Query

Something strange has been happening to me lately. Indecision. It started when one of my practising friends from medical school called one evening. He asked my advice on an offer he'd recently received from the medical school. Mark's story was like this: he excelled at every clinical rotation. At the end of each rotation, he'd be encouraged by every preceptor to go into that particular specialty because he had such an obvious aptitude for it. Mark was understandably confused by this; each time he received glowing feedback, he would logically feel that X specialty was the one for him — until he became embroiled in rotation Y, which would, inevitably, end with another glowing evaluation and a positive recommendation. Mark reasoned that he might as well position himself to do everything he was good at. He chose Family Medicine.

Figure. Photo by: Fred Sebastian

All went well for several years — until he received a call from a specialist friend who had happened to talk to one of Mark's old teachers. When the friend mentioned Mark's name, the faculty member went on at length about how good a student Mark had been and how good a practising doctor he must be. The faculty member even offered, through the intermediary, a residency to Mark if Mark wished to reconsider his choice of Family Medicine. Mark's friend passed the information along. Mark followed up on it; soon a residency contract arrived in his mailbox, but, before he signed it, he decided he should ask around for advice. He called me.

When I'm asked for advice from my patients, I'm very careful to not make their decisions for them. The reasons are simple. First of all, the patient should make up her own mind. Secondly, if I choose for her, then I can be blamed if things don't work out. Therefore, I took care to weigh the pros and cons of Mark's situation. The cons: Mark would end up in a limited field, seeing a limited number of problems each day. He would be confined to an academic centre and have no opportunity for the small-town experience that he had been thus far enjoying. He would suffer a drastic fall in income over the course of the residency. He'd be forced to work in an underserviced centre for the first few years after the conclusion of the residency in order to repay the sponsor community.

Then I moved on to the pros: he would be a specialist, and, unfairly, specialists command more respect from today's society. He would be an expert in a field, not a generalist, and so, as an authority, would be able to handle more in that field. Most importantly, he would be a consultant, someone who would offer reassurance and advice to poor generalists who are baffled or confused and in need of his help. It was this latter factor that I really urged him to consider, asking him: “How do you feel after you've talked to a specialist who has been really helpful? Reassured? Confident? Now compare that with someone who belittles you, who gives you the impression that you're incapable of dealing with simple problems and are just wasting his time?”

Mark called me a few months later to say that he had returned to residency. But even before his second call, I had begun to wonder if perhaps I also should return to residency. I loathe certain aspects of general practice: being wedded to problem patients; relatively lower remuneration and a treadmill practice pattern; the attitude of certain patients that they need a specialist before they can be “properly” diagnosed and treated; the much higher proportion — outside of psychiatry — of psychosomatic illness; the lack of real pathology; the knowing a little about too much.

I'm tempted. I turn the question on itself: What's keeping me here? Why continue to practise Family Medicine? And, after all my complaining, the simple answer is: I like it. I like follow up; I like the front line; I like working things up; I like owning more than one body part or blood type. But then the question is: Would I like a specialty as much as I do Family Medicine?

I'll have to ask Mark in a few years. A month ago, over the phone, he whispered: “And if I don't like it, I can always go back to Family Medicine!” Perhaps that's answer enough.

— Dr. Ursus