Sunday, December 01, 2013

Tis the season

I find that my anxiety is very predictable. It may not be seasonal per se, but it is reliably present just prior to major life decisions. My anxiety has been at an especially high level for several months, and it is due to two/three major upcoming life decisions: whether to have another baby, whether to do a fellowship (and in what), and whether to move in the near future.

Since items two and three are related, I'll talk about those mostly. Just a quick note on the kid issue: we'd love to have another, but timing is an issue. I thought when we were first married 11 years ago we'd have two kids; after children one and two were a girl and a boy, respectively, I was waiting to feel "done." We didn't feel done yet, and hence had baby #3, who is really not much of a baby anymore. After a difficult pregnancy, a dramatic labor and delivery, and two days in the NICU, I was sure I'd feel done after 3. I don't--really never have--and we have been debating what to do. If you had told newlywed me I'd be thinking about 4 kids in the future, I would have laughed in your face. But, we have the space, we have the means, and most of all we have the love. Life is short and chaotic. I know having another baby is likely to have me be looked down upon professionally--seriously, I get head shaking already when I tell them I have three kids--but it's not about what other people want me to do. Tim and I are on board mentally; it's the planning that is being worked out. More on that in the near future.

Anyway, as I mentioned, items two and three are related. Both are intricately tied to my career goals. I don't get a chance to write here much. It's been a bit of a rollercoaster these last few months about exactly how I will go about my career. I've always been headed towards academic medicine. I love teaching, I love research (though basic science/translational/clinical is still a toss-up), and I feel much more comfortable in an outpatient clinic or basic inpatient wards. I hate the ICU, I do procedures begrudgingly, and I love the collaborative environment of an academic medical center.

So, the journey has looked something like this:

-medical school, towards the end: planned to do cardiology, as it seemed like my best chance to pair my research interests with a career that allowed me to still see patients

-intern year: total burnout, no cardiology experience, but so tired of call that I wanted to find a career that didn't involve overnight call or urgent procedures. Tried to get excited about heme/onc; hated inpatient oncology (which admittedly, even oncology attendings describe as brutal); did some outpatient oncology clinics and didn't mind them (but I like outpatient in general). Didn't mind GI too much, but then I had a bunch of end stage liver and chronic abdominal pain patients, and GI came off the list.

-early 2nd year residency: started off w/cardiology at the VA, which is a mix of basic telemetry (chest pain, heart failure, arrhythmias) and cardiac ICU (NSTEMIs, bad heart failure, aortic dissection). All STEMIs, LVADs, etc go to another hospital. I was very nervous because this is the first 30 hour call I had experienced in residency (interns do night float but can't do >16 hour shifts, supposedly). And in the VA hospital, the only medical doctors on overnight are the cardiology resident, one MICU resident, the admitting night resident, and the coverage intern. No fellows, no attendings. There are some surgery people, an urgent care doctor, and a hospitalist (who doesn't work with our services), but that's it. So you are very nearly alone.

There were nights that were very slow, and some that were busy for non-urgent matters (family meetings at 1 AM, etc). But I somehow missed out on a lot of the craziness that hit my co-residents on their call nights. I learned a lot on that rotation, I liked the attendings that I worked with, and I generally enjoyed the month.

And so, cardiology moved back to the top of the list of potential fellowship spots.

I still didn't like the idea of a brutal call schedule for three years after residency. The fellows I worked with regularly rotated overnight call in the CICU at the main hospital, cath lab coverage, and weekend coverage on various services. And that was during the months that they weren't already scheduled to be in the CICU or in the cath lab. The fellows were very busy. The idea of basically being as busy as an intern, but having much more responsibility, for three more years is not very appealing.

And cardiology is very procedure heavy. I am not someone who wakes up in the morning dreaming about putting lines and catheters in people. I can do it; I just prefer not to. Of course, cardiology requires you to perform something like >400 cardiac catheterizations in order to be certified, which usually works out to 4-6 months in the cath lab over a 3 year fellowship. And there are about as many months in the cardiac ICU, with things like pacers and Swan-Ganz catheters and other items that need to be put in urgently at the bedside.

Overall, not very appealing to me. There are people who eat and breathe this stuff. I am not one.

But, I had several people tell me that it can be short term pain. A number of fellows and senior residents applying for cardiology all said that once you are through fellowship, you can do whatever type of practice you want. Many people choose to continue to do procedures because that it was brings in the money. However, it's not mandatory, and especially in something like academic medicine, it wouldn't be required.

And I like the topic. I like physiology. I like the molecular aspects of the heart. I think there is so much potential for both research and medical advances in the field. I enjoy reading about it, listening to people discuss it, and watching it applied in clinical settings.

