Friday, November 18, 2016

Reflections 50 (!) Years Out

I have a medical school anniversary coming up – 50th! Never thought this would come. I specialize in denial; it's my primary defense, and I'm sticking to it. As my classmate Bob Ruberg observed many moons ago, walking around the old school, “We have now become the old farts!” Indeed, now we are the even older farts.

Looking forward to our reunion next June, perhaps, the old question has arisen on the class listserve: do you honor or regret your choice of medicine as a career? One of our classmates observed:

We have lived through the end of medicine's conversion from an art to a science. We are now seeing the conversion to a business. … I've been asking older physicians (65 yo and greater) whether they would become physicians in this time setting. Less than 1/4 of them would.  What say you, HMS 67?  What career would you select if you were in college today?”

So far, everyone has responded that he or she would choose medicine again, what a great profession it is, and that their careers have been fulfilling. Here is my response, amended by some reflection since I jotted it down, more discursive than most responses, not unexpectedly.

Why all this talk about medicine losing its luster? It's not a simple question, I think. The most disappointed and even bitter critics come generally from the private practice realm, often rugged individualists, people who didn't want bosses, people who wanted to do what they wanted to do, people who enjoyed being king of the hill in their towns, often people who made a fair amount of money. Or some subset of those. Or from doctors who ruled the roost in their hospitals and have been taken down by corporatization.

Academics, on the other hand, usually don't bemoan the older days. In academia things haven't changed a great deal. There always was some bureaucracy, there always were groups, there always was the three-legged stool, and academics aren't making any less money. At least that's what I understand; I may be wrong.

For practitioners, there has been a great deal of change, starting with insurance and government and pressure to conform one way or another and then yet another, the need to form groups, pressure from hospitals, Medicare crap, pressure on fees, etc. And the rising tide of administrators, fueled by hospital consolidation, governmental mandates, etc. If you just wanted to practice medicine and do the right thing and be true to yourself and do well by doing good, it became harder. A lot of nonsense came into existence, having to listen to “marketers,” prove that what you were doing was the right thing when it always was the right thing to begin with, and other kinds of crap. Last year I read Henry Marsh's book Do No Harm – he's an English neurosurgeon – really good book. What he has had to put up with in the NHS! Well, a lot of it has come here.

For myself, I wound up being an entrepreneurial pediatrician who built a big group, and instead of feeling oppressed by the new forces, I found happiness in fighting them and going with the flow of emerging larger groups and doing well by doing good in building the group, taking care of my people, and as an owner-administrator building systems of care and helping to direct people so that the docs in my group could “just practice medicine.” Mostly, my docs were very happy, and I was happy for that. The practice staff also appreciated being in a place that treated them with respect, and most importantly, consistently put the patient first. Staff join a medical practice with some respect for the place of medicine in people's lives, and when they find their mission honored, they feel some fulfillment. I myself have found it all very fulfilling and interesting. I was also able to publish along the way, so I did my own academic stuff without academia. I've always done a lot of stuff alone.

Medicine is a great profession and always will be. The great advances in what we can do for people, and being able to do good for people off the street from all walks of life, is all very fulfilling. It's true that when you help others you are helping yourself even more. I didn't know that before I did it. Yes, there is lots of crap. I wish docs would get together better and fight the crap, and make sure the administrators and business people, whose ethics often don't match ours, don't call the shots. My view might be influenced here by our local conditions, but when I talk with colleagues across the country, there is some agreement.

My stepdaughter worked for me, then became a pediatrician, worked for me again, and is now Associate Professor at UCSF, head of the eating disorders program, and unlike so many of her academic colleagues, knows how to see patients and not mess around. She is a wonderful doctor and the most productive in the department and a great teacher. Her 6 and 1/2 old daughter, with whom I have an ongoing love affair, was going to be a doctor until she started taking a course on animals and now wants to be a vet. We'll see.

It was hard for me to become a doctor, ironically, because my dad was a doctor, and I found it hard to follow in his footsteps. But with every passing year I am more grateful that I became one, and even now when I just see patients a half day a week, and very few patients at that, I still hope that I'm becoming a better doctor every year. Frankly, I've always found it hard to measure up, to really be good enough. But I guess there's nothing wrong with having high ideals. In freshman year in college a guy in our dorm was so excited about his paper, “The Relevance of an Impossible Ethical Ideal.” I struggled to think about it as he raved on. That was in 1959. I think I'm seeing what he meant.

Budd Shenkin

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