Saturday, March 19, 2011

Full circle

It's been a crazy few months. I feel completely behind in my life (as well as constantly exhausted), which many people would say is to be expected from long hours/overnight call/weekends during my surgery rotation. However, back in October or so, I was on neurology (which also had long hours), writing my thesis in the evenings, and teaching a chemistry class every other weekend (and grading whenever I had time). And Josh was only 6 mos old then--while he is still not a champion sleeper, he is doing much better now than he was then.

So why do I feel so overwhelmed right now?

I think a lot of it has to do with decisions. Starting in July, I will be a fourth year medical student. Which means I will start applying for a residency position. Which means I better decide what the heck I want to do so I know where I will apply. Which means I need to schedule rotations that will help me figure out what the heck I want to do.

I have friends who are sure they know what they want. Some have known since they entered medical school, some found a field that goes well with their PhD research, and others found a clinical area during their clerkships that they love but had never considered before.

I envy them.

For them, they know what they are doing, so they know how to structure their time in order to get the best letters, when to schedule their Step 2 licensing exam, and when they will have time for electives. There isn't a time crunch.  That is not the case for me. Since my clerkships run until the end of June, I essentially have July and August to figure out what I want to do. Applications begin on Sept. 1.

I had hoped to do an internal medicine AI in July or August, but they were booked, so I ended up with September. The pediatrics AIs are booked until November I think. I have the option to do electives in July or August, but I am not sure what I want to see. I initially figured that I'd end up in adult cardiology, since that is the closest match to my research interests. I'll probably try to get a cardiology elective in July/August if I can. As for what else might be a good choice--I'm stumped. I have to do a month of emergency medicine and a month of geriatrics per our med school requirements, but I might push those until after interview season. I also have to do another AI, and I might try to do a psych one later (more for fun than anything else).

For licensing purposes, after third year requirements are done, I need 7.5 months of clinical time. Two months are my AIs, two months are ER/geriatrics, and I have one month of credit from my clinical tutorial during my PhD. That leaves me a minimum of 2.5 months of electives. I want to do a cardiology elective, and I think a radiology elective might be helpful for me in general. So, I have to find another 2 weeks of clinical work at a minimum. I'm not too worried about that (and if people have suggestions on helpful rotations, I am game).

The last several months have been extra stressful because all of these decisions about the future have been on my mind. I assumed coming into third year I'd do internal medicine. Unfortunately, medicine is my last rotation of third year. What happens if I don't like it? I'm back to square one. There are a few areas that are definitely out--neurology and OB/gyn for sure. Pediatrics has potential in terms of a specialty, but I couldn't do general peds every day, and I have no exposure to specialty pediatrics, so how would I know if that is a good fit? Psychiatry was very interesting, and I am drawn to "thinking" specialties more than "doing" specialties thus far. However, I have no exposure to outpatient psych, there is a lot of overlap with neuro, and I don't want to solely be doing 15 minute med checks--but a lifetime of inpatient psych seems overwhelming as well. 

So far, I have been drawn to areas in which I've received good mentoring. That's why I thought internal medicine was originally a sure thing--I had a wonderful clinical preceptor for three years, and I looked forward to my one afternoon a week in his clinic. I had a great psych attending for a month. I really enjoyed working with all of the pediatric attendings. I felt like all of these people were human--they cared for their patients, they loved their jobs, but they also had families and a life. They treated me like a human and not like a burden.  My question is this: did I like these rotations because I like the material, or did I like them because I felt that my personality seemed to mesh well with the attendings with whom I was working?

Surgery exemplifies that dichotomy for me. Really, the act of surgery doesn't bother me--I don't wake up every morning excited to cut someone open (as some of my residents do), but I also don't dread it. Vascular surgery is pretty boring, but I don't hate it. I drew a blood gas and intubated a patient within the first few days of the rotation, so I'm not put off by procedures. The actual practice of surgery is ok--I could do it, but I don't dream about it.

The culture, however, makes it seem completely out of the question. It is completely hierarchical, misogynistic, and impersonal. People are rude and angry. No one seems to like their job. No one teaches. I would like to say that is unique to my service, but the other two surgery services at the VA seem worse, if that is possible. I haven't heard good things about any of the other hospital services either. These people are great surgeons, but they are miserable human beings. They have no lives outside the hospital, and if they are married/have kids, they rarely get to spend time with their family.

That is not how I want to live my life.

Who knows, maybe if I had been with a crappy attending in psychiatry, I'd never even think twice about it. Maybe if I had worked with an outstanding OB/gyn I'd be more interested in the field. I'm not even going to pretend neurology was an option--let's be realistic :) But really, I'm looking back at my experiences and trying to understand how much of my interest is related to the practice of that field and how much is related to how well I fit into the culture of each rotation.

That has been my stress--what if I choose a field based on a month of experiences in one specific hospital? What if that was an anomaly? How do I separate liking the practice of a certain type of medicine and liking the culture?

