Why I left a top children’s hospital for a private office

All medical students and residents, those with any sense of introspection anyway, wonder if we (they) should be on the front lines. We wonder if we should be meeting, examining, trying to diagnose and treat families and children when we know that an experienced clinician just around the corner or in the next room could see the patient, perform the procedure faster and with more panache than our feeble skills will allow.

I remember being a senior resident in the NICU dreading the OB board. The 24 week twins, the 26 week prolonged ruptured membranes. I did not sleep and I had a lot of diarrhea worrying about those babies getting born at night when no attending was in house. What would I want for my own child? I remember the newborn with the congenital heart defect that I was so worried about I carried down a flight of stairs without an elevator ride or an incubator to get him to the NICU, impulsive, naive, terrified and maybe a wee bit justified that the well baby nursery was not the right place for such an infant. And of course there were the newborns that I intubated with more difficulty than an experienced neonatologist. Was that unethical or part of my training? I wanted to be more confident, but realistically I could not shake the feeling that if it were my baby I would want the attending not the resident putting a breathing tube in the lungs.

Fast forward to the last six years of pediatric practice in an outpatient clinic where there are no immediate life threatening emergencies. Yet I am the attending. I am the one trusting my patients, many of the them poor some with complex medical histories to a mix of transitory people: the nurse practitioner in training, the medical student, the family practice, dental or pediatric resident. Granted I see the patient after the trainees, sometimes 45 minutes after, while a toddler cries with inexperienced hands and a mother rolls her head and sighs at yet another obstacle to the care of her child. I wonder if I am doing right by my patients. I think about my jam packed schedule due to other commitments that take me away from direct patient care. I think about my son with seizures, autism, global delay and know whole heartedly that I would never bring him to a university primary care clinic to be seen by residents and medical students with a cycle time of 2 hours for a well visit.

So I flee to the private medical office, that offers maybe more in salary, reputation, and autonomy but inferior medical, dental, and retirement benefits. I no longer take Medicaid, no poor or lower working class children. No kids that were mirror images of myself and my family growing up in the rust belt. I cannot afford to as a matter of livelihood, business expense.

I imagine that I will find a better way. I will take a student or a pediatric resident in my personal office and show them how patient care is about relationships not diagnoses knowing full well that as a 20 something student I saw pathology not people. Maybe they will be more mature than I was. Maybe they will not need to have a child with a disability to see the holes in health care that I see. Maybe they will give up that potentially lucrative fellowship for primary care or at the very least see that a single payer system for all equals social justice. Or maybe they will see that a very tired, and burned out teacher sold out to private practice because the fight was too big, too distant to matter anyway.

There are two separate systems of health care in this country that break down along class lines with poor children and their mothers often receiving less personal medical experiences. Because I am no longer serving such families, it would be hypocritical for me to advise the deep pockets of free standing children’s hospitals that can with their money and influence improve the plight of such folks. I am leaving a hospital that incentivized research, education, and administration with titles and promotions. Pushed physicians to secure grants as a way of measuring their worth and “punished” them by having them work extra hours doing direct patient care if they were not fully funded. I am leaving a hospital that believed the medical home consists of the walls of a clinic open ridiculous hours where clinical guidelines and algorithms are followed and patients are plugged into one of those instead of having access to a regular provider. A clinic where those regular primary care providers were treated as if their skill can be matched my a researcher who staffs the clinic a half day a week. A hospital that diminishes experienced clinicians who prefer direct patient care because they can find no meaningful metric to assess their value.

So I’ll bury my head in the sand as a suburban doctor and find a way to volunteer as a mother and humanitarian at the local food bank, food store or church. I will bill the 99213 or 99214 for the earache, worried well, or rash and discuss vaccines and other anticipatory guidance with families that by the very nature of their education and economic status need me very little with few exceptions. I’ll finally have continuity without bureaucracy. I’ll go home to my own family a little earlier and a little less emotionally drained.

Have I sold out? What do you think?

