A Difficult Time
My Journey in Medicine	by Jerry Sobieraj, MD © 2001
Available at and Published by
Also available at:

Chapter 12: What does experience get you?

I have become old enough to have learned the value of experience. In my younger days, pure youthful enthusiasm, and intelligence could keep me ahead of the pack. As I have had more opportunity to witness the ways of the world and Medicine, in particular, I have been able to gain a perspective that cannot be taught, but only slowly garnered. I have learned when to be patient, and when to "step on the gas". In addition, the sheer depth of my knowledge has increased beyond what I would ever have expected. I can still remember many things verbatim as they were taught to me in med school and during my residency. I also have been able to fine tune this knowledge with experience, which has taught me, just because it made sense, didn't mean it was true.

So what had this experienced gained me? A comfort level with my knowledge base, to be sure. It has led to colleagues asking my opinion as to how they might have managed a difficult clinical problem. It has given me the opportunity to share my clinical skills with my colleagues during Medical Grand Rounds (the big academic conference each week) and to teach Medical Students and internal medicine residents when I am supervising on the hospital wards. It has also given me a cadre of faithful patients, who implicitly trusted my judgment. It has also given my patients long waits between appointments, because my superiors desired to maintain a particular output (i.e. productivity). It has made it harder for me to talk with my patients, to find out what made them tick, and to understand their issues during the times allotted. It has made me feel rushed and at times, harried. In other words, in terms of what I did most of the time, i.e. take care of patients, it didn’t have as many returns as I had hoped.

So, what was the point? To use a metaphor; when I played hockey in my 40s, I no longer had the legs on the ice (and some might argue I never did) to keep up with 20 year olds who skated alongside me. Yet I could see the ice and the play of the game much better now than during my youth. What I now lacked in speed, could partially be compensated for by my improved view of the play. Similarly, I didn't have the energy of the 25 year old residents I taught, but I could help them see the big picture, and keep the residents from barking up the wrong tree. My experience was at least partially compensated. I was able to precept residents in their primary care clinics, which afforded me the opportunity to help them develop a long term perspective when managing a patient’s issues (as I would tell them, "you can't run a marathon in the first mile"). I was also asked to serve as ward attending, and share my knowledge and judgment with Medical Students and residents as they confronted and managed potentially seriously ill patients.

Yet, these activities were at best a quarter of my annual schedule. The bulk of my time was spent as a primary care doctor. I saw people, I listened to them, I evaluated their situation and I helped them devise a plan for managing their medical problems. What did my experience get me in this bulk of my work load? It definitely got me the multitude of problems I have already noted in earlier chapters. Yet, it didn't allow me more time to talk with people, which was my main pleasure in primary care (the intimate sharing of medical issues with patients allows us to experience some vicarious living). It didn't give me more time to explore areas of interest to me (both within Medicine and in other areas). It didn't give me more time with my family (just to keep up with paperwork, I found myself going in for 6 hours one Saturday per month). So what was the point (it surely didn't give me more money, though my boss kept giving me nominal annual raises hoping the crumbs would do the trick and keep me satisfied)?

A colleague of mine confided in me, that in 1996, his superior had thought of letting him go as a free agent, because he had fresh young faculty members ready to take his place. My colleague was a bright, hard working cardiologist. He had always taken the practice of cardiology seriously, understanding the complex nuances of cardiac disease. He was affable, and an outstanding teacher. But he wanted a raise. He could have doubled his salary by leaving for private practice. He likely would have left the academic medical center (AMC) if his boss didn't move up the ladder, clearing the way for a new chief of cardiology, who valued his clinical skills. He still could have earned double his current salary in private practice, but at the AMC he was able to obtain some respect for his activities, and some time to develop areas of interest to him. I’m sure this was only partial compensation, but enough to keep him on board for the time being.

As I alluded to earlier, this wasn’t about making money. I felt that I made plenty of money. I noted earlier, even though I was on the low side of the doctor pay scale, my income still permitted me to be in the top 1% of American wage earners. The problem that I had was the inability of the Health care system to distinguish one’s work from another. The Health care system reinforced filling in the boxes, and making the coding of services match up with one’s narrative. If they matched, one was paid, if they didn't, one would take a pay cut. The amount one received when submitting a billing code was the same in one’s first year as a practicing physician, as in one’s twentieth year. I’m not aware of this extent of disregard for experience in other professions.

We have developed a system of Health care that has encouraged the cheapest form of delivery, by the least experienced practitioner. There were some time management skills that practitioners needed to learn, but from a corporate point of view, all primary care providers were interchangeable. Health care was at a stage equivalent to when the automotive industry was being converted to a production line. As in those times, the Health care system had people who were trying to analyze the minimum amount of time needed to perform service X, and making that the standard. It has been referred to as “productivity”, but it has been much more destructive than productive.

Table of Contents