If you haven't seen it already, you need to check out this cartoon from the underwear drawer. I try to be open minded about life experiences--that whole "not judging a book by its cover" thing--but as Tim likes to say, sometimes stereotypes are a great timesaver. Also, if you are in the medical field and haven't seen ortho vs. anesthesia on xtranormal, you need to go here. I laughed so hard I almost fell off my chair. Granted, it was during an overnight call and I was slaphappy, but still...

Anyway, I've found many of the stereotypes about the type of person attracted to each field to be generally true. There are exceptions, as there are to anything, but it definitely seems like each field seems to attract its own kind. I'm not sure where I fit. I am enough of a people person to not want something like radiology or pathology that has little to no contact. However, I don't know that I could do something like family medicine that involves one billion outpatient clinic appointments every week. I'd like to do something that mixes longitudinal care outpatient, maybe some inpatient, and maybe some semi-urgent consulting (not like ER, more like a doc saw a patient and is worried about XYZ and called me...)

That takes me back full circle, something like a medical cardiology.

I actually was fairly encouraged on Friday afternoon. I was post-call but didn't get to sleep after call Friday because we had mandatory lectures at the medical school. Instead, I left the hospital after rounds, got home about 8:30 AM, drank half a pot of very strong coffee, got some work done at home, and went back to the med school about 11:30. We had a small group session with one of the cardiologists I had never met before. And I LOVED it. Most of the students were zoning out or not interested. You'd think I'd be so exhausted I'd be falling over. Instead, I drank it up. I learned about new criteria for categorizing patient's cardiac risk and how to best interpret test results in ways clinicians don't normally do. I was so interested that I spoke to the doctor afterward about what it would take to work in his clinic (which unfortunately only runs one day a week). It tied together clinical cardiology, bench research, biochemistry/pharmacology, and translational research.

Granted, it is still not a clinical experience with patients, but it was so nice to remember how it felt to be excited about a field of medicine. There is still the chance that I will loathe medicine or cardiology once I am on the wards, but there's a glimmer of hope that maybe my best specialty match is still out there.

I haven't completely ruled out pediatrics or psych, but I feel much better about medicine.

I've rationalized it in several other ways too. First, if I do medicine in residency, I still have tons of specialty options. I could do something with more procedures, like GI, or I could do something more hands-off like infectious disease. I could do academic medicine, private practice, government healthcare, research, or even industry like working for a pharmaceutical company. There are way more jobs for adult specialists than pediatric specialists, so I have more choices in terms of practice environments and geography. Most of all, I can find a specialty with a good fit in terms of the forms of patient care (inpatient, outpatient, etc) that I like.

It feels a bit like a cop-out to say it, but it buys me some time to figure out exactly what subspecialty I want to do. Maybe I'll love medicine during my clerkship and have no doubts that is what I want to do. Maybe I'll hate it, in which case it is time for plan B. Maybe I'll like it equally with psych and pediatrics, and then I'll need to weigh pros/cons. I can't predict how I'll feel after spending clinical time in medicine. I do feel a lot better after yesterday's lecture in terms of the subject material, though. What can I say--I'm a nerd, and I love evidence-based medicine.

So, over the course of the last year, I've come full circle back to cardiology as a potential specialty. I'm hoping that the stereotype of cardiologists (which puts them in a category similar to surgeons) is not true. If it is, I need to decide if I can get through training dealing with that attitude until I can get into a job post-training that is a better fit for what I want. That is still TBD.

I wouldn't call this an official decision of what I want to do, it's a start.

And we still haven't made any of the other important life decisions yet. Still no idea on if/when we want more kids, where we want to live/work, etc. One thing at a time, I guess.


  1. two words: pediatric endocrinology!

    just kidding. sort of! good lifestyle (in terms of time, not $ -- we are NOT well-compensated but really it's not like poverty, just not riches), interesting cases, tons of research opportunities, cute kids, flexibility, and in demand.

    i felt the same way about surgery!! hated every.single.second. and yet my wonderful husband loves it -- and he is the farthest thing from a mean hierarchical jerk. he just loves the OR and puts up with the culture (and someday, may even have the power to change it at least on a micro-level). so to each their own :)

    try not to stress too much over doing things in the right order -- if you excel in whatever the rotations are and kickass on boards, you will have the flexibility to choose whatever you want in the end! plus, the MD/PhD is like a badge of honor - programs love that :)

  2. Nikki2:17 PM

    I was going to ask about endocronology too...I thought that was more of your research (but it changed so often, forgive me for not keeping track!). Oh what about genetics (thinking and working with patients)? I had to do an out patient rotation in genetics as part of my clinical rotations (yet another indicator that I'm best behind a bench, cuz while I'm all about patients, I prefer them on paper!) and it seems like it might be a good fit?

    I must go and try to find myself a job/postdoc now...good luck!