Kozel hailed from a dysfunctional alcoholic family in a depressed, small New York town, and dreamed of escape. Finding her passion - science - at age 15, she settled on becoming a physician. In this part memoir-part discourse, she recounts the years spent in college and medical school, having "whiteknuckled" her way there, before moving into a residency position in the US Navy.
Her recollections of life as a medical student brought back the acrid stench of my medical school's formaldehyde-fumed dissection hall (her body's name was Pickles - mine was Mrs. Bojangles), the insecurities of those first patient encounters on the wards, and the mnemonic tricks we used to recount the names of skull bones, cranial nerves and the likes. And then came the harrowing and thrilling first ventures into the OR -- sleep-deprived as she was ... and we were. I recall having to leave the OR to avoid a faint as a med student, when called out of bed to help with the amputation of a gangrenous lower leg at 3 AM. Her up-close descriptions plunged me backwards into that time of intellectual satiation and exhaustion as if it were but a few years ago.
Her broad Navy internship in Internal Medicine was not atypical from that any of us has been through - intense work, unrelentingly long hours, and immense on-the-job learning. The year included a pediatric rotation and it was there that she found her calling. There came a moment when she acknowledged "I came to realize that I felt more at home in my doctor skin that I ever had".
Ensconced in the cocoon of the US military healthcare system, as a Navy pediatrician trainee both in the US and in Japan, Kozel was unprepared for the realities of civilian medical practice when she and her fellow physician husband were finally released from their Navy obligations.
It is in the second half of the book where my deepest identification occurred. Kozel has managed to articulate astutely the frustrations I felt as a family physician working in a failing "healthcare system" (in my case, deeply managed and capitated care on the West Coast). She has illustrated her journey from idealistic practitioner to disillusioned, burned-out physician with stories, the likes of which I could have matched her one for one. She hammers home repeatedly how insanely perverse our medical care reimbursement is, and why we are apparently a runaway train on the track to nowhere, with our bandaid fixes and entrenched pandering to special interests. She suggests fixes, many of which seem quite sensible AND doable.
The paragraphs that struck me most forcibly were these:
"It is ironic that the safety nets the government provides to poor children are called "entitlements." This is the least entitled segment of our society. Uninsured or underinsured children, or ones on Medicaid (link is mine), may have trouble finding a practice to accept them. They are more likely to use public clinics, and never be seen by the same practitioner twice. Their parents are more likely to hold off bringing them to care until it is absolutely necessary. They're more likely to wait for hours in a crowded ER for a common ailment, because they have nowhere else to go.
Entitlement, from my perspective means demanding that your doctor do an ear check at 10 o'clock at night because your otherwise well three-year-old seems fussy. Entitlement is expecting that your doctor will see your child at 5 AM to diagnose a rash, so you will know if the child can go to daycare or not. Entitlement is insisting on going over, one more time, the pros and cons of keeping a cat when you know your child has cat allergies, as the ticking of the clock competes with the sound of all those kids hacking and coughing out there in the waiting room."
Kozel's night of reckoning occurred after a particularly tedious day in the office when she arrived home after 10 PM, to a sleeping family. Within minutes, she was called back to the hospital, and on the road, realized "I can't keep doing this.
I won't spoil the remainder of the story, in which she grapples with one of the toughest decisions some of us, as highly educated and trained professionals, face when considering the unfolding of our remaining working lives.
I read with curiosity the book reviews on Amazon, wondering about those who perceived her as a whining physician who elected not to stick around to help with the solution. The perception is obviously alive and well that physicians are obligated to sacrifice self and family on the altar of public need!
To all tired and frustrated physicians struggling to make sense of your life and work, I recommend this book. It will let you know that you are not alone, and it will validate your disillusioned observations about the problems within the US healthcare system.
To all medical students and those contemplating a physician career, I recommend this book. It will help you enter with eyes wide wide open, and perhaps inspire your devotion to creating solutions before you are too burned out to summon up the energy.
To all policymakers who are grappling with how to fix our broken health care system, I recommend this book as well. It will shed light on one of the "dirty secrets" in medicine -- how the System is grinding down and spitting out doctors. It should have you worried.
And to the rest of you, who view physicians with a mix of gratitude, resentment, mistrust and even envy, I recommend this book. Perhaps it's time to look in the mirror and see what part you might be playing in helping your physician journey in and out of medicine!
But then, that is just my bias…