Dear Random Asshole on my Cell,

Who the hell are you and why are you calling me? Oh, it's because someone dialed your number from my phone seven times and you want to find out who it is. Well, I'm not telling you my name, I don't care how belligerent you are. You called me. Why don't you tell me who you are and where you live?

Ever hear of someone misdialing? Yeah, it was that. Your number happens to be one number off from my work number. Get the f--k over it and stop calling me. Or, better yet, block my number. It may be hard for you to believe, but I don't want to talk to you.

Love,
Nichole

******************

Dear Bitch in the BMW 325i,

Before you even start on me, I know you're female and here's why: 1) the only people in a Nordstrom's parking lot at 2:00 on a Friday afternoon are female and 2) I saw some crap in your car.

No, I wasn't spying on you, but you parked so freaking close to the line in the already super-compact space, I couldn't help but notice. I'm sure you didn't realize how close you were, since it was on the right side of your car, but did you see the car that is on your left? Yeah, that's called a SmartCar. It's like the smallest car on the market. You could hug the left line of your space and still have enough room to open your door all the freaking way.

So, in the future, please be a little more considerate of the people with whom you share this world. It will come back to you, I promise.

Love,
Nichole

The format for this post was inspired by a post done a long time ago by Nilsa. I don't know which one and I don't feel like finding it, but she's awesome and you should read anything she has to write anyway.

I met with the other younger surgeon today with whom I could potentially share space. It was all very encouraging and he would love that I could help defray his costs a bit. But he might not be there on a long term basis because he, too, is would potentially leave the hospital, leaving me to hold the bag for his 10 year lease.

We talked about his expenses and the way he runs his office in specifics, but also about the business of surgery in this area in general. There is an exceptionally large Kaiser type institution that sucks up a lot of potential business in this area, and all reports are that they are only getting larger. But I have also heard not good things about this institution and would rather not be a part of it if I could avoid it. So I asked him... if he could relocate, given the set up in our area and how hard it is to make it as a general surgeon, would he? Simply put, yes.

Which leaves me in a real bind. I have been suspecting this for some time. The insurance patterns are quite different here because there are so many doctors clamoring for work that the insurance companies can get away with paying less. A lot less.

Here's a good example. I recently operated on a young man who is very intelligent. He had a lot of questions during his hospital stay regarding various fees, to which I didn't know the answer. I've seen him several times in the office since his discharge, and this last time, I told him I didn't need to see him any more... he was better. At that point, he started talking to me about the fees. The hospital fees were outrageous and they charged him over $4,000 and made sure they talked to him about it two days after his surgery. Another doctor assisted me in the surgery because he likes to assist, but that meant he could collect an assistant fee. And since he saw him every day after the surgery, he charged a daily visit fee. But me? For the operation (which was in the middle of the night), the pre-operative consultation, the week's worth of in hospital management, and three post-operative office visits, I collected only $700. The assistant made just as much as I did.

This isn't the exception; it's the rule.

I don't have an MBA. I wasn't trained in billing, so I don't know how to make the most of my reports to But various insurance companies or even what is allowable.

So now I'm left wondering... do I stay in this area and avoid incurring more debt in salary repayment to the hospital? That could mean a less favorable business environment in a market already saturated with surgeons. Or do I take the temporary debt to repay my salary and move to a more favorable area for doctors? One where surgeons get paid to take ER call and don't have to deal with ridiculous insurance contracts that devalue their time and efforts?

I don't know. And tonight, all these questions are weighing on me. What am I supposed to do?

About a month ago, I met with another younger surgeon to discuss my business strategy and to see if I could go into practice with him. Conversations between two surgeons must be entertaining to an outsider: we speak rapidly and are to the point, quite unlike most other conversations that are laden with innuendos, passive aggressiveness, and implications.

Towards the end of the conversation, though, he turned on his "talking normally" mode. "I want to tell you something that I've heard, but it's only out of a desire to help you be successful and get more referrals."

"Uh... ok. What?"

