"I want a piece of power, and I always have."

Vicky Brownell is in family practice with the Woodland Medical Group in Northern California. She is the forty-two year old married mother of two children..

It wasn't until I became a nurse that I realized I hated nursing school and the experience of being a nurse. I wasn't getting into the flow of it. The nursing game is nebulous and the stakes are not as high as they are in medicine. Whether you fold a sheet this way or write a care plan that way, I really didn't see as having that much importance. It was minutiae they were focused on. It wasn't that I couldn't play the game; I just got bored with it really fast.

In medical school and medicine the stakes are high. There's so much to know that you are constantly barraged with how ignorant you are until you get older. Then the game gets really fun to play. I'm not really competitive. I just want to be making my own decisions.

When I've thought about why I went on to become a doctor, I've inevitably come to this: It's a power issue. I want a piece of power, and I always have. Nursing was at odds with that, because if you weren't the supervisor, you didn't even do your nursing the way you thought it should be done. As a floor nurse there's very little power.

As a nurse practitioner I had a little more power, especially with Chester, who was a private doc. Many a month he did all his own OB call, since he was not in a call group. One horrible October he did twenty-three deliveries. Every one of those deliveries would drag him out of the office, so many a day I was alone in the office. He would give me his prescription pad and he had his signature stamp and I'd stamp it. I had a lot of latitude. He'd come to me and ask me questions: "What's the best antibiotic to use in this case, Vicky?"

He was a wonderful teacher. At one point, after I had gone off to work at Kaiser, he fell off the roof and broke his arm. He was in traction in the hospital and he said, "Vicky, I want you to work in my office for a month while I recover." And I said, "Well, I can't do that because Kaiser won't let me. I'd have to leave them, and I don't really want to do that." Then I said, "Oh, by the way, Chester, I'm doing my pre-med work, because there's really nothing about your job I can't do." I naively said that to him. He remembers it. There's this short little dynamo saying, "I can do your job." Because that's what those five years had taught me, that I was very capable. Anybody could do this; it's knowledge and common sense.

Later, in family practice residency, I did part of my gyn clerkships with him. He's taught me quite a few procedures that other family practice doctors don't do. When I went down there I was pregnant with my second and I said to him, "You know, Chester, I owe you an apology. There's a whole lot about your job I can't do."


I was a child of the sixties. I grew up in San Francisco. When I was eighteen, it was the summer of love, with the Panhandle and the hippies and the happening things right where I was. That shaped my initial college career because I was busy for three years doing social stuff that had very little to do with anything else. I started out at Berkeley and subsequently transferred to Davis. Basically I was busy with theater, and marching in Sacramento. Consequently my grades were highly mediocre.

My family is very traditional. My mom was a stay-at-home mom, although she is a very strong individual and always managed my father's business affairs. He's an ophthalmologist, and she's quite a business woman. They are comfortable today because of her business acumen. But what she did was in the house, so she was always there when we came home.

She thought of herself as a housewife, but was very comfortable with who she was and who she is and her opinions. No one would consider my mother wishy-washy. But the wife stayed at home and took care of the kids and that's the way it was. You had dinner parties, you were active in the Temple and you did things that promoted your husband's career. That was your job. And she did it well.

I had managed to pass through college but I was not an outstanding student. I did consider medicine at the time, briefly, but it was very hard to get in. At one point my mother said to mt, "Well, Vicky, you are going to have to work and earn a living. Why don't you go into nursing? You can always fall back on nursing."

It felt okay because my whole family was medical. My father had taken me to the hospital on his rounds. Through the skin of my teeth, I got into nursing school. A vociferous friend of my father's who was on the clinical faculty at UCSF basically went over there and said, "You should accept her."

So I went to the UC San Francisco program. Two years into nursing school I knew it was a mistake. I went to the counselors at the medical school and said I would like to consider applying. They said, "No way. You're already in health care, you're in the field." They were really discouraging. On top of that, when I went to the Berkeley campus, thinking I'd pick up some of the requirements for medical school, I sat in on a biochemistry class and was so lost that I thought, I'm not smart enough.

