Tuesday, August 30, 2011

Should I stay or should I go? A real mid-life crisis

It was like taking a ride in a time machine.

I had the chance, last week, to meet the incoming class of medical students at the University of Saskatchewan.  Just over 30 years ago, I sat where they were sitting, likewise listening to some old-timer blather on about what he had done during his career and what I had to look forward to.  

At that point, I hadn't yet examined a patient, written a prescription, or even taken an anatomy class.  In retrospect, I had no idea what I was getting into.  I was thrilled to be in the class, yet totally bewildered.  I recognized the same look on some of the faces of these new medical students.

I felt a mid-life crisis well up.

I've joked about mid-life crisis before, but I think I'm beginning to appreciate what it's really all about.  I've been practicing urology for almost 20 years.   That means I'm beyond the half-way point of my surgical career.  My upcoming birthday is a noteworthy one, in an over-the-hill way.  So, I've been thinking a lot lately about what I should be doing with the 2nd half of my career.  The topic I was addressing with the students only fueled my angst.

I was part of a panel discussion about physician leader and civic professionalism.  Our group included 2 practicing physicians (myself included), a physician administrator, a resident and a 3rd year medical student.  The course instructor had asked us to reflect on our own leadership experiences - why we took leadership roles, what we found satisfying about them, and what challenges physician leaders face.

I confessed that I spent my time in medical school, and the first 10 years of my practice, actively avoiding these roles.  In fact, one of the first leadership positions I took on was our office's Advanced Access/Clinical Practice Redesign work - the same work you've seen documented in this blog for the last 4 years.  That experience has taught me a lot about leadership, and encouraged me to seek out further leadership training and opportunities.  The other panel members related similar stories.

Giving the positive side of leadership work is easy and fun. And misleading.  Being a physician leader is hard work.  There are a lot of barriers to success, and talking about those reminded me of the questions I've been struggling with about my career’s direction.

Physician leaders are not readily recognized and valued for the work they do.  Brent Thoma, the ER resident on the panel, made this point when he spoke about his own experience as a class leader during medical school.  He pointed out that there are many scholarships for students who excel academically.  Top students in basic and clinical sciences receive recognition and rewards.  But, other students who choose to spend some of their valuable time in organizing class gatherings, charity fundraisers or the provision of healthcare to under-serviced communities don't get the same acknowledgement.  He was pleased to report that the College of Medicine had a new scholarship for such medical student leaders.

It's not any easier for practicing physicians.  First and foremost, doctors value clinical work, followed by teaching and research.  Administration and leadership are often  look upon with distain.  "He's gone over to the Dark Side" is a common jibe.  

Also, many physicians take a pay cut if they sacrifice clinical work to take on leadership roles.  For other health professions, an administrative/leadership role might mean greater opportunity for career advancement, with increased compensation and status. That's usually not the case for physicians.

Physicians have often been thrust into leadership roles without adequate preparation.   Until recently, leadership training was not a part of the formal medical school curriculum.  In the same way that doctors starting medical practice are presumed (by virtue of their doctor-ness) to be competent to teach medical students, they are presumed to be naturally competent leaders.  This assumption leads to uninspiring results for the healthcare system, and frustration and discouragement for the unprepared physician leader.

After the panel discussion, all these impediments to physician leadership were swirling inside my head, only to be accentuated by my reading, later that day, Andre Picard's interview with outgoing CMA president, Jeff Turnbull.  The piece's title, When even Dr. Optimism is losing faith in medicare, it's time to fix it, tells the story. Turnbull reports his frustration with "the lack of leadership, co-ordinated management, accountability and responsibility and, yes, needless waste.  Worse, we allow staggering inefficiency, ineffective management processes, incoherent decision-making and practice variations that undermine quality and safety."

While Turnbull insists that he remains optimistic, imagine what resolve it must take to maintain that outlook, given the dysfunction he has seen at every level of healthcare, from the highest level of health policy to individual patient care.

Turnbull's sentiments, while on a grander scale, are similar to mine as I've been trying to decide what direction to take.  While the leadership work I've undertaken so far has been very rewarding, it can be stressful, and takes me away from the clinical work that I also enjoy.  Improvement projects never seem to move as quickly as I would like.  

It would be so much easier to keep my head down and retreat to the familiar trenches of clinical practice.  After 20 years, there’s a comfortable level of competence.  While there’s enough variety and challenge to keep things stimulating, the learning curve has flattened.  I have a great group of partners and staff to work with.  I could give up the meetings and committees and projects.  I could be home for supper more reliably.  And, the money is good.  Great, actually.

It’s a little disturbing to acknowledge the allure of the familiar ground of clinical medicine.

The question I’ve been asking myself is: Why fight it? Why not give up leadership work? 

I think I have the answer:  Medical leadership is not separate from clinical practice; it is an extension of clinical practice.  The will to lead flows from the desire to bring about change.  Once I understood that changing only my own practice severely limited the improvement my patients could experience, I was compelled to try to influence change beyond each single physician-patient encounter.

Experiencing, on a daily basis, the frustrations that Dr. Turnbull described, fuels my will to change things.  But, I don’t intend to change The System - that amorphous, slippery, anonymous, maddening thing.  I don’t think I can change that.

But, people made The System, and they – we - remake it everyday.  I think I can help, convince and cajole people (and myself!) to work differently, and through collective effort, we can replace The System with something we will be proud to be part of.

There’s great joy in that.

And so, crisis resolved. 

I'm turning 50, and I’m not turning back.


  1. There is great reward in making a difference for the 1,000,000 patients who call this province home.
    Your articles Kishore are always a good tonic!

  2. Thanks for the reminder of our million reasons...

  3. Thank you for being the leader that you are. I think that I can speak for a great number when I say that you are an inspiration to so very many people.

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