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.


  1. D. C. Sessions

    Some people can’t get enough.

    One of our patrollers (when he takes off the red jacket) is fresh out of the Air Force and in family practice. Ski patrol is even more poorly compensated than family practice (as in, you pay to do it.) So how come he’s already one of the ones you can count on being there even when he’s not scheduled?

    Maybe there’s a clue in our oldest patroller. He’s well past 80, and as much as we worry about him we know that the year he stops is the year he dies. There’s just something about helping other people.

  2. I’ve thought about this quite a bit, and I would definitely go into Internal Medicine again, given the choice. It’s an HONOR to be able to do this kind of work for people, and actually to get paid for it. I think there are very few things that are more fulfilling than being an internist.

    However, because we am so invested in our careers, I feel it is our OBLIGATION to fight for change and fairness. Just because a teacher loves what they do, does that somehow prohibit them from striking? I am not suggesting that we strike, but that we consider how these “prices” came to be, and why there is a certain unfairness in the system. I believe, like with all goods and services, that the only real FAIR prices are the ones set by the simple laws of economics: supply and demand. If people are willing to pay $200 per ticket to see Rolling Stones concert, then that’s how much they’ll get.

    Unfortunately, the very nature of a third party payor system, with the insurance companies or the government as middlemen, destroys the entire free market. It is now a centrally planned economy where bureaucrats sitting in some office somewhere the patient and doctor will never see, determine what they see fit to be “fair prices.” Kind of like how bread was priced in the old Soviet Union. That worked out pretty well, didn’t it?

    I feel that if patients somehow FELT the cost of these services, and they had to determine in some way how valuable the services really were, things would change for the better. Most people with ear wax would figure out a safe way to remove it at home, while patients with life threatening chronic diseases would prioritize a little better and perhaps forgo the Rolling Stones concert this year. Even if the government were to provide health care to ALL of the people who can’t afford it, why can’t they give them an ALLOWANCE of a fixed amount of money and then let THEM decide how they want to spend the money. Does Joe really need the knee replacement this year, or should he save up some funds a little, spend the money on his diabetes visits and medications for now, and get the new knee NEXT year?

    The patients having some role in the economic equation is the only way to bring any fairness into the pricing of medical services. Until then, we’re doomed to continue down the same pathway of unfairness and mixed up incentives.

  3. I’m on the reverse end of this one. I went to college sure I wanted to be a doctor. My father voiced his skepticism early but I insisted, and he didn’t want to seem unsupportive so he started encouraging me.

    I wasn’t long before I stopped liking the idea, even though I’m still in undergrad I realized I picked it because it was what everyone else was doing. I was a biology major too. In the end I realized that medicine was like anything else: A calling. You don’t choose it, it chooses you.

    Medicine rejected me, and chemistry looked down at me and said, “What are you doing over there? Come over here, the party’s just getting started!” I came. I saw. I fell in love.

    I think that a good proportion of pre-meds like the idea of being a doctor, but not much else. I was like that, and so were a few of my friends. I know one guy who’s now studying music.

    Don’t sacrifice your passions to study medicine, study medicine if it’s your passion!

  4. Tomorrow I take my wife to the endocrinologist. She has diabetes AND she has an inoperable tumor in her spine that makes her essentially a paraplegic. I’m not looking for sympathy here but if the endocrinologist gives my wife the slightest bit of grief regarding her blood sugar management (latest A1C is 7.2), then my wife will probably rip her throat out. I sometimes wonder if the Dr. understands the difficulty in maintaining a ‘perfect lifestyle’ when they can’t f#$#in walk to the toilet in time to prevent an accident.

    Sorry, just had a bad day and needed to vent!

    My $0.02.

  5. I took the MCAT twice (once on a dare, the other on a serious note), and I was in the 90% percentile. Most of the “adults” around me wanted me to go to medical school since I got such a good score. But the person whose influence mattered the most was my mother. She sat me down and told me that it would be an enormous sacrifice. Basically, she asked if I wanted to start saving the world now or later, and did I want to do it one person at a time or groups of people at a time.

    I’m into my second year as an Epidemiologist with a State Health Deparment. I love this job, but I love the work that comes with it even more. “The Chemist” spoke the truth about passions. I don’t think medicine would have been mine… Public Health is.

  6. Rogue Epidemiologist

    Ren, I’m on the other side of you. I took the MCAT twice, and also scored comparably well. I really wanted to go into medicine, but I didn’t make it because my GPA was too low. Rejections across the board.

