Graduation from my residency program was a bittersweet experience. At the time, my specialty was suffering from a crippling job shortage, so our futures were uncertain, and a dark mood had come to permeate my radiology residency. We were disgruntled with the specialty, with the system, and with medicine in general. I attended my graduation without any guests and only stayed long enough to receive my certificate.

I was, however, honored and happy to attend a different residency program’s graduation ceremony the night before I left my home state. My hospital’s family medicine residency had invited me to receive a teaching award a few days after my own graduation, and this is actually the ceremony that I invited the most important person in my life to attend with me as we watched a new class of family medicine doctors move onward to independent practice.

I am still struck at the extent to which these family medicine physicians had formed bonds with their faculty and their peers. These physicians were truly friends with each other, and their affable personalities no doubt affected their choice of specialty. Their program director was moved to tears as she described each graduate, and the ceremony later evolved into a fun party, as the faculty physicians dressed up as minions in a hilarious skit. A modern version of the movie Patch Adams had come to life.

A former student of mine, Dr. R., was graduating that night. We had worked together for a month when I was an internal medicine intern, and she was a medical student four years earlier. Dr. R. stands out in my mind as particularly passionate about medicine and, more importantly, her relationship with patients. Also, from a small town not far from where I grew up, her approach to health care represented a synergistic convergence of wholesome, rustic hospitality and crafty medical decision making. She had agreed to a state-funded scholarship program that covered tuition and a monthly stipend during medical school in exchange for later practicing primary care in a rural setting for four years after residency. Unfortunately for the state, only two-thirds of those participating in the scholarship program were going on to fulfill the rural primary care agreement as of 2010, so there was and still is a massive need for the school to graduate such practitioners.

After graduation night, Dr. R. and her friend/fellow graduate would be on their way to work in a community clinic in a rural county. The new doctors were godsends to their clinic, and they were justifiably lauded as heroes in the press and among their new patients. Not only did they fill a void in health care in general, but they were also able to address a dire need for female physicians in this county. This seemed like a veritable win-win for the doctors and the system.

The good feelings did not last long. These women soon found out that there is a reason why this community had such a demand for highly qualified young medical talent. They came face-to-face with the good-old-boy nature of medicine in this small town. Oppressed by a lack of medical progressivity and frank sexism by clinic leadership, the doctors were obstructed in multiple attempts to implement their vision despite being hired under the pretense of independent practice.

Even worse, they faced long hours, high-stress levels, and an insolvent business model. Take home compensation was shockingly low, in some years 80 percent less than average for a family medicine physician. Subject to such clearly unsustainable practice environments, both doctors departed as soon as their scholarship commitments were fulfilled.

There are personal, circumstantial, and structural factors that contributed to the demise of the practice. Some years later, myself and my formerly disgruntled radiology resident colleagues are doing well in life. I work in a specialty in which my job largely consists of rendering an opinion on a limited medical dataset without a patient conversation or time spent after hours charting to make sure that a facility can recover its charges. This efficiency pays off in my employer’s bottom line, but my specialty would be less rewarding to someone like Dr. R., who is truly interested in sitting down with a patient to address the root causes of declining health. I am trained to interpret advanced imaging tests, but Dr. R. is skilled in keeping the patients from needing my expensive tests in the first place. Preventing illness through health maintenance and surveillance outside the hospital is sadly poorly rewarded, a trend that is often exacerbated in rural areas which are heavily inundated by low reimbursement insurers and/or patients who simply can’t afford pay their medical bills and keep food on the table at the same time.

As for Dr. R. and her practice partner, they have my utmost respect for trying to do their best for the patients of that rural community during those four years of personal sacrifice even though the system failed them. I hope that they look back as fondly on their graduation night as I do. I find comfort in learning that they have since become medical school faculty where they can teach the next generation of doctors and impart the same excitement and devotion to family medicine that I saw in them several years ago. Just like their teachers before them, I hope that they can find an occasion or two to don a costume or share a laugh with their trainees or patients if and when a smile proves to be more therapeutic than a medication. Nothing could be more heroic than that.

Cory Michael is a radiologist.

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