5 years and 50 blogs later: Big lessons from the real world

Henry Rosevear, MDDr. Rosevear is a urologist in community practice in Colorado Springs, CO. Urology Times blogs present opinions, advice, and news from urologists and other urology professionals. Opinions expressed by bloggers are their own, and do not necessarily reflect the views of Urology Times or its parent company, UBM Medica. Please let your voice be heard by joining the conversation in the comments section of each post.

Residency is tough. I started my first Urology Times blog post almost 5 years ago with that line. While it is certainly true, life in the real world is not easier, it’s just a bit more financially rewarding.

I was recently asked by a good friend and physician, who is considering retiring early, if I regret going into medicine. It's a question that seems almost trendy to ask given the data emerging about physician burnout both in general (BMJ 2017; 358:j3360) and among urologists specifically (Urology Practice 2017; 4:155–61). My answer was an emphatic no. I enjoy medicine (usually).

I enjoy operating (usually), and I believe that we are well compensated (mostly). But I also believe that the world of medicine in 2018 is not what I expected it to be and certainly not what medical school or residency led me to believe it would be. Three big lessons from the “real world” come to mind.

First, the simple truth is that the majority of what I do in clinic can and probably should be done by simply following published guidelines. This is not to say that zebras don't occasionally walk into clinic, but common things are common by definition. Let's take a situation I encounter on a daily basis: the middle-aged patient with microscopic hematuria. The guidelines are pretty clear. This patient (assuming kidney function and allergies not withstanding) needs a CT IVP and cystoscopy (no cytology), according to AUA guidelines on asymptomatic microhematuria in adults).

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Everything else is almost moot. With documented microscopic hematuria, is there anything in the family history that is going to change what I do? This patient has an uncle twice removed on his mother's side with porphyria, so clearly I can skip the CT, right? Wrong. If you are playing blackjack and are dealt 20, what the dealer shows is irrelevant; the correct play is to hold. You don't win every time but you win the vast majority of times.

The era of the small-town doctors like myself thinking that they are smarter than the experts is over. While that may mean better care for the majority of patients, it is not always a pleasant thought. I invested years of my life and gave up many weekends with my family to learn my profession, and it does hurt sometimes to think that I am not the world's expert on microscopic hematuria. But the truth is that the men and women who wrote those guidelines do know more than I do.

Thus, by practicing good, evidence-based, guideline-driven medicine, I can almost turn my brain off, and that is likely one of the drivers of burnout today. Who wants to go to work every day to do something that a literate 10-year-old could do? Or if you want to scare yourself, something that IBM's Watson could do?

Second, complications hurt. While I do my fair share of major inpatient cases, the majority of what I do is outpatient urology. I believe strongly that Henry Ford was right that an assembly line worker doing the same thing every day is better at it than a renaissance man who tries to do a little of everything. Again, though, this likely contributes to burnout because while it now takes me 15 minutes to do a ureteroscopy that in residency took over an hour, some of the challenge of the case is gone. But I know that a patient will get a better outcome for an RPLND if I send him to the University of Colorado and just keep doing my ureteroscopies (and vice versa, as some of the university's patients would likely have a better ureteroscopy with me).

With that in mind, I certainly get my fair share of complications, and they hurt. I've spent many a night replaying a situation in my mind trying to figure out what I should or should not have done to avoid getting myself into some trouble. We operate millimeters from disaster on a regular basis and sometimes I think it is more than just good luck that we don’t encounter more complications.

Next: "The last and greatest lesson I’ve learned in my 5 years in the real world"

The last and greatest lesson I’ve learned in my 5 years in the real world-the one I was least prepared to learn and that I spend more time dealing with than I care to admit-is that medicine is a business. Adam Smith, the Scottish economist, once said, “It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own interest.”

I’ve learned many times over that hospitals, industry reps, and insurance companies hire very smart, well-trained people who wake up every day with one goal in mind: screwing me and my business.

Read - Cost variation among urologists: Can we trim the fat?

Do you really need an example? I’ll give you two. About a year ago, our practice noticed that one of our insurance companies was reimbursing less than we expected. After much digging, it turns out the insurer had sent a letter stating it was going to significantly decrease reimbursement unless we objected. The letter got lost, we didn’t object, and there you have it. Or how about a hospital leveraging its dominant market position to create a narrow network that excludes independent providers of ancillary services, even if that independent provider can provide higher quality care at a cheaper rate?

Nothing illegal about either move, and Adam Smith is probably smiling at the cleverness of the individuals running those two businesses. But have you ever wondered what would happen if we spent as much time trying to optimize the delivery of medicine as we spend staying in business?

Am I arguing that all of us small-town doctors who run our own practices should throw in the towel? Absolutely not. In a world of limited health care resources, a doctor who understands the business of medicine can deliver better, higher quality, more affordable medicine than some cog in the wheel of big business.

After 5 years of practice and 50 blogs, do I regret my decision to go into medicine? No. I would simply advise any young doctor getting ready to leave residency to know and follow your guidelines, pray you don’t have complications, and learn the business of medicine.

More from Dr. Rosevear:

Physician employment: Both good and bad results

How profit enters the product development equation

Do you own an S corp? Why I made the switch

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