The Solo Practitioner: Postcards From the Edge of Extinction

Nicholas Genes, MD, PhD


February 27, 2007

Is solo practice going the way of the dinosaurs? If so, there's at least 1 "dinosaur" who intends to remain a viable part of the modern culture. This isolated solo practitioner has started a Web site, Musings of a Dinosaur, where the self-named "#1 Dinosaur" (who also goes by Dr. Dino) shares the ups and downs of a job and way of life that may be nearing extinction.

Dr. Genes: How long have you thought of yourself as a dinosaur? And, really, how accurate can that be? You're savvy enough to have ventured online and started blogging, and CME keeps you up-to-date. Plus, being in solo practice for 17 years means you've still got a ways to go before retirement.

Dr. Dino: I will be 48 next week. I've wanted to be a doctor since I was in third grade, and that's exactly what I did, going straight through the 4 years each of college and med school. (I knew I really needed the full 4 years of college to mature some, so I didn't apply to any of the 6-year combined programs.) That was followed directly by residency, 1 year of working for another practice, and then the hanging out of my own shingle.

Although the word "dinosaur" has the connotation of "old," that's not really how I mean it. It's more the idea of being isolated, peers becoming more scarce, and living in a hostile environment that threatens my very existence. That, plus I thought it would make a cute blogging persona, letting me talk about the tar pit, the International Council of Dinosaurs, District 9 (ICD-9), marble dinosaur eggs (instead of clinical pearls), and referring to students in my office as "hatchlings."

Musings of a Dinosaur hosts Grand Rounds
February 27, 2007.

Dr. Genes: You write well; did your blog grow out of an interest in writing?

Dr. Dino: Because I am serious about my writing and about pursuing publication, I've done quite a bit of research into the publishing industry. In early December, I posted "Everything You Need to Know About Publishing," which I think distills the whole process into a fairly compact essay.

Blogging is basically writing, and frankly, I got into blogging more from the writing side than the medical side. My writing community is a free Web site called "Forward Motion," and my blogging mentor/example is "Miss Snark," a literary agent who tells it like it is. I began my first novel with Forward Motion's "Only a Novel" course at the beginning of 2004 and never looked back. I finished the novel that I wrote for the course, eventually realized that it sucked, and trunked it (shoved it in a trunk under the bed).

At first I thought I only had that 1 novel in me, but of course, to the surprise of no one at Forward Motion, the ideas kept coming. In November 2005, I wrote my first novel for "NaNoWriMo," and in November 2006 I wrote my second. The first one didn't suck, so I self-published it. The second one does suck, so don't look for it any time soon. I was working on another (with 4 competing ideas floating around in my brain), but recently -- in response to some stuff in the medical blogosphere, actually -- another idea came to me almost completely formed, so I gave myself permission to stop working on the old one and get going on the new one instead. Just for the record, I am not a medical writer like Dr. Charles or Sid Schwab. Obviously, the medical aspects are extremely accurate because of my profession, but what I write is commercial fiction.

Dr. Genes: A lot of your posts read a little like kindly advice, the wisdom from a sage. Do you think blogging is taking the place of working in a teaching institution?

Dr. Dino: I have actually done a fair amount of teaching over the years. I've had students and residents at every level of training rotate through my office. I've also precepted several groups of students in the "How to do an H&P" course, usually called something like "Introduction to Clinical Medicine," usually given in the second year of med school. Teaching is the professional version of procreation, and I find it more and more rewarding as the years go by.

I'd never want to be at a teaching facility full-time because of the paradox of family practice: You can't really learn it in training. Oh, the attendings did a great job of indoctrinating us with the idea of forging bonds with our own patients, but the reality was that we were only going to be there for 3 years. Furthermore, the savvy patients finally came to realize that, and stuck with the attendings.

