General Internal Medicine Physician

Folsom, CA
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Interview Date: 12/28/07

Interviewer: Jenae Cohn

What is your job title?

I'm a general internal medicine physician.

What are your primary responsibilities?

Providing medical care to patients who identify me as their primary care physician.

How is your time allotted at work?

Scheduled office visits represent most of my time. I see patients for a total of six hours a day. The rest of the time is spent reviewing laboratory reports, X-ray reports, returning phone calls, responding to patient phone calls, and coordinating care with other doctors regarding the patients who I have provided care for. Up until recently, providing care to patients in the hospital took up 10-15% of my time, whether it was responding to phone calls or visiting them.

Why do you no longer do the hospital work?

Several reasons. One: the amount of time required, the uncertainty of the schedule (nights, weekends), phone calls, the unpredictable nature of the job and the frequent disruption in the other parts of my life all made hospital work increasingly unsatisfying. Also, my hospital and other hospitals like it are increasingly utilizing doctors in such a way that the hospital procedures are increasingly geared to the hospitalists' schedules and routines, and are not accommodating to people like me, who were providing both outpatient hospital work and care.

What are some of the biggest challenges you face on a daily basis?

The biggest challenge is time management. Patients will frequently come to the hospital with a set of problems, and the amount of time required to adequately address their problems, address preventative care, and often address their psychosocial needs takes more time than I have to offer. Given the scheduling requirements for the office business to be sustainable, there are increasing time demands to do more in a shorter period of time.

How do you overcome some of those problems?

I think the best way for me to deal with this is not to be so focused on sticking to my schedule, and if things run over time-wise, to not be so disturbed by the scheduling irregularities.

How in control are you of that scheduling?

Ultimately, I'm entirely in control if it as I can adjust it, but I need to balance control of my schedule with the financial realities of running my office to be successful. I mean, I can see just a few patients for a longer period of time, but since I'm largely compensated by how many patients I can see each day, the reality of the business needs sometimes conflict with the needs of my patients' medical problems.

What kinds of people do you work with?

When I was doing hospital care, I interacted with nurses or other ancillary staff at the hospital. Outside the hospital, most of my contact is with other physicians and typically specialists who are sharing the care of mutual patients.

Do you ever feel lonely in private practice?

I would enjoy more opportunities for intellectual and technical peer interactions or discussing patient care problems both in general and in specific.

How did you decide to become a physician?

I knew I wanted to work with people, although I didn't go to college expecting to go to medical school. I initially thought I'd be doing something like psychology, but I was advised that I would have more career flexibility if I went into medicine as opposed to psychology, because I could always go and do psychiatry if I wanted to. So, knowing that I could perform well in math and science, medicine seemed to be an avenue to do what I wanted to do, but with greater flexibility.

Can you describe your career path to me?

I went to college and eventually earned a double major in psychology and biology. I went immediately from college to medical school, but once I was in medical school, I decided I did not want to specialize in psychiatry. I thought that general internal medicine was the best match for me. I then did an internal medicine residency, and while I was doing the internal medicine residency, I decided that in general internal medicine, where I had the broadest kinds of problems rather than specializing in a specific area, I could treat a more diverse group of problems. It was my perspective that a well-motivated general internal medicine physician could take care of 95% of the problems that patients had, and could do that very well, whereas specialty physicians could only take care of problems within their specialization.

What is the main distinction between a residency program and medical school?

All residencies, including internal medicine, are programs where doctors get their "clinical" training, whereas medical school provides the "basic science" parts of your training and an introduction to "clinical" training. Physicians are not able to be clinically competent until they have completed both an internship and residency, and you can't even get a license to practice medicine without doing at least an internship, which is the first year of training after medical school.

What is the difference between an internship and a residency?

An internship usually takes place during the first year after medical school, and sometimes is incorporated into a residency, but not always. For example, some people who become radiologists or ophthalmologists or dermatologists will do a different kind of first-year training than people who become surgeons or internal physicians or pediatricians. Their internship is less focused, more survey-like, and their residency is more focused on their particular specialty.

Do you think your experiences are typical?

The career path through medical school is rather standardized, but following medical school, the career paths become more specialized.

Does that affect how you treat the patients?

I think it's most important for me to try to continually try to be in the patient's shoes, and to see the world from their perspective rather than my professional perspective.

Typically, how do you begin your day? How many hours per day are you working? What's a typical day on the job like?

I spend six hours seeing patients, but I spend probably three to four hours of the day without patient contact.

What do you do in your non-patient hours?

Review test reports, answer phone calls, coordinate care with other physicians and chart the results of my patient care.

How much variety do you see on a daily basis?

Common problems tend to occur commonly like headaches, abdominal pain, back pain, general fatigue. Fortunately, symptoms do not represent life-threatening difficulties most of the time. Different people and different personalities are the most variable part of my day, and that variability is much greater than the kinds of medical problems that I treat. However, as a general internal medical physician, the scope of my care is very broad, including everything from rashes to sprained ankles to heart attacks, strokes, diabetes, and so on.

Do you feel like there's enough variety in your work?

