Don't quit your day job

A kidney stone reminded this FP of his important work in clinical medicine.

By Gil L. Solomon, MD
Family Physician/West Hills, CA

After sitting all day at a conference in New York, I was anxious to get some exercise. I had a good early morning run to the reservoir in Central Park, but an intense back pain began soon after I returned to the hotel. When lying down brought no relief, I knew I had to head to the local emergency room.

Within three minutes of my arrival at Beth Israel Medical Center, I was on a gurney in the ED, and two minutes later, an emergency physician was at my side. He agreed with my diagnosis of a probable stone and started the diagnostic attack. When the UA showed no hematuria, he ordered a CT scan that was diagnostic for a 3 mm stone in the distal ureter.

While we looked at the film, he said, "I can't recall what size stone passes easily." Since I've taken care of many kidney stone patients, I knew that stones less than 4 mm would most likely see the light of day—reassuring to someone who had to get on a plane in 24 hours.

Walking out of the hospital with my X-rays and a narcotics prescription, I remembered to come back and ask for a sieve to catch the stone. Would I have remembered it if I had spent the last five years sitting behind a desk? Would I have remembered what size stone passes easily? I don't think so.

The topic of being an active practicing physician was fresh on my mind, in light of the presentations I had heard the previous day at my conference. Many of the doctors on the panel had discussed the drift of physicians into administrative medicine, entrepreneurial ventures, or early retirement.

The panelists had also described problems with the health care system that reinforced my belief that current clinical knowledge is important. For example, a Midwestern ob/gyn told us of her difficulty finding good labor nurses. Would I one day be looking over a nurse's shoulder at a future grandchild's fetal heart tracing, making sure no mistakes are made? And when an internist discussed the possibility that the entire health care system in California could implode, I wondered if my skills might be necessary to treat myself and my family.

Administrative medicine, with its shorter hours and reduced call, may be tempting, but I'll pass. I want to know how to treat my reflux esophagitis, my Achilles tendinitis, my asthma, and my renal colic. If my wife ruptures her disk again or is considering ERT, I want to be able to advise her intelligently. And if the problem is beyond my expertise, I want to have experience with specialists to know who is good and who isn't.

Mind you, I'm not a stranger to administrative medicine. Since 1994, I'd done utilization review part time for Aetna. Ironically, when I returned from the conference, I found a letter from Aetna informing me that my services (along with those of all the other part-time advisers) would no longer be needed. A month before, I'd lost a similar job with Blue Cross of California, when the state changed its law requiring same-specialty review.

Maybe your practice is giving you as much pain as a kidney stone, but the pain may pass, just as my stone did an hour or so after I returned to the hotel. I caught it in the sieve I'd remembered to ask for. I don't know if I'll be quite so lucky with my medical conditions in the future. So, for the time being, I'll keep my hand in clinical medicine, with all its tension, thanklessness, and frustrations.

Before you decide to chuck clinical medicine, give careful consideration to whether you really want to give up your "day job." The insecurities that are part of a new career may be the least part of your worries.

 

Gil Solomon. Don't quit your day job. Medical Economics 2003;7:89.