Everything you get taught about how wonderful longitudinal care is is absolutely true. But you don't get it for yourself until after training -- when you're out and doing it. So the best I can do is model it for the students and residents, let them share in the relationships that I have with my patients, and reassure them that they, too, can have it someday.

Blogging is a little different: partly teaching, partly PR, partly venting, under the guise of raising awareness of the issues facing medicine -- specifically solo family practice -- in this day and age.

The opportunity to reach a much wider audience is thrilling and a little scary. It's been 6 months now since this dinosaur crawled back from the edge of the tar pit and took the leap out into the blogosphere, and frankly, it's been a hell of a ride.

Dr. Genes: Tell me about some of your favorite posts -- things that garnered a lot of comments, or something you worked hard to express.

Dr. Dino: I've got a box on my sidebar called "Favorite Posts," and that's what they are. The post entitled "Good Enough" was a response to a medical student bemoaning his "mediocre" med school. Reading it over again, not only do I still think it's a fine piece of writing, but I find that I am also expressing the concept that "good enough" means that quality is not linear. This idea is also the issue in all of the Pay for Performance posts and discussions with other bloggers. The most knowledgeable diagnosticians, the best surgical technicians, the most adept endoscopists, and the most empathetic therapists are all evaluated along totally different continuums. Being the best doctor for the patient in front of you is plenty good enough, an eminently attainable goal.

I think that the post with the greatest potential to enhance the everyday practice of medicine is "Bevel Down," the story of a technique shown to me many years ago that I didn't try for many years after that. I still think if more people tried rotating that bevel 180°, regardless of decades of "this is how I was taught," they'd be amazed at how much easier and less traumatic they (and their patients) would find phlebotomy.

"Rad Rage," an expression that I think should be incorporated into medical slang, is about my increasing frustrations dealing with a noncomputerized radiology department. Although the language becomes quite foul by the end, what I'm proud of is the way in which the writing escalates as my exasperation grows. I tried to pull the reader along for the emotional ride -- hopefully eliciting a giggle or two along the way -- and the comments seemed to validate that I succeeded at this.

Dr. Genes: You write about making less money every year while dealing with increasing hassles, regulations, and absurdities. Do you have any regrets about becoming a doctor? What would you counsel students if you were at a teaching hospital? What do you suggest to your kids (you know, when they're actually listening)?

Dr. Dino: As I said above, I've wanted to do this ever since I was in third grade. Being a doctor is such a part of my soul that no, there's no way I could ever regret it. The essence of it -- using my intellect and my humanity to help people, whether by diagnosing and treating an acute illness, reassuring someone that they don't have something serious, helping someone learn how to raise a child, or easing someone's last days -- remains the most satisfying endeavor I could ever imagine. The setting I have chosen, solo practice, allows me to do that more directly and completely than I could ever hope to accomplish any other way: no partners to fight with over prescribing antibiotics or giving human papillomavirus (HPV) vaccine, no hospital bureaucracy forcing me to see 8 patients per hour, no bored government clerks being rude to my patients. It's great. I would have to rate my personal satisfaction as 100%.

What I resent, deeply and bitterly, is my devotion to my patients and my profession being exploited by that faceless, nameless, amoral machine known as the insurance and pharma industries to siphon money -- including my livelihood -- out of the system and into their pockets.

As to what I'd tell my kids (who have been known to listen once in a while, although they've rarely expressed any real interest in anything that I've had to say), I suppose it would be that careerwise, medicine is becoming akin to the arts. Acting, painting, music, and the like are wonderful if you have the passion and the talent, but -- for the most part -- they are no way to make a living. If you love it, go for it, but you have to love it. And yes, there's plenty to love.

Dr. Genes: There's plenty in Dr. Dino's writings to support that. And there will be even more when the #1 Dinosaur hosts Grand Rounds the collection of the best of online medical writing. Stop by Musings of a Dinosaur on February 27, 2007 to see what doctors, nurses, students, and healthcare professionals have written on the theme of change and permanence.


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