My FM Story
Bruce Greenberg, MD, FAAFP
I made a tentative decision to retire in July 2018 after 40 years of practicing rural Family Medicine. I was considered one of the "dinosaurs." Unique aspects of my career included being a graduate of one of the early FP residency programs and recipient of initial board certification, practicing in the same location for my entire career, and doing full-scope care including inpatient and obstetrics from beginning to end.
My decision to become a physician was formed at the age of four after seeing an exhibit about medicine in a museum. It's not often that people get to do what they dream about as a young child. I came from a lower middle class working family and didn't really have any medical role models. I just had some vague illusion in my mind of what it would be like to be a "country doctor."
I did my undergraduate work at UC Berkeley, as it was the nearest campus to where we lived at the time, and I couldn't afford to go away to college. I was accepted into one of the early classes at the UC Davis School of Medicine, which was in its "infancy." I matched for residency at Natividad Medical Center in Salinas, an old county hospital that had been approved for one of the "new era" Family Practice programs.
While a second year resident, we got a call from the doctors down at Mee Memorial Hospital in King City. They were getting older and more fatigued, and they wanted to know if any of the residents wanted to do weekend coverage and emergency room work. Several of us, who had just gotten our California licenses, began to rotate there. Near the end of my residency, the local docs asked if I'd like to come on full-time, and I accepted.
My wife-to-be wasn't thrilled about my choice. She had been more of a "big city girl" and felt like she was being dragged to a "cow town." We had met a short time after I started the residency. She was a single mom working her way through college as a ward clerk and translator, and I was impressed by her motivation. Having grown up in both New York and Puerto Rico, she was fluent in both languages. The standing joke became that even after I was capable enough in Spanish to see patients on my own, I would still ask for a translator, just so we could visit with each other at work.
I joined a wonderful group that included five FPs, a Pediatrician, an Internist, and a General Surgeon. We didn't have an Ob-gyn in those days, so the FPs did all of the deliveries, and the surgeon and some of the FPs shared call for C-sections. Anything that was higher risk was generally shipped out to a larger facility. The physicians all lived locally, and they were very involved in the community. Some of the docs would come in to round on their own patients on Saturdays, and we would sit and have coffee together and chat. We frequently had group dinner parties. The members of the original practice had even personally borrowed money to get the "new" local hospital started in the early 1960s.
After about 20 years in practice, the playing field changed. Expenses were up and reimbursements were down, and just keeping the doors open was a struggle. The local hospital had a new CEO, and he offered to acquire our group and take the pressure off of us, so that we could just be physicians and not try to double as business managers. The hospital paid off the practice debts and the building mortgage, and we became salaried "employed self-contractors." They also had the resources to recruit new providers, and at one point in time, the medical staff had 10 Family Physicians, nearly all of whom did inpatient care and obstetrics, a Peds, an Internist, a General Surgeon, and two Ob-gyns.
Over the next decade or so, the demographics altered, and fewer providers wanted to come to, or reside in, our local area. Some docs decided to live an hour away in what they perceived as more upscale communities with better school districts. However, typically, after commuting for a year or two and having to stay nearby while on call, they would decide to leave. Also, certain specialties were staffed by "shift workers" who came to the local facilities from far away for a week or two, then went back to their "real homes." This pattern somewhat eroded the strong sense of "community" that the practice had previously enjoyed. The outside docs were there to "work" but not to necessarily be involved in local events.
Teaching medical students and residents quickly became one of my favorite aspects of practice. I started out by receiving UCSF students who were doing their Family Medicine rotations at Natividad. Later, some Touro University students came down, as I had known a doctor during residency who had become an associate dean there. After attending an alumni event at UC Davis and speaking to one of the deans, I started receiving students for rural FP electives. Eventually, we became a certified site when the Rural-PRIME officially kicked off at UCD. Some residents at Natividad also rotated down, from time to time, for electives. I had become the director of Allied Health at Mee, so I started to accept and train FNP and PA students from various schools.
I decided to expand my horizons even further. Since my wife had been born on a farm in Puerto Rico, we had purchased some property there and decided to build a vacation home. I visited the medical schools and some residencies on the Island, and I started to receive students at my practice through a program I coined the "Bridge Across the Sea." During one of my trips to PR, we ventured out to a hospital in the mountains in a very remote rural area. The location was, in many ways, not too dissimilar from my own practice setting, but even more isolated. I struck up a friendship with the medical director, who was a fellow FP, and they agreed to take some interested students and residents from California for electives.
Over the years, I tried to participate in as many events as possible in our Southern Monterey County community. It seemed that there were fewer and fewer of us who lived locally to perform that function. I worked at many of the local high school football games as medical support, and I attended events where we performed athletic pre-participation physicals. I also went to football, baseball, and basketball games as a way to de-stress from work. Being a small community, there was usually a relative or child of a friend playing in the game. Even though I wasn't officially there to "work," I always responded when they motioned me down to the field or court to evaluate a player with a nosebleed, asthma attack, or dislocated finger. In 2002, I was awarded the "Humanitarian of the Year Award" by the UC Davis School of Medicine Alumni Association for "outstanding service to the community."
The electronic medical record was a challenge for the more veteran physicians after so many years of paper charting. Many patients complained that the doctors appeared to spend more time preoccupied with their computers than with the patient's care. It just seemed to take one of the more human elements out of our practice. I elected to not use the computers in the patient exam rooms, just to jot a few notes on paper and do the rest of the charting in my office across the hall. It was my way of feeling that I was still making patient care a priority.
