Choosing a specialty, part 2

"Hi Ifinding, in a future post, could you briefly describe the negatives that swayed you against other specialties? BTW, I really enjoy your blog. I just discovered it yesterday and can't stop reading it!"

I live to please, so here are some thoughts that swayed me from one specialty to another. Keep in mind that these are thoughts that I had regarding specialties that applied to ME and may not apply to you.

Family medicine: I liked the concept, with regular patients and continuity of care. However, I didn't like taking care of kids, and I didn't like the extreme breadth of disease.

Pediatrics: I don't like taking care of kids. When a 72 yr old diabetic has a heart attack and dies, it's unfortunate, but at least I can console myself and say he had a good run. When a 6 yr old dies, that invariably falls on me. Peds deals with a lot of genetic diseases which are rare, but you can't afford to miss. I hate genetic disorders. Peds has parents. I hate parents.

Psychiatry: while I didn't enjoy adult psych, I really loved child psych. I thought the kids were so precious, and I was absolutely struck by the tragedy of their cases, and how for so many of them, their only fault was being born to shitty parents. However, in the end, I couldn't take the tragic nature of the field.

OB/Gyn: I really liked Gyn. Relatively healthy patients, limited number of interventions, good split between clinic and surgery. I thought it was really neat. The OB part I could've done without, but nothing trumps introducing a mother to her new baby. But so many women didn't want anything to do with me because I was a man, and I wanted to make more lasting connections with my patients.

Surgery: Wow, fun. I really enjoyed the technical nature and the quest for excellence, but the bedside portion was so pitiful. We would do a hemicolectomy for obstruction from metastatic colon cancer, and never talk to the patient about their abysmal prognosis. I didn't want to 'sign off' of a patient who needed help.

Anesthesia: 99% boring, 1% terror. Hate boredom. Hate terror.

Dermatology: I loved derm. L-O-V-E-D. Office procedures, almost entirely outpatient, as much continuity as I wanted, get to see some bizarre and unusual disease mixed in with simple but fulfilling care. If I had the board scores for it, I would've done derm, but I'm just not that smart.

Radiology: Zero direct patient care. No thanks.

Neurology: All diagnosis, no treatment.

Pathology: The most scientific of all specialties, the greatest arbiter of diagnosis, but the only time I get to work with patients is when they're dead. While I loved the science, I wanted to see patients.

So in the end, I went with internal medicine. I loved the diagnostic challenges, the continuity of care, the limited focus compared to family, the treatment aspects, and the attitude. Internists are generally somewhat anal-retentive folks, and a little OCD. We obsess over tests and meds and things like sensitivity and likelihood ratios. There is a constant fight between the art of medicine and the science. In adult care, we are management kings.

But also, we are a dumping ground. We admit patients spurned by every other service: Gyn, neuro, surgery, when everyone else passes, the patient goes to medicine. While I find this aggravating, I also feel that someone has to look out for the patient.

I came to peace with this fact when I talked to a US Marine a while back. I was marveling at his bravery, enlisting in the branch of the services known for being the first to fight. You don't join the marines to avoid war; you join to get your hands dirty. Rather than be proud of his service, he completely downplayed it. "Y'know, when there's a job to do, someone has to step up and say 'I'll do it.'"

And although I'm not in the military, this is pretty much my attitude towards internal medicine. I did not become a doctor to avoid work. I became a doctor because I felt that I could do some good. And whenever people complain that medicine is a dumping ground, my reply is always that there is a patient who needs help, and if no one else will step up, I will. I have even been so bold as to tell other doctors if they don't want to do what's right, then I will.

And when I die, I hope that people won't say what I nice person I was, or that I'll be missed. What I want people to remember about me is that when I was needed, I always answered. I did not become a doctor to rest on my laurels. I came to work.


When I was finishing up residency, I was working with some medical students. One of the students was absolutely gorgeous. She had this wavy, brunette hair that seemed to flow like water. And she had this scent to her that was so intoxicating. I found myself following her unconsciously, completely entranced by her smell.

She had a crush on me too. Sometimes, I don't know these things. My social skills are poor at best. But with this girl, I knew. Her gaze would linger a little too long. She would look down when I was talking to her, afraid to make eye contact. She kept her head tilted slightly, in that kind of daydreaming pose.

I think about this girl every now and then, and the long string of girls like her whom I have met briefly, and then have left my life. Either I was going or they were, never in those ideal circumstances you see in the movies. And so we meet and we part, with the vague notion that maybe we could've done something, but for the timing.

And I realize now that the problem was never the circumstances or the timing or whatever else. The problem was the choices I've made. When you can appreciate the choices you've made in life, it becomes very difficult to avoid reality. I've made some choices, some of which were terrible. And it became clear to me that as unhappy as I've been, it was from my own hand.

People make fun of the second Matrix movie, but there was an extremely profound line in it. The Oracle tells Neo, "We can never see past the choices we don't understand... you've already made the choice. Now you have to understand it."

When I heard this line in the movie, I thought this was so trite. But looking at my own life, I can see now that my life is composed of the decisions I have already made, and the most anxiety, the most angst is tied behind decisions that I have made and never understood. And as I shed light on them, it becomes clear to me the effects of these choices, and how terrible it truly is that we can't change the decisions we've already made.

Because for the last 15 years of my life, I have chosen everything over love. I was scared of love, and I still am. And it scares me because everything I love leaves me. And gazing with a critical eye, I can see that I have made some remarkably poor choices, in order that I could wake up in the morning and not shoot myself, but exorcising all joy from my life.

Now, understanding the choices I've made is all very enlightening, but it doesn't answer the very simple question: will I choose to love? I don't know. It's one thing to see the gears. It's another thing to be a clocksmith.

Choosing a specialty

Recently, I was talking to a 3rd year student, and he was trying to figure out what to do with his life. He was still a little lost, like most people in their 3rd year. Everything either seems fun or horrible. Everyone expects that moment of, 'This is what I want to do with the rest of my life!' but in reality, few of us get that moment. I can't tell you when I decided on internal medicine. I just did.

I tell most people that they should go with the pathology. Whatever diseases interest you are probably things that will continue to interest you, because the patients can't all be winners. This student told me that he wanted to do ER because he didn't want to see the same thing over and over. I was polite enough not to laugh in his face.

The truth is that every specialty has its bread and butter. For me, that's hypertension and diabetes. For the surgeon, it's gallbladders and appendices. And all specialties have their chronic patients. You can't choose a specialty aiming to avoid these chronic folks or to dodge the routine diseases. The only way to dodge that stuff is to go into a field without direct care: radiology, anesthesia, path...

When I was trying to decide, I posed a simple but profound question to myself: what is my staple diet? Sometimes I get a taste for Mexican, but I can eat rice every day for the rest of my life. And that's what choosing a specialty is like to me. What can I see again and again and always find satisfying? That's the specialty for me.