entrance to our clinic was in the building, but I knew there had to be one just for these people, because clearly the entered the building and our clinic without once noticing the line of FIFTY @#$%^&* PEOPLE trying to register at the front desk and spilling out of the waiting rooms. They also don’t realize (really through no fault of their own) that bringing in a list of questions that looks like the Magna Carta will actually distract their physician from focusing on what is truly important at the moment. No matter how delicately and professionally I let them know that I would only be able to address their top two or three concerns that day, they inevitably looked completely crushed when they realized that I would have to leave the room in ten minutes to actually go take care of other people too.
3. The “I Can’t Be Bothered To Learn How This Place Works” Patient: These patients are especially choice. Despite the fact that they have been coming to your clinic for years, they can’t be bothered to learn anything about how the place runs. Consequently, they are always angry about something each time they come in for a visit. Often, it’s the exact same thing as last time, and even more often, it’s something I have zero control over fixing. Yes, our parking garage is run by Satan. Yes, it constantly takes at least an extra 20 minutes to find a spot or get the valets to park your car. I too have the joy of parking in this garage, but somehow I manage to allot the extra time I know it will take to park my car, so I am not late as you were today and every other day you have come in bitching about the parking garage.
My favorite was one father in particular who, every single visit, would throw a Grade A tantrum about being seen by a medical student or resident. I worked in a teaching hospital, which means we were affiliated with a School of Medicine. That we were an institution of learning was no mystery: the name of the hospital has the word “University” in the title, and was actually physically on the campus of the University. This meant that students and residents in training would be part of the medical care team (this is how we turn students into the adult doctors who will be taking care of you when you are old!) Yet every time this guy would come in he would rip the poor student or resident a new anal orifice, and demand to see the attending physician immediately. Apparently, he had gained quite a reputation for this among the staff and even my colleagues. When he invariably landed in the resident clinic I was supervising and started screaming in the hallway, I marched out of the attending room, walked up to him, and very publicly explained to him how a teaching hospital worked. I also invited him to explore private practices in the area to see if those might be a better fit for his needs, as they would not have students and residents working in them.
One might think that my efforts to find this gentlemen the best fit for his needs might not go over so well with my administration, given that I was encouraging him to get with the program or get out. However, the incredibly “progressive” thinking in my institution meant that they had crunched the numbers, and come to the realization that a new patient was worth far more money than a returning one. A new patient history and exam are much more detailed (and therefore billed at a higher level) than the visit for someone already known to the system. So as far as they were concerned, this guy could go suck it – there would be a brand new shiny patient to take his place who was worth a lot more. Isn’t managed care medicine great!?!?
4. The Staff Abuser: This is fairly self-explanatory. These are the people who come in an scream bloody murder at each and every staff person they encounter. Check-in staff, annihilated. Screening nurse, bawled out. Managed care coordinator, decimated. But then somehow by the time I see them, they have miraculously transformed into the sweetest, kindest, brown-nosiest person I have ever seen. As if I somehow managed to completely miss the Armageddon they just laid down in my waiting room, and I think they must be the kindest people I have ever met in the whole world. Something about these folks in particular sickens me – the fact that you kiss up to me because I have an M.D. after my name makes me like you less, not more.
5. The “Why Do You Even Come Here” Patients: I think these folks may be the winners as far as I’m concerned. For the life of me, I never understood why they even came to the clinic at all. They already had decided what they were going to do, they had no interest in any medical advice I had to offer, they never followed any instructions that were given, and then were stupefied when their kids would run into problems. One family I worked with were staunchly against vaccinating their children. This wasn’t new to me – there were plenty of families in the community I worked in who chose not to vaccinate their children for a variety of reasons. (Whether I think this is a reasonable choice or not is another blog entirely….)