I met with one of the cardiology attendings a few weeks ago whose story sounds similar to mine. He did medicine but was avoiding committing to cardiology (for him, it was because his dad was a cardiologist, and he didn't want to blindly follow suit). He explored other options but then did some research and fell in love with cardiology. He now runs a basic research lab, is involved in the residency program, and attends on the inpatient wards a few weeks a year. He didn't feel procedure driven and prefers not to be in the ICU. He too told me that cardiology can be a pathway to whatever career. You just have to get through fellowship.

-recent residency: I think I've mentioned before, but I am in a subset of my residency that gives extra time to outpatient care. I do three month blocks that are all outpatient (with weekend coverage on the inpatient wards/ICU about every other weekend). I'm finishing up my second of four 3-month blocks. There are parts of it that I really love, and other parts that are extraordinarily stressful. I love knowing my patients (I co-manage a panel with my partner, who rotates on outpatient during the months I am back on inpatient). I like the relationship aspect. I am learning A TON of outpatient medicine, which I was not prior to switching into this program. I am forced to take responsibility for follow up and med changes. But, when there is a difficult patient, I have to own it. I am dealing with a patient now who is unhappy that he is no longer being prescribed narcotics for his pain. After I saw him and the pain team saw him, we held a meeting and all agreed to be on the same page. However, he calls nearly every day (sometimes many times per day), comes to urgent care, and despite meeting with him and explaining the decision in person, he is angry and upset with me (not his pain team, me) for not writing his narcotics. I had a nice 4-day migraine about that last week.

Doing outpatient care overall is something I feel suits me. I love the relationships with patients, I like that (generally) things are not an emergency and if I need to do some research or call a consult, I have time for that. I don't mind diabetes, high blood pressure, or most of the other chronic diseases I see regularly.

I do struggle with musculoskeletal complaints. I can inject arthritic knees; what I can't do is magically cure chronic low back pain that doesn't need surgery and doesn't respond to physical therapy/non-opiate pain meds or other conservative treatment. Psych comorbidities are rampant in my patient population, which makes adherence and shared decision-making difficult at times. Really, I feel more comfortable with the psych than I do the musculoskeletal.

I debated doing primary care after residency was done, but honestly, I don't think I can do chronic musculoskeletal pain for the rest of my life. And there are other issues too--a lot of patients want handicap placards or doctor's notes for things I feel are not appropriate for them. I try to explain this, but I don't think I get through to them, and all they end up doing is going to someone else and having them sign it. I feel like I am swimming upstream on those issues a lot of the time.

And I want to do research, which I feel is difficult in the primary care setting. My hospital, as well as most of the others in the city, do not allocate dollars to primary care doctors wishing to do research. And I'm not just talking about basic science (which is unheard of in the primary care community, for the most part). Even things like quality improvement are not really supported here.

I did have a conversation with an attending last week who assured me that is not the case everywhere. There are institutions, some only a few hours away, that allocated significant dollars to primary care faculty (TENURED faculty) to do translational or clinical research.

So, I'm basically deciding between two choices: cardiology, which has a brutal fellowship but then will allow me to do whatever I want (within reason) afterward, or primary care w/research, which doesn't exist here but supposedly does in other places.

Today, at this moment, I think I am more on the cardiology side of the fence. I have cardiac ICU coming up in January, which is largely agreed to be the hardest rotation in our residency program. I've been told not to let it change my mind, but I think I will have a hard time not allowing it to be influential, as I would be spending a lot of time there as a fellow.

I've also been doing two outpatient cardiology clinics per week as part of my outpatient time. I've really enjoyed them, but again, I like outpatient in general. Part of outpatient cardiology is very cookie cutter--there are clear guidelines on what medications people should be on, based on their cardiac history--but I've found there is a little more finesse than I previously appreciated. The same part of cardiology that appeals to me (the large body of evidence-based research) can also make some of chronic management seem boring, since you either are or are not following guidelines. But each patient is different, and managing meds/dosages/etc to minimize symptoms does vary from person to person.

Also, I feel as though patients treat specialists differently than they treat their PCPs. In my primary care clinic, I have many new patient no-shows and some chronic patients that routinely miss their appointments. In cardiology clinic, almost no one no-shows, people come early, and they generally listen when you tell them about their condition and how to adjust their meds. I can give the exact same information in my primary clinic, but the impact is nowhere near what it is coming from me in cardiology clinic. It's probably a selection bias, but it is a pleasant perk.

How does this tie into item #3 (moving)? Well, cardiology is selective. Extremely competitive. If I want to do fellowship, I need to be able to move around. I've been told that my PhD will (finally) be helpful in the fellowship application process, but as there are only 5 cardiology slots in my hospital (and only 2/5 are given to the institution's current medicine residents), I need to be open minded. There are other cardiology slots in the city, but for academic medicine, my current institution is the best choice among them (despite the reputation of The Hospital Down the Road).