For me, personally (and I'm not sure this is necessarily true for everyone) the balance between the psychosocial care I provide and the intellectual problem-solving I have to do is somewhat skewed. I spend more time on the psychosocial issues than the intellectual cognitive skills, which I would like to utilize to a greater degree.

What do you mean when you say "intellectual cognitive skills?"

I would like to spend more time researching and applying new biomedical technologies, as opposed to providing people help with their psychological and emotional problems, which often require a great deal of time and can be emotionally draining. In other words, if your friends were all calling you about their crises in their lives on a daily basis and asking you to help them, you wouldn't have as much time to do something you love, like read a good book. I love the technical and intellectual challenges of my work, and for me personally, I would like to spend more time on that facet than on the more draining psychological and social problem-solving that is inherently part of my job.

What do you do to satisfy those intellectual needs?

When I identify patients with less common medical problems that I could refer to a specialist, I tend to make the time to educate myself about those rare problems, and if I believe I am competent to do so, to treat those rare problems, rather than referring the patient to another doctor. I also have areas of specialty work within internal medicine, such as HIV care, that provide me with those intellectual opportunities.

Is there a part of your regular workday that you most look forward to?

There are parts of my work I definitely enjoy more than others, but it doesn't happen during a specific time or necessarily a specific place within my day.

Is there a part of your regular workday that you find the most challenging?

The time-pressured part is the least enjoyable, but knowing that I've helped someone understand the nature of their problem and have given them tools to help resolve that problem is very gratifying.

What is the typical salary range for your job?

The salary range really differs based on the demographic of patients you're serving, and whether you're in private practice or providing care through a large medical group. Some physicians who provide care through the public health system, such as healthcare provided by county government, may have a significantly lower income. In general, salaries range between $125,000 to $225,000 a year. There are individuals above and below those extremes.

Do you receive other forms of compensation aside from salary?

If you work for a large medical group, or another practice, it's salaried, but private practice is equivalent to running a small business, and you're not salaried.

How do you balance your revenues with your expenses when maintaining your private practice?

In essence, I don't. I earn essentially less and less every year, but many people like me try to have more ways that they create revenue. Some people try to provide services that generate more revenue. I have a bone density machine. Some people in my position do things like Botox shots, or provide other services as a way to generate more revenue, because the traditional ways of acquiring revenue do not allow you to be successful in an environment where revenue is shrinking relative to the rate of increasing expenses. In other words, for people like me, expenses have increased much greater than revenues have over the last ten to fifteen years.

What kinds of expenses are these?

Staff salaries, rents, costs of supplies. Government, which is the largest payer of services for the patients I see, has not increased their compensation or fees. Medicare has only increased my fees 5% over the last ten years, but my expenses have increased 10% over the last ten years. That is true in general for all doctors, but since internal medicine physicians are one of the lower earning specialty areas, it is particularly hard for internal medical physicians to stay in private practice.

So, what are the advantages of being in private practice?

Historically, private practice physicians did financially better than in groups, but the most important draws for me were to be able to have greater control over my practice environment and to be able to create the practice environment that was best for me.

Do other people choose it for similar reasons?

I think so. I think most people choose private practice because they like to be able to provide care in a specific way that works best for them. For some people, they want to set their own hours, or they want to avoid the bureaucracies of a large group. A smaller private practice is a more personalized practice setting. There's not a barrier between you and the patients. Patients come to the practice because they bond with you and the people in your practice, whereas in a large group, patients are not coming for you individually for personalized treatment; they're coming to get generic medical care.

Does your job feel stable?

In the past, I would have said "yes," but for the reasons I said before, I believe private practice has an uncertain future.

How does your job affect your social and family life?

When I was providing hospital care, which was unpredictable, it impacted my social and family life because there was a chance I would have to leave and go to the hospital at any time -weekends, days, or nights - but now that I no longer do that, I have much greater predictability in regards to my time.

How often do you take vacations? How long do your vacations typically last?

In private practice, and specifically because I'm by myself in private practice, vacations are very hard to take, because there's no one else to do the work when I'm not there. Many doctors are part of a small or large group, so being away is easier. Also, because private practice people generate their income, if they don't work, they don't get a paycheck. I take a big vacation once a year that lasts less than two weeks.

When do you plan to retire?

I don't think I ever want to retire. I like my work a lot and I would like to continue working as long as I am intellectually capable of doing my job. I will probably work fewer hours per week, but I can't imagine not doing my job at some level.

What are the most satisfying parts of your career?

Knowing that I've been of service to someone, knowing that my skills have allowed me to give someone something they didn't have before.

Are there any major sacrifices you've had to make for your career?

Yeah. I think starting with college and continuing through medical school, the demands of those programs limited social and recreational activities. With the career path that I've chosen, those limitations have continued. Many people are shifting their balance between work and family and social plans; people want careers that demand less of them work-wise, and give them more in terms of their social and family needs.

If you could change anything about your career, what would you change?

