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Uncharacteristic Optimism

11/7/2010

6 Comments

 
There are certain stories in life that are so consistently true they're retold ad nauseam: pretty people rule high school; first dates are awkward; working in a cubicle is suffocating to the human spirit; blind dates are awkward; most of college is spent drinking and trying to get laid; dating is awkward.  These are the stories from our own lives that we laugh about with our friends and cry about when we're alone.  While less prevalent in the world at large, all third year medical students have their own set of universal tales of woe.  The two major themes are our clinical mishaps (the time I wanted to press the "nurse assist" button but instead pressed the "patient has no heartbeat" alarm) and general lack of respect for our status as a human beings (residents, attendings, and staff who either abuse us or treat us as though we do not exist).

And while I've found that many attendings are not necessarily inclined to take time out of their busy schedule to teach, they are willing to take the time and reinforce their superiority.  For every time that I've been genuinely mentored by a physician and asked what I hope to do with my career, I've also been sneered at, "So, what do you want to do when you grow up?"  At first the over-achieving part of every medical student wants to hedge their bets and attempt to make a good impression by reporting back the same exact specialty as the inquiring physician.  You even probably convince yourself that it's a possibility so that you don't have to be a liar.  But as my third year continues I've lost the heart to muster up fake sincerity.  These days I just state, "family medicine."  Usually I tack on a weak, "... but I'm keeping an open mind."

It's at this point that attendings seize the moment to share their wisdom.  They all start with the cursory nod to family medicine, "Primary care is really important. They need good people."  With those niceties out of the way, they then point out the various reasons why I'm about to make a mistake.  Firstly, "Unless you're in a rural area, family practitioners don't get to do anything but refer people." And secondly, "Nurse practitioners and Physician Assistants are taking over outpatient care; it's best to specialize because you'll always have a distinct skill." This statement subtly implies that outpatient medicine is not complicated enough for professionals of our caliber.  Sometimes they even appeal to my ego and imply that I'm "too good" to become a family physician.  And though it's never explicitly stated, we both know I'm choosing a path that will pay far less than the overwhelming majority of other specialties.  While I sit there politely and try to behave like the perfect mentee, my own mind is in a state of panic.
For the most part, though I sound bitter and sarcastic, these conversations are usually quite sincere and kind.  In fact, it's only the attendings who actually care that spend the time to discuss these things with me. The attendings that don't give a shit, just nod and continue ignoring me.  Like all people, I respond well to people who care about me and want to agree with them.  And though there are days where I think I know more than I'm given credit for, I still recognize that these are people with decades of experience as medical doctors.  This, combined with the fact that that I actually have enjoyed all of my rotations, makes me long to want to follow their advice.  What a happy coincidence it would be if it just so happened that I loved implanting pacemakers!  Not only would my work be fulfilling, but I'd also be joining the ranks of a highly respected and specialized field. Oh, and I'd make bank while doing it.  And though I can remind myself that there is a whole profession of doctors who have chosen family medicine and have not ceased to exist, I have to admit that it can be quite anxiety provoking.

As the fugue continues it becomes harder to play along and it only becomes more clear to me that family medicine is my calling.  However, it doesn't mean that there aren't uncomfortable truths that can be unsettling.  NPs and PAs are quite competent and as we continue to scrutinize healthcare spending practices, I think it's clear that more and more basic clinical work will be delegated.  In fact, a hospitalist once said that he suspected that all of outpatient primary care could be done by NPs and PAs.  As the nation debates changes in healthcare delivery and the numbers of NPs and PAs grow, I can't help but wonder if I'm choosing to go into a field that will soon be obsolete.  And an even more uncomfortable thought, "If I wanted to do outpatient primary care, did I go into the entirely wrong profession? Should I have become a PA? And if that's the case and I had known that to begin with, would my pride and sense of prestige have allowed me to do so?"  Then again, how could a PA be interchangeable with a MD if we spend so many more years in training?
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i am jealous of the brilliance of xkcd all the time
My girlfriend once made the comment that healthcare actually misuses PAs and NPs.  All too often there are more MDs than PAs and NPs in a clinic and really it should be the other way around. And ultimately it was this comment and the world of business that has saved me.  I was munching on three different types of macaroni and cheese at a soul food themed wrap up for the annual Net Impact conference and catching up with a friend from college that I hadn't seen in years.  When she asked me what kind of doctor I hoped to become, my usual answer, suddenly flew off with enthusiasm.  It occurred to me that as doctors, because our jobs are traditionally to cure disease, we're often in the mindset of overcoming obstacles.  However, surrounded by progressive business people, I realized that to them, obstacles were opportunities.  Suddenly I grew excited about the prospects of Family Medicine and the possibilities for change.

