Six Months Under My Belt and I'm Coming Up for Air

It's been quite a six month stretch. No blogging, just working. These first few months of practice have been both entirely predictable in many ways and totally surprising in others. First, the predictable: sometimes long stressful hours fraught with uncertainty about knowledge, compassion, talent and/or any number of other attributes that a competent oncologist is supposed to have. Lack of experience leading to frantic running back and forth to Google and PubMed and UpToDate in an attempt to understand what I'm supposed to be doing (all this after already 4 years of med school and 7 years of training). Some politics with dealing with referring physicians, competing groups, academic centers. And so on and on.

Now for the less anticipated things. Well, first of all, commuting sucks. It's better now that I have books on tape, but after not having to commute much for most of my life, even the 30 minute drive to my outer office is somewhat painful. I can't imagine how people drive for hours and hours when they live far out in the suburbs or exurbs or whatever it's called. I guess I should have known about commuting, but, hey, I've been locked up in one hospital for the last 7 years. Give a brother a break.

Two, I kind of like the "business" side of things. Yes, for all my railing against the system, for all my complaints about the inefficiencies of things (and there are still many, many inefficiencies), the fact is that running a private practice is like running a corporation. Whether it's ethical and meaningful and trustworthy has less to do with the inherent nature of the "industry" and more to the individuals. Enron versus Google for instance. Both money-making giants, one a lot more corrupt than the other. But, being involved in the design, structure, development and delivery of medical care under the control of your own hands is, after years under the yoke of hierarchical and sometimes nonsensical training, quite, well... refreshing. There is just something to being part of an organic process, a growing organism that you can shape so directly with your input, your attitude, your know-how. When I mean the "business", I'm not talking about money. I'm talking about the "ownership" aspect, as in "taking ownership of our own lives" kind of thing, or "ownership society" a la the hated Dubya. It's just plain nice to talk with partners about how and what we want to do in the future and just go out and do it. No grants, no blah-blahing, no kowtowing to superiors... just a small, nimble organization hoping to develop a good way of helping people and a culture of success and caring.

That brings me to number three. The money. After a month, the money becomes meaningless. Seriously. Money is kind of the thing that matters a ton when you don't have it. When I was making the $35,000/year resident salary while working 110 hours a week, I would think sometimes how it must be so nice to make a bigger salary, all the freedom, the satisfaction. How in some ways my disgruntlement at times was related to feeling underappreciated. Don't get me wrong, you make peanuts as a medical trainee, after spending your whole life studying and accumulating $150,000 in debt to go to school. It can be daunting at times. But once you make a little more money, unless you have a ton of other financial needs, the luster of it fades quickly. Honestly, my lifestyle hasn't changed a bit. I just have finally started paying off some loans and saving for the first time. It's just a little security but it really doesn't make me any happier and it certainly isn't a driving force to continue my work. The bottom line is that no amount of money makes working so hard worthwhile if you don't love it.

Number four. I LOVE IT 80% of the time, loathe it 10% and am somewhat numb 10% of the time. I thought those percentages would be different when I started. I won't tell you how different. Anyway, being a doctor is great. It is the most challenging and interesting thing ever. Far more challenging than my training. Medical training is stressful in terms of the hours spent and the insecurity of learning while taking care of generally sick inpatients. However, there was usually a "superior", someone who had both the final say and the final responsibility. Now, I am that person. It's nice to sort of know what to do, but sometimes the burden of the responsibility, especially in cancer care, is a bit heavy. Also, the paperwork... yuck. The paperwork truly is burdensome. When it's just me and a patient in an exam room, I'm in heaven. When it's this form or that, or dictate this or sign that, it's torture. Administrative issues are really painful.

Five. Politics. Not the Iraq war kind, but the medical-industrial complex kind. The there-is-a-lot-of-dinero-on-the-line kind. There is this palpable tension between doctors and the hospitals and the insurers. A strange love triangle that is unsurprisingly devoid of love and affection. I assumed there was more politics in the academic center. In a way, there is more in practice. And, it's somewhat less transparent. In academics, you have smart and not-so-smart professors pushing for glory, publications, promotions, lab space, etc. It's predictable and you can sort of understand the game that is afoot. In practice, it is a little more opaque. Yes, money is at the center, but it is sometimes hard to assess other doctors, patients, insurers and hospitals in terms of their motivations, maneuvers and manipulations. Not to get all Machiavellian, but with a lot of money on the line in medical care, a shrinking pie and some greedy folks, sometimes it's hard to know how much you have to fight to "get patients". After all, a doctor who sees no patients has no practice, and therefore has nothing. It's complicated. I'll allude to it in future blogs.

Lastly, dealing with the dreaded Pharma reps. Painful. Very. Unbearable. Yet... yet, there is some use SOMETIMES. Most of the time, you feel like you're dealing with total charlatans who sneak around plying some snake oil. But, every now and then, someone is actually helpful. They sometimes provide useful (and often biased) information on a drug or a side effect or a way of getting a drug to an uninsured patient. Yes, there is ultimately something in it for them and yes, I've had reps offer me chances to "speak on the lecture circuit" and make cash, but every now and then you have a relatively decent rep who is reasonably intelligent who is also helpful... okay, I confessed it.

So, I finished half of a year in practice. I had to go underground for a while. Overwhelmed, just processing, mentally fried. Hopefully, I'm back. Passed my boards. Taking my first vacation tomorrow. Just felt like my old blogging self. 2007 is hopefully going to be a good year. CancerDoc is hopefully coming back. There is just too much out there to talk about.