Goodbye to all of that

For what it's worth: it's never too late or, in my case, too early to be whoever you want to be. There's no time limit, stop whenever you want. You can change or stay the same, there are no rules to this thing. We can make the best or the worst of it. I hope you make the best of it. And I hope you see things that startle you. I hope you feel things you never felt before. I hope you meet people with a different point of view. I hope you live a life you're proud of. If you find that you're not, I hope you have the strength to start all over again.

Eric Roth  The Curious Case of Benjamin Button


"I would like to focus on my international work."

That was the talk track, the explanation I gave when people asked why I had resigned from my job.  It is a respectable explanation, one that makes people feel good. If you repeat something enough,  everyone, including the speaker, starts believing it.  While the statement is true, it is incomplete.  The decision to leave my job was much more complicated and difficult than the talk track would imply. The fact that I left without any definite future employment shows how untenable the work situation had become.

On my last day the orthopedic staff and physicians gathered at a local Tex-Mex restaurant for a farewell happy hour. My mood was a bit melancholy as I reflected on the previous 2.5 years. I had been so optimistic when I joined this practice.  I hoped that this would be my last job. I could finally do what I trained for, namely to focus on hand surgery, to be in charge of my staff and schedule, and to make enough money so that I could work in the developing world every couple of years. Malcolm Gladwell in his book Outliers talks about the three things people need to be satisfied in their job: doing complex tasks, having autonomy, and feeling properly compensated for their efforts. In my practice I lost autonomy over my schedule, my staff, my time in the OR. I was told how many patients to see, when to see them, and how I should always say “yes.”   And I was starting to dip into my savings.  At the end of two years, I was 0 for 3. That’s when I realized it was time for me to go. I figured if I was working for free, at least I could do work that was satisfying to me. 

At the core of why I became a physician is a very simple desire:  I want to help people. Becoming an orthopedic surgeon meant I could fix limbs, alleviate pain, restore function, and quality of life. Over the last 15 years of clinical practice, my very particular set of skills have become obscured by layers of less impressive skills. There is the charting, dictation, billing/coding, legal work, paperwork,  and emails taking up several hours a day, after I am already exhausted from patient care.  I need to worry about payor mix and poor reimbursements, which do not nearly compensate for the baseline level of risk and stress.  There is the threat of malpractice, the surgical complications, the severely injured or unhappy patients.  There is the emergency room call, with its unpredictability, and impact on schedules and sleep.

At least with call patients, I was treating real emergencies such as infections, fractures and lacerations. The vast majority of patients I was seeing in clinic did not have surgical problems. As primary care physicians are increasingly pressed for time, and often inadequately trained in orthopedic issues, they sometimes refer anyone with a musculoskeletal complaint to a sub specialist.  Patient visits thus revolve around managing pain issues and expectations, instilling coping mechanisms, and minimizing catastrophizing behaviors.  While I am qualified and competent to provide behavioral health counseling, it can be emotionally draining when it constitutes the majority of my practice.  All these above-mentioned factors feel like death by papercuts (or mosquito bites, or any other seemingly minor insult, which when compounded, becomes quite intolerable).

Almost every physician I know is considering making a change.  Whether working fewer hours, retiring early, or leaving the practice of medicine altogether, doctors are doing what they need to do to survive.  There is much talk of work/life balance.  There are entire courses devoted to physician wellness, or the non-clinical practice of medicine.  It truly is a public health epidemic.  I do not pretend to speak for all physicians, however.  I can only share my experiences.

What lies ahead is still unknown.  I am fortunate to have the means and opportunity to take a break.  The Buddhist term "bardo" refers to the intermediate state between death and rebirth.  It can also refer  metaphorically to times of suspension or transition.  This state of being is both frightening and exhilarating (think of standing on the precipice of a cliff).   It is with gratitude for this precious time that I will proceed.  I have increased my journaling and meditating.  I have been reading more, which is my default coping mechanism in times of uncertainty.  I have enlisted a career coach to help reassess professional and personal goals.  He encouraged me to blog.

In the immediate future, I plan to teach and work overseas. I will be heading to Malawi in August, and Myanmar in October.  I will work as a consultant for chart reviews and independent medical exams, on a limited basis.  I may do locum tenens work when I return from my travels abroad.  In what capacity I will return to clinical medical practice in the US remains unclear.  I still love being a physician and a surgeon.  I just need to create a life where my vocation can sustain me.