When studying social movements and why they take hold, the old school of thought was that people rose up together when the situation became so oppressive that it was unbearable.  However, after further study, it's become clear that history has not followed that pattern.  In fact, social movements ignite when people feel like there's a chance for change.  In other words, optimism is required.  And it finally dawned on me.  The current turmoil of primary care, the changes in the way we practice and who practices, and the political landscape of healthcare reform scare me because my future is unknown. I'm selecting a profession based on what it looks like now even though it will probably be drastically different by the time I actually start practicing.  On the other hand, for as long as I can remember, I've dreamed of starting a revolution.  This might be my chance.
6 Comments
Wendy Liu
12/8/2010 02:49:16 am

Hi, Jess,
did not get a chance to read your blog for sometime. This is a tough decision. As you know, I know a lot of doctors through work. We talk about families and kids sometimes. They all share their concerns about you want to be family doctor. This is more of a practical/fininancial concern. You will owe just as much money and would be paid far less than the doctors with a specialty. You will owe a mortgage with no house. There is also the political environment to consider. President Obama needs more family doctors for his health care reform, but the reimbursement for the family doctors from medicare is scheduled to be cut in the near future. It probably will make more sense to practice in hospital like hospitalist instead of private practice.
You may not care right now, but family doctor will always be the lowest ranking doctor in the totem pole. It may get to you at some point in the future.
I know this is not what you want to hear. I am debating if I should submit this comment. I decide to send it anyway. This is not be the first time or last time you are mad at me.

Mom

Reply
H. Y. Guh
12/16/2010 11:49:02 pm

Hi, Jess,

I echo Mommy's concerns about being a family doctor and am sure this is a challenging subject for you as well.

Chinese has a saying: if you want to help people, you must help yourself and be sufficient first. Given the current status and future prospects for a family physician, you need hedge your bet. What could you do to help the needy if you are bogged down by debts and scarce resources?

In my view, all medical students should have a specialty first and then spend some time in general practices. Maybe this is not practical in the current system, but if you want to challenge and change the status quo, this is one thing you may consider.

I know you have reasoned the "family doctor" issue deeply and logically. On the other hand, if you decide to become a family doctor, you should be prepared for a potentially devastating outcome: financially broken, inability to practice for the poor not because of medical incompetency, and discriminated by your specialized peers.

You may get offended and unpleasant by my views. As parents, Mom and I have experienced tough reality and worry about your idealistic selection. I believe one should balance ideal with reality, and I hope you will find a good medium.

By the way, you do write well and I enjoy the blogs very much.

Love,
Dad

Reply
OldCodger link
12/21/2010 02:56:30 pm

I have never read your muses previously - but just read yours entitled "Medical Education and the "Atypical' Presentation." Hence, I arrived here.

I am an old quack - veteran of well over a decade in the ER and as a Trauma Surgeon. Ironically, today I am in China where I do a bit of teaching and function as a "lao wai doctor" for the local foreign community.

I remember having your idealism when I attended med school after 5 years as a medic during Vietnam. Your critique of the curriculum using the white male diagnosis spectrum is correct. However, you may wish to consider the fact that med school cannot, nor is it intended to teach about every possible diagnosis or contingency. If one wishes to specialize, then all the other factors of diagnosis can be learned.

Your current schooling is nothing more than an introduction to medicine. Comprehensive, yes. All inclusive, no. Your real "schooling" will come during your internship. In your internships, and beyond, you will spend a very significant amount of time researching real life problems. That is how experience is built.

As for becoming a family practitioner I tend to agree that field is in a great decline. Part of the problem is people's perception of medicine. When someone else if paying the bill - be it the insurance company or the government - they want the absolute best that they can get. That is a specialist. Alternatively, they want an instant cure, which is not practical.