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  • Anonymous

    I enjoyed reading your piece. As an academic ID doc, I sympathize with many of your sentiments. You have not “sold out” – I don’t believe in that concept — everyone who goes into medicine has to practice in the way that suits their personality and goals, otherwise, you will never last, nor will you help anyone. I provide primary care to HIV infected patients in a state that is very protective of this group, and I chose this clinical area largely because it is one of the few realms where marginalized patients (primarily with Medicaid) can get excellent care. I love primary care but I echo your sentiments regarding the average urban clinic setting, it is a recipe for burn-out. I see this clearly in our internal medicine practice, a giant clinic with 150 residents and major issues relating to continuity and ownership. For Attendings who choose that setting, it is important to find other outlets for personal satisfaction, because the clinical work itself is not inherently sustainable. You mention the push to teach or do research; yes some view this as a burden, but I think it is more of a lifeline, a way to balance a clinical life that very few can manage full time without burnout.

  • http://www.facebook.com/profile.php?id=1624302541 Bruce Ramshaw

    You bring up many of the flaws in our current academic health care system.  I spent eight years in private practice and eight years in academia (the last five as a tenured prof and division chief).  I quit two years ago and am now helping to start a new model of academic medicine because I believe we need a new model for patient care, for educating health care trainees and for how we do research- we are starting a patient-centered, team based approach, using the principles of systems science and continuous learning and clinical quality improvement.  I don’t think you sold out.  But, I don’t think the private practice model in our current system is a solution (but it might give you some more time and autonomy).  I wish you the best with your practice.

  • http://twitter.com/SeattleMamaDoc WendySueSwanson MD

    Of course you haven’t sold out. You’re taking care of yourself, your patients, and your family. Stop what you’re doing right now (if you’re reading my response) and go read Dr Ludwig’s piece in Pediatrics entitled “Striving for Polygamy” where he discusses the need to maintain a marriage to yourself, your family, and your career. 
    http://pediatrics.aappublications.org/content/early/2011/01/12/peds.2010-2171.full.pdf+html

    I love what you wrote; it makes so much sense to me. It’s exactly why I didn’t do gen academic peds (I knew my clinical portion of tim would never be valued) and do my clinical care with a well organized private practice. I do, fortunately, get to see patients with medicaid, though and the economic and SES diversity in my clinic remains….but I don’t get to teach and that is a huge loss to me.

    I also delivered my babies at a private hospital for exactly the same reason you mention (I too was a second/third year resident attending deliveries of ELBW neonates in a high risk academic hosp). What I wish most of all as I step back from your brave story, is that you didn’t need to maintain anonymity to feel like you could share your journey…
    Thanks for this post!

  • Anonymous

    As a graduating resident I have spent the last 2 years in my clinic were I see 90% medicaid, medicare or no insurance. I am not even seeing the billing that occurs (don’t have too, Im salaried), but I am already wishing for the day I can say goodbye to medicaid. Not for the difference in reimbursement, but the difference in patients. Occasionally I get to work in a office were the majority of the patients are commercial insurance, and I see the difference in patients. They are functional people who are working and trying to make a life. Not the 23 year old applying for disability because they have chronic back pain or bipolar disorder and claim they can’t work for the rest of their life.

    I too grew up on medicaid as a child and a recipient of food stamps while growing up and am thankful that they were there. I learned the value of hard work and want to take care of people who also value hard work and making an effort in society and in their health. Call me a hippocrit, but I too want to enjoy time with my family with as little stress as possible. I will still volunteer and help my society, but I will help those willing to help themselves first. 

  • http://twitter.com/MsWZ MsWZ

    I don’t think you should look at it as selling out. It wasn’t working for you…

    That said, you do not seem inspired in your practice.

    Perhaps that is the greater disservice to yourself and your patients?

    Keep speaking out!

  • http://www.facebook.com/profile.php?id=558041620 Vikas Desai

    a top children’s hospital will always be able to attract good docs, you aren’t the first to leave an academic clinic, i wouldn’t worry

  • http://expatdoctormom.com/ Expat Doctor Mom

    You did not sell out! 

    At this moment, you may feel like you are doing a disservice for the underserved.  You have done your part, more than most.  And just you wait, the rewards of the relationship in private practice can’t be beat.  My first 6 years in private practice led to the loveliest practice of my career. One I would have never of left had there only been 1 person to factor in the decision.

    I  ditto biotechnicality’s sentiments below

    The beauty of life is building the balance you need as an individual, wife, mother and physician so you can be the best you!

    Good luck in your journey!

  • Anonymous

    Wow, this really brought things into perspective for me. I’m not a doctor yet because I am still going to school, but I can definitely see what you are saying. I think that you did the right thing leaving. It wasn’t working out and you can’t push yourself to do something that you know isn”t right.

    Good luck with everything