May 23, 2017

Parental Pressure to Be a Doctor – Did This Happen To You?

mount-everest

I was lucky. I had parents who never tried to push me into a specific career direction. They held pretty loose reins and let my brothers and I chart our own futures. We became a physicist, an engineer, and a physician. When I announced I was going to be an Art History Major, I’m sure my mom and dad bit their tongues and scratched their heads. But they let me make my own decisions and my own mistakes. After a year of studying Italian Baroque painters, I was scratching my head too.

I know a lot of you have not been so fortunate. I hear your stories. One physician told me his mother recounts how she would push him around in his stroller, proclaiming to strangers, “This is my son and he is going to be a doctor.” He tried his best to live up to her expectations, but when he was in medical school, he called his mother up to tell her this decision was a mistake. She wouldn’t accept it and made it clear how devastated she would be if he quit. To help himself make it through, he used to imagine his medical school was made of glass. Pretending that he could see through the walls made him feel less trapped. Decades later, this physician is dealing with a deep sense of regret for having followed a path that was not his own.

He was able to make it through (for better or worse) but for some, the body and mind can revolt. One young physician, who had been “directed” into medicine by family pressures, began experiencing depression in medical school, which continued into residency and was compounded by chronic fatigue-like symptoms. Being unable to perform to expectations, despite having been a top-notch student, she left residency.

Over a period of time, her depression and symptoms resolved, yet if she took steps to return to residency, the symptoms abruptly recurred. She is trying to figure out the right career path for herself, but the challenge is compounded by external pressure. She shared with me, “Now my entire family (including extended family) is in a united front to convince me to continue in medicine, as long as it is a specialty acceptable to them. Overall, there was and is a lot of controlling in my family as it relates to my career… Parents really should give kids the opportunity to explore careers and decide for themselves!! At the end of the day, I have to learn to trust myself, right?”

Right! I wholeheartedly agree.

I do believe most parents genuinely want their children to be happy and successful. Many work very hard and make significant sacrifices so their children can have the best chance for a fulfilling life. However, when these good intentions are muddied with parental attachment to a fixed idea of what their son or daughter should do or be, there is no longer a clear space for direction to come from within. I’d be rich if I had a nickel for every time someone told me that growing up they heard, “You are going to be a doctor, a lawyer or an engineer.”

Medicine can be a great career but it’s challenging and places a lot of responsibility on the individual. There are considerable sacrifices – the years of studying and training, countless sleepless nights on call, the challenge of balancing work and family, the long hours, giving up outside interests, etc. The decision should really be one’s own. When we become doctors, we are the ones who are responsible for our patients. When there is a bad outcome, it’s our responsibility. When a patient dies, it’s on our heart. If we are sued, we are the ones in court. The joys are ours too, but they come with a price, and we need to have consented freely to that cost.

When my Uncle Tom was dying from lung cancer, he asked me to take him to a talk on the difference between love and attachment. The speaker held out a clenched fist to illustrate the concept of attachment. He explained that when we are coming from attachment, we hold tight and cling to what we want – whether it is a person, an idea or an outcome. Attachment stems from fear of loss and makes us resistant to other perspectives. He then opened his hand and stretched out his fingers so his palm was facing up. “This is love,” he said. He explained that love comes from trust and gives space to others. Love is not invested in having things be a certain way, but desires for truth to be revealed, even if it is painful.

In order for each of us to find the truth of who we are, we need the chance to figure out our own calling and purpose. It is one of the big mysteries and joys of life.

When I think of people such as Martin Luther King, Elizabeth Taylor, Georgia O’Keefe, Ben Franklin, and Ghandi, it’s hard for me to imagine them being anything other than who they were. What if they had all been told to be doctors? It’s hard to even conceive of this. What they did was so much a part of who they were. Whether we become famous or not, whether we have a “do-or-die” calling or not, we should still have the chance to find out who we were created to be.

No one else should be selecting our destiny for us. I doubt there are very few individuals who climbed Mount Everest because their parents wanted them to. Becoming a physician is akin to climbing a kind of medical Mount Everest. The choice should be yours. Everest needs to be calling you.