"Some of the primary care docs and ER docs are a little put off by how many questions you ask when they call you for a consult. I know in residency we drill them, and it's fine to drill their nurse, but you should just say, 'Thank you so much for the consult, I'll be right there.' You should be kissing these people's asses, not giving them the third degree. [pause] They don't need someone to be condescending to them, and believe me, I did that in residency, but these people are your life-blood."

I was stunned. I'm genuinely interested in my new patient. What are their other medical problems? What did the study show? What do their labs look like? These seem like reasonable questions. And as far as condescending? I don't talk down to anyone. I treat everyone the same. I may have been exasperated with an internal medicine resident while I was training, but it was rare.

There is one particular emergency doc I have a particularly good relationship with -- I'm not surprised she's female. (She'll even call me, not for a consult, but because she's stumped and would like me to brainstorm with her. I'm honored that she would think to do so.) One night, at the end of the discussion of the patient, I asked her, "Lucy (name changed), can I ask you a question? Do I... ask too many questions when you call for a consult?"

At first, she didn't get it. But then I recounted the conversation I had with the other surgeon a few weeks prior. Then she saw it all clearly.

"I see exactly what is going on here, Nichole. And I know which ER docs he was talking about. Let me tell you something: this is still a male dominated profession. And these other doctors that you supposedly ask too many questions of... they don't like be asked details by a competent female surgeon."

These pricks are too intimidated that I'm good at my job and I don't have a penis and they express this by talking shit about me by saying I'm condescending and threatening not to give me patients. Unbe-fucking-lievable. And the shittiest thing of all? I really do have to kiss these douchebag's asses if I want work.

The minute I knew I passed the general surgery boards, I had a list of things that I wanted to tackle. The current job situation has postponed several of those goals (like learning German), but I was still able to join a book club.

This book club is dedicated to reading books on the Modern Library Classics 100 list, which is the perfect kind of book club for me. Reading of all kinds is great, but I really wasn't interested in reading chick lit or Oprah's picks.

The book for April was Appointment in Samarra, which I had never read before. It was good. I made notes. The night of the book club meeting, I made sure I wasn't on call. But that night, a primary care physician specifically asked for me to see his patient. And any good business person can tell you that to get more business you need to be available. So I saw the patient and operated on him instead of going to the book club.

The ladies were all sweet and understanding that I had missed the meeting. They told me their choice for the next meeting: A Passage to India by E.M. Forester. Of all the books I read in college (and I read a lot for a science major because I liked those kinds of classes), this was the book I hated the most. I can't believe I have to read it again. But if I don't want to seem like a flake, I'd better get started. The next meeting is June 11th.

I just hope that more than ten years is enough to give me a different, and perhaps better, perspective on this novel.

What books have you read during your education that you never, ever would consider reading again? Why?

ETA: After posting, I realized that what I said about chick lit and Oprah's books could be interpreted as a tad bit elitist. It's not that I'm above reading that stuff. My choice for brain candy literature is fantasy, like elves and dwarfs and stuff. (Yes, I'm a complete nerd.) But I don't need a book club to fully understand those kinds of books. That's all fluff and fun. I need a book club... a discussion... about the classics: to more completely understand the richer novels, their nuances, and why they are considered classics.

Last year at this time, I was looking forward to graduation and a new job that started in September. That new job carried with it an excellent guaranteed salary and a one year contract. The salary is there for me to live on while I build my practice, get my name out there, and get known by the community. Any money that I earned by seeing patients and operating would be deducted from the amount given by the hospital, all while keeping my salary level the same. I had high hopes that by this point in that first year, I would no longer need to draw any money from the hospital.

But then the economy turned to crap, people lost their jobs and their insurance, and those who still did have insurance didn't want to have non-urgent surgeries because they would need to take time off work. I'm still drawing a large amount of my monthly salary from the hospital and am trying to figure out what I'm supposed to do when my contract is up in September.

If I stay in the area (not necessarily with the same surgeon) for three years, I don't have to repay the hospital. They decided to invest in me and my business. But if I leave, I need to pay back what they gave me to supplement my measly earnings. Sounds fair. Here's the thing. My receivables are not enough for a salary, let alone sharing expenses with another surgeon or starting up my own practice.