I don't think I'd have to be willing to go ANYWHERE, and there are certain things I would not do. For instance, we are not big city people, and we could never live somewhere like NYC after being in the burbs for so long. Some cities, like Chicago or DC, we could survive (though probably not afford). I wouldn't mind going a little south and losing some winter. And there are several Midwest cities with good programs. The issue is more of logistics. Anywhere we go that isn't Cleveland will involved selling a house, moving Sophie out of school, and losing the family backup system we have here. It's not impossible, and I would do it for the right opportunity, but it's something I don't take lightly. I moved around a lot as a kid--7 schools, 4 cities, 2 states from K through 9th grade--and while I think it helped me grow as a person, I'd rather not do that if I don't have to. If I go somewhere for residency, I'd like it to be somewhere that has the potential for me to stay and get a job after I finish the program.

So, the anxiety. Basically it comes down to timing. I need to know what I am doing and have letters of recommendation ready by late spring 2014. Applications open summer 2014, interviews are in the fall, rank lists are due in November, and the match is early December. So in almost exactly 1 year, for better or worse, this will all be decided. The issue is more so from now to spring. I need to commit. I need to say, "Yes, it is cardiology." Today I feel about 85% sure that is it. Other days it is 50/50. After CICU, I'm worried it will be <50 and="" back="" hope="" i="" nbsp="" not.="" one="" p="" square="" then="" to="" what="">
If I can't be nearly 100% by spring, I may have to come up with a plan B. Maybe I will do a hospitalist year and then apply a year later. There are some other one year fellowship options too. I don't know. I feel like committing to the intensity of a cardiology fellowship requires me to be damn sure I know what I am doing.

So, I don't know for sure what I am doing, I don't know if it will require me to move and uproot my family, but I need to decide within the next few months. And oh, we might have another baby.

Though, one quick aside on that; as crazy as it seems, this would be the best time to have another baby, despite all the uncertainty. Working out my 3rd year residency schedule would be much easier that working out a cardiology or other fellowship schedule, so better now than later. That, and with Noah turning 2 in January, I think that we'd have a harder time getting back into the newborn routine waiting until he was 5 or 6 and having another one than we would just squeezing the last one in now. The spreads, age-wise, are 30 months between Sophie and Josh and 21 months between Josh and Noah. I think the 30 month spread was about perfect for us. Josh and Noah were really close in age, which was especially difficult given how colicky Noah was, but they are buddies now. I don't know what the spread will be for the next one, and every family have different preferences, but I'd rather have them be closer instead of farther apart. Once I am sleeping regularly and have all the kids out of diapers, I think I'd have a tough time going back. And I am not far from the magical age of 35, when suddenly you are Advanced Maternal Age and have all of the extra hoops that come along with that (though after having many friends w/kids after that age, I don't understand how there can be such a concrete line about when pregnancy becomes more "high risk.")

In summary: I have no idea what I am doing with my life, I am leaning towards making that more complicated by having a FOURTH!!!! child, and in a year I may know that I need to pack up my family and move to a brand new party of the country where I know no one.

Or, maybe things will work out and be just fine. I've taken a crazy path this far, and it's great. I guess I'll know in a year.

Friday, August 30, 2013

Pondering

I've been stressing a lot lately (ok, not just lately) about choosing the next path in my career. I can't say I've decided anything. It's interesting though--sometimes a phrase just sticks in your head, and it feels like a personal message. I feel like I got one of those on Sunday. I don't get into religious stuff on the interwebs much, but I have to say: most of the time, the readings at church are things I take as general life direction. But this Sunday, I felt like I was getting tapped on the head. Bear with me, I'll come back to this.

I'm at a crossroads with decisions. I need to choose the next step on my career path, which will likely be some kind of fellowship, by the end of this year. I have little to no elective time to figure it out. So I am stressing about choosing the right area.

I did a month of cardiology earlier this year (mix of wards and ICU, mostly wards), and while the 30-hour calls were tough, I generally enjoyed it. Having said that, the prospect of being in the cath lab for six months or more, plus CICU time, in a fellowship is enough to give me hives. I like the physiology of the heart; I like the potential for research. I am not so into procedures. I've been told procedures are inevitable in a cardiology fellowship but optional once you are in a faculty position. I had a senior resident and a cards fellow tell me the entire rotation that I should just do cardiology fellowship as a path to an academic position. I agreed with them that my research background had me set up for this.

