“How’s the New Job Working Out for You, Doc?”

When I completed my residency in 2002, I did something that was already considered unique. I bought a medical practice from a retiring physician and literally hung out my shingle. Over the next 15 years in rural private practice, I served my community by being a part of it. My mission was to do everything I could to be the community health leader that my friends and neighbors deserved.

I practiced full-spectrum family medicine and did all of the routine things that now amaze us about doctors from the golden age of 20th century family medicine. My patients appreciated the old-fashioned feel of my practice and were always surprised when I let them in on my behind-the-scenes world of modern technology, evidence-based resources, and how my team studied and modified the latest care delivery models to serve our patients better. I managed to be an active and available father to three growing daughters, went on vacations (but not enough of them entirely separated from meetings), didn’t go bankrupt, and taught lots of medical students and residents in my office. Being part of the teaching process was usually fun for my patients, and I let them know that when they were the object of my lessons, they were taking part in an important training process.

Last year, I recognized that my care delivery model was becoming stale and that it was my teaching activities that were sustaining my joy in practice. I wanted to expand my impact as a family physician but wasn’t looking forward to another practice redesign or running my fee-for-service hamster wheel faster just to reach more patients. A medical student on rotation in my office helped me see an alternative plan. “I never knew practicing medicine like this was possible anymore,” he said. “If I hadn’t been assigned to your office, I bet I never would have known how it really works.” How sad that he had encountered so few teachers able to pass along the skills of the “real family doc.”

As I contemplated his comment, I began to see more clearly that my sense of mission as a physician was evolving. I came to understand that there could be another chapter in my career that could have a multiplying effect on what I had brought to my rural community. I opened a dialogue with a residency classmate of mine who had become the residency program director at our alma mater 30 minutes away. He graciously weighed the program’s educational needs against my skill set and we determined that a transition to full-time teaching could be a win-win. I would still have an active clinical practice as a residency faculty, and could populate that with patients willing to drive a bit from my rural practice site. My other patients would be in the capable hands of several wonderful new family docs in a nearby community. Best of all, I would be able to focus my time on teaching the real skills of private practice, rural medicine, and community leadership.

There was a general sense of disappointment in my rural community upon hearing the news. However, as I began to talk with my patients about the reasons for my decision, most found it within themselves to see the larger purpose in the transition—and the opportunities for better care my change of focus could mean for lots of other communities. I told my patients from the start that this was not a “grass is greener on the other side” move and I have certainly found that to be true.

Full-time teaching can overflow my schedule just like full-time clinical practice could. The frustrations of administrative work in a residency clinic are much the same as the frustrations of administrative work in my private practice. The budget is bigger, but no less tenuous at times. The stress I felt from a relatively underresourced rural practice strikes fairly close to the stresses I feel from a resource-heavy training site. The things about private practice that increase the risk of physician burnout are different than the things about full-time teaching that can do the same—but they both exert the same pressure.

I loved the wonderful professional people that I worked with (all three of them!) when I was the “boss.” My new team is huge by comparison, but the sense of higher purpose that I feel from my faculty colleagues is mission congruent (one of the many new phrases I’ve learned in the last 15 months) with my own beliefs about teaching. I wonder daily why anyone in private practice has ever uttered the phrase, “Those docs in the ivory tower sure have it easy.”

There are joys and struggles in private practice. There are also joys and struggles in teaching. The specialty of family medicine needs physicians who are willing to be leaders in both of these roles so that we can most effectively reshape how family medicine is delivered. Strong leadership in these complementary areas will better serve the next generation of patients, and also the next generation of physicians.

I am happy to have crossed the unfortunate divide that has developed between teaching and doing our profession, and hope that my past experiences and present opportunities can narrow that chasm. Will the community impact promised by a career in teaching be realized? Will I someday regret that I let an opportunity to stay in my practice and “teach in place” slip away? I live uncomfortably with these unknowns.

Just now I’m off to see some patients. My first appointment is with a fellow from my old practice who I’m seeing in the residency clinic for the first time. Like most of those patients, I am expecting him to ask at some point, “How’s the new job working out for you, Doc?”

Where will I begin?