The physician stories were used by permission.

Using Your Internal GPS for Career Change

Is your internal GPS telling you it’s time to change your career direction? Is it saying “Recalculate! Recalculate!” but leaving you stranded at the crossroads, failing to provide any further instruction?

If so, it can feel overwhelming, daunting, and confusing.

 

give-me-a-map-woman-final

Uncertainty is uncomfortable. It’s natural to wish for some kind of roadmap to guide us through a process of change.

It makes sense that we feel this way. To become a physician, we had every step mapped out for us. Yes, it was quite a climb, but even Everest has a summit and there is one way up. If you don’t give up and make it to the top, you win. There is guaranteed employment, a career with status, and a paycheck.

 

stair-step-cartoon

 

There is a sense of security in such a well-trodden path where the finish line is visible before you even start. However, as our high physician burnout rates reveal, there is no guarantee of happiness. There is no certainty that the rules of engagement won’t change or that expectations will be met.

The shifting sand at the top of the seemingly sturdy staircase has left many considering other options. Instead of using the staircase that guided us, we now have to create our own path.

If we were wired like Lewis and Clark, we wouldn’t have gone into medicine. We’d be bushwhacking with Sacajawea by our side, discovering new lands – not practicing evidence based medicine.

But in spite of our predilections, we may find ourselves staring into a great expanse of non-clinical career terrain, wondering where even to take the first step?

Since we don’t have the prefab staircase outside of traditional practice, we have to use a different approach. Siri had the right idea. We need to use our internal GPS. We need to be able to listen to ourselves and hear our own guidance.

The connections may be a bit rusty if we’ve had to push down that inner voice in service of our career. It may take time to start hearing our true inner voice and what we need and want. When we start to listen, we might be confused by the presence of two voices, one coming from fear-based thinking (The False Self) and the other coming from trust-based thinking (The True Self). Here are some identifying characteristics to distinguish the two:

The False Self – fear-based and self-doubting

  • Sees problems rather than possibility
  • Jumps to the “What if’s” – what could go wrong
  • Is accompanied by anxiety
  • Sells your abilities short
  • Has to see all the steps before starting

The True Self – confident and trusting

  • Focuses on possibilities rather than problems
  • Is able to imagine success
  • Creates a sense of calm internally
  • Does not over or underestimate your abilities
  • Is comfortable taking steps without having all the answers

How do we turn up the volume on the True Self and mute the False self?

1. Start noticing anxious, fear-based thoughts. Write these down and note the frequency.
2. Look at the fears objectively and see if they make rational sense.
3. Take stock of all you have already accomplished and the challenges you have met.
4. Give yourself permission to accept whatever feelings you are having. Get curious about their origin, rather than judging them.
5. Practice mindfulness or meditation techniques to help quiet and train the mind so it is not so reactive.
6. Do things you enjoy and love. This will awaken the heart, which is part of the internal GPS
7. Believe in the value of your individual uniqueness. Embrace your path and don’t worry if it doesn’t look like anyone else’s.

Our Internal GPS = an awakened heart + rational, non fear-based thinking

To get started on your career transformation, you don’t need to enter a specific destination into your GPS. You can start with a commitment you make to yourself. It can be a simple statement such as:

“I want to enjoy my work.”

“I want my work to be fulfilling.”

“I want to have quality family time.”

“I want to make a difference in a way that is meaningful.”

“I want to use my creativity.”

“I want to use my brain more and be challenged.”

Your internal GPS will start to work on the initial steps, and as you gain more clarity, keep refining the destination. Staircase or no staircase, it’s OK to “recalculate” so you end up in the right place – for you.

Hot. Getting Hotter. The Physician Advisor Role

physician-handshake-shutterstockAre you stressed by 15 minute patient visits, assembly line medicine and not having a voice? Would you like to use your clinical knowledge but not do direct patient care? If so, you may be interested in the up and coming role of the physician advisor. Before you consider opening a Subway franchise, please read on.