I've loved having the private practice for somewhat selfish reasons. Having the control, having the flexibility, having the kinds of relationships I've had with patients has been very gratifying, but in some ways it has been very selfish. I would reluctantly give up those benefits and perks, but I've given up personal freedoms and social and family interactions in order to have those selfish gains.

Have you seen any major changes in the field of medicine since you began working?

Fewer people are doing private practice, and that trend will probably continue to where fewer will enter private practice, and more people will be employees of some large healthcare system, in part because the aspects of running a small business are increasingly challenging. Due to the way physicians are compensated, it is harder for general internal medicinists and physicians to be successful in private practice from a business standpoint. Many group practices in essence subsidize the primary care component of their private practice. In other words, if I'm in a group with 500 doctors, and the group provides comprehensive care to a large population of patients, the money within that group can be distributed in any way the group sees fit, and the group distributes monies to primary care physicians that they couldn't generate within the current business environment by themselves. For people like me, it costs so much to run an office, the way I'm paid, I can't make enough money by providing services to make the business successful. So, in large groups, they know that, so they essentially take money from a more financially successful part of their practice to a less financially successful part of their practice. Most medical students are not choosing programs in internal medicine and primary care mostly because of income and lifestyle.

What changes do you think will be made to private practice?

Every private practice is really unique depending on the community they live in and the population they serve, but private practice in specific and healthcare in general has to undergo large fundamental changes given the economics of providing healthcare. The population is getting older, so because of those demographic factors, aging population, increasing cost of medical technology, government is going to require that practice be different than it has been in the past largely due to economic factors. You may have heard that Medicare is going to go bankrupt like social security, and it's because the cost of providing care is getting higher and has been for decades and the revenues to pay for that care don't exist. The United States spends more per capita providing healthcare than any other country in the world, yet the United States does not have the best healthcare outcomes, so we don't get the best value for our dollar. Our healthcare has to change to accommodate those facts.

So you think those changes will eliminate private practice?

Depending on what form those changes take, it will have an effect on changing the private practice. Whether those changes will eliminate private practice or just modify it, it will inevitably be different.

Do you have any predictions about the nature of those changes?

I don't know. There are multiple models for providing general primary care in the world, and some of them have preserved a private practice-like work environment, even if the government is providing payment. In this country, we don't provide universal healthcare, nor is the government the sole provider of healthcare. Our healthcare system has been largely developed along a private insurer basis, and that model has driven the way healthcare is provided.

Do you think it will become more difficult to get a job as a physician?

No. There will always be physician jobs, and the act of providing care and the process of providing care is great and will continue to be a wonderful job, but the work environment will continue to change until we as a country decide on what kind of system of healthcare we want to provide. So, medicine intrinsically will be a great job, and the actual work that I do will always be great work, but the enjoyment of the work will be significantly challenged by the manner in which people will be required to deliver treatment.

What do you know now that would have been helpful to you when you first started working?

I don't think I would have chosen any differently, but there are times that I can be resentful about the discrepancy between the kind of work and the quantity of work I do relative to other careers, both in and outside of medicine, with regards to financial compensation. I don't think I would choose differently, because I think I have the greatest job in the world, but I think I would have liked to know that I could work less and have greater income, work less hard and have more free time, or work less and develop other interests. But I have more material benefits than I ever thought I would, and I'm really pleased with those, but sometimes in comparing myself to other professionals, I think that I'm not compensated proportionally to the demands of my work.

What kinds of skills are required to be a good physician?

I think there are different skills acquired at different points in the training and the implementation of my work in the real world. In other words, the skills needed to do pre-med and medical school are significantly different than the skills needed to be successful in the application of your knowledge in the real world. In pre-med and medical school, the ability to function as a very disciplined, focused student is most helpful. However, in providing primary care psychological skills, social skills, and emotional skills are most helpful.

What do you mean by "social" and "emotional" skills?

Being empathic. Patients frequently have needs that they're unable to identify, and being able to help them identify what they really need or what they're really worried about is a critical part of my job. For example, someone will come in with a headache, and they're worried about a brain tumor, but the cause of their headache is really stress from work, a relationship, or some other part of their life, and their physical symptoms are often a manifestation of their own psychological and social needs, but they are not aware of that at the time.

So, how do you distinguish between a physical illness and a psychological manifestation of that illness?

The big part of my job is to be able to know what symptoms are typical of serious diseases like brain tumors, blood clots, and so on, and to distinguish those symptoms from the symptoms that are more typical of stress or depression or anxiety or worry. Then, examining people will give additional clues as to whether their symptoms are due to a psychological or emotional cause as opposed to a primary physical cause like a tumor or a blood clot. Eventually deciding which people needed further testing, such as x-rays, MRIs, blood tests, further allows one to decide whether there is an emotional or psychological need that needs to be treated, or a physical problem that needs to be treated. Sometimes people have both a physical problem and significant psychological and emotional problems, so trying to determine which particular problem is causing a particular symptom and trying to direct your treatment at both simultaneously is challenging.

What kind of career advice would you give someone?

I think if you enjoy people and have the capacity and enjoy applying scientific principles, this is a great job to utilize many different facets of your personality.

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