Adventures and lessons from my first years in practice
This article is the sixth of a six-part series, written in the hope that it will be useful to those who are considering or preparing for a career in medicine, and at least entertaining and uplifting for the rest of you:
- First Decisions: Deciding to become a doctor
- Apply Yourself: Undergraduate studies
- The Academic Eating Contest: Medical school preclinical years
- Academic Vertigo and the Identity Crisis: Clinical rotations and specialty choice
- Keep Your Nose Above Water: Surviving residency
- Living the Dream: The transition from training to practice
During medical school orientation one of the speakers gave us all a piece of paper and told us to draw a picture of ourselves in the future as a practicing doctor. This is what I drew. When I showed it to my wife recently she laughed out loud. “The misshapen head! The baldness! It all speaks of being terribly misused, for years,” she said. (It also speaks of my primitive drawing skills; necks are optional.) It is true that a lot of my hair fell out during my medical training, but I suspect that most of it would have fallen out anyway, and thankfully my head did not become deformed. But residency does take its toll on your life in the neglect of your personal relationships, hobbies, health habits, and everything else which is not directly related to your work. This last part of the series will discuss the process of trying to put your life back together after the trial is over.
It is a bit weird to act like a real doctor for the first time. That imposter feeling I described in the last post will hit you pretty hard the first time you make a patient care decision or perform a procedure without supervision. My first working day as a fully credentialed neurologist was in the EMG lab, and I remember how it felt to stick a needle in someone’s muscle for the first time without an attending physician looking over my shoulder. Residency teaches you how to project confidence even when you don’t know all of the answers, and that skill will definitely come in handy during this transition. During your first few months in practice you will learn many things that are just impossible to learn as a trainee. This is an exciting time!
Seize the Reins
Altogether I spent twenty-six years of my life in formal education, starting with Kindergarten and ending with my fellowship in neuromuscular medicine. Half of those years were after high school. Graduating doctors have spent the vast majority of their lives as students, and the thought of going out into the real world can be quite intimidating.
Formal education conditions us to be somewhat passive about our working conditions. Every new phase of training has different rules, which we quickly learn, and we become masters at doing what we are told. When we finish our training it is only natural to look around and wait for someone to tell us what to do next. But this is your opportunity to finally decide your own way! You have the prerogative to steer yourself in your career; you don’t need anyone’s permission to decide what is right for you.
Interviewing for a job is a totally different experience at this stage of the game. The medical school interviews involved begging, pleading, groveling on the floor, “Please, oh, please let me in!” But now that you are a board-certified residency-trained doctor it is your prospective employer’s turn to grovel and beg. This depends of course on what specialty you choose, and how much in demand that specialty is where you are interviewing, but you will be treated well in your job search no matter what.
I initially chose to stay in academics, more from inertia and loyalty than anything else. My colleagues in the neurology department were smart, fun, and interesting people that I got along with, and I really loved teaching residents and medical students. During my fellowship I found that medical research was pretty interesting, and I developed some database design skills that made me a useful contributor to the research in my department.
There also seemed to be a lack of other options. Doing almost all of my training at an academic hospital gave me a certain bias against community practice. I had interviewed with a local hospital, but I turned down their offer because it just didn’t seem like the right thing to do. But that’s not to say that academics ever felt like the right thing to do either. It just seemed like the safest option to take in the absence of really knowing what I wanted. Although I was confident that I could succeed in academics, and pressed forward trying to build my career, I was never entirely sure that it was where I belonged.
After two years my wife and I decided that the Lord wanted us to do something else. I described this in a previous post, but I will add a few details here because time has given me new perspective on the decision. The job I moved to is in a small town in the middle of nowhere, and I am the only neurologist for a few hundred miles along a sparsely populated stretch of freeway. Patients come from at least nine different counties to see me, and before I came to town the nearest neurologist was an hour away. When I told my brother I was going to take this job, he said, “You’re going to be the first neurologist in the history of the town? They should make you a belt buckle! They should have the mayor come for a ribbon cutting ceremony!” (Neither of those things happened, by the way.)
But I still had misgivings about leaving academics. When I interviewed with the hospital administrator at my new job I told him this, and his reply changed my perspective and my life forever. He said something like, “Do you want to make a difference in the real world? Then come here! The people in this town need you, and you can help them more by coming here and serving them than you can by publishing any number of papers.” And I knew he was right. Partly because all of the papers I published were on such narrow topics in rare diseases that no one ever reads them or cites them anyway. But mostly because I felt in my heart that he was right.
This western desert is my home, where my ancestors toiled away their lives to build Zion. My mission is to serve these rural communities, because these are my people and I am needed here. I love this land, its mountains, its history, and its people. As much as I liked my academic work, I never felt the same sense of calling or belonging in my first job.
Leaving my research behind was hard, because I had just started a really promising clinical trial which was going to kick-start my career. I had also distinguished myself as a favorite teacher among the residents, and it was hard to leave them. But my wife and I were confident that moving was the right thing to do, and the Lord confirmed our choice with a string of miracles to help us make the transition.