Physician advisors serve as liaisons between the clinical staff and the administration in the hospital. They assist with case management (length of stay, patient status), medical necessity, Medicare regulations, claim denials, and documentation. Jobs can be both hospital-based and in companies offering these services remotely for hospitals. Part and full-time work is available.

In July I attended the 4th National Physician Advisor and UR Team Boot Camp with two of my clients. The conference was an invigorating blend of presentations, breakout sessions, networking, and even a mock ALJ (Administrative Law Judge) hearing for a claims appeal. No boots or camping were required, and the only suffering was braving the triple digit Texas heat to go to dinner.

One of the speakers at the conference, Dr. Phillip Baker, an OB/GYN with 31 years in private practice, described how as a physician advisor he helps other doctors. He gave the example of a surgeon whose care was being denied and the next step was for him to have a peer-to-peer call with the insurance company’s medical director. Dr. Baker said, “I remember being in that situation and I would have mouthed off and said something like, ‘What the heck do you know about caring for patients? You’re not a surgeon!’ Now I can take that burden off that surgeon, make the call myself, and do both him and the hospital a favor. I chitchat with the medical director, take time to ask about the kids and it goes a lot better.”

In the past year, Dr. Baker and his nurse assistant have been able to recoup 11 ½ million dollars for his hospital. Sounds like good job security to me!

I asked Dr. Baker his secret to success with the insurance medical directors. “I come from the perspective that we are both doctors, we both went to medical school. I’m an OB/GYN. I don’t know everything, but I know basic medicine. I take the time to get to know directors and don’t take anything personally. I love what I do.”

As you are probably realizing, to be successful as a physician advisor, emotional intelligence and a tough skin are critical. It’s also helpful to have a good reputation in the hospital system where you want to work.

My client, Dr. Helen Shields, an OB/GYN hospitalist was at the Boot Camp in preparation for a new position as a physician advisor. As of this time, she has started working remotely 20 hours a week for a private company. The Physician Advisor Boot Camp was her first toe-dip in this whole new arena and she shared this feedback, “I felt the Boot Camp provided a good introduction and overview of what a hospital-based physician advisor’s job may entail. I was impressed with the team approach to assist the hospital with legal, regulatory and financial services, and the recurrent theme to do what’s right and best for the patient.”

In the training for her new job, Dr. Shields says she enjoys learning about this other side of medicine and expanding her knowledge base of medicine in general. She adds that she is very happy to have made this transition.

At the end of the Boot Camp, I turned to my other client who was there, Dr. Timothy Owolabi, a Family Practice physician who is a full-time physician advisor, and asked him to describe in one word what he got out of the conference. He thought for a minute and then replied, “Community.” Dr. Owolabi was hired at the beginning of the year to be the physician advisor for his healthcare system. He went on to say, “Conferences such as this one, and the vibrant physician advisor community provide invaluable resources and support.” He added “Becoming a physician advisor had been a continuous exercise in patience, critical thinking, improving negotiation skills and trying to learn rules that are always subject to change. It’s been hard, but rising to the challenge is rewarding.”

You may be wondering, besides FP’s and OB/GYN’s……

Who becomes a physician advisor?

Doctors who enter this area need to be licensed, preferably board certified and have been in practice for a minimum of 3 – 5 years post-residency.

The most common specialties are internal medicine (especially hospitalists) and family practice. However, entrance from OB/GYN, surgery, anesthesiology, pediatrics, emergency medicine, and other areas is possible. It is very helpful to have in-patient experience.

How does one get started as a physician advisor?

  • Shadow the physician advisor at your hospital (if you have one)
  • Serve on committees for peer review, quality, safety, etc.
  • Start doing utilization review, benefits management, and/or appeal work
  • Attend a physician advisor boot camp or conference
  • Join the ACPA (American College of Physician Advisors)
  • Join NAPA (National Association of Physician Advisors)
  • Search on job boards for “physician advisor” positions

I’ll never forget what one veteran physician advisor told me about becoming a physician advisor. He said at first the doctors in the hospital would move to the other side of the hall when they saw him coming. But in time, after seeing that he was their advocate, not their foe, they would be flagging him down for help.