Then I found out about a program for becoming a nurse practitioner. That was a lot closer to being a doctor and having some decision-making and more pathology and less with the hands- on aspects of nursing that you get in nursing school. I applied to that program as a third year, senior student. They only accepted two senior students into the program and I ranked third. But they did guarantee me a spot if I came back in the master's program. And I thought, Why not? I hate what I'm doing. I can't do bedside nursing, so I better.

So I went back for my master's, and actually, I liked it. I was very good and doctors had a lot of respect for me because I was very focused and very clinically oriented. I wasn't into the nursing ADLs. OB/GYN was my field, and I was very lucky to get that job with the private OB/GYN doctor's office right off the bat when I graduated. For a while I was happy as a clam there. Still thinking I wasn't smart enough for medicine, this was good, this suited me.

As time went by, the newness wore off and the difficulties came around. I had to refer all the good stuff. Just when it got interesting, I couldn't do it. The way I managed patients even with minor problems was never entirely up to me. It was whatever he wanted: "You have to do it this way." For a while I said okay. I did a couple of projects on my own, published articles about pap smears and cervical cancer, became active politically with nurse practitioner organizations, and in all of this I never really liked what I was doing. Chester hired me twenty hours a week, and to boost those hours I was also working in clinics all around the area. Once you develop a reasonable reputation, when this one goes on vacation or takes leave, they want you to come over there. I was working in Walnut Creek, Newark, Oakland, San Francisco and Mountain View. It made for some long days, and you get to the point where you don't even know where your purse is supposed to go.

I decided I could use something more permanent with more hours, and Kaiser Redwood City was hiring. So I interviewed and got the job, but that was even worse. It was better in that I had a place where my purse went and better in terms of benefits, but it was much worse in that now I didn't have to please one doctor, I had to please ten. I could never make my own decisions. You go crazy doing that for ten people, and you realize how petty all that little stuff is.

On my 29th birthday I decided I hated what I was doing, I hated the situation I was in and I was either going to quit, grow my nails and have babies, or try a career change. I talked to an obstetrician/gynecologist, I talked to a woman who had her doctor of education in nursing, and I talked to someone who had a Ph.D. who was working in research.

My husband's a lawyer. I investigated law school. Law wasn't a good fit; I could feel that right away. And the doctorate in nursing, I thought, That's always an option but I already hate what I'm doing, why would I want to do more of it? Business school was a little better than law school, but business is not something that comes easily. I'd been dancing around with all these options without realizing that I kept coming back to one thing--medicine.

I was older now and it was going to be even harder to get into medical school. I decided to take this chemistry course and I remember sitting at the top of the steps in my underwear crying, because how was I going to go back to school? I couldn't do chemistry before. I was going to make a fool of myself in front of eighteen year olds. My husband, wise as he is, said, "Well, Vicky, no one's asking you to do the whole term. Just go tonight. If you don't like it, don't go tomorrow. But make that decision tomorrow."

He was right. I went. It was wonderful. I got more and more committed. I was absolutely, without a doubt, doing the right thing. I was working full-time nights and taking classes half time. I started at twenty-nine and I entered med school at thirty-three.

For the years I did my pre-med work, we were coming and going and leaving messages on the refrigerator, constantly. Vicky can't be there, she has to work. Vicky can't be there, she has a test. My family were all in San Francisco at that time, but it was, "Well, you'll just have to celebrate without Vicky." That's how it was.

Thank God George Washington University Medical School agreed that I had promise and accepted me. It was hard. It was hard for everyone. I think probably any monkey can do medicine. All it takes is common sense and a knowledge base. The problem is, you have four years to get that knowledge base. If you're not really smart and don't work really hard--you can't just be really smart, you have to work really hard, too--you can't get that knowledge base in four years. If we had eleven years of medical school, anyone with common sense could do it. All of intermediate metabolism in a month!

