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.


Anonymous said...

Student nurse here -

Just wanted to let you know that I enjoy reading your posts. It's almost like sitting down and listening to someone talk. Anyway, keep writing!

Future Doc said...

any views on emergency medicine?

Anonymous said...

Emergency medicine - the most simple decision making protocol ever devised. Admit vs Don't Admit. Don't know why it takes 3 years to learn that.

valleygirl said...

Great post - quite entertaining!

incidental findings said...

Future doc: you really don't want to know my opinion on emergency medicine...

Anonymous said...

i want to know your opinion on emrgency, and on orthopedics and on plastics. i'm interested in the hand.

Also, ifindings, you might want to consider rewording something above. You say "good split between clinic and surgery" in your obgyn assessment. I'd say that
'split' is a suitable word to describe any other specialty. or maybe the best word for this one? ;)


incidental findings said...

Double entendres aside, OB/Gyn is a nice balance between surgery and clinic.

And since there is demand for it, I will shit on everyone's dreams of ER medicine in a future post.

Anonymous said...

but as a hospitalist, I love ER physicians! =D

plastics is a pretty cool surgical subspecialty... but beyond the cool reconstructions and cosmetic stuff, there's a lot of not-so-sexy stuff like skin flaps for decubs and stuff.

Anonymous said...

ooh.. and ortho! another one of my favorites.. I personally think it's ashame that some of the smartest kids in med school go do ortho just to get dumbed down a little... no seriously, it's a good old boys club with power tools. however, I really don't mind watching after ortho patients - it's safer for the patients when the hospitalist consults or admits the patient anyways to prevent FOOBA.

incidental findings said...

FYI, FOOBA = Found on Ortho, barely alive.

I did not expect this much interest in specialties, especially considering my opinion is the one of a general internist. However, I will oblige.

I will comment quickly on plastics. I think plastic surgery is awesome, and not because you get to