The next National Physician Advisor and Team UR Boot Camp will be July 19th-21st, 2017 in Bonita Springs, Florida. If you want to go, but can’t make the trip, you can join in live via Webcast. It could be the start of a great new career.

Dear Hippocrates: I want a divorce

LS Lara Photo

Dear Hippocrates,

I want a divorce.

Let’s face it, you and I were young, idealistic, and naive when we met. Everyone said we were “perfect for each other”, valedictorian and humanitarian. We thought we could change the world, one sacrifice at a time. Sleep deprivation, grueling academic hurdles, delayed gratification. We proudly wore those badges as a testament to our commitment together when we started our board certified family medicine profession in 2003.

I should’ve signed a pre-nup.

Slowly, the tendrils of distrust curled around our world. Insurance didn’t trust our decision-making, so formularies became a paradoxical, rigid moving target. Patients wouldn’t trust our recommendations, certain that their latest Google search was far more medically sound. Hospital administration stopped trusting. Our world became a time and date-stamped arena, visible to all, helpful to none. Once a pillar of scientific benevolence, doctors were now stripped of power and treated with public skepticism.

To rein in this metastatic distrust, you suggested we collect and curate data. Surely, this would “improve” our nation’s floundering healthcare system, right?! Never mind the suicidal grandfather in room 3….but did he agree to get his colonoscopy and tetanus updated?! Who cares if the basal cell skin cancer was recognized and treated on Mrs. Jones, did she sign up for a mammogram?!   My resentment grew with each step into this minefield of check boxes.

This wasn’t the life I planned for us. The inequality felt oppressive. I gazed longingly at our neighbors: The Specialists. Their grassy-green lives appeared unfettered by regulations because they could just advise, “Follow up with your primary care doctor. They’ll take care of it all.”

But I couldn’t.

Your expectations of our relationship had morphed into something unrecognizable. Gone were the moments I hoped to bask in the glow of empathy, caring, and healing. Do you recall the vows we took, Hippocrates? “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.”

A far cry from your modern version. Today’s words are icily brisk as we shiver past each other in the crowded hallways. You speak in modifiers, ICD-10 codes, and triplicate forms. My Love Languages are Touch and Words. Yours is EMR. Your eyes practically glow brighter than the screen when a new data collection feature is unveiled, lengthening the nurse’s duties from 15 to 20 minutes for each patient check-in. It’s obvious you love to flirt with inefficiency.

You shift the boundaries of our relationship on a daily basis, expecting me to jump through unnecessary hoops against the backdrop of “more patient access.” How can I detect the insidious hemochromatosis, or educate the infertile polycystic patient when I’m interrupted with your ridiculous demands to answer every message or refill with neck-breaking speed?

First, do no harm….correct?

Yet, I continued to adapt my workflow to be more efficient, clinging to the knowledge that if I didn’t care, who would? I work harder, you pay me less. (Even less as a female physician). And now all we do is fight over money, when we really should be fighting over the real downfall of us: your adultery. When you stepped out and had an affair with Press Ganey, you changed the tapestry of our relationship forever.

In your short-sighted effort to measure value based on antiquated patient satisfaction scores, you adeptly placed my vitality and compassion in hospice. How can my worth be stripped down to a number, when I’m pressured to see more volume, squeezing as much as I can in 15 minutes? I feel under appreciated, and I deserve better.

It’s not about the money, Hippocrates. It never was. No matter how many miles I run, sun salutations I cycle through, or glasses of wine I sip, I decided:

We have become incompatible.

Our core values have diverged so far apart, it’s impossible to reconcile our differences. Despite the tone of this letter, I am not angry, I’m disappointed. However, I’m filled more with gratitude for our chapter together. Relationships aren’t measured in time, but rather the amount of growth and meaning. Because of you, I have an amazing skill set, memories to fill my heart, and a clear foundation to pursue my next passion….customizable to my definitions.

