Thursday, February 21, 2013


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.