Words of Wisdom To Myself

I got an anniversary card the other day, congratulating me on my 2nd year being on staff in my respective hospital.

2 years. How time flies. I've left my alma mater 2 years already? And then, I spoke to John, my buddy from fellowship who's 4 hours away, and we compared notes. Now that I'm out on my own, what would I have told myself, that tired but still naive fellow, into his 12th year of medical education, back in 2008? What would I have said to prepare myself? Not that I hate my job now (but admittedly there are some things I don't love, either), but what would I have said?

That the learning never stops.

Geez, you'd think that with 5 years of medschool, 3 years of specialty training and 3 years of subspecialty, that I'd be done with learning. But no. The learning has only begun. Except now, I'm on my own, learning from my patients, from my mistakes. No longer looking up to my Professors for guidance, realizing, partially still in shock, that I'm a Prof myself now, and my students and residents look to me for answers.

That you sometimes don't get to decide who becomes your patients.

Being a subspecialist, I'd like to think that I'm good, no, damned good in some things. My diagnostic rates for thyroid biopsies surpasses many others. I'm pretty confident of hitting a nodule no bigger than 5 mm (if indicated). I've seen about 15 pheos, a dozen insulinomas. There are some things I'm good at doing. But, as I no longer practice general medicine, there are simply some things I don't do well anymore. But inexplicably, I'm still asked to see patients for depression, weight gain, mood swings, skin problems. And all you can say: "I'm sorry, as an endocrinologist there isn't anything I can do for you..."

You realize the innocence of fellowship has shielded you from the harsh realities of the world.

Patients who can't afford their medications and their visits. Overpriced drugs, often peddled by pharma who strolls in to your office in spiffy suits, or supershort miniskirts, while trying to sweet talk you. In the meantime, you know just who is paying for the lunch the pharma rep is trying to buy you: Your patients. No, thank you.

You also shamefully realize that it is a business.

You realize you sometimes will have to disagree with your colleagues on principle. Some may feel that we should never turn away business. But unfortunately (or fortunately?) you were taught to treat patients with a real hormonal disorder, and you learn to despise seeing patients just for the sake of generating revenue, whether or not their GPs were wrong in sending them to endo.

Life doesn't really get cushier.

Yes, the salary's better than a PGY-6. But the hours aren't better. The calls aren't better. The patient loads aren't better. And now, you're made to cover 5 different hospitals all around town, and it's preposterous that some feel we need a monopoly here.

You also get to know your patients.

Now, more than fellowship when you're really staffed by someone else, these are YOUR patients. You are their doctor. And so you learn to share hugs and laughs when they get their diabetes controlled. You share a few tears when they have a miscarriage, or lose a family member. You genuinely get touched, when they make a special trip to the clinic just to drop off a home-made throw for your baby, or some banana bread for you.

You never really get used to all that respect.

Really. I've been a doctor for 9 years. And yet, I'm still uncomfortable with older patients and colleagues calling me Dr. Vagus. I may have the paper qualifications, but they have much more life qualifications and experiences. I don't think that makes me more of a person than they are. And truth be told, I miss being called by my first name. I've love it for my nurses or patients to call me by name.

Sometimes, you're it.

Whether you like it or not. What should be done for that patient with the metastatic pheochromocytoma? Or the Stage 3 follicular-variant papillary thyroid cancer? What about that patient who has resistant hypoglycemia despite having had 4 amps of D50 and being on a D10 drip? You might not be 100% certain, but at least with the training you've had, you're 90% sure, and in the hospital you are probably most qualified to handle the case. And so, trust your instincts, trust your gut. That 12 years of training has to be worth something, right?

And sometimes, you have to flex your ego muscles.

You have the qualifications. You are a doctor, a subspecialist. You know what you're talking about (usually!). The damned insurance companies don't, and often neither do their medical directors. And so, if they are refusing to pay for that echo as part of the pre-op evaluation in your acromegaly patient with the striking edema, it is up to you to stand up to them and say, "Acromegaly can cause cardiomyopathy; I am concerned about this patient's ability to safely undergo surgery. Would you like to be responsible for this patient's death on the table?". After all, you're it. You're the patient's doctor, and you're his advocate. No one else. He belongs to you, and you to him. You will have to look out for his interests above everything else.