BMJ, doi: 10.1136/bmjusa.03040008, (Published 6 May 2003)

Filler

Both sides now: a leap from academics to solo practice

From BMJ USA 2003;April:208

Posted on the outside of my office door were two of my favorite quotes: George Bernard Shaw's "I want to be thoroughly used up when I die. Life is no brief shining candle to me, but a brightly lit torch that I want to burn as brightly as possible before handing it on to the next generation," and "Education is not the filling of a pail but the lighting of a fire" by William Butler Yeats. Teaching students and residents was indeed the "fire in my belly," my calling and passion for 19 years, after I stumbled into an academic career straight out of residency.

Although numerous teaching awards had validated my career path, the best rewards were from the learners who often presented to my open door to ask advice about residency choices, balancing family life, personal dilemmas, or patient problems. That "aha moment" during rounds when the junior student made the connection between theory and clinical application got me up in the morning.

So how is it that I find myself in solo practice in California, a state that has one of the lowest Medicare reimbursement rates? Why did I go from being professor of medicine at the Medical College of Wisconsin and department director of ambulatory education to being one of the private practice internists whom I used to beg to take students?

Six months ago, if you had suggested this scenario to me, I would have told you it was impossible. But three months later, as I look out my office window at the mountains and vineyards, I can say that this has been an incredibly rich learning experience and challenge. For those who are also at midlife and contemplating a similar change, I share my thoughts and glimpses of both sides.

As a clinician-educator, I loved the variety of classroom didactics, curriculum development, writing, administration, hospital rounds, bedside teaching, and patient care. Ironically, however, the buffer of being in a learning environment led to some intellectual laziness, of which I was unaware until now. An academic can rely on grand rounds, clinic conferences, journal clubs, lecture handouts, and even the learners themselves to supply the latest evidence. I could assign a Medline search to the resident or ask the student to consult the Cochrane database on her Palm. Now, the concepts of "just-in-time" and "need-to-know" learning are very real to me.

On my first night on call I got three unit admissions to the 280-bed community hospital with which I am affiliated. The first patient, transferred by helicopter, was a 56-year-old woman who was hypothermic, hypotensive, comatose, and ventilator-dependent after an overdose of diazepam and methocarbamol. I had not done unit medicine since I was a resident. My initial thought was to call the fellow or resident to place an arterial line, but alas, I was "it." For the second patient, a 76-year-old gentleman with malignant hypertension and possible evolving ischemic stroke, I wanted to read the latest stroke guidelines, so I visited my favorite web site, bmj.com, and found them within minutes. The third patient was a 36-year-old drug abuser who was intubated following an overdose of tricyclic antidepressants. Fortunately, all three patients did well and I went to the office the next morning on two hours of sleep, both exhausted and exhilarated. I definitely felt I had survived a rite of passage.

My two biggest fears were missing students and residents, and whether I could go from seeing patients just two mornings a week to every day. The latter turned out to be surprisingly easy. I've discovered that "all the world's a classroom" (to paraphrase Shakespeare); patients of all ages, given the time and opportunity, are among the most eager learners. Although there have been many times when I have wished a student were present to see a patient with fascinating physical findings or complex medical issues, I've also found that nurses and other ancillary staff are anxious to glean bits of knowledge and experience to aid in patient care.

Probably the biggest personal change (other than the longer working hours) is my reading habits. I used to read journals to impart knowledge to others and for my own scholarly work. Now I read ravenously because I want to be a better clinician and business manager. I scan journals for evidence-based medicine, but I also need quick methods, such as software tools, to access information in day-to-day patient care. I devour the "throwaways" that tell me how to be a better boss, what kind of electronic medical records to investigate, how to improve coding and reimbursement, and how to run the office more efficiently.

Leaving my comfort zone has given me a new appreciation for what thousands of primary care physicians do around the world. They are the hospitalists, consultants, clinic doctors, and business managers trying to stay current, control costs, and provide the best care without the backup of a large academic center or multi-specialty clinic. In the ivory tower, I did not appreciate how difficult a task this is and how much admiration is owed them. I do now ... having been on both sides.

Rebekah Wang-Cheng

clinical professor of medicine, Medical College of Wisconsin, Milwaukee; internist in private practice, St Helena, California; associate editor, BMJ USA

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