Congratulations! You are an amazing group of young men and women. In college, medical school and residency your dedication and discipline, but most of all your idealism helped you to persevere and conquer some difficult challenges. In college, your friends studying philosophy and literature and history wondered how you had the endurance to study biochemistry and organic chemistry and calculus. Not to mention the Krebs Citric Acid Cycle.
You studied hard because you knew that you would be competing with hundreds of other dedicated over-achievers for a limited number of seats. Some of you attended foreign medical schools and faced tremendous challenges learning a new language and accommodating to a new culture. What idealism that must have required!
In medical school, anatomy was not as bad as you had imagined, but the basic sciences were grueling. A few of your less idealistic colleagues succumbed to the pressure and quit. When you saw your first patient with an acute abdomen, you were scared. Was it appendicitis or diverticulitis or just a virus? It was your idealism that inspired you to choose primary care. You liked the idea of connecting with your patients and working with them for a lifetime. You persisted even though some of your teachers told you that primary care was a dying field, that it had no prestige in the medical hierarchy. Their words hurt but they didn’t take away your idealism.
During residency, you pulled it all together. Each year you grew more capable. Pneumonias, myocardial infarctions, asthmatic cases, acute abdomens all surrendered to your clinical skills. You didn’t see very many primary care doctors because your hospital probably used hospitalists. You wondered about all those warnings you had heard about choosing primary care. But your idealism came to your rescue.
Well, now you are now full-fledged primary care doctors!
As you make your way don’t lose that idealism that kept you going. Honor it. Your idealism will give you comfort in the days ahead as economic pressures threaten the humanitarian impulses that inspired you to become primary care physicians.
Many of you will be working in health systems controlled by hospitals or in large medical groups because it is almost impossible for young doctors to set up their own practices. Buying computers and information technology is expensive. And learning how to deal with different insurers’ guidelines is almost as bad as organic chemistry.
Working in a large organization will give you great sense of security. Nurses, office space, billing services, quick access to imaging and laboratory facilities will all be provided for you. Even malpractice insurance. But there will be a price to pay. You will be paid according to your productivity. The more patients you see, the more you will get paid. You may not be able to spend the time that you wanted with your patients. And the pressure to “produce” will seduce you into substituting CAT scans and laboratory tests for the simple act of talking. Although this may bother you at first, the house that you and your spouse are thinking of buying will try to push aside the voice of idealism. But keep listening, so far your idealism has been your best friend.
As time passes, your practices will get busier. The number of lab tests, visiting nurse and home health care agency reports, emergency room reports, surgical reports, requests for prescription refills, requests for chart reviews by insurers and quality assurance organizations, and many other requests for information requiring your attention will take up more of your time. You may find that you can negotiate with your organization to let you see a limited number of patients so that you can practice the kind of primary care that you dreamed of while training. But instead they may give you a nurse practitioner or physician associate to see your less complicated cases. This will keep productivity up while you will be seeing your sickest patients. Though this isn’t what you expected primary care was going to be like you will be told that actually it is the “ideal” model of primary care. If you don’t believe it then fight to make things right. Your idealism will help you.
Somewhere along the way you may get entangled in a malpractice suit even though you have done nothing wrong. This will probably be a life-changing experience for you, leading you to question the noble goals of medicine and the logic of the legal system. When the suit has been settled you will probably have second thoughts about how you criticized doctors who practiced defensively. Don’t let the experience sour you forever. Instead, channel your frustration into making the malpractice system better. A colleague who has been through the litigation process can be a great source of strength and comfort.
Most of all realize that you have a life outside of medicine. Find something besides medicine that interests you, and that will broaden your understanding of the world outside of medicine. It will make you a better person and a better doctor. Tap into that idealism that gave you strength all through your training.
Finally, spend some time in medical politics. Your state and county medical societies, the medical profession need your help. Without it they are not as strong as they need to be. Don’t believe that doctors cannot push back against the forces that are against them. They can.
Keep your idealism alive and use it to protect all that you thought primary care should be.
Edward J. Volpintesta is an internal medicine physician who writes in The Yale Journal for Humanities in Medicine.
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