Now the clinical years, third and fourth years, I thought would be wonderful. My first rotation was OB and I was very comfortable. I would go assess the patient and say, "She's XYZ, probably this, that or the other thing." They weren't used to that. They wanted a medical student who would come out and say, "This is the situation. I'm not quite sure what to do." I learned the hard way, unfortunately. After that I hardly ever said I was a nurse and things got along swimmingly.

In my third year I wanted to go into ophthalmology. My dad was an ophthalmologist. I didn't match in ophtho, though, and I had to scramble to get into the general match. Or I could sit out a year and reapply to ophtho. But at this point I'm thirty-seven and pregnant. I cried for about twenty-four hours because I didn't get into ophtho and then I thought, This is not the end of the road. Life is a series of choices and if this one doesn't work out, maybe that's only because there's a better one in store for you.

I had interviewed at internal medicine programs. Then I did one month of family practice rotation in med school and fell in love with it. But it was time to send in our choices for the match and it was too late to go interview. What I did was, I chose those programs that were either one year transitional programs or, like one particular program, where people during my interview told me, "We give you a one-year contract. If we like you at the end of a year, we renew your contract." I thought, Wow, if they're that committed to me then I can be that committed to them.

Knowing I didn't want to stay in internal medicine, I thought it would still be nice to come back to California and be local to interview for a family practice residency. I started at Pacific Medical Center, then interviewed for family practice. I was very lucky. Davis was expanding their second and third year programs the year I was looking, so I got one of their extra positions in the second year and didn't have to repeat my internship.

The worst part about my internship was that I had a new baby. He was six weeks old when I started. That was a challenge and a half. But I had good fellow interns and I enjoyed it. I was offered a second year.

I don't think my nursing background--mostly outpatient and labor and delivery--helped me a lot during training. Now if you had been an ICU nurse where you were dealing with intensive unstable medical problems and seeing congestive failure managed and codes, or on a med/surg floor where you were seeing infections handled, then it might be more helpful. But I didn't have any of that, so it was new to me. Plus you were expected to think about care from an entirely different point of view.

I had already fulfilled my internal medicine requirements when I came up here, but I opted to do an extra month of Kaiser. Everyone said, "You're crazy!" But I'd never done any medicine as a resident, only as an intern when you're a scut puppy, you're not really licensed and you don't have any responsibilities. As a resident, especially at Kaiser, you're running your own intensive unit patients. You have a lot of responsibility. I really enjoyed it.

I decided I didn't want to do OB in family practice. That was because of my experience as a labor and delivery room nurse. I saw a couple of cases go real sour real quick. I'm talking three minutes to get a good baby. Most family practice docs don't do sections and if you can't do a section, in my personal opinion, you have no business doing OB. If you can't just grab a scalpel and get the baby out, you have a dead baby. That wasn't acceptable to me. that's why I had told Chester there was a lot about his job I couldn't do.

But I have a lot of new babies now. Because of the managed care environment, it's easier to get patients and families sent back to your office. So I tend to get my babies back. Plus I'm very aggressive and make clear to all the obstetricians that I want to see my babies back. If they haven't sent a baby back to me, I'll ask them, "Was the baby sick? What happened? Was that a tough delivery? Well, I'm not sure I understand why I don't have that baby back."

I'm coming off a week-end on-call, which was the absolute worst week-end of my entire two years here. I have never been so busy on-call in my whole career. I got abused and hammered. There's a gargantuan difference in lifestyle between nurses and doctors. The truth of the matter is in nursing if you want an 8 to 5 job, you can get it, and when you leave at five, you've left. That's not so in medicine. Choosing to put in overtime or not, forget that in medicine. I'm not the kind of person who could do the positions in medicine that are like that, anyway.