However, I feel burnt out. I've so far this year done a month of cardiology, two weeks of night float, and am on week 2.5 of 4 of general wards at the VA medical center. I thought intern year hours were tough; senioring on the wards usually means I don't finish staffing and writing notes until after 2 AM, and then I am back the next day. This cycle repeats every four days. There are no days when I am not admitting at all, which I did have as an intern. And being early in the year, my team consists of two acting interns (fourth year medical students, who carry patients but cannot sign orders/notes, which means I do that) and two brand new interns, neither of whom want to do medicine (one psych, one neuro) and have never done any medicine rotations before, nor are they at all familiar with the VA system. It has been a series of very long days.

And honestly, I know that I signed up for this. But I am getting tired of having no life. I do have some outpatient time coming up, but then I am often on weekend cross coverage. And seeing up to 14 patients in a day in outpatient clinic means I am still there fairly late writing notes. I am not saying it will be a walk in the park, but it will be easier than inpatient. I hope.

And I have a crazy schedule the middle of second year; lots of ICU, tough ward months, etc. Third year should be better, though there are tough rotations then as well. So, I know I am in for almost two more years of this.

And that is where my hesitation with fellowship comes in. All fellows work hard, especially the first year, but cardiology is tough. Lots of ICU, lots of procedures, and lots of overnight call. And even on something like consult service, there are tons of patients to see and notes to write. It is understood that you are signing on for 2-3 years of constant work. So for as much as the academic in me is interested in pursuing cardiology to continue my research interests, the idea of committing to another 2-3 years of brutal schedules is less than appealing.

My conundrum is this: am I hesitant because I think it is too hard? Or am hesitant because I am just tired? If there was another field that really called to me, I don't think I would be as concerned. But I keep going through the list in my head, and I can't come up with anything that jumps out. GI? I think some of the autoimmune/inflammatory stuff is interesting, but I don't want to be scoping all day, and end stage liver is the worst. Heme/onc? I like the idea of metabolic targets for therapeutics (which ties into my research) and the continuity of care with patients, but it seems overwhelmingly broad, and I really have a hard time with all of the terminal cancer patients that get admitted to the hospital for miserable chemo as a last ditch effort when everything inside me says these people should go home and be comfortable. Endocrine? Some of the rare stuff is interesting, but the basic diabetes/thyroid stuff is not terribly interesting to me. Nephrology? Just not interested in the kidney, at all. Rheumatology? The autoimmune part is interesting, but I really don't like joint/musculoskeletal stuff. 

Anyway, the list goes on like that. And when it comes to cardiology, there are two sides to the issue. One is avoiding it because of the terrible work load, as I mentioned. That issue is therefore crossing cardiology off the list for the wrong reasons. The other issue is including cardiology on the list for the wrong reasons. Yes, I did a lot of animal cardiology in my PhD. But my research is broader than that, and I could transfer it to a lot of fields. I don't want to gravitate to cardiology just because it is my comfort zone, and it feels safer than exploring something new.

So how does this tie in to that initial comment I made about church speaking to me? I've been ruminating about the fellowship workload issue. And then at church, despite my three kids and the herd of other people's kids in the cry room, two verses came to me crystal clear during the service:

The first was from the second reading (Hebrews 12):
Endure your trials as “discipline”;
God treats you as sons.
For what “son” is there whom his father does not discipline?
At the time,
all discipline seems a cause not for joy but for pain,
yet later it brings the peaceful fruit of righteousness
to those who are trained by it.
So strengthen your drooping hands and your weak knees.
Make straight paths for your feet,
that what is lame may not be disjointed but healed.


Ok, I thought. Trials, discipline--I feel like that is the place I am in right now with my residency, and this was telling me to suck it up. Good will come from this. Cool.

Then there was the gospel reading verse (Luke 13):
Strive to enter through the narrow gate,
for many, I tell you, will attempt to enter
but will not be strong enough


Crap. The narrow gate? As in, not taking the easy way out?

Ok, I get it. Like I said initially, I don't think this was a clear message that I should or shouldn't do any one specialty. But it reminded me that if I am going to do something, I should do it for the right reasons. And trying to do things the easy way isn't the right reason.

I feel like most of my life has been about delayed gratification, with only a few (actually, three) exceptions. And those exceptions are my adorable and exhausting children. I am quickly approaching my mid thirties, and I am more and more getting frustrated with how much of my life I am putting on hold for my career. Having said that, I also feel that my career is a calling, and this is what I am meant to be doing.

There are people out there doing this work/life balance thing far better than me. I am always looking for ways to improve, and maybe some day there will be more flexibility for me. There is no flexibility in my residency, and I don't know what fellowship will hold. But every day, I wake up and wonder if I am making the best choices.  

There are several big choices on the horizon, some career related, some personal. That is for another time (things are fine, don't worry). But I keep hearing those verses about discipline and the narrow gate, and I know that I've got to make choices for the right reasons. I need to include personal and family things in those choices, don't mistake what I am saying. But just deciding not to do something because I am tired of working hard isn't the way to make a decision.