I am at a loss trying to figure out what type of revolution you wish to start as a family practitioner. There is very little satisfaction (from my perspective) in being a generalist. Very little challenge. Quite often, a very droll existence. Everything is quite cut and dried. If your goal is to create acceptance of your proposed area of practice - that will be extremely difficult to do since a PA can do the same as you.

From an economic perspective, I tend to agree with your parents.

From a philosophical perspective, there is not much room for radicals in the medical profession. Sure, you can go and serve the needs of those you may consider to be disenfranchised and you may do some benefit there and feel some satisfaction. But, should you consider that, remember that you are dealing largely with people who feel they are entitled to medical care that will suit only their own perceptions.

I doubt if you will take advice - given both of your parents statement that you will likely be upset. All that I can tell you from my long experiences in life, reality is a bitch. People have become very demanding about what, and how it is given to them. Individuals have little investment in their own health - and if ObamaCare becomes the norm, they will have even less invested and become more critical and demanding. Americans have lost sight of the concept of quality of life and are more concerned about quantity of life.

Yes, as a medical student you are on the bottom of the totem pole. It can be tough on the ego and self esteem. Please do not let that get to you. It is one of the rites of passage in every career that one goes into. Wait until you have to live with the thoughts of losing a patient that you believe later you could have saved had you noticed something or tried a different treatment plan. Then you may better understand those who are now your mentors.

Idealism is a great thing, but it is often quite incompatible with reality. Being able to recognize that comes with age and experience. Most of the old idealistic hippies that I knew back in the 60's have all given up on idealism and are quite steeped in reality. The rest are still living hand to mouth, quite often with a bong in their hand, still trying to find the idealist world where everyone is hugging and kissing everyone else.

Reply
Jess
12/26/2010 01:17:16 pm

Dear OldCodger,

Thanks for taking the time to comment! Your advice doesn't anger or upset me, but I think your thoughts actually illustrate exactly why we need more radicals in medicine. You describe the medical profession as something doctors are a passive actor in: a dispenser of care, without any larger impact. The inability to even imagine how a primary care doctor could revolutionize the way people think about health demonstrates how narrowly we're trained to think!

I think that many people believe that being a generalist is "very little challenge" and "a droll existence." Sometimes I fall into the trap of half believing that all orthopedic surgeons are stupid, Obgyns are bitches, and psychiatrists are simply SSRI pez dispensers. Then I remember how simplistic and reductive these thoughts can be. It seems that those things are said about every specialty by every other specialty. I also think it's a shame that primary care doctors are seen as generalists as opposed to specialists in primary care. And while I think it's widely recognized that family doctors tend to garner less respect and earn less money, it still seems impossible that as a doctor I would ever earn less or be disrespected more than my previous jobs in the hotel industry/most people in this world.

And finally, I agree that the point is not to teach every medical fact known to man. My critique was not about the facts that we're taught but the framework in which we are indoctrinated to think about medicine and medical decision making.

Reply
Jamie
12/28/2010 02:52:55 pm

Jess,

you are my ONLY friend in med school who is going into primary care. And I know a lot of people going into medicine. As a public health revolutionary myself, you give me hope for medicine and for the evolving field of primary care. Change within a field can be a very exciting thing.

We absolutely need radicals in medicine. i'm with you 100%. It pained me to read comments unsupportive of your choice. I'm late to this but I thought I'd put in my two cents.

I guess while I understand the need to be realistic about one's career choice and professional/financial stability, I'm also realistic about the fact that real "reform" has to come from within the physician workforce too. I applaud your choice. That said, whatever you end up doing (primary care, specialty, etc) --I am sure you will find a way to bring the revolution.

Kudos.

Jamie

Reply
Eric
12/29/2010 02:38:35 pm

Hi Jess - I found your blog through Jamie. I'm currently studying for my MCATs and want to go into family medicine, as well. I looked up the average salaries for family doctors and it's still pretty high given the background I'm from. More than that, I have pretty strong experiences with doing something that is "good for me" but doesn't fulfill me as a person - I end up depressed and having to change focuses. For me, if I wasn't going to do family medicine, pediatrics or something along those lines, I think I would switch careers all together.

I still haven't figured out how to reconcile the idea that I could be a PA or NP and do nearly the same thing. The city I'm doing my MFA in has nearly no MDs - everything is run by PAs outside of the hospital. But I'm glad you're contending with the same issues and still think the field is worth pursuing.

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