For instance, I'm off-call. I am not around and yet I have a patient, a little girl, who's going for a CT. I still have my damn beeper on because I told them to page me. I want to know what the results are. I'm going to go over there and see her and if she needs admission, I'll admit her. On my week-ends off-call I see my patients in the hospital because they're my patients. I feel obligated to do that. I'm in town. I'm two blocks away. It takes ten or fifteen minutes for me to go in. It's not like they're taking up my day. And my kid, Thomas, comes with me, so it's fun. We do it together.

A patient last night formed blood clots in his legs. They were treating him for that, and he started throwing emboli to his lungs. It is a large complication. What should we do about it? There are as many different approaches to patients and the way you deal with them in important decision-making as there are doctors. Some are very paternalistic: "I am father figure. I know what's best for you and here's the choice I've made for you," maybe not even mentioning the other options the patient has.

I'm probably way on the other side of that. I investigated the choices my patient had, the most conservative to the most invasive, contacting two specialists because I personally didn't know too much about the pros and cons of the most aggressive procedure that was being suggested. I spent a good deal of time talking with them, making a list, jotting things down and then I went to the patient.

I walked in and told my patient, "This is the most conservative, this is the most aggressive. What we should do is not at all clear. It depends on how well we can predict the future and since none of us can do that very well, the choices are difficult. You just have to try them on for size and tell me what you want to do."


I was married just as I finished my master's. When I went back to pre-med my husband was getting his master's in tax law. I had promised him I would work him through that, so, not wanting to make my goals secondary but trying to live up to obligations, I tried to handle both at the same time. When I was accepted to medical school he had not gotten that great a job in San Francisco, which is a tough market to crack.

We had the good fortune to buy a house in San Mateo in 1978. And sold it for twice what we bought it for in 1983. So we had gotten from the sale of the house alone enough to pay for med school. It was only an issue of living expenses in Washington, D.C.--and my husband was an attorney. We had a tiny 900 square foot townhouse that we enjoyed no end.

My husband started working at an accounting firm in their two-man legal department. He worked there for three years and then they decided to reorganize, and let both lawyers go. So he started work with another lawyer who hired him on as an associate. We had a hard time deciding whether to stay there another year because he liked working with Sam so much. But we ultimately wanted to come back to California.

At thirty-seven I said to Jim, "I don't think there's going to be a good time to have kids, so we better get cooking now." I didn't want to be pregnant and an intern. The fourth year of medical school is the best time to be pregnant. And that's what we did.

We knew we would only be in San Francisco a year. I was working 90 hours a week and we needed someone with Tom, so Jim stayed home for a whole year.

Then we came up to Davis and got a nanny. Jim went back to work for a high-power local firm. They kept working him harder and harder. Sixty-five hours a week wasn't enough, seventy hours wasn't enough, seventy-five wasn't enough. Finally he and one of the lead partners clashed. Jim had worked and worked to the point where he just said "enough," and turned around and left.

I was in residency when I became pregnant with our second. So Jim took care of the baby again. Finally he set up a small practice out of the house, and he has a few clients but not too many. He does a lot of child care, and some work. There's a lot of burnout among lawyers. That's essentially what happened.

David was born the July before I finished my residency in October. In November I contacted Tom about this position. A friend was moonlighting here and said they were looking for a third physician. I interviewed and loved Tom, the facility and what I'd be doing here. It was perfect. It felt comfortable.

I love family practice and I'm good at it. From that point of view I'm happy. But if I were going back, I'd go into ophthalmology. I always liked it. It's so clean, the surgery. So tiny, delicate. To them a drop of blood is a veritable hemorrhage. Working on eyes is very rewarding. Most people are happy when you save their eyesight or you provide them with slightly better eyesight. It's a happy speciality. But I'm not unhappy with the way things are.

The way I see it, I'm a foot soldier. I'm not the general. My specialists behind me are the generals. I'm the foot soldier and I take care of doing 80% of what has to be done on the field. I have no aspirations to do more. I've accomplished a lot. I'm right up there. This is where I want to be, doing what I want to do.