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Knowing when it's time to move on


How hard is it to leave when patients need you so much? This doctor knows.


Your Career Guide
Solving the midcareer puzzle

Knowing when it's time to move on

How hard is it to leave when patients need you so much? This doctor knows.

By Thomas J. Richards, MD
Family Physician/Ventura, CA

Looking down on the lights of Los Angeles from my coach seat, I replayed once more the words I'd heard so many years before, as the dean gave his welcoming address to a fresh crop of medical students.

"Medicine," he said, "is a cruel mistress." It would call us away from family and friends, and beckon us at times when we would just as soon be left alone. He also warned us against "getting seduced by the need." Being needed is one of the most basic and powerful of all human desires, he cautioned, but we shouldn't let it become so important to us that we would neglect our spouses, our families, or ourselves.

Cruel mistress. Seduced. A surprising choice of words. We were in Utah, after all. I remember the look on his face as he spoke, a look of both pleasure and pain as though a long and slightly barbed thorn had just been pulled from the soft instep of his foot. He'd been there.

His words came back to me from time to time over the years, usually when I was tired or frustrated, asking myself why I hadn't become a plumber or a teacher. Below me, Los Angeles sprawled as far as I could see, a luminous blob washed up on the shore, catching its breath and pulsing against the sharp black outline of the Pacific. I had left southern California five years before, vowing not to return. I was going where I was really needed.

I had spent the past three years in a sleepy little town in northeastern Wyoming—about 7,000 people in the county and not a single traffic light, no movie theaters, and not one clothing store, let alone a mall. Thirty-five miles to the nearest latte or gym—if the roads were open and I wasn't on call.

As one of three physicians in the county, I helped staff the hospital and its attached nursing home, three clinics (one for each town in the county), and the emergency room. Not emergency department—emergency room, no bigger than a one-car garage. There was one nurse, and maybe a respiratory therapist on call. It had all the unpredictability of any ER, but only a fraction of the capabilities. There were no consultants to come in and help with a difficult case, just the doctor on call that day.

I'd learned a lot. I was needed, and it felt good. I made a difference and, a couple of times, I even saved a life. So, as the lights of LA crept closer, I thought: What am I doing here on an interview trip? Why am I leaving rural family practice? The romantic notion of the country doctor is as much a part of Americana as the kindly minister and the tough but honest sheriff. As I went from one interview to the next, the only people who seemed to understand were fellow physicians who had also left rural practice. Kindred spirits. They would nod and sigh.

I talked vaguely about wanting to return to warm winters and sandy beaches, but in truth, I was leaving because after three years of a kind of minor-rock-star celebrity status in a small town, I had stopped enjoying things in life. I'd lost weight and slept poorly. I was depressed, and I knew it. At one point, I even put a box of antidepressant samples in my desk drawer but never used them. I chose instead to change my situation.

It was a hard decision. People needed me and had come to rely on me, to trust me, literally, with their lives. I had worked hard to earn that trust—on call every third night for three years. The constancy of my call schedule was much worse than its occasional intensity. I imagined scenarios, and lived through a few, when there was a genuine medical emergency and I didn't know what to do. Somehow everything turned out all right, but it was hard to relax.

At some point, for reasons I can't explain, I began to get angry. Angry when I got called out, I spent the 10-minute drive to the hospital calming myself down, reminding myself that it wasn't the patient's fault that I wasn't in the mood to be a doctor just then. Vacations helped, but they were never long enough. It was time for a change.

As the plane descended into LA, I realized that I both dreaded and looked forward to that change. I was giving up a life that was rewarding but was eating me alive, moment by moment. Part of me longed for anonymity, to be a small fish in a pond the size of the Pacific. There was also a feeling of loss and of having abandoned my patients.

There was also, however, a sense of self-betrayal in staying, of knowing that I wasn't treating myself as well as I should be. How many times had I told my patients to exercise three times a week, eat well, and reduce stress? I wasn't practicing any of these principles. Actually, I don't know many physicians who do. We don't have time, and to make the time would require us to spend less of it on people who need us.

That's the motivation, I think. I don't believe we're in it for the money. A very few, perhaps, are in it for the glory. Most of us became physicians because we feel a deep, powerful need to help and an unrecognized need to be needed. I don't think that's all bad, but like all things it's not healthy in the extreme. It's hard to say No when you know you're needed. By the time you realize that your livelihood is taking over your life, you may be a long way down that slippery slope.

As the plane neared the tarmac, I reminded myself that the most dangerous parts of any flight are takeoff and landing. Airplanes can land and take off safely, I thought, because they maintain their balance. If I didn't want to spend my life going from one emotional tailspin to the next, I would have to learn to keep my balance.


Thomas Richards. Knowing when it's time to move on. Medical Economics 2001;1:127.

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