Friday, August 30, 2013


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.