I’m excited to offer a blog series on Careers in Family Medicine. As I recently reflected on my career path and turns, I noted many truly amazing family physicians I know and how their career paths developed. Because I work with a number of residents considering how to use their skills in sustainable and meaningful ways, I thought it would be nice to highlight a few of the many career options open to family physicians.
Over the next three to four months, I will highlight physicians in rural practice, value-based care, academic medicine, the US Department of State, medical foundation multi-specialty practice and leadership, direct primary care (DPC), federally qualified health center (FQHC) with OB, hospital medicine, military medicine, traditional private practice, tribal health, academic leadership, academic leadership, department chair, C-suite leadership, advocacy and leadership, sports medicine, palliative care and global health to name a few. These category names are a bit arbitrary as they often blend together but wanted to offer a wide array of what's possible based on those I've crossed paths with as you are looking at aligning your values, career goals, and fulfillment in a rewarding profession.
I thought to get the ball rolling, I’d write my own stepping stones and takeaways from my 24 years post-residency career.
First, I was fairly certain, as a mom of two kids and a husband in his second residency, that I wanted outpatient only with minimal call. I interviewed at the 2 largest providers in our hometown where I would commute for a couple of years while my husband completed residency. One was very rigid and treated me very much like a cog in a wheel. Fortunately, I saw a contrast. The second organization treated me as if I was valuable - giving me options on which location I’d prefer and which times of to start and finish clinic. They gave me a budget to outfit my office and a target number of clinic slots I needed to keep open. And importantly, they gave me a base guarantee for a little while. I chose the second one. I did not even think of negotiating.
First position. It was a large multi-specialty physician-owned practice. I discovered the importance of autonomy, which was largely given to each physician. I learned about the financials and the leadership aspects of running a practice because the physicians in our location met monthly with a very savvy office manager. I had a voice and felt valued.
I grew in my humility in medicine, finally being free of the toxic blame and critical culture of the academic medical center housing multiple specialty training programs. I experienced firsthand how hard it was for patients without adequate insurance to get care - but had enough freedom to write off visits and supplies. I formed great relationships with my panel.
The most interesting thing I experienced was the specialists joining together and voting primary care out of the group since we were “money losers” – despite that, for every $1 we made, they made $4 in referrals. I also realized how difficult it is to change established referral patterns once you know who you trust clinically (in the end they made the more profitable, but less ethical, IMHO, decision).
Finally, once we sold ourselves to a for-profit entity to become fiscally viable, I started seeing someone sitting across from me telling me I needed to order just a few more tests, such as EKG’s per week, to improve my RVUs. I didn’t like how that started to influence my thinking.
After 3 ½ years, I was also experiencing much mom guilt. There really wasn’t any I knew to talk to about it. I didn’t have many women mentors, and the ones I did either didn’t have children or theirs were grown and out of the house. The only person part-time in our system was forced out despite her being part-time due to a medical condition. She didn’t have the energy or budget to fight the large organization. I knew part-time for myself, then, was out of the question. I also had a non-compete.
And so, I presented to my husband a plan that involved him being the sole provider for the household. 😳 He is incredibly supportive. He may have said something to the effect of, “Do you want to give me time to build up my private practice and pay down student debt first?” And I explained that he would have at least 3 months to do so since I had to give that much notice. 😬
After saying uncomfortable goodbyes to my patient panel, I began to look around at how I would keep up my clinical skills while I devoted more time to the kids. It proved more challenging than I expected to volunteer. I toyed with working part-time for the prison system which wouldn’t have broken my non-compete, but it seemed a bit daunting. And then, a man who was starting a faith-based indigent care clinic found me and asked if I would consider starting it with him.
Second position. And so I took on my first leadership position as medical director in underserved care. I learned a ton by joining the community board that worked on healthcare access, networked with other free clinics in the state, and began filling needed positions. I worked with those I met from 3 competing hospitals to work together to provide clinical support by demonstrating the savings of patients having a place to go instead of their EDs. With laboratory and radiology services to medical waste management and many others, we began a full volunteer, wholly donor-funded clinic for those who fell through the cracks, sort of speak. (This was before the ACA.)
Lessons learned included the importance of data to drive resources. I also learned that being the person responsible for every decision results in a bottleneck- everything needed my recommendation, advice, or approval between each patient encounter.
I took some leadership courses and learned the importance of collaboration and empowering others with decisions and responsibilities. I learned flexibility because working with all volunteers to cover the work was akin to playing Tetris. I also learned the power of community and the power of doing something bigger than yourself. I learned about supervising trainees that we took from a couple of nearby locations. I knew I deeply missed academics.
Thankfully, when it was time for us to move to Alaska, people were in key positions to keep the process going. (They 10x’d several times over the years and are still flourishing.) Alaska was my husband’s idea – before the reality shows. After 2 years of hearing him talk about it, and seeing they had a family medicine residency, we hopped on a plane. Stepping off the plane and seeing mountains and water and breath-taking beauty, I was in. That was 16 years ago.
Third position. Core faculty at a community family medicine program. When I started, there was no opt-out of anything. Since it had been 9 years since I had delivered a baby, I updated my OB by being proctored for 40 deliveries and running the triage area, and getting it signed off – just like being a resident again. I had very solid inpatient training, so I wasn’t required to do any additional retraining for the hospital.
