Young Doctor Award

2002 Writing Contest

My longest year

When the realities of modern medicine wore him down, the author gave up his dream of private family practice.

By John A. Vaughn, MD
Family Physician/Columbus, OH

Shortly before I abandoned my calling as a family physician in private practice, I saw a nice new patient who had problems with gout and hypertension. She'd been referred to me by her son. The visit was just what family medicine is supposed to be: I started her on medications, reviewed the preventive health measures she needed to follow, and asked her to schedule another visit in two weeks. Although I'd still be at the practice when she returned, she made her follow-up appointment with one of my partners. "Might as well," I overheard her tell our front-desk clerk. "He'll be gone shortly anyway."

Thus began the last month of my longest year.

Things will improve, we convince ourselves

That January, I'd joined the group with an enthusiasm for family practice that residency had almost drained out of me. Two friends had bought the practice from a retiring physician. After two years, they were ready to expand—and I was thrilled that they'd asked me to be a part of that expansion. What better way to start my career, I thought, than with close colleagues who shared my philosophy of medicine?

We moved into larger office space, and things were great, despite my need to moonlight to supplement what was still a part-time salary.

Together, we scanned old charts the retiring doctor had left behind. By now, his progress notes had the faded look of old skin—as if they, too, had aged along with the patients they described. The level of documentation was equally reminiscent of another age. Notes on an entire visit consisted of nothing more than "Cold. Penicillin" or "Rash. Not significant." Reading a 1958 radiology report made me feel like a medical archeologist— as did looking at a bill, written in the physician's own hand and dated sometime in 1977. For six visits, the total came to $88. How times had changed! Together, my partners and I would usher the practice into the modern age.

In March, we had our first lesson in the economies of scale. Although we all worked part-time while waiting for our schedules to fill up, we had full-time malpractice policies to pay for. The move to the larger office had also increased our rent and staff costs. With patient volume stagnating, even the part-time salary I'd been guaranteed became a financial burden on the practice. We were hemorrhaging money.

We tried sending out change-of-address notices to our existing patients. When that failed to generate new business, we decided to call in consultants who specialized in health care marketing.

Our meeting with them could be best described as a comedy of errors. We dismissed their ideas as either too desperate (thank our patients for choosing us as their physician, and let them know we'd appreciate any referrals) or too surreal (what exactly is a "media event"?).

So, like patients who don't take their medication because they don't feel sick, we ignored the problem.

I'm making less than the delivery boy

Things didn't improve. July rolled around and our financial situation was as grim as ever.

Colleagues outside the practice urged me to jump ship, but I refused. Not only had I convinced myself that volume would increase, but I wanted to be loyal to partners who were, after all, also my friends. I simply couldn't stand the thought of leaving them, not after they'd gone months without a salary so they could pay me. Instead, I decided to refocus my energies on building the infrastructure of the practice. I would have to continue moonlighting, of course, but I was committed to making things work.

In November, however, my part-time salary guarantee was rescinded. The practice could no longer afford to pay me, our accountant said. The cut would reduce my monthly net income by more than two-thirds. Suddenly, I faced a fear I'd never expected to face as a physician: not being able to pay my bills.

That fear was accompanied by an overreaching anger. I was angry that, after amassing an enormous debt during seven years of medical school and residency, I made less than the kid who delivered our lunch. I was angry that the physicians who'd preceded us had been unable to maintain the autonomy and income necessary to pay for that training. I was angry at the health insurance system that had trained patients to demand health care as a right, but had taught them that it was worth only a $5 copay. My partners and I had done everything that medicine had asked of us, but we still couldn't make a living.

Then a colleague who owned another practice told me that he was looking for a partner. I expressed an interest, but didn't say anything to my partners for several reasons. First, I still clung to the hope that, despite everything, we could make the practice work. Second, I needed my malpractice and health insurance. And third, I hadn't decided whether the move was a good one. Why repeat the same mistake there that I'd made here?

And so I felt guilty that I couldn't help my current practice, and guiltier still that I was thinking of leaving it.

Nostalgic for a time I never knew

In early January, I received a letter that resolved my dilemma and finally brought my longest year to an end.

The letter, from our accountant, asked me to reimburse half the cost of my malpractice premium, since the policy covered my moonlighting as well as my work for the practice.

I was furious. Certainly, we needed to control costs, but asking me to pay for something that I did in order to be able to work at the practice seemed patently unfair. I refused, and the matter was quickly dropped. But I knew that the relationship between my partners and me would never be the same again.

By month's end, I'd left the practice and accepted a salaried position in urgent care with a large group practice. Initially, I viewed the move as an acknowledgment of my personal failure—a fall from the true faith of Family Practice.

But I now know that I haven't abandoned my calling so much as my calling has changed. I have learned to respect the financial side of medicine. I have learned that medicine is neither personal nor a business. It is a personal business and by acting like it was more one than the other, I put myself in a terrible state.

My view of medicine at the beginning of this long year seems as distant to me now as those old charts once did. I view them with less condescension and more nostalgia than someone my age should have. I'm jealous of the old family doctor and his certainty that he could capture his patients' lives in blue fountain pen ink. In their abbreviated way, those notes say something more truly personal than today's most advanced electronic medical record ever could.

But I also realize that I am not as different from him as I once thought. Like him, and like doctors of every age, I've adapted to the world that I practice in—and take care of my patients the best way that I can with the tools that I have in the world in which I live.

Enter the 2003 Doctors' Writing Contest

 

John Vaughn. My longest year. Medical Economics Mar. 7, 2003;80:59.