I’m writing this breakup piece about my relationship with medicine more than a year after pulling the trigger, because yeah…it’s taken me this long to process it. I hope that having given the whole ordeal some time to percolate will result in me providing a thoughtful and balanced post-mortem. But, as I haven’t mapped out this post and am simply going stream of consciousness, I can’t promise that it won’t devolve into more of an Alanis Morissette, You Oughta Know-esque rant, similar to my 2017 post that struck a chord with thousands of doctors: Top 5 Reasons Why Your Doctor is Quitting.
In what is likely to be an in vain attempt to inoculate myself against the inevitable criticisms of trolls, let me be clear: I’ve been extraordinarily fortunate to have had a remunerative career in medicine which, combined with a long period of frugal living and an even longer bull market, has granted me the freedom to walk out the door displaying a third-finger salute to Admin. I also admit that there’s much about the job that I love and miss very much: those light-bulb moments when a patient suddenly grasps a concept about her body that’s been mysteriously elusive for years; the intellectual stimulation; discussing tough cases with peers; the unusually incredible nurses, dietitians, and medical assistants in my old department…I’m sure there’s more.
But reality is reality, and at the end of the day, none of that was enough to make the job suck less – or at least be tolerable enough to keep me hanging on any longer. So what happened? How did my practice of medicine scuttle along the spectrum from noble calling to painful day job in significantly less time than what would ordinarily be considered a full career?
Remember the good old days?
This isn’t going to be some Pollyanna-ish exercise in revisionist history, contaminated by recall bias and selective memory.1 No, there were indeed many frustrations at the beginning of my career that have consolidated the belief that my generation has completely missed out on the Golden Age of Medicine: before the insurance company tail was allowed to wag the practice of medicine dog; before the pressure to “produce” was allowed to supersede quality; before administrative bloat was allowed to proliferate and procreate like Gremlins splashed with water, driving the insatiable demand for more revenue; and before an obsessive focus on decreasing expenses led to a practice environment in which a bad outcome due to insufficient resources had become a matter of “when” as opposed to “if.”
All that said, I was reasonably happy with my practice in the early days. Along with another endocrinologist, I was building a department more or less from scratch. It wasn’t unusual for referring colleagues at our multi-specialty group to tell us, “It’s so great to finally have a solid endo department.” When we needed logistical help, it wasn’t all that hard to walk into the Chief Medical Officer’s office and request it. My partner and I were treated like the professionals we were; if we needed to close our schedules for an hour or two to take necessary meetings elsewhere in the clinic, we did just that, without an expectation that we would “make up” those hours later.
Don’t get me wrong – there were initial signs that the outpatient treadmill might not be perfectly suited to my preferences. I realized fairly early in my career that long days of seeing patients every 20-40 minutes are a fairly exhausting endeavor; I was a bit worried that I wouldn’t last 30 years at that pace. I know there are doctors who can do this, all the while feeling blessed that patients have entrusted them with their lives. I’m just not one of those doctors. Yes, I felt blessed. But damn, there’s a lot that needs to be accomplished in those 20 minutes, and it can feel like a race against the clock when one values staying on-time.2 Plus, I sometimes buckled under the weight of my patients’ (occasionally) crushing and unreasonable expectations of what I could do for them.
In what is sure to come off like a humble brag, I am partly responsible for cultivating a practice that encouraged the referral of tough cases which strained the capacity of my empathy well. Primary care doctors and other specialty colleagues knew I was very good at telling people what they needed to hear, as opposed to what they wanted to hear. And I could often do it in a way that left people feeling like the visit had been productive, even if I didn’t provide all the answers they wanted. Hormones Demystified blog haters will surely be shocked that I could be so delicate, given my bull in a china-shop style in some previous posts. But I guess I’m just a pervert for nuance.
Organizational growth leads to bad things, every time
The above statement is probably hyperbolic, but I simply don’t know of any medical group that has experienced rapid growth, yet continues to function efficiently with happy doctors, happy staff, and happy patients. Perhaps one exists, but until someone can prove it to me, it’s Sasquatch.
As my multi-specialty group grew, it outgrew its original horizontal administrative structure. And thus we embarked on a lengthy, quixotic quest to reorganize the organization in a way that made sense and could address the myriad needs of a sprawling medical group. Spoiler alert: they’re still at it. If you’re interested in revisiting that painful era, I wrote about it at length in How to Kill a Medical Practice.
Ultimately, our financially struggling group was bought, then sold and bought again. Many – if not most – U.S. physicians reading this will have either gone through such a process or be working for a group that has within the last 5-10 years. Having gone through it twice, I had a front row seat to the same movie the second time around.
We all remember the Bill Murray classic Groundhog Day, in which the protagonist wakes up each day and realizes he is reliving the same day ad infinitum. See where I’m going with this? The sad thing about this analogy is that, while Bill’s character eventually capitalized on his plight by learning a ton of new skills and becoming a better person, my organization learned very little from two separate acquisitions and became a progressively more dysfunctional beast and an even worse place to work.