“In the end, only three things matter: how much you loved, how gently you lived, and how gracefully you let go of things not meant for you.” -Buddha

Best wishes,

Your American Family Doctor

P.S.— you can keep my stethoscope, but please return my boxed set of “The Walking Dead”. The moment those zombies hit, I’ll volunteer to be everyone’s Hershel.

This guest blog first appeared on KevinMD and was written by my client Dr. Lara Salyer.  After working things out with Hippocrates, Dr. Lara is opening her own Functional Medicine practice in Wisconsin in 2017.  Thank you, Dr. Lara, for sharing your wonderfully clever and timely post with us.

Functional Medicine – Could It Be For You?

functional-medicine-tree

 

I didn’t set out looking for a Functional Medicine doctor. I wasn’t sure what such doctors do. But that’s where I ended up. I was suffering from “nonspecific, slowly progressive gym funk.” You might be thinking, JUST WASH YOUR GYM CLOTHES! I wish it had been that simple. Rather, my issue was not having enough energy to work out at the gym. Some days I would put in a respectable effort and break a sweat. But on other days, I’d spend more time sitting on the machines than actually using them. Was I just lazy? Not getting enough sleep? Eating too many chips? I wasn’t sure.  After routine blood work failed to show a reason for my gym funk, I by chance found a Functional Medicine doctor.

Before I go on, let me share a definition of Functional Medicine from the Institute for Functional Medicine (IFM) Website:

“Functional Medicine addresses the underlying causes of disease, using a systems oriented approach and engaging both patient and practitioner in a therapeutic partnership…By shifting the traditional disease-centered focus of medical practice to a more patient-centered approach, Functional Medicine practitioners spend time with their patients, listening to their histories and looking at the interactions among genetic, environmental, and lifestyle factors that can influence long-term health and complex, chronic disease. In this way, Functional Medicine supports the unique expression of health and vitality for each individual.”

Back to my story….

The Functional Medicine doctor took a detailed history, did a lot of blood testing, and found out I had a methylation defect. This was news to me. There were some other issues that showed up which made sense from my history – i.e., a low vitamin D which may have contributed to a prior unexplained stress fracture, and a few other findings. She prescribed methylfolate, vitamin D, multivitamins, and some other supplements. After about 6 – 8 weeks, I noticed more energy and was able to work out much more consistently.

I can’t say for certain if the methylation defect was the culprit (it’s apparently pretty common), but if I stop the methylfolate, doing so adversely impacts my energy. Whatever the truth is, I was able to see a physician who could spend as much time as need with me, addressed my problem, and provided effective treatment.  And she didn’t have to deal with insurance. Sound good?

Hoping this career direction might be an option for some of my war-weary physician clients, I decided to attend the Institute for Functional Medicine’s foundational course – Applying Functional Medicine in Clinical Practice. Even though I was only able to attend the first of five days, I felt I had a good toe-dip into the program.

The first day was packed with presentations, round-table case studies, and time for networking and super delicious, healthy snacks (I’d go back for the food alone). The aim of this course was to provide an in-depth experience of the IFM’s model of assessing and treating patients. Additional training can be taken, leading to a certification in Functional Medicine.

Here is a partial list of topics addressed during the conference:

  • Root Causes and Treatment of GI Dysfunction
  • Immune Dysfunction and Inflammation
  • Food Allergies, Sensitivities, and Intolerances
  • Prescribing an Elimination Diet
  • ABCD’s of Nutritional Evaluation
  • Assessment and Treatment of Adrenal and Thyroid Dysfunction
  • Understanding Sex Hormones
  • Managing a Woman’s Hormones
  • Mitochondria and Energy Dynamics
  • Insight, Intuition, and the Therapeutic Partnership

While at the conference, I ran into a friend of mine, Dr. Julie Reardon. Julie is a Family Practice physician who completed a fellowship in Integrative Medicine and has a busy private practice in Austin. We did a post-conference debriefing. She said she has already been using some of the Functional Medicine approaches with her patients, but that the conference was a fantastic learning experience.

