Eleven Cents

I am struggling with a frustrating reality: a person hoping to do research to build up the culture of life has to do twice as much work as a person who hopes to do amoral clinical research. Becoming a clinician-scientist is hard enough. They have to see enough patients, do enough surgery (when applicable), and earn enough grant money to make their institution value them. This means they have to stay on top of their clinical game. And like it or not, this usually means they have to choose result- and revenue-generating research topics.

Becoming an academic physician who also builds up the humanity of the unborn or builds up the science behind FABMs is even harder. Those topics don't make money and don't make friends, so these people either can't overtly do this research (i.e. they have to cloak it as MIGS or MFM) or they have to do amoral popular research in parallel. In my limited experience of successful pro-culture-of-life physicians, there is a proportion involved: the more pro-life/pro-family research you do, the more amoral research you do. The more you cloak your pro-life/pro-family research, the less you have to lead two lives to put bread on the table.

This initially made me very frustrated. Why should I have to do twice as much work as other people in order to do the research I care about? In this age of non-discrimination, why should I be effectively treated differently because of my beliefs? Of course, I realize that I'm not alone. I'm sure there are hundreds of MDs and PhDs who have pet topics that are non-fundable because they are too obscure, too unstudied, or not flashy enough to earn grants. But still! This is different. Want to do research that builds up humanity and saves the world? Tough luck.

This makes me think of a story from my childhood. I was at a big family reunion as an early teen. I have a lot of cousins that span almost two decades in age, and we were all at the pool. There was a wading pool for the little cousins and a regular pool for the "big kids." Most of the kids who could swim were in the big kid pool. Then the reunion held an event: all the adults tossed coins into the pool and the kids could keep any that they picked up.

The competition in the "big kid" pool was fierce! I was bumping into people and the coins I was diving for would get picked up by someone else. I think I ended up with a penny and two nickels. I was actually pretty pleased with myself.

I was pleased, that is, until I went over to my dad, who was with my younger sister by the wading pool. My younger sister was with the little kids and had collected almost a dollar, just by bending over and picking up coins. She hadn't even gotten her face wet. I was so angry! I worked so hard to get eleven cents and my younger sister, who had no appreciation for money anyway, had easily collected almost ten times what I got! And I hadn't even realized that the wading pool was an option. My pleasure turned into hurt.

My dad took the chance to teach me something I have thought about several times since then. "There will always be people who get eleven cents with lots of work and people who get dollars without doing much," he said. Later in life, he would add, "We're called to be faithful, not successful." So I'll try to apply this attitude to work. I will do what I can to pursue my calling faithfully.

A Limit to to Primary Care?

Ever wonder why the pictures of offices are so weird? Me, too.
Somebody put some better free media on wikimedia, please.

As a future specialist, I'm struggling with letting go of primary care. As a pre-med and medical student I got frustrated when my OB/GYN didn't refill my albuterol for mild intermittent asthma. In response, I promised myself that I would not forget basic medicine.

The other day in continuity clinic, I saw a woman with a few medical problems. I wanted to do her age-appropriate USPSTF screening, which is germane to primary care. I had to look up the recommendations because I don't do a lot of screening and immunizations. I care for a single sex population which is largely of reproductive age, and my anticipatory guidance and lifestyle modifications are almost always about pregnancy and sexual behavior.

But I like being a responsible doctor, so I've modified my well woman templates based on age and USPSTF and CDC recommendations. I've built in HEADS screens for adolescents and breast and colon cancer risk scores for older patients. I remember how to read EKGs and do when I order them. I remember how to read chest X-rays and do when I order them. And I know the first few options for medical therapy for the most common problems: community-acquired infections, hypertension, diabetes, obesity, asthma, hypothyroidism, depression, early heart failure, and high cholesterol. I can respond to a heart attack or a stroke.

I'm not pretending I could be a successful family medicine or internal medicine resident. I have to look up the screening recommendations every time. I don't remember or know more than half of the medications they use, I'm sure. I can't ever remember the childhood milestones and immunizations. Don't look to me when someone's in kidney, liver, respiratory, or late heart failure. Find someone else for the endocrinology zebras and for the love of the patient, please have someone else run the code.

But I can look up what the evidence says when I have a well woman exam. So I looked up the tests I was supposed to order. When I went to staff the patient, my generalist attending scrapped most of my plan. "There's a limit to how much primary care we can do," she said.

This made me sad. Most of these women don't have another doctor. If they do, I begin to wonder why that other doctor can't do their pap tests (until things get surgical). I wish women only had to see one doctor unless they had more advanced medical problems. I enjoy continuity of care and building the physician-patient relationship. I find preventative screening a fascinating topic and a very satisfying intervention to execute. I love discussing lifestyle modifications because they knock at the door of virtue.

That said, I'm heading for fellowship and leaving primary care further and further behind. I think that primary care is an excellent sphere for midlevel practitioners, even though I love it.

In the future, there will certainly be a limit to how much primary care I do. If I become an MFM, I will do basically zero primary care and I will rely on specialists to help me manage the medical problems for my high risk patients with heart disease and other problems. (I'll still manage plenty of hypertensive disorders, obesity, diabetes, and thyroid disease myself.) That's a little hard to swallow, but I still dream of extending myself by joining a multidisciplinary practice that can be a hub for a woman's healthcare, so she doesn't have to spread out her time, energy, and medical records.

The "Safe Harbor" Idea is a Myth

I am going to apply for a fellowship that doesn't involve contraception. Am I running away?

There are several fellowships off generalist practice that could try to circumvent prescription of contraception. One could to MIGS, and only be a women's surgeon (sometimes management of endo could leave you in a tricky spot). One could to gynecologic oncology, and only operate and give chemo on women with cancer (safest bet, but hardest to get). One could do MFM, and only take care of people who are already pregnant (postpartum concerns especially in the heart failure patients becomes tricky). Am I running away by seeking one of these?

I don't think so. I want to do MFM for another reason: my interest in early pregnancy, ectopic rescue, and placentation. I love complex physiology. I love crises and encouraging women through them. I love life and protecting it. I am going into MFM to bolster the research that supports the embryo and the fetus as a person. I'm doing it to be more effective as a pro-life physician.

It bothers me when people assume I'm doing MFM to avoid contraception. At the same time, I can't hide the fact that it's rather convenient that MFM means my scope of practice isn't as restricted.

A few people I've told about this decision are very happy with it and give the response that makes my skin crawl. "Oh, so the contraception think won't be much of an issue. It's like a safe harbor." I hate being called a coward. (It's too close to the truth, anyway.) Besides, I'm not really escaping anything. MFM is soaked with termination and sterilization. What kind of escape is that? In order of most to least protective, it goes Onc > MIGS > MFM. 

I also dislike that Catholics should have to seek a "safe harbor." We should be able to practice in any field. If we have limits, we're like 100% of other physicians, and we are fortunate (?) to live in a country where the things we don't provide can be provided by someone else. I shouldn't have to go hide in internal medicine or surgery (I thought about it!). I should be able to be an OB/GYN. If we all ran away into safe harbors, who would witness to the truth? Who would challenge the paradigm?

Not only the "safe harbor" idea fundamentally flawed, but it's also a myth. There is no safe place to be a physician who trusts his conscience more than he trusts his lawyer and the guidelines of his professional organization. In the coming decades it will be a growing challenge for anyone who wants to do the right thing, whether or not he plans for a safe career.