Actually, let me amend that last statement: I think there was a lot of learning going on, but it could be divided into two categories, neither of which had the potential to make the practice of medicine tangibly better. I would file the first type of learning under the heading, “fatalistic learning.” Many of us had been sitting in leadership meetings for years by this point, where our charismatic and earnest Chief Medical Officer would tell us some version of “salvation is just around the corner,” and she would be just convincing enough to bolster morale for another few weeks. And then we would dutifully report back to our colleagues that yes, times are tough, but there’s a plan, and we’re going to keep plugging away in service of executing that vision.
I think I was one of the earliest disgruntled physician leaders to realize that we were powerless to fix the most broken aspects of the system and things would never get substantially better – ever. Eventually, many others succumbed to the same fatalistic outlook, which of course trickled down to other doctors, nurse practitioners, and clinical staff.
I’m sure that Jocko Willink would have a few choice words for me at this point, and heck, he’d probably make some great points about owning it all and doing more with less. I’m not going to tell Jocko he’s off-base on this one because, frankly, have you seen this guy? Not a man with whom you want to disagree.
But the point here is: There were so many fires burning simultaneously, all the time. And when we asked for extinguishers, that request was “escalated” into the black hole of our parent company. So then we asked for a hose, and that request was escalated into the same black hole. So we asked for a few watering cans, and that got escalated. So then we asked for shovels, to start the arduous process of digging trenches around the fires, hoping to contain them, and…escalated. And on and on and on down the line, until we ran out of creative solutions and elaborate workarounds that didn’t depend on the largesse of a stingy parent company that rakes in many billions of dollars in revenue each year. At that point, all that was left to do was evacuate. So I did.
Physician and nurse leaders become collaborators
Remember a few paragraphs ago, when I said that there were two types of learning occurring at my organization? While many physicians and other employees descended into fatalism, still others turned to opportunism, as in: they saw a chance to climb the administrative ladder. While I initially hesitated to use the word “collaborators” to describe these local leaders, given I clearly don’t mean to convey a severity equivalent to the term’s monstrous historical underpinnings, I decided that the term itself describes them too well to not use it.3
It is this particular strain of leader for whom I have the most disdain, as it is the one that, instead of advocating for clinical colleagues, sold them out. These physician and nurse administrators learned that, in order to rise through the ranks of the parent company’s bloated bureaucracy, all they had to do was tell their direct superiors whatever they wanted to hear. If there was any initiative afoot that physicians were sure to hate but Admin wanted to implement, Admin just needed a few well-placed collaborators to exert some downward force. Those leaders’ actions helped their superiors check that particular box, which would lead to the superiors’ superiors being able to check that box, and so on up the chain. Hearty back slaps and bonuses for everyone!4
This dynamic necessarily led to the impression that these physicians and nurses – with whom we used to work so closely and have mutual trust – now viewed us as problem children who needed to be disciplined into obedience. One particular physician administrator/clinician was fond of exclaiming, in leadership meetings, “We have to hold their feet to the fire!” This haughty, tone-deaf, unsympathetic attitude toward physician colleagues was not uncommon among the leaders being rapidly promoted.
Another nurse administrator, with whom I had worked closely for years and liked very much (still do!), was the wall off of which all requests for additional clinical staff bounced. While I understand that he was executing what he believed to be the organization’s orders, I was incredibly disappointed that he believed (still does!) that our clinical staff just needed to work harder to cope with an electronic in-basket that routinely had a couple hundred untouched items at the end of every day. Never mind that we were regularly losing staff because our department had become an exceedingly difficult and frustrating place to work. Never mind that we had patients waiting 1-2 weeks for a response to their emails, phone calls, and refill requests (the lack of an obvious bad outcome being due more to luck than anything else). Never mind that the department’s clinicians begged administrators at all levels of the group for help, offering specific examples of how precarious things had become. No, we were told that in order to get more help, we would first need to show that we could generate more income to help pay for that help.5 I know it’s subtle, but does anyone else see the catch-22 here 🙄?
When managers are valued more than clinicians and clinical staff
Managing any clinical department at my group is a very, very difficult job, as should be obvious from everything I’ve written thus far. The best managers – who may or may not have any prior medical training (e.g. medical assistants) – are skilled at making their front-line staff and clinicians feel heard and supported, even if the manager can’t deliver on a given request. And then you have my department’s manager, who presided over the worst period of tanking morale and staff turnover that the department has ever had.
This manager is a very smart person with good intentions, who nonetheless never should have been permitted to manage people. Rigid thinking and lack of empathy may work well in the accounting department, for example, but not in the realm of clinical care. One former medical assistant – one of the best with whom I’ve ever worked – regularly told me that dealing with this manager was so painful that she would have quit long before if it wasn’t for the great working relationship we had with each other. Yeah, she eventually quit. I couldn’t blame her, nor could I do anything to crowbar that manager out of my department.
