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.