For the month of February, I am partnering with EJ from DadsDollarsDebts to share both old and new content. This is the third golden oldie post he has shared from his site. This post originally appeared on his site in June, 2017. This Friday, he will share a new post directly with in lieu of my regular post. Make sure you check it out!
Throughout training I had an idea, and that idea was that I would be a great academic physician. I had the right training and completed research from college through fellowship. I had received research grants from medical school through fellowship, published numerous papers, and started defining a niche. Everything was going great. Academia here I come. Private practice was not in the plans.
Attendinghood
Then attendinghood arrived. I looked for positions in academic centers. Limited by geographical boundaries, I interviewed at 2 traditional academic centers. These sites were traditional academic centers with assistant, associate, and full professors full of R and K grants. There were students, residents and fellows. The third center was what I call pseudo-academic with students, residents, and fellows but less NIH funded research. There were definitely a lot of people producing research. It was just on their own time with various funding routes.
I debated between the various institutions and finally decided to go with the less traditional academic centers. Here I was a 100% clinical but with the opportunity to teach and perform research. Over the next few years I focused on my niche (cardio-oncology), practiced general cardiology, and performed the research I wanted. It was not my planned career, but I was doing the things I wanted.
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Medical skills
Over that time my medical skills improved in some fields and atrophied in others. I was no longer dealing with arrhythmia. Why mess with hard to control atrial fibrillation when the electrophysiologist (EP) was down the hall. I did not have to think heavily regarding ischemic patients because my interventional colleagues would be happy to chime in. By being a general cardiologist at a academic center my overall cardiology skills atrophied. Sure I was great at hypertension management (better than my interventional or EP colleagues) and heart failure management (though not transplants or those requiring inotropes).
I was getting better and better at cardio-oncology, my chosen niche, but part of me was dying. All those years of training were fading into the ether of time. I did not mind so much as life was comfortable and easy, but it did make me a little sad. So after 4 years, I decided to move. The reasons for the move was multi-factorial but here I was, 4 years later in a new city and now in a private practice group. Not only private practice, but in a remote setting.
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Private practice
So here I am now, 1 year into my new practice. Over that time I have become a better doctor. More rounded. I manage my own anti-arrhythmics and perform my own cardioversions. I decide which valve cases need a transesophageal echocardiogram and do it. Then I decide who should and should not get surgery. My skills for determining who to send an hour away for either an outpatient or inpatient angiogram are tuned. I listen to the intricacies of the history and look for the subtle changes in the ECG before sending someone for an invasive procedure. No longer having the interventionalist there for a second opinion, I am forced to make more decisions. I even am doing my own bedside echocardiograms, a skill I gave up years ago.
Here I am 1 year into private practice and I can tell you that I have become a better doctor. I imagine this is the case with most private physicians. We have to be more of a generalist. There is no dark corner of our niche to huddle in and forget the rest of medicine. We do not have the thousands of resources and people backing us up, allowing for us to shirk our decisions.
Perceptions
This is why I am surprised as to how poorly private practice doctors are seen in academics. The academicians, and honestly society, hold the academic centers up on a pedestal. It is in these houses that the best care is provided. While for some centers and more specifically some very rare or hard to treat diseases this is true, for the general, run of the mill diseases I think that private practice docs may be better off. They may provide better care with a higher continuity in that care. No sign offs or explaining what the history is to 5 other people. No students and housestaff to screw up orders and complicate rounds. In many ways, the private practice is a better place to get care.
So here I am now, in private practice, a more rounded doctor. I can still focus on my niche and my research if I want, but at the end of the day, my clinical acumen continues to grow. Will I ever go back to academics, only time will tell, but for now I will stay in my small hospital and enjoy fine tuning my clinical practice.
What do you think, are academic centers placed on a false pedestal by society? Do you prefer care at the big academic center or the big clinical center?