The Long Haul
As I wrote in a previous post, residency training teaches you that you can tolerate anything for 30 hours or 30 days. Survival mode will get you through almost anything, but only if you expect things to get better after you graduate. When you start your first real job, still limping from your residency burnout, you realize with a muted terror that you are going to be practicing medicine for 30+ years! And what if things don’t get any better at that point? What do you do then?
This is where you have to assert yourself and shape your practice to fit your needs. The goal here is no longer mere survival; it is sustainability, balance, and endurance. You can not (and should not) live in survival mode for 30+ years. Practicing medicine is rewarding and enjoyable. It should feel that way!
My favorite parable on this subject is by Dike Drummond, MD, who likened a medical career to a wild 800 pound gorilla which you have invited to live in your house. This gorilla will take over every room and eat all of your food, just as your medical career will take over and monopolize your life unless you set some firm boundaries. Finding work-life balance is essentially the task of training your gorilla. (From Work Life Balance for Doctors – Three Steps to Saying NO with Grace and Power)
One crucial point is that you probably have to change your attitude about well-being. Keeping myself (and my wife) happy is a patient care imperative. Why? I am the only neurologist for many miles, covering a very large rural area. If I burn out here, or if my wife gets tired of my job before I do, then we will move on to a different job and this region will have lost its only neurologist. That would be a tragedy for a lot of people. Taking care of yourself is not selfish, because you can’t care for others in a sustainable way unless you can meet your own needs as well in the process.
Is your final graduation the end of the tunnel, or just another window? That depends on you. Graduating residents and fellows need to spend some time learning about occupational burnout. It is true that this is an incredibly stressful occupation with a powerful dark side, but don’t just play the victim like doctors usually do on this subject! The power is in your hands to shape your own destiny. You must learn the skills to identify and manage your own burnout, because no one else will manage it for you. Dr. Drummond has some really useful resources at his website and in his book to help with time management, teamwork, efficiency, enforcement of work-life boundaries, etc. I will describe four specific things which I have found to be very helpful:
First, choose your employer carefully. Some are better than others at allowing physicians the freedom we need to manage burnout. My current employer is exceptionally good in that regard. (And we are still hiring all over the region! Contact me for more information.)
Second, have a daily 5-10 minute huddle with your team, including your front desk receptionist, medical assistant, office manager, and whoever else helps with the work of getting patients in and out of your clinic. Medicine is a team sport, and you are the leader of your team. Getting everyone to pull in the same direction will go a long way towards making your work easier and more enjoyable. I have been leading team huddles for over a year, and it has transformed my clinic in a positive way. Right now we are in the process of revising my clinic’s no-show policy, and this has been a collaborative effort with everyone giving input. Be grateful for your team and tell them often how much you appreciate their work. Remember that office support staff can experience occupational burnout too, and you can do a lot to reduce turnover of staff in your office by soliciting and valuing everyone’s contributions.
Third, you should keep data on yourself to track your progress. This data needs to be at your fingertips, not locked away in your EMR. A simple spreadsheet will do. I keep track of the number of patients I see every day, the number of notes I have left to write at the end of clinic, the time it takes me to wrap things up, and the time of day when I walk out the door to go home. Exploring this data has helped me to identify areas for self-improvement, as I will explain below. You will have your own efficiency problems, and they will probably be different from mine, but tracking this data will help you find them. It is an exercise well worth your time. (Contact me if you want to see my spreadsheet; I would be happy to share.)
Fourth, don’t leave all of your notes until the end of clinic, which is what I used to do every day. I would finish a 9-hour day in clinic and still have 5 or 6 notes to write before I could go home to my family. Note writing is less efficient and less accurate at the end of the day. When the last patient walks out the door it is really easy to waste time doing avoidance behaviors before starting in on your pile of notes. You have been working hard all day, and you deserve a break. So you spend some time eating, reading the news, or whatever, before you start writing those notes. Before you know it an hour and a half has passed and you are still not home to your family.
One day I complained to a colleague about this, and he told me that he always finishes his previous note before seeing the next patient, even when he is behind schedule. I decided to try doing that, and within a few weeks I had developed a system that worked for me. My notes became more accurate and each note was taking only a quarter of the time it would normally take to write them at the end of the day. The time I spent wrapping things up after clinic gradually reduced from 90 minutes, to 60 minutes, and then to 30 minutes over the course of a few months. Watching my note writing stats improve over time was exciting, motivating, and empowering. My wife was so happy to have more of my help in the evenings. Imagine what you could do with your family if you had an extra hour with them every day!
Revenge of the Hobbies, and More!
The return of your normal life outside of work feels like the thawing of Narnia after the 100-year winter without Christmas. For me the thaw started during the last few months of residency, after I had finished all of my inpatient hospital months. One day I decided that I would go on a bike ride, and by the end of that month I had decided to make this a regular habit. Three months later I started running, and by the end of my first year in practice I was training for my first marathon. Endurance exercise is a wonderful way to keep balance in your life, and as soon as the worst part of residency was over this was the first flower to start blooming again.
