What am I doing in medicine? That is a big part of what this blog is supposed to be for. Most conversations on the topic lead to a superficial answer. I’m exploring the real answer for myself. Part of it is circumstance of course. I mean, I can look back at the times I made decisions that led me in this direction.

Yesterday I was seeing patients in clinic and staffing with one of my favorite preceptors. An absolute role model if there ever was one. She’s caring, thorough, thoughtful, patient, and she has also shared that she’s burned out and she knows there must be a better way of practicing than through our current system. But anyways, there we are. I had already seen 5 patients, and one or two of them had already significantly delayed me, or somehow thrown my mojo off to the point that I was looking to get in and out of those last 2 rooms. I was trying to do what I believe our system encourages us to do which is to put patients into boxes, label the diagnosis and prescribe a medication. Intellectually I’m a critic of this process, but practically I work in this system so sometimes it’s best to resign myself to the process.

So I had this gentleman who was in is 50s there to establish care. He’d been trying to lose weight and was interested in trying a medication that a friend had recommended, phentermine. He has been having outbreaks of herpes and needed a medication refill. He had a rash on his shoulder that I peeked at and believed a steroid might help. After trying to cram his complaints into the little boxes I stepped out of the room to precept and I went to this favored preceptor for the first time that day. And as I told her the story, she had more specific questions that I didn’t have answers to. How often did he have herpes outbreaks (should he be on a daily vs as needed medication)? What else had he been trying to do for weight loss? And maybe I could do a little more reading on the drug and get back to him. What were the other symptoms of the rash? Was he using any new products that could be responsible? (Is he having a contact allergy?)

These are good questions and she is a good doctor. These are questions I am capable of asking, but ones that I did not. I am (still (always))learning, and I am glad to have this great preceptor pushing me a bit. Many times my experience “precepting” is just whizzing through the story and it’s like a check off process, no learning, just a formality. But at this moment I was getting so much feedback that I was feeling demoralized. I was recognizing that I don’t like providing medical care. I don’t like asking so many questions and being so thorough. Even though it’s the right medical care, I felt like the wrong person for the job. I just wanted to get through my day and get myself home.

And so it comes back to “Why am I on this medical route?” I plan to continue on for another 10 months and end up with a board certificate in family medicine. But I don’t actually want to be a family medicine provider. I do not want to work in primary care.

One practical part of the answer is loans. I borrowed a lot of money, and I’ve yet to put a dent in that debt. I have had this idea, one that I haven’t shared too much, which is that part of the value in being “highly trained” is the capacity to earn a high wage. My goal is not to have a huge income, but to have a flexible life. By earning a higher wage, I have thought that I could work fewer hours. The logic of this is simple, but the practicalities of working less in the field of medicine are not so easy. Part of that is the medical culture. Many employers are looking for full timers, and they want you to take call and on and on. There are exceptions of course, and I will likely end up exploring those exceptions. Like locums for example…

I still believe that I AM in the right place when all is said and done. Residency is hard. The modern medical system stinks and primary care is dysfunctional. But primary care is also necessary. And so that creates this position where I am getting the skills to do this broken job, and I want my work to be in the direction of making it better. I value meaningful work, and the fact that my day-to-day duties often feel to be a means to an end is just one of the many reasons why this route is so difficult.

I have this interest in what I have been thinking of as “radical medicine”. By radical, I mean “striking at the root of things.” And in this view, I do start to wander from mainstream medicine into alternative. Because in my view, the roots are behavior patterns and psychological processes. In my dream clinic, I aim to empower. The work I aim to be doing is partially intellectual in processing the available evidence, and it is partially compassionate or empathetic “work.” It is spending time with people with presence. And I think to do this work I need to build a new model. A 99213 code sent to an insurance company is a box that it’s time to break out of.