I was in love. With the job, with the people, with the challenges, the projects, the curriculum, the mentoring, and being back in the trenches. The flexibility of how I filled my admin. Being back on top of the newer clinical data and changes was amazing. I went through UW’s faculty development fellowship and grew in my role as an educator, deepened my skills with interacting with trainees in difficulty, and learned some ACGME and ABFM regulations and the like.
I lost the old narrative that I couldn’t create anything “new” only “copy.” I restructured didactics and the program evaluation process. I created an evidence-based OB reference book in conjunction with our obstetricians and MFMs and forged healthier relationships with community attendings.
The volume and complexity of the patients were somewhat akin to my own residency (although, at least in mine, we had a large acute care and peds practice that balanced it out). But it felt very meaningful even though, admittedly, it was hard.
It wasn’t long before I realized my love for the job was more like a love-hate relationship – and I had no idea how to stop checking all the boxes, aiming for unrealistic perfection with every task, and over-relying on external validation. To get the work done, my self-care was definitely on the back burner. It wasn’t long before I stopped socializing with staff and colleagues in order to keep checking those boxes and keep my ego afloat because I never left work undone. Well, that was my undoing. Losing connection at work was my last lifeline to any semblance of rest and recovery.
I became increasingly impatient with my colleagues should they “delay” my projects or “break” the system that I had working. I was constantly in a negative state about everything. I was disengaged at home, having no bandwidth to interact. I didn’t know the term burnout, but that’s what was happening. I remember thinking, if I just could have straightforward appendicitis and be forced to be in the hospital for a couple of days to rest without guilt, that seemed so inviting. Looking back, it’s not unexpected that, with one public challenge from my PD, I wrote my resignation letter on the spot (– not how I like to show up in the world.) You can read my recently published narrative essay about that time here.
Thankfully, he supported me staying as on-call/locums faculty, which I remain today. I reached out to friends in the community and found a private practice looking for a part-time provider. And I said some sad goodbyes to my second continuity patient panel, though I took a couple of complex ones with me.
Fourth position. I became a part-time contracted physician at a private outpatient-only setting that the husband-and-wife owners had set up to enjoy the practice of medicine instead of maximizing profits.
Refreshing autonomy with how I practiced returned. It felt like a micro-private practice, all my own in some ways. I had time! - 30-50 minutes with each patient. The MAs learned my preferences and adapted. The owners intentionally created a family-like atmosphere and harvested benefits. The culture was that staff related well to each other, front and back—minimal whispers and drama. I recovered my old self. I reinstituted self-care. I found joy in clinical practice again because of the time and resources.
Once I learned of the importance of coaching (more on that story here), I knew I had to take it to residents and faculty. There were so many tools I was unaware of that would have likely kept me from burning out. However, I don’t have regrets -- my burnout wasn’t wasted. It spurred me on to invest in coach training to take it into academic family medicine – the core of the US healthcare system, especially in underserved locations and populations. (COVID also created some unique and unusual challenges during this time). And so, once again, I found myself saying some goodbyes to a patient panel.
Current practice. Now that I am coaching full-time, I retain the locum’s position for the residency. I’m no longer in the trenches of L&D or the hospital, but love working with residents in the clinic. I also partner with the Behavioral Health faculty to bring Physician Toolbox Talks to the program. I also enjoy filling in at our local FQHC and seeing patients from time to time. What I’m learning from this setting and season is the importance of continuity which was sacrificed to be in this new role. (I recently sat in on a primary care healthcare forum where someone actually said “Continuity doesn’t really matter.” I could take a whole blog series on my response. Let it suffice to say I took a deep breath and remembered everyone is entitled to their own perspective.)
I discovered that I still enjoy filling a need – whether at the residency or the community clinic. And I have a whole new ability to cope with the multiple complex challenges of caring for the underserved. Part of that is having enough rest and recovery to rise to the occasion. But acceptance has been a powerful tool in my belt. (If you receive my Sunday’s story with Sides – you know I’ve highlighted that a couple of times). When I stopped arguing with reality about how things “should” be, and just dealt with things as they were, my capacity to do the work increased.
My journey is in contrast to that of my father, who worked in the same town in primary care for 40 years and saw generations of patients in the same families. So many great outcomes with that approach as well. That's the point. There are many ways to design the career that works best for you and your family - all of them will help patients.
And since I’m not writing for the New Yorker here, though, I’m about to rival its length, I will end here.
I guess take-home lessons that exist in my story: 1. You can reinvent yourself 2. There is good and bad with every position. 3. It’s not easy to leave a patient panel. But it wasn’t time wasted – we had valuable, trusted relationships for the period of time I was there. 4. You learn skills in each position that will serve you in your next. 5. Mindset is important to sustaining the work. 6. Rest and recovery are paramount no matter what type of job you go into – and the kicker is – YOU are the only one who can prioritize it.
Stay tuned as our Official JoyFM - Careers in Family Medicine Interview Blog series starts next week! I’m excited to highlight various ways family physicians can find fulfillment and care for those needing primary care – in sustainable and enjoyable ways. Next week, will highlight rural family medicine.
Until then – have a joy-filled week! Tonya
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