Music wasn’t too far behind. I found a software synthesizer that was fun to program, and which could be neglected for weeks or months at a time without complaining. After a few years I had finished a few songs that I liked, and I was ready to get more ambitious and record guitars and vocals again. Recently I decided to finish that album I had given up on during residency.
It is hard to take your wife out for a date very often when you have a bunch of little kids and you are crazy busy with your work. When our oldest kids became mature enough to babysit the younger ones, my wife and I started going out to eat together every week. At first we just went to a local hamburger stand and shared a shake, then quickly drove back home to make sure that the kids were all still alive. Over time we developed more confidence in our babysitters, and spent more time exploring the local food offerings, and developing preferences for some over others. One week as we were leaving the house I asked where she wanted to eat. She replied, “Well, last week I chose the Thai restaurant, so it is only fair that this week I should let you choose the Thai restaurant.” Not all of our dates involve consuming calories, or even spending money; sometimes we go hiking, biking, or running together. Sometimes our date is something mundane like going to Walmart or a secondhand store. It has been wonderful to spend so much time with this woman whom I love, and who has shared so much in the sacrifices that made our present comfortable life possible.
Some Elbow Room in your Budget
The salary at my first job was a significant increase over what I earned during training. I remember standing in the hallway at church talking to a couple of friends about a week before my first big paycheck came. “My wife and kids are swirling like vultures just waiting for my first paycheck to arrive,” I complained. “They have already planned how they are going to spend the whole thing.” Suddenly I noticed that my wife was a few feet away and walking towards me, and that she had just heard what I said! She started flapping her arms and pretended to fly towards me like a vulture, smiling and laughing at me.
The vultures decided on a trampoline, which has been a favorite toy in the back yard ever since. I talked them into buying a used one, which saved me half of the price.
For the most part we have exercised fiscal austerity, paying down our debts and saving for a rainy day rather than splurging on a lot of expensive toys. But it is really nice to have some wiggle room for necessities and emergencies. I think back to our former days of poverty and I just shudder to think of how close we were to financial disaster on so many occasions.
We still pay our tithing and trust the Lord to always provide what we need. Everything we have belongs to him anyway. The Lord declared, “Behold, all these properties are mine, or else your faith is vain, […] And if the properties are mine, then ye are stewards” (Doctrine and Covenants 104:55-56). This is the correct attitude to have, whether your possessions are great or small.
Those monster student debts had accrued (and capitalized) over $50K of interest by the time I could afford to make payments on them. Having more debt than your annual pre-tax salary is depressing, but I started to make monthly payments and over time I have seen the principal amount decrease. As of this writing I still have a lot of debt to pay off, but if I continue to make extra payments like I have for the past year I think it will be all paid off in another year or so.
I once read an interesting economic analysis about physician salaries. (The original post seems to have disappeared, but this one is similar.) The basic argument is that when you factor in the extra years of training and the enormous student loans that need to be repaid, doctors end up making about the same hourly wage as high school teachers. I’m not sure that I agree with all of the assumptions, but it definitely is true that doctors start out behind the game economically. By the time I landed my first real job as a medical doctor many of my classmates from high school and college had been working in their careers and saving for retirement for over a decade.
Last Thoughts: On Becoming
The process of becoming a doctor is long and requires enormous amounts of work and sacrifice. But I am glad that I did it. President Nelson was right when he said that those long years would come and go whether or not you use them to become a doctor. I am so grateful that I utilized my opportunities, that I succeeded in becoming what I set out to become.
President Hinckley was also right: education was the key which has unlocked the door of opportunity for me. I am grateful to live in a beautiful place, serving the people of a community who appreciate and value my work. This opportunity could not have come to me without my education.
These long years have changed the way I think about and see other people. I can understand more about how they feel, and I have a greater desire and capacity to help them. But not all of the changes are positive, and practicing doctors have to struggle against the tendency to be cynical and to lose compassion for patients.
My training also changed my perspective on what is really important in life. The smelter of residency burned away some nonessential things, and helped me see that my faith and my family need to take the highest priority.
This is a story about becoming a doctor, but it is also a story about becoming a husband, a father, a gospel teacher, and more. I have told a specific story about my career training, but the principles are generalizable to other self-improvement efforts, including our efforts to repent and overcome our sins. Whatever your situation, I hope that my story will help you see that God has a plan for you. You can follow that plan if you listen with your heart and have the courage to obey. Unexpected blessings will be waiting for you along the way. There will be hard experiences on your journey, and during those times you must keep a tenacious grip on your faith. You can become what the Lord wants you to become because he will help you.
Ultimately our goal is to succeed in life, not just in a career. All of us will one day stand before God to talk with him about what we did during our lives. I suspect that God will care very little about what my job was, and will be far more interested in how I developed my character. Do I sincerely love people the way Jesus taught us to? Am I patient and kind, or cynical and rude? Do I love what is right, or would I rather indulge in what is wrong?
Previous posts with stories from this time period: Mormon Doctoring, In Everything Give Thanks, Best Efforts and Highest Priority, Burning Out and Back Again, Is Life Fair?, Forced Family Fun (In a Jar!).
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