Going to Puerto Rico a couple of months after the 2017 hurricanes was an eye opening experience. While our home there had suffered essentially no structural damage, there was a lot of clean up and repair work needed on the property. We also became involved in a community organization and made many new friends. The electricity was still out in our area, and people were using generators, when available, for power. It was especially challenging for persons with health problems who needed to receive oxygen or were on home IV therapy. We spent some time checking up on those folks in their homes, and the local community was very appreciative. We decided that we needed to spend more time there in the future.
Time seemed to pass, and the years had flown by quickly. I realized that I wasn't getting any younger! I had managed to keep myself in good health over my career, but I decided that longevity required rest, relaxation, and the lack of stress - which often ran counter to the work situation. Unfortunately, a lot of the doctors had left the community, and it had become more difficult to recruit. Also, the work that had seemed easy to do in my 30s, 40s, and 50s with many colleagues became increasingly more difficult in my 60s with our waning medical staff.
Not unlike professional athletes, physicians must maintain a high level of skills and energy in order to do a good job. At some point, our days of achieving that demanding level of effectiveness seem to run out. Also, my family had seen a number of our medical friends and colleagues try to extend their careers, only to die or become disabled in the process from illnesses such as heart attacks or cancer. During a trip to our home in Puerto Rico in the summer of 2017, I looked out over a forest and the mountains from a rooftop deck, and I told myself that it was going to be my final year in medical practice.
Since I could hardly believe that I had made such a weighty decision, I decided to talk it over with my family and sit on the idea for six months. They were completely supportive. Around New Years, I told people at the Hospital that I would be leaving in July. While they understood it, they had a hard time accepting it. To many, I was known as the "Rock of Gibraltar" for my consistency, and they lamented over having to think about whom they could possibly find to replace me and cover all of the functions I had presided over. Many felt that I would just get bored and come back to work after a couple of weeks away. I finally decided that I really didn't want to give up practicing medicine entirely. However, after 40 years, I definitely owed some time and concessions to my family.
I devised a plan that I thought would give me the best of both worlds. I would leave on July 1, as scheduled, for almost a month of rest and relaxation. I would then return to a flexible schedule that permitted me to work half the number of days per year of a full-time person. I could essentially take vacation whenever I wanted as long as sufficient notice was given, and I could arrange any combination of full days and half days that meshed with the practice. I decided that, for the most part, I would be doing little, if any, inpatient care, obstetrics, and on call duties, focusing mostly on clinic practice -- although I kept my hospital privileges active.
I felt that I had "done my share" as a full-scope Family Practitioner and estimated that during my career, I had engaged in more than 200,000 patient visits (including inpatients and outpatients), delivered over 3,000 babies, and spent more than 2,000 nights on call. With the declining number of full-scope FPs available, out of necessity, the Hospital had brought in an adult medicine hospitalist group, outside doctors to cover newborns and pediatric admits, and there was always an Ob-gyn on call. Having the FPs perform these functions had just been the "icing on the cake" for us "dinosaurs."
I entered the last two weeks of full-time practice with many thoughts and emotions. We had a big celebration in King City for our 40th wedding anniversary, I did my last scheduled night on call, and I attended the Natividad resident graduation as a member of their first graduating class in 1978. A couple of days later, we boarded the plane and flew to Puerto Rico. It was relaxing as we visited relatives, participated in a few community events, and had another 40th anniversary celebration for Island friends, family, and neighbors. I even agreed to do some chart reviews remotely for the practice in California while away, just so I didn't lose touch completely.
Although we had offered to do medical work during our stay, this need had greatly diminished, since almost a year had passed since the hurricanes. We could see many signs of rebuilding, although it was clearly incomplete, and some things would just take years to get back to normal. Unfortunately, we learned that most of the homebound people we had visited the month after the storm had since passed away due to complications from their illnesses.
After three weeks in the Caribbean, it seemed like time to return to California and my new arrangement at work. I went back and found, fortunately, that I hadn't forgotten 40 years of learning in my time away! Also, one of the Natividad second-year residents was rotating with me, so that made it more interesting. I felt refreshed by his enthusiasm for medicine and said to myself, "I think I can still do this." So, I was pleased with my decision to continue to work part-time instead of leaving entirely.
I had developed significant nasal congestion and sinus inflammation during the last week of our trip. The heat and humidity, the locals said, generated spores that caused allergic problems for those not used to it. Also, the Island had been covered by dust coming all the way from the Sahara desert, which was very irritating. I tried a lot of over the counter remedies and figured it would clear up once I got back in the California air I was accustomed to. However, when it didn't improve in a week, I went to see a colleague to be checked and received a couple of prescription medications that provided rapid relief.
The experience taught me a couple of valuable lessons. I could now see why my patients had been so appreciative of me over the years for making even a small intervention in their health that had made them feel better. Also, after enjoying my own overall good health for years, and having to endure only a short period of discomfort, I began to better understand how difficult it must really be for people to live with chronic illness. We might see these patients for a just few minutes during a routine work day, but for them, dealing with their medical problems was their entire existence.
After a couple of weeks, I had settled into my new role. I was seeing about 20 patients a day, a little less than before, and supervising some Allied Health providers. I was still involved in recruitment of physicians to our practice. They even convinced me to do a weekend on call as they were short-handed, and it wasn't as bad as I had anticipated. While I found that I wasn't able to attend to every one of my patients' urgent needs, as I had tried to do in the past, I was able to still see them for most of their routine care.
Finally, my interest in writing this article stemmed from a desire to demonstrate that Family Medicine can, indeed, be a rewarding career. The rural practice part of it isn't for everyone, but I have been told that there is a resurgence of FP residency graduates who want to do more of a full-spectrum practice. I would like nothing more, a few years down the road, to know that a number of dedicated recent grads had stepped into our practice and planned to be there for the foreseeable future, much as I, myself, had done 40 years earlier. I would appreciate that any comments or practice interest questions be sent to me at: firstname.lastname@example.org.