Anyway, just thought I'd brain dump a little. Life slows down briefly in another 11 days, so maybe more time to think and ponder in the not too distant future.

Thursday, February 21, 2013

Perspective


I occasionally have a moment to reflect on my life and wonder if I am missing a message. I wonder if all of the barriers I faced during my PhD were trials meant to make me stronger, or if they were messages telling me that I need to stop being stubborn and take the option offered to me. Over the last month, I've felt as though I am being sent another message by way of coincidences, but I haven't figured out what that message is.

I am uncertain as to what I want to do after my internal medicine residency. I have always planned to specialize in a field, for lots of reasons. No real need to go into it too much today, but specializing would likely help me to enter academic medicine, and it also fits my personality of wanting to know as much as I can about one particular field. Given that my PhD was in cardiac physiology and metabolism, I figured that I would specialize in cardiology. Unfortunately, my clinical experiences with cardiology haven't appealed to me as much as I had hoped (and I've really tried to like it). And as I've mentioned before, it's a tough lifestyle to commit to unless you really, really love what you are doing.

Since cardiology is out (or at least far down on the list) right now, I've been trying to think of other fields that might be a good match. Rheumatology is academic, and I like the autoimmune aspect of it. However, I dislike the musculoskeletal system and joint taps, and the clinical rheumatology I've done so far hasn't been super interesting. I spent one day in the GI endoscopy suite, and that was enough to rule out GI. I've had limited experience with other fields as well, but up until about a month ago, the two areas that seemed to be front runners were hematology/oncology and infectious disease.

ID (infectious disease) was on the list because I enjoyed the month I was on the ID service, and we have very good ID doctors and researchers at my hospital. Ironically, "bugs and drugs" (microbiology and antibiotics) were two of the disciplines I had the most trouble learning in medical school because I felt like it was mostly rote memorization; I like physiology better because it is thinking about how things work.

Heme/onc appealed to me from the academic side. My background in metabolism and chemistry makes chemotherapy a natural direction for my research interests. It doesn't hurt that my hospital just built a freestanding cancer hospital and attracted a bunch of new researchers to the institution. However, after spending a month on the inpatient cancer service, I was doubting whether I had the emotional fortitude to do heme/onc. One of the attendings made me promise to do outpatient heme/onc before I decided to cross the specialty off my list.

A month ago, I took two weeks of my elective time and did outpatient heme/onc. The attendings were very kind and really allowed me time to talk to their patients. I enjoyed the rotation--though in all honesty, I enjoy outpatient ANYTHING over inpatient. I wasn't really sparked to jump into heme/onc, but I wasn't turned off either. It was a blandly pleasant experience.

While I was doing heme/onc, I got some very difficult family news. My uncle, my dad's brother, my godfather, was diagnosed with stage IV pancreatic cancer. It was very sudden--he went in to have his gallbladder removed, and he was discharged without surgery and with a terminal cancer diagnosis. This happened at a hospital not part of my health system, and I am not saying this to badmouth another hospital, but I was absolutely appalled at how he was treated during his stay. The sudden diagnosis was awful enough, but he was sent out with no close followup, no referrals, and no plan for managing his disease. I thought about all of the services (medical, social, spiritual) we provide to patients with a new diagnosis, and I thought about how he was treated, and it made me want to punch his surgeons in the face.

Once I got over my short-term anger, I felt deeply saddened, as did my entire family. We all struggled with the idea that my uncle, who is one of the kindest, most pleasant people you could ever meet, had a disease that no one could fix. And the poor man was miserable from the cancer and had been given no help in treating his symptoms. It was heartbreaking. His kids--my cousins--are in almost the exact age range of my siblings and me. The thought that they would be losing him so soon reflexively made me think about the what ifs--what if that was one of my parents? I've said here before that one of my greatest fears after doing my inpatient cancer rotation was to see someone I love, especially someone in the prime of their life, be diagnosed with cancer. And now, here was that fear. It felt selfish to even think about how upset all of us in the extended family were, knowing that it was infinitely harder for my uncle, aunt, and cousins dealing with this.

I was so deeply saddened by my uncle's diagnosis that I almost couldn't go back to outpatient clinic to see other people dealing with cancer. I made it through, but I was touched so profoundly that I doubted whether I would be able to work in a field where the endpoint was so often mortality. Outpatient heme/onc is far better than inpatient, but I just had a sense that so much of it is watching and waiting, almost with a resignation that ultimately these patients will have to face their cancer again, that no remission is permanent, that there is no such thing as a complete cure.