Against all odds, I actually found another medical assistant who was smart, motivated, curious, efficient, and great with patients – another unicorn! What were the chances? We must keep her happy at all costs, right? Especially since there is a regional shortage of MAs, right? You know where this is going…
By this point, I was hanging on to my clinical career by my fingertips, like Tom Cruise hanging off a cliff, building, or helicopter skid in…literally any action movie in which he has starred. I had cut back significantly on my time in the office and was already doing some non-clinical work elsewhere. As an aside, in discussions about physician burnout, I’ve often seen the recommendation to “go part-time.” I agree it’s a good option that can prolong career longevity in someone who is otherwise ready to pack it all in. However, what’s missing from the conversation is the fact that there’s a parabolic (basically an upside-down U) curve with the y-axis representing how well the part-time gig is functioning and the x-axis representing how far back one has trimmed one’s practice hours. Essentially, what I’m saying is that being in the office two or three days per week can work. But as you get closer to just one day in the office, you start to realize that your patients’ problems and requests don’t necessarily conform to your limited availability.
To that point, I realized that I wasn’t doing the best job of promptly servicing my patients’ needs. But the combination of patients regularly imploring me to not quit and a great MA who was holding my absentee practice together with Scotch tape made me feel unready to leave. And then I returned from a vacation only to learn that my MA was jumping ship because our manager wouldn’t work with her to make a few reasonable accommodations in her schedule.
Straw? Meet camel’s back. It sounds ridiculous to say that I ended my clinical career because my MA left. And I hope that you can see it was so much more than that. But in that moment, when she told me she was leaving, I knew that I was mentally done – done worrying that our backlog of phone calls would lead to a bad patient outcome and a lawsuit; done running on the hamster wheel of production; done with non-value add managers being valued more than physicians who generate the revenue that keeps the lights on; done being beholden to a schedule that felt increasingly suffocating despite being pruned almost to the roots; done working somewhere where I not only had lost the power to make decisions but also the ability to even influence the department’s operational dynamics.
Many of you will understandably want to know why I didn’t find a better clinical job or start my own practice. With respect to the former, I started looking around several years ago (in my area only, as I love where I live and have no desire to leave). What I found is that the grass isn’t greener anywhere else; it’s just a different shade of brown. I did find one enticing opportunity that would have allowed me to incorporate more teaching/mentoring into my practice, which would have been a huge positive. But the position required that I build significant infrastructure at an outpost of a larger institution and, frankly, I didn’t want to allocate my energy reserves to banging my head against that metaphorical wall again. Plus, if I’m honest, I’d spent many years building something great, and it was taking me forever to truly accept that it had morphed into something that no longer resembled what I had built.6
As for starting my own practice…perhaps if I had read the tea leaves better, I could have done that 10 or so years ago when I was still full of vim and vigor. At this age and stage of my career, however, the barriers to entry are simply more than I care to take on.7 Before we get off this subject, I do believe that the pendulum must swing back toward fragmentation into small, private practices, in order for physicians to reclaim their autonomy and the joy of medicine. Anecdotally, I am aware of many primary care doctors and some endocrinologists who have hung out their own shingles and are much happier for it (despite the host of headaches that comes with running your own practice). Can the juggernaut of ever-increasing consolidation be corralled by a few cowboys and cowgirls striking off on their own, here and there? I’m not so sure. But I can say that working for a large hospital system, corporation, or private equity group will often lead to burnt out physicians retiring early or – even worse – wishing they could retire early.
What does the future hold for me and – for those of you who care – Hormones Demystified? I’m going to leave this one as a cliffhanger, as I think there’s a lot more to say, and I’m well past 3000 words deep into this post. You may just need to wait for Hormones Demystified – the book. Or better yet: Hormones Demystified – the Hulu original docudramedy starring Ryan Reynolds as yours truly…
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Image Credit: Photo by Arny Mogensen on Unsplash
- Yes, I know that all such recountings will, almost by definition, be subject to recall bias and selective memory. I can only do my best, and that will have to suffice.
- I am notorious for being über-punctual.
- But just to be extra, extra clear, for the hypersensitive folks out there who think I’m equating these folks with Nazi collaborators, I am not doing that. That type of catastrophization would be absurd and I would never do it.
- Let me be clear that I do not know the extent to which leaders received bonuses for operating income-improving measures like starving their respective departments of human and financial capital. Even if they weren’t directly incentivized with cash, it was entirely obvious that leaders who could advocate effectively for Admin would be promoted over leaders who chose to advocate for their colleagues.
- This was made even more frustrating by the fact that our department had a respectable operating income for an endocrinology department; it just didn’t meet Admin’s arbitrary and somewhat unrealistic target.
- Even though my good friend over at Reflections of a Millennial Doctor had told me, “HD, your practice is no longer what you built. You need to accept that.” Despite the fact she’s a millennial, she occasionally says something very wise.
- Such barriers include but are not limited to: the Herculean task of dealing with insurance companies as a solo practitioner (unless one decides to not accept insurance); setting up an electronic medical record and billing system; hiring and managing staff or a virtual assistant; advertising and search engine optimization; networking; and finding coverage when on vacation.