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“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Monday, June 13, 2011
    Medicine and the Media, Part Deux

    Strap in, people: It's time for another round of controversy. The latest article making the rounds of the medical Twitter world is this piece published in the New York Times - "Don't Quit This Day Job." The author, a female anesthesiologist, makes the case in this essay that women doctors should not be encouraged to work part-time or to leave medicine for family reasons. Since primary care specialties such as pediatrics, internal medicine, and OB-GYN are now largely female, primary care is suffering because of female doctors' choices to either quit or work part time. For her efforts she's been pegged "misogynist" by at least a couple female doctors I follow.

    I agree with her. I am not a fan of part-time medicine, and I am one of those annoying old-school docs who feel that a career in medicine is every bit as much of a commitment as a marriage. Full disclosure here: I'm not married myself, never have been. I don't have children and likely never will. I can stay in the office till midnight if I want and I won't disrupt anyone's dinner or miss any Little League games. My father, now retired, was an old school doc who spent a lot of nights and weekends at the hospital - though he made a big effort to come home and eat dinner with us kids, put us to bed, then went back to the hospital to finish rounds. I learned from him that medicine requires total commitment. I never expected anything else. Therefore, feel free to read the rest of this post with a grain of salt.

    The part-time medical gig? In my opinion it can't be done, at least not well. Even when you aren't in the office, patients are still calling. Prescriptions need to be filled. Questions have to be answered, labs have to be reviewed. Who's doing this if you aren't? One of your resentful partners who doesn't know the patient, that's who. Face the facts: no one wants to clean up after you. The patients, also, don't appreciate being told that "Doctor So-and-So is out today, she'll call you tomorrow." Trust me, for most patients tomorrow is Not Good Enough. And for a really sick patient, delay can make the difference between being hospitalized and being able to be treated as an outpatient. I think of medicine as a jealous mistress: Anything you do that takes time away from her, she resents. And she will make you pay. But she does reward loyalty.

    When I went into practice I joined a group that (in large part) shares my attitude toward medicine. The Firm does employ part-time docs, but we expect people to show some level of commitment to medicine and to your fellow members of the group. If you show up for a job interview and your first questions are about the availability of part time work and how much vacation time you get, you aren't going to endear yourself to the folks who do the hiring around here. We've seen our share of doctors who join the group, get pregnant, give birth and leave the group a year or two later because they find the hours too much (even when working part time). If you're planning a career in medicine you need to know this basic rule: take the number of hours you work per week seeing patients. Multiply it by 1.5 to 1.8. That's the amount of time you're going to spend practicing medicine. The extra 0.5-0.8 goes for phone calls, charting, wrestling with insurance companies for authorizations, etc. It cannot be ignored; you have to factor it in somehow. What I'm trying to say is, There is no such thing as a nine-to-three job in primary care. To quote the author of the NYT piece, "If you want to be a doctor, be a doctor." Don't do this dip-your-toe-in-the-water crap. Be a help to your patients and partners, not a hindrance.

    I think often of one doctor who used to be a member of our group. She was a great doctor and a joy to work with, but she left for a hospitalist gig where she could work one 24-hour shift and one 12-hour shift per week and spend the rest of her time with her kids. I can understand her choice, but the group lost a good doctor (after paying for her childbirth leave of absence, I might add) and the patients lost continuity of care. Again. I can't tell you how many times I have been asked by a patient who's been through three or four doctors in our group, "Are you going anywhere?"

    I probably should clarify my attitude toward part-time docs here: I respect women who somehow manage to juggle child rearing and work. Frankly, I can't imagine how they do it. No matter what you're doing, you're plagued by guilt that you aren't doing something else: Either your family or your patients are getting shortchanged. Professional women also tend to put off childbearing, so often they are coping with fertility treatments on top of everything else. I absolutely could not do that. But when I hear some of the older docs in The Firm complaining about how all the doctors joining the group want to go part-time, I have to confess my empathies are with the old school. If my fellow doctors are out with fertility treatments/pregnancy issues/sick kids, we have to pay extra to hire locum tenens coverage and/or the other docs in the group get stuck with the burden of caring for their patients. But what about feminist solidarity? I hear from the audience. Screw it, I respond cheerfully. Medical solidarity trumps feminist solidarity. Heck, it even trumps relationships. We have plenty of docs in the group whose careers have lasted longer than their marriages.

    But is that healthy? Is that right? they persist. Honestly, it's the way medicine is - at least the way primary care is. The doctor-patient relationship is the anchor of primary care, and if medicine changes to become more family-friendly, it will be the first thing to go. Those of you who disagree: have you had ill friends or relatives? Have you noticed any difference in their medical coverage in the last few years? Are you finding that the doctor you knew simply is not available, or has been replaced by a covering physician whom you don't know? Bet you the answers are yes.

    Medicine is a club - not an elitist club, but you do have to earn your way in. Once you're in you are expected to do your share of the heavy lifting. It's an obligation, but also an honor. The more doctors come to view medicine as a part-time responsibility, the more patients will suffer for it. And remember, we're all patients sooner or later. So are our parents, our kids, our friends. I think this is what the author of the article was trying to say. Instead of slapping the label of "misogynist" on her, it might help to think this through. Can you really say that she's not right?

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    Wednesday, June 01, 2011
    Gonna Stay Where I Am

    As is the standard after any vacation, I had a small mountain of mail piled on my desk to greet me when I came back. Sorting through it I found a pamphlet entitled "Non-Clinical Careers for Physicians: Your Action Plan for the Future." Good Lord, I thought. Are there that many cranky docs out there fantasizing about never seeing patients again?

    Apparently there are. The inside cover pitches this seminar as follows:

    This course is designed for physicians who:
      Don't enjoy going to work anymore
      Are interested in making more money than what clinical medicine provides
      Want to explore their options
      [the world's biggest cop-out line - Ed.]
      Are frustrated and dissatisfied with their current career

    And many other reasons listed, but I think you get the idea.

    The seminar includes meetings with employers and recruiters, lectures and 'breakout sessions' on topics like "The Physician Inventor" (OK, that one intrigues me), "Communicate and Network Your Way to a New Career," "Opportunities for Physicians in the Biopharmaceutical Industry" [and in other fields: disability insurance, consulting firms, medical device companies and so forth]. All of this in two days for only $1295 US!

    At this point my inner red flag started waving. This sounds like a ripoff. Not in the sense that it's illegal at all, just that any doc who knows how to network could probably figure out a lot of this stuff by asking around. Specialists, drug reps, insurance company staff, talking to their medical school's alumni association... you know, what people who aren't doctors do when they look for jobs.

    More to the point, none of these career options sound interesting to me. I do not want an administrative job. I like primary care and interacting with patients, and through good fortune I belong to a stable medical group which pays me a salary. My checks don't bounce; I don't have to worry about paying the office rent. I know not all doctors can say the same. But if I were in that position and money was tight I might moonlight somewhere or (as above) would try a spot of networking on my own first.

    The back of the pamphlet offered a fiction writing seminar for physicians later in the year. Now that I may find harder to resist! I've got this idea. There's this primary care doctor, see, who uncovers a bioterrorism plot in between filling out disability forms and fighting drug plans for authorizing medications. It's guaranteed to be a bestseller... if I can just sit down and write it...

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