This family in particular made a huge stink every visit about not doing things that weren’t “natural”, which for them included not vaccinating their kids. Every time I patiently reviewed the potential risks of not vaccinating with them, and had them sign a form stating we had discussed just that. This went on for years, until the day one of the kids caught Pertussis (Whooping Cough), which he proceeded to spread to his entire unvaccinated family. Pertussis is one of those illnesses that, while incredibly annoying in older children and adults, is actually often fatal in infancy, which is why we vaccinate against it and outbreaks are closely monitored. The mother called me, horrified, to complain that the Department of Health had come to her home to investigate the mini-outbreak that had occurred there. Well what on earth did you think was going to happen?
Not wanting to end on a completely negative note, I think it’s worth mentioning that for every type of patient I mentioned above, there was an equally lovely and appreciative person for whom providing medical care was a joy. Too bad we can’t bottle those and save them for a rainy day.
DISCLAIMER: The following blog addresses some very real issues regarding providing medical care in this day and age in the U.S. Despite my struggles to reconcile my own feelings about practicing primary care, I still do and always will love medicine. I cannot emphasize it enough. I trained to become a knowledgable, compassionate, and competent doctor, and my love for that will never change. It’s all the other bull***t that keeps getting in the way and messing things up.
It only makes sense that my first real post would address the huge dead elephant in the room. At the age of 37, I took a big breath and completely walked away from my career in clinical medicine. Obviously, I didn’t just wake up one day and decide to quit being a practicing doctor. This was a heart-wrenching resignation that was made over many years and many countless attempts to fall back in love with being a practicing physician. I also think it’s important to mention that I am not one of those folks who came out of the womb knowing I absolutely had to be a doctor. There have always been other interests and talents in my life that have pulled at me in other directions, and I have never worried that the sun would somehow fail to rise in the morning if I decided to do something else. I have shifted my horses in midstream, become my own boss, and am doing a combination of medical consulting and foreign language interpreting, and quite honestly cannot remember a time when I have been happier in my work (more on that later….)
Still, what was it exactly that lead me to basically (and with much relief) walk away from what appeared to be a thriving clinical career and throw all my colleagues into an apoplectic fit? The answers do not only belong to me, but to a startling number of my fellow physicians who are struggling daily with the urge to simply give up.
According to a 2011 JAMA article by Dyrbye and Shanafelt, an estimated 30 to 40% of physicians are experiencing burnout. It’s not just a few disgruntled docs who have been at it too long and need to spend more time finding their inner zen. Burnout among our nation’s physicians is nothing short of an epidemic right now, and one we cannot afford given that we have some of the poorest medical outcomes among industrialized nations. Yes, we all love to think that America is the mecca of medical care, but compared with other economically-industrialized countries, our statistics are some of the least desirable in areas like infant mortality and life expectancy (OCED health data 2011).
So what’s at the heart of this tsunami of doctor burnout? There are lots of articles and research efforts being devoted to this very question. Right now there is an interesting article posted on kevinmd.com regarding gender differences in physician burnout. For me, I did a lot of introspective thinking in the six months I took off after my resignation. I don’t claim that every other physician experiences these issues the same way I did. But for me, they were very real and ultimately forced me to walk away from clinical practice in order to salvage my love for it.
After much thought and soul-searching, here are the things that drove me to leave clinical medicine (in no apparent order):
- Managed Care Impositions
- Administration Without Vision (aka “Looking for Icebergs Instead of Bailing Water”)
- Grossly Negligent Support Staff
- Passive Parents
- A Voiceless Faculty
- A Startling Self-Realization
My blog posts over time will address each of these, and will probably require a decent amount of red wine to get everything put down honestly and accurately. I hope for some of my colleagues, this may serve as some comfort knowing you are not the only one feeling this way. And for others not in the field, I hope you will find this helpful in taking away a little empathy for what your doctors deal with in their work day. Cheers….
Forgive my stumbling around my new blogsite as I try to catch up with the rest of the 21st century. I’ll be posting something of actual reading value soon, and I hope you will come back often to see what’s new. I look forward to exploring some uncharted territory when it comes to recovering from burnout, and not just posting a bunch of bitter comments. Ok, well some of the comments will be snarky and bitter I’m sure. But I’m hoping there will be plenty of lovely moments peeking out like weeds between the cracks in the sidewalk.