Now what?

I gave my 3 month notice about 4 months ago now. It was clear that the rural hospitalist program in which I worked was not going to continue to be my happy place. (Corporate medicine, hospital acquiring outpatient practices, staff changes, politics, health care trends leading to everything progressively sucking, see prior blog post...) What next?

First, I could do exactly what I was doing a few years ago (filling in at hospitals in need all over the region), without working at my local hospital. I could go to the hospitals I knew well in neighboring states and do hospitalist shifts as a locum tenens physician. I could even sign up for regular part time work, say 7 days a month of either 12 or 24 hour shifts, somewhere within a day's drive of where I live. The money would be good and the time off pretty well uninterrupted with adequate blocks of time to travel and teach ultrasound. Sounds great, except for that week. Seven days of high stress, being away from home, the likelihood of increasing patient loads with associated low morale in the workplace, abundant opportunity to make mistakes that would lead to patient injury, burnout, lawsuits... None of that is foreign to me, but I think maybe I don't want to do that anymore. Wow. No more super-sick patients, running to the bedside, making life or death decisions, holding down the fort. No more getting it right in a high stakes situation and the satisfaction of doing my part in a team effort that saves a life.

So if I don't do hospitalist shifts, what's left? Outpatient medicine can be hard too, with tightly scheduled patients who could have anything from a stubbed toe to a heart attack, time off restricted by a puzzle of different providers' schedules and needs, office politics. Charting after hours, figuring out complex medical and social needs and knowing the community resources to take care of them. Quality measures. Staying on top of preventive care recommendations. Billing.

Outpatient medicine comes in many flavors, though. As I looked around a few options arose that were very exciting.

First, I read about an opening in the student health center of the local university. That sounded like fun! School holidays off, amazing benefits, healthy patients with plenty of resources, no need to work in the summer...

I applied. It might have been great, for all of the above reasons, but it might have been terrible too for different reasons. Even though a student health center is not part of the mega-corporation that is health care in America, it is part of a corporation of sorts. Decisions are made by the university whose primary concerns are recruiting students and whose expertise is in educating them. One of the most important features of student health clinics for the university administration is to sound attractive to freshmen and their parents while minimizing costs. This may not align with providing good medical care. As an employee I would have had very little say in how things were done and the leadership structure is of such complexity that I'm not sure how changes would even be made. Also the office that they offered me had no windows.

So there also was the small internal medicine clinic associated with my hospital. It would have been a comfy transition, working with people I know and like. There would have been abundant flexibility. But here comes the very tricky part. It is very hard to recruit a good internist to a rural clinic. The other physician I would have joined is aging, as am I, and taking on patients in a small community means making a commitment to ensuring that they have high quality answers to their questions or needs 24 hours a day, seven days a week. The two of us could maybe make that happen for awhile, but I'm not sure how long we could keep it up. And how about when one of us gets sick, or goes on vacation or retires? Then what? Do we just give notice that we aren't there?  I'm not sure that hospitals know how to manage outpatient medicine. Sending a patient to the emergency room is not an adequate solution to most of the questions I have received after hours in my decades of doing outpatient medicine and taking call. To do this right, you need a bigger group of doctors with similar competencies. A two physician practice, even if backed up by nurse practitioners, is a sketchy situation unless the two agree to be constantly on call. If we did take on this big responsibility, such as job would be a pretty hard sell for another younger internal medicine doctor, making it near impossible to replace us at retirement.

One of my friends told me that the community healthcare center in town was probably hiring physicians. I emailed the contact person. This clinic is a Federally Qualified Healthcare Center (FQHC). This means that it is a healthcare center for an underserved population with a board of directors (half of which must be made up of patients), a sliding fee scale and comprehensive medical care. FQHC's are eligible for grants and so can provide services to patients who can't afford to pay, along with patients on lower reimbursing health insurance including Medicaid. This clinic is designed to work with patients who don't find it easy to get healthcare in the private clinics in town. It serves people with addiction problems, homelessness and poverty as well as none of these things. This organization started as the clinic associated with a transitional housing place and has grown, now with several clinics over an area of a few hundred miles. They have an in-house pharmacy that provides drugs at affordable prices, in-house counseling, addiction treatment, diabetic education, a dentist and professionals that can help people navigate through the medical system. I interviewed. They seem nice. There are ways they cut costs that make me uncomfortable, like using medical assistants instead of registered nurses. But apparently it works for them.

So that's my new job. I'm going to be working as a consulting internist for a FQHC, covering two of the closer clinics. I will get to see how they do it. The population I will be working with is one that is disproportionately represented in hospitals because their health is bad and they sometimes let things slide. They need the best care they can get and I'm going to see how I can contribute to that. As a hospitalist I took care of patients who had gotten so sick that they could no longer manage at home. When I worked as a primary care doctor I had the opportunity to keep them healthy enough that they might not end up in the hospital. It's kind of exciting to go back to the job of keeping people well. I'm going to be providing health care, as much as possible, rather than sickness care. It seems like the right thing to do and I suspect it will be fun.