The surgeon I'm with now wanted me to pay half of his expenses. (Which, by the way, is exorbitant, according to several knowledgeable sources, considering where I am in my practice development.) That would be $10,000/mo. Most previous months, I haven't even made that. So that option is out.

Another seasoned surgeon is in the area. But he's solo and has been for quite some time. He was recently sharing space with another younger surgeon, who just recently moved out. He's not ready or willing to share space with another new person quite so soon. (There are also some very crazy personal dynamics going on between him and the surgeon I currently work with, but there's no need to explain all that.) Bottom line: that option is out, too.

There is one other surgeon I could share space with. But he's got space in the brand new medical office building, which has very high rent. I'm not even sure if I could afford to work there. Besides, he's unhappy with his experience at this hospital and is actively seeking employment at a nearby hospital. So he might not even be there for much longer. This option is questionable.

And that's it. No other surgeons to share space with. I'd need to leave. But to make leaving doable with the salary repayment I'm going to have to do would mean that I would have to get a nearly impossibly high salary somewhere else.

I'd have to move. By myself. Because Daniel is nearly a partner at his firm; he can't move now. There are a couple of surgeons in my hometown that would love to share space with me, but they can't offer me a salary. (They wouldn't even charge me expenses to begin with!) I'm waiting to hear back from a couple of hospitals about what they can do for me. But I doubt it will be high enough to offset the "cost" of leaving my area. The only plus about being in my hometown is that my mom, sister, and some old friends are still there. I wouldn't be completely alone.

The other (less desirable) option, is to do work that is called locum tenens. Which basically means I travel around the country and fill in for a month, three months, six months... while another surgeon is recovering from an illness, traveling, or whatever. The biggest thing there is that I would be completely isolated. And not building a practice. And not having a guaranteed income once a job was done.

I have no idea where I'm going to end up and all these possibilities need to be kept open... all the balls need to be in the air simultaneously. Needless to say, the whole thing has got me stressed to the max. Not sleeping well, nightmares, waking up early freaking out (and, I hate to admit it, crying more)... all that.

I've been told I have good hands, but I'm not sure how many more balls I can juggle at once.

Traffic patterns around here are fairly predictable, as they are in most metropolitan areas. Miss your departure window by five minutes, and you can easily add 30 minutes to your commute.

They're predictable on the weekdays, that is. On weekends? All bets are off. There seems to be no rhyme or reason to it; I've tried to figure it out. That's what I do. I'm a figure-outer.

This lack of predictability can be an issue when I need to get to work for an operation. For a surgery to happen on a weekend, a series of events are set into motion, all starting with me. First, I talk to the charge nurse for the hospital. I tell her the name of the patient, the surgery we're going to do, and when I want to do it. Then she calls the operating room team, which consists of a recovery room nurse, a circulating nurse and a scrub tech. Then she calls the anesthesiologist to tell him/her when the surgery is.

I have an issue with being late. Chronic lateness implies that you think you and your time is more important than everyone else's. (Yes, I have many issues with the President's lateness. It's disrespectful.) But when I book a surgery on the weekend, I am positively neurotic about being late. These four other people have lots of other things they'd rather be doing than waiting for my ass to get to the OR.

Recently, I did have to do an operation on the weekend. I left my house with about 20 minutes to spare; a good practice on the weekend considering traffic. But this particular day, everyone was driving like idiots. Under the posted speed limit. Slow cars in the fast lane. Lots of cars out in general.

So in an attempt to not be late and show disrespect for my colleagues, I was kinda weaving in and out of traffic a bit. 100 yards from my exit, I get pulled over. I was stopped for three reasons: following too closely and two unsafe lane changes. Then I was asked if I had a reason for driving like that. I told him I was trying to get to the hospital because I needed to do a procedure. He asked me if I was a doctor (I was in scrubs). When I said yes, he asked to see my medical license. He scolded me a little, reminded me that I have likely seen the results of really bad accidents, and to be more careful.

And he let me go. That almost never happens out here, especially given how much money the state needs. I thanked him profusely.

Ever get out of a ticket? How'd ya do it?