I could talk about all of the things I've felt since my uncle was diagnosed, but it feels selfish to talk about, as my personal struggle can't touch what his family is dealing with. Fast forward a few weeks, and he has been set up with an oncologist, getting some symptom improvement with palliative chemo, and we as a huge extended family have made it a priority to spend as much time together as we can for as long as we have him. I'm a person of faith (though not as much as I should be), but my medical background has made me realistic about what to expect. My uncle is realistic as well, and for the most part so is my extended family. I'm still sad and upset, but I've advanced a little in my stages of grief. I still think about him nearly constantly. And reflecting on how my family has dealt with his diagnosis has me thinking about writing heme/onc off the list.

Last week, when I was freaking out about not knowing what I am meant to do with my life, I had a thought. And it was so obvious, I wasn't sure why it hadn't struck me before. I wanted a field that would let me do research and teaching. And the research I had done before was on the heart--but it was also about metabolism. And my research involved not just heart failure, but insulin resistance. I could look at it from the angle of the heart as a cardiologist, or I could look at is from the insulin/metabolism perspective--through endocrinology. Duh.

To be truthful, I had considered endocrinology before, but I had ignored it for several reasons. First, after dealing with my old PI, who was an endocrinologist, I didn't have a very good impression of the field. Second, it is one of the few programs in my hospital that I feel is academically weak--really, there is no basic science or translational work being done (though some good clinical research). However, that "other" big medical system in the city has a very good endocrinology program--which just makes our department seem that much worse.

Third, I hadn't seen people who got excited about their work. So many of our patients are diabetic, and most of the doctors I have worked with refer to endocrinology when they become frustrated with dealing with non compliant diabetic patients. I think it is very important to work with non compliant patients--we as doctors can't give up on them--but it can be a very emotionally exhausting group to deal with as your clinic cohort day in and day out. And as residents, these are the patients we generally see in endocrinology clinic. There are more interesting endocrinology patients out there--but they are the group seen by fellows.

When I thought about endocrinology as an option, I almost smacked myself. I had been excluding it based on my biases from my limited interactions with both endocrinology practitioners and patients. It seemed so obvious now. And while it isn't ideal that my hospital has a weak program, there might be a way I could do some work at "that hospital down the street" if I really wanted to pursue metabolism research.

This past weekend, I was fairly certain that I had worked out my life plan. I had even started looking into programs. I got to keep my interest in metabolism but avoid the emotional pain of dealing with cancer.

And then I started my radiology elective/jeopardy call (jeopardy means that if anyone calls off/needs coverage, I get called in). I figured this was a low-stress rotation that would help me in my radiology deficiencies. And on the first day, I started talking to a radiology attending...doing research in chemotherapy. It was right in my line of interest. We were reading CT scans with the radiology resident (who patiently put up with the hijacked conversation). When the attending started talking about his research, he said, "I can tell that you are interested just by the way your eyes lit up." When he heard about my research background and my chemistry major, he excitedly said, "That's it! You have to do heme/onc--I need to get the next generation excited about this work!" And his work was exciting--and interesting--and clinically relevant.

And in about an hour, I was back to considering heme/onc again.

So I am basically back to where I started. The pragmatic part of me says that if I don't want to do cardiology but I want to keep in the same area as my thesis research, endocrinology is the obvious choice. I haven't yet had an endo experience that has gotten me really excited, but there is still time. The emotional part of me leans towards heme/onc. There is so much potential for impactful research--I don't think I would ever use the word "cure," but metabolism is an obvious target for cancer treatment. The issue is my emotional attachment. It's both a blessing and a curse. I got so involved with my patients on the cancer service--each little victory was so uplifting, but ultimately most of the outcomes were heartbreaking. The outpatient heme/onc experience I had was more positive, but now having had cancer touch me so personally, I don't know if I could disengage emotionally enough to see cancer every day.

I want a practice where I develop a relationship with patients. That is why I chose medicine and not just basic science. I want to see my patients every few months, check in with them, see what adjustments need to be made, and make them feel like they are a partner in their care. I also want to stay involved with research. And I want that research to be clinically relevant. I don't know yet whether it will be bench based or a clinical trial. I just want it to be something that has potential to impact treatment and improve the lives of more patients than I could ever see in clinic. I was to be academically stimulated, I'd love to have the opportunity to teach on occasion, and I want to be active in a scientific and clinical community.

I am an emotional person, and I'm not planning to change that. What I am learning is that I need to control my emotions. There are so many other interns that seem cool and collected at all times. That isn't me. I have yet to do an inpatient rotation that hasn't seen me lock myself in a bathroom for a few minutes just to get a good cry. I accept that, I do what needs to be done, and I move on. I want to be emotionally there for my patients too, but I know that for my own long-term sanity I need to find some space. It hasn't even been a year of residency yet. I know that I am headed for huge burnout if I don't find some emotional distance.

