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Avoiding the Shoals of Contracts and Codes

When a Dartmouth Medical School graduate finishes her training and enters practice, she learns that the patient-care part of medicine, which she loves, is subsumed in a sea of insurance contracts and billing codes. In this excerpt from a book about her experiences, she tells of navigating a whole new aspect of medicine.

By Emily R. Transue, M.D.

As I pressed the new parking sticker carefully onto my windshield, I paused to consider what the small sliver of plastic represented. At the age of 29, after 24 continuous years of education, I was about to begin what could be calledmy first real job. My new business card burned in my pocket: "Emily R. Transue, M.D., General Internal Medicine." I was starting practice as a primary-care physician.

With a laugh, I thought back to the day I'd decided to go to medical school. It was early in my senior year of college; a biology major, I was scrambling for a new career path after realizing I didn't want to spend my life at a lab bench. I'd done Parkinson's research with primates and reasoned that if monkeys were interesting, people must be even more so.

I called my grandparents to announce my momentous decision. "But we hate doctors,"my grandmother protested. Through all my years of medical training, whenever a physician amputated the wrong leg, administered the wrong medication, or made some other terrible mistake, my grandmother would send me a news clipping. I was never sure if these were warnings about what might occur if I applied myself inadequately, or simply further evidence that physicians were an untrustworthy lot.

During my second year at Dartmouth Medical School, my grandmother called to tell me my grandfather had developed atrial fibrillation, an irregular heart rhythm. It's usually treated with blood thinners, to reduce the risk of clotting, and with cardioversion, a brief electrical shock to restore the heart's rhythm. "They're giving your grandfather rat poison," my grandmother declared. Rat poison is made from warfarin, the same compound used medicinally to thin blood. "Then they're going to electrocute him," she added. I had to admit that these were precisely the kinds of barbaric things people in my chosen profession did.

Still, here I was. Absurdly, the parking sticker brought home what my employment contract, application for hospital privileges, and order for business cards had not. During the eight years since I'd started medical school, everything I had done had been temporary. Student clerkships lasted four to eight weeks, residency rotations a month. My year as chief resident, helping run the program I'd finished the year before, was the longest I had spent in any single role; and even that was clearly defined as transient, for my successor had been chosen before I started. In all that time, I had hung temporary parking placards from my rearview mirror. The

sticky teal rectangle I was now putting on my windshield seemed to symbolize an end to transience. After eight years of working toward this point, I was entering an unfamiliar permanence.

Afew weeks earlier, the ink barely dry on my employment contract, I had signed another sheaf of papers, buying my first house. My possessions were still in boxes, the wonder of owning a piece of land and the home that sat on it still fresh. As I finished affixing the parking sticker and walked into the angular brick and glass building housing the clinic I'd joined, I was bursting with the richness and strangeness of my new life. I had a job, a piano, two cats, a house. I was a long way from Ohio, where I grew up, and from New Hampshire, where I went to medical school. I was a long way from my family, who were spread from California to Massachusetts. My grandparents, the ones who hated doctors, were in Pennsylvania.

Nonetheless, I had put down roots in Seattle. I could feel them under the maple tree in my new front yard, even in the glue of the parking sticker. I was about to walk into the clinic and begin to grow roots of another sort—putting on my white coat and meeting strangers who would become my patients, as I grew into my role as their doctor.

I had finished the hard years of residency, the 100-hour weeks and 36-hour shifts, the drama of the hospital and the emergency room. I had seen a lot of people die or nearly die during those years, and I thought I knew plenty about grief and loss and healing. I little imagined how much more I would learn in the coming years. Much of my newfound knowledge would come frompatients I would care for, not just in the episodic crises of the hospital but in the slower, richer arc of sickness and health that a primary-care doctor sees.

I could only begin to glimpse all this in my

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Transue, an internist in Seattle, Wash., is a 1996 graduate of Dartmouth Medical School. She began writing patient narratives while she was a student at DMS as a way to process the emotions of medicine. Many of her stories have appeared in Dartmouth Medicine during the years since then. She is also the author of two books published by St. Martin's Press—On Call: A Doctor's Days and Nights in Residency and Patient by Patient: Lessons in Love, Loss, Hope, and Healing from a Doctor's Practice. This feature is excerpted from the latter book by permission of St. Martin's Press, LLC; it is copyright 2008 by the author.

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