“It was like being back in medical school, and drinking from a fire hydrant, but in a good way,” she said. “We delved into a lot of the science and biochemistry (remember the Krebs cycle?). They have excellent tools and resources for us to use in our practice, such as the Functional Medicine Timeline to capture the patient’s medical history in a way that makes it much easier to see connections, correlations and inciting events.”

She was clearly very energized by her experience, summing it up by adding, “My greatest surprise and pleasure out of all it was that the Institute for Functional Medicine embraces uncertainty in practice. They give us the science and tools to work with, but they keep the art of medicine alive by not being so rigid in the approach. They are willing to think outside the box.”

In addition to running into Julie, I had another stroke of luck getting to meet with one of my clients, Dr. Lara Salyer, a family physician from Wisconsin.

We had a chat a few weeks later and she shared some impressions of her experience,

“Initially I thought my career fatigue was due to medicine in general. But in reality, it’s the way our current primary care office visit is structured. As a traditional Family Practice doctor, we aren’t allowed the time or supportive resources to make any substantial impact in mind-body-spirit health as a whole. Learning about Functional Medicine inspired me to reconsider staying in medicine. I am excited to dig deeper into the biochemistry and physiology to help patients live a healthier life, hopefully with less reliance on prescriptions. My favorite part was connecting with other physicians who had already transitioned into their Functional Medicine practices. I understand it takes time and there are challenges, but I am willing to give it a try.”

I asked Lara if she had any advice for other doctors experiencing burnout? She offered these words, “Before you abandon medicine, take a look at this. If you went into medicine because you care about motivating the individual and making real changes socially and humanitarianly, don’t jump ship just yet. Check out Functional Medicine.”

Let’s say you check out Functional Medicine and do the training. What kinds of opportunities exist?

This is where I got a big surprise.

Before I did my research for this blog, I was only familiar with doctors who hung up their own shingle and started a practice from scratch or incorporated Functional Medicine into an existing practice.

Then I stumbled upon this website, Integrated and Functional Connections, where there are actual jobs (I mean real, live, jobs!) for Functional Medicine physicians! Currently, there are postings by the Cleveland Clinic, Baylor Scott and White, and the Sutter Medical Group, to mention a few. Before I could even finish reviewing the jobs, I reached out to Lisa McDonald, founder of Integrated Connections, to learn more. Lisa is truly passionate about her role in connecting her clients with healthcare providers. She is very excited about the significant increase in job opportunities since she started her company 7 years ago. When asked about compensation, Lisa responded, “The salaries have also been increasing, and are now competitive to those a Family Practice or Internal Medicine physician makes in the more traditional positions.”

It was very encouraging to hear that both smaller practices and large healthcare systems are recruiting for Functional Medicine physicians.

Although the specialties Lisa recruits from are predominantly Family Practice and Internal Medicine, physicians from a wide range of specialties have become certified in Functional Medicine.

The most common specialties I noticed on the IFM FIND A PRACTITIONER page are:

Family Medicine, Internal Medicine and (IM subspecialties), Emergency Medicine, Anesthesiology, Neurology, Physical Medicine and Rehab, OB/GYN, and Pediatrics. However, I also saw doctors from these areas as well: Psychiatry, Surgery, Radiology, Dermatology, Radiation Oncology, and Ophthalmology. Some physicians devote their entire practice to Functional Medicine, while others offer the model as a complement to their established practice.

If you are interested in learning more:

IFM offers 2 free online eLearning courses, which provide an overview of Functional Medicine and Functional Nutrition.

You can read here about the IFM certification program. And see a listing of upcoming conferences and courses here.

Functional Medicine uses both traditional and novel approaches to help patients. It may be something you want to consider, or not. The good news is that there are options to explore if you are frustrated by the current practice environment. You get to decide if something could work better for you. At the very least, being able to connect with doctors who are finding their passion again may provide some hope and inspiration for your own journey