    So I’m an epidemiologist. I like it, but I don’t love it. I get by, but I’m not fulfilled. Public health is awesome, but I really think familiy medicine or infectious disease would have been … awesomer.

    I need to go find something else to do. Maybe I’ll come back as the Rogue Optometrist or Rogue Pharmacist.

  7. Interrobang

    Does Joe really need the knee replacement this year, or should he save up some funds a little, spend the money on his diabetes visits and medications for now, and get the new knee NEXT year?

    Maybe he needs both now, because he needs to keep his job. Maybe he’s about to be fired because he can’t stand all day, or maybe because being in pain constantly from his bad knee is making him cranky all the time, so much so that even his kids can’t stand him. (Lemme guess, you’re able-bodied, right?) Maybe another year of pain from the knee will drive him into depression and suicide. Maybe he couldn’t afford to see the doctor about the knee back when it was a little nothing, and so now he needs a knee replacement that could have been preventable if he’d had the kind of preventive care you get when you have a single-payer system. Ninety percent of healthcare just isn’t a “consumer choice”; you either need it or you don’t.

    Sorry you folks don’t like paying taxes, but you get what you pay for in terms of goverment, at least if you can be bothered to elect some people who actually care about governance, instead of convincing people by example that government is always the problem and never the solution…

  8. The Blind Watchmaker

    In primary care, cynicism can come easily.

    We spent time, money, sweat and tears becoming a doctor. We have learned physiology, pharmacology, anatomy, and pathology. We have compassion. We felt like the world needed us. After years of training, we were going to save lives and make a difference.

    Then, the contracts came. You cannot see many people without contracts. I sat in a room with a stack of insurance company contracts and signed, signed, signed. I read the first one, but the last one I just signed.

    Now I was on to saving lives.

    New doctors get new patients. That means that they are changing doctors. That means they need refills on meds, many of which are controlled, addicting substances. They need referrals to other doctors. They have paperwork that needs filling out. They have prior authorizations that need to be called into insurance “doctors”.

    After 12 years of practice, I would like to think that I have done some good. Some patients even thank you. I have known many for many years. I have learned to deal with the bureaucracy to some degree. I have talked to many of them over and over about healthy lifestyles. And as their waistlines grew, so did their medication lists grow. And so did the amount of prior authorizations. And so did the amount of referrals.

    The idealism of practicing good medicine sometimes gets buried under mountains of bureaucratic red tape. But if you look under the tape, the idealism is still there. Sometimes.

  9. Speaking from the table, this patient would like to humbly thank any of you who choose internal medicine to keep people like me around. Being a type 1 kid with diabetes who grew up to become a type 1 adult (still with the diabetes–no, you don’t grow out of it and no, it doesn’t morph into type 2), I can tell you that most people like me don’t want to patronize the healthcare system any more than we absolutely have to. We live with our own care regimen every day, every hour, every minute.

  10. I am a physician in what would be considered a highly-desirable subspecialty in a highly-desirable specialty. I enjoy my job when it involves practicing medicine and surgery. I do not particularly like the small-business aspects of the work or the third-party relationships that involve insurers and the government. I resent so much of my time being taken up by these players.

    Would I make the same choice of career again? No, I don’t think so. I could have been happy doing other things and have found other things that required far less investment of money and time and left more freedom for living. I am not alone by far in thinking this way either. Yes, It is gratifying to save lives and keep people from becoming disabled. It is nice to be able to sense a benefit to your work in a concrete way. But one of the inherent traps doctors build for themselves is overly-idealizing the sense of calling and their desire to help (“I love my patients–they must love me”); it makes for inspirational reading when the background talk is droning on about RVUs, but it can be a setup for devastating disappointment as well. I have seen this in colleagues, and seen it end promising careers.

    In our time, most people would rather not worry about paying a doctor directly for service. They would rather pay an insurance company to do that and to negotiate schedules and the like. I can’t say that is wrong or difficult to understand; it isn’t. But there are consequences of this kind of involvement, and the results will play out in time. The lag time to see big changes in medicine is long (my educational path alone was thirteen years, and it takes a few years more of work after finishing residency for most doctors’ careers to develop a trajectory). Eventually we will see change in those who choose this profession because of the changes in the ground prepared before them. Will we like what we get? I don’t know. I do know that those who complain about costs and the numbers of uninsured in the USA who say nothing could be worse than what we presently have are wrong. There is worse, it may cost less than what we spend now, but things could definitely be worse.

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