It's hard. I feel powerless when I think about how I've done all this training, and all I have to offer my uncle are the same things I had before: love, support, and just showing up when the family needs to be together. I didn't have to go through ten years of medical/science training and a residency to do that. I hope I am more useful to my patients, but their struggles touch me too. I think ultimately my specialty choice will depend on the balance between pragmatism and emotion.

I am sure that being touched by cancer on a personal level will shape my choice as well. There are things that happen to all of us and to those we love, and there is opportunity to grow from everything. I need to find what I am supposed to learn. I'm still not sure I've learned the right life lessons, but I hope I keep looking.

I've really stepped back and looked at life from a new perspective this last month. I've made sacrifices and begged for help from my coworkers so that I could make family more of a priority. Medicine does a good job of forcing you to put your own life on the back burner. You feel that you owe your "80" hours a week to your program, your hospital, and your patients. What I am (slowly) learning is that I need to be a grounded person to be a good doctor. And family is how I stay grounded.

I don't know what the coming weeks and months will hold. I am sure I am in for many more transformative experiences. And in a few years, I may look back at this post and laugh at how much my thinking has changed. For now, I want to step back, re-evaluate my priorities, and think about how I can be what I need to be for all of the people in my life.

Sunday, January 13, 2013

Mid year update

(Note: posted on night 7/8 of night float, as it took me a while to get to blogger from the hospital)

I am on night two (of 8 shifts total) of night float. Essentially, that means that two interns cover the majority of the medicine patients in the hospital. Right now, I am carrying the load of 12 interns overnight. That is intimidating and also completely unreal. I am almost exactly halfway through my intern year, and I figure now (at 2 AM, no less) is as good a time as any to reflect. At least until the next nurse pages me :)

Rotations:
Some of these I have reflected on already, but maybe time has given me more perspective. No time for run-throughs now, just a list...
-Infectious disease
-General medicine (VA)
-Primary care (VA)
-MICU (absolutely hated this rotation!)
-Vacation
-Neurology (disliked, thought it was pointless)
-Cancer
-Urgent care/ MICU coverage (VA)
-Night float

Big changes: I was in the MICU when I realized I didn't want to do cardiology anymore. Honestly, I had been slightly unimpressed with it as a medical student. I attributed that to just following people around, as well as having one community physician not quite be the model that I would prefer (think typical cardiologist stereotype). I was on general medicine when I watched a procedure in the cath lab and thought, "well, I could do this if I had to, but I'm not very excited about it." When I was absolutely hating my life in the MICU, I thought about the fact that the cardiology fellows had up to five months in the CICU, as well as several months in the cath lab. And they were constantly on call--which was not going to change much once they were attendings. I thought about my interests, and then I thought about what I want out of life. I think cardiology has very interesting research potential, but clinically, it leaves me a little cold. And a three year fellowship that was equal if not more time consuming than intern year? I knew I would really have to love something to commit to that. And right now, cardiology isn't it.

I have several friends and colleagues considering heme/onc for fellowship. Superficially, this seems to hit the big points for me: patient centered care with continuity, a patient-physician partnership, research potential, fairly decent work/life balance, and a bonus of getting to use some of my undergraduate chemistry background for chemotherapy.  It's still on the list, and I feel that it needs a chance. But after a month on the inpatient cancer service, I don't know if I have the emotional stamina for it. And two nights of night float have me seriously concerned. I had so many end stage patients, many of whom passed away within days to weeks of discharge. Granted, most of the people we admit have widespread disease and are admitted for management of their advancing cancer, so they usually come in with a poor prognosis. What bothered me most were the young patients, many with families, who are at the end of their lives. We had multiple women in their early 40s with children pass away from cancer. And in the MICU as well as on the floor, I have either covered patients or had patients covered by other members of my team with end stage cancer in their early 20s. It absolutely breaks my heart to think about these people, who a matter of months (or sometimes weeks) prior were going about their lives. Most of these patients passed away within months of their initial diagnosis. I am sure it hurts because it is so close to home. I see myself, or Tim, in these patients. I can't even imagine not being there for my kids.

And I think all of my introspection about my mortality has really affected my thinking about what I want to do. I have spent the last ten years of my life busting my butt to do what I am doing now. I realize that intern year is tough for everyone; I am not fixated on how difficult this year has been and continues to be. But I think about the next step: in 2.5 years, I will be moving on. I will either be starting a fellowship or starting a job as a physician. My life has been about delayed gratification; in just a few short years, there is potential to start reaping the rewards of my sacrifices. What do I want to do? And has it all been worth it?

