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.