So, would you do it again?

(I felt Doctor Signout deserved a more complete answer, so here it is.)

I’m surrounded by cynicism. Doctors make particularly good cynics (although not always the best skeptics). Why are we cynics? Pehaps because we see human behavior in the raw. On a daily—no, hourly—basis, we see people making decisions that destory their bodies. People who make good decisions end up at the doctor, but people who make bad decisions seem to end up at the a lot doctor more. Much of the pathology I see is preventable disease.

Still, doctors’ cynicism is often tempered by a good deal of compassion. I’ve seen the most hardened docs talking trash in the back office, only to moments later walk into the room of a patient, hold their hand, and find a way to reach them.

Medicine is a diverse set of professions. A radiologist can go through their career (nearly) without speaking to a patient, or can choose to spend extra time with a patient before a procedure explaining it, calming fears, in short, being a doctor. Other fields, such as mine, are dominated by interpersonal interaction. In the past, these interactions made up the bulk of useful medicine, as the “medical stuff” didn’t actually do much. The last few decades have seen remarkable advances in preventing and treating many of the big killers. In the past, it was the surgeons who perhaps had the best shot at saving a life. Now, we internists share that glory.

Before the discovery of insulin, diabetics died—quickly. Now, we not only know how to keep diabetics alive, but we know how to prevent the vascular complications that maim and kill them. This isn’t done with a scalpel or a shot, but with our knowledge and education. We know that keeping blood sugars in a certain range reduces the risk of blindness, kidney failure, and other diabetic complications. We know that keeping the blood pressure and cholesterol of diabetics low prevents heart attacks and strokes. Performing these daily miracles requires listening to patients, examining them, and teaching them. If you want to know how the sausage is made, let’s look at a typical diabetic appointment with me.

First, the medical assistant will take your vital signs as ask you how you’re doing. Then I’ll come in and chat, and watching you and listening to you will give me valuable clues to your overall health. Do you lean in trying to hear me? Are you forgetful? Do you look uncomfortable, as if your back or legs hurt? Does your skin look good? Do you smell funny?

Next, I’ll retake your vital signs, and do a brief physical, based on any complaints you may have, and based on my needs to know how you’re doing. I’ll likely check your feet, and remind you to do the same. Looking at my diabetic flow sheet, I’ll make sure you’ve seen the eye doctor, and I’ll make sure I’ve checked your labs. Then I’ll ask the medical assistant to step in and take your blood and urine. If you have protein in your urine, I’ll likely adjust some medications. If your blood pressure isn’t at goal, another adjustment. If you’ve gained weight, we’ll talk about how to drop it. All this and more goes into a typical “brief” visit. If you and I do this right, we can drop your risk of complications dramatically, literally saving life and limb. I can typically collect about 80-110 dollars for this.

If I clean out your ears instead, I can get about $90. No limbs saved, no kidney’s rescued. But the wax will be gone. And it’s fast.

Which leads to the reason that a fraction of U.S. med school grads (about 2%) are going into primary care—lots of debt, lower pay.

The financial stresses of being a young doctor (including starting a practice, having a family, caring for patients, etc.) are tremendous, and are system pushes the talent away. Still, for people who love medicine, love other people, love to wake up every morning knowing that you are making a concrete difference, the sacrifice in time and money is worth it.

I suppose I consider myself a “compassionate cynic”. I have a realistic view of human beings, but since I know that people are imperfect, I am less likely to be judgemental. Sure, our system is strained, and until we fix it we will continue to have to import our primary care talent. But even with its flaws, I love internal medicine too much (and perhaps have too much invested) to doubt my decision to do what I do.