I feel a great deal of guilt that I spend so much time away from my family. While I am on nights, I get to see my kids for about 45 minutes per day. I am so thankful that night float is only two weeks long at a time, but it really makes me think. I've broken my life up into little chunks just to get myself through it. Only 6 more night float shifts; before, it was, "only two more weeks of MICU" or "only three more long calls." I feel like my life, and in turn my family's lives, are just moving by. I know that this schedule is not unique to me. And it also was not a surprise. I wonder though: what will it take to make me feel that all of this sacrifice has been worth it? What is the measuring stick? Money? Really, that has never been important to me (hence why I could give up cardiology so easily). We have made do on a student's stipend, and residency pay is laughable considering the actual hourly wage when you calculate it. So if not money, then what? Prestige? I don't care. Making a difference? There are lots of other ways to do that; I really enjoyed teaching, and that would have been a viable alternative. Academics? Research? I really don't know.

It's difficult being in a place where you are surrounded by sick people all the time. It skews your perception. And being in a tertiary care center, these patients are SICK. When I was in the MICU, outside hospitals would transfer their complicated patients to us because they were too critical to manage at the other facility. And these patients would come in more stable than some of the patients we safely manage on the floor. So, the patient population notwithstanding, working in a hospital affects your perspective. I've seen young and old people who are sick, critically sick, terminally sick, and many of them die--despite our best efforts. It makes you wonder how anyone can be healthy, how anyone lives to a ripe old age. I am 32; I have had patients younger than me die. It doesn't matter if patients have families, or if they were in school, or if they hadn't finished what they set out to do in life. Disease didn't care. And it makes me fearful for the people I know and love.

I know that the statistics tell us that most people will not die young. However, now having seen it and almost having it feel common, it makes me scared. What if? What if I'm the one that gets cancer next? What if someone I love gets the resistant infection? Will I regret how much (or how little) time I have spent with the people I love? Will all of the decades of delayed gratification really be "worth it"?

One of the attendings that worked on the cancer service offered very good perspective on the patients we see in the hospital. He said that heme/onc is 95% of the time an outpatient specialty. Most patients see their physicians outpatient, get chemotherapy or radiation outpatient, and many are cured or improved as outpatients. The people who come into the hospital are the 5%. Even in his practice, which focuses on late stage cancer, most of his patients do not come into the hospital. Our inpatients are so sick that they can no longer be managed outpatient. He was the one that encouraged me to see patients in outpatient settings before I cross heme/onc off the list.

This year has been so full of ups and downs. I believe I have cried (privately, so far not publicly) on every rotation I have been on. I feel overwhelmed on a regular basis, I feel like I will never learn everything that I need to know, and I worry that all of my training will never help me be a good enough doctor for my patients. And then there are times when I cry for other reasons. I have been touched so deeply by some of my patients and their families. I have never expected recognition from my patients. Really, it's unrealistic, and you set yourself up for disappointment if you expect external validation. But on the occasions where patients or families have pulled me aside and said how much my care means to them, it absolutely moves me. It makes those long nights, those tearful huddles in the bathroom, seem like nothing. Pats on the back from colleagues are nice, but warm words from the people I work so hard to care for are like gold.

It is unoriginal and passé, but I want to be a doctor to help people. I have said for many years now that I want to be a doctor to help people on a personal level, and I want to be a scientist to help people I have never met. I know what I want my life to be like in 10 years. I want to be in academic medicine, with a regular outpatient clinic. I want the opportunity to be involved in research, either as a collaborator or a PI, on a project that is relevant to patient care. I want the opportunity to do occasional teaching, whether it be at the medical student, resident, or fellow level (I would do graduate/undergraduate as well, though I realize those opportunities are nearly nonexistent). I think several weeks per year of inpatient service are fine and would challenge me to stay up to date on more critical care than outpatient alone. And I accept that any job will have call/coverage, but I want that to be less than half of the time (and the less, the better).

I don't know what field exactly this dream job will be in. I always saw myself in a specialty, especially since I want to be involved in research, but maybe general medicine needs to stay on the table. I feel like specializing is a safety net for me, and it fits my PhD persona. I like knowing everything I can about a niche. General medicine intimidates me because it is broad; even with all of the technology available now, general medicine requires you to be a walking differential diagnosis machine. That is not a skill with which I feel comfortable yet.

I really don't know where things will go. And I know it is still a few years away, but it affects decisions now. How do I spend my elective time? With whom do I need to develop a professional connection?

I don't really get a choice about how I spend my time intern year. I took the only choice I had; I elected to change my schedule around by joining a pathway in the program that allows for more outpatient clinic. I am hoping that turns out to be the right decision. Even if I don't do general medicine, becoming a better outpatient provider will be a useful skill for any future path.

I don't know yet how I will determine whether all of the sacrifices I have made are "worth it." And I don't know how long I will have on this earth to figure it out. But for now, I just have to keep surviving for my own sanity, and I have to sneak in as much time with the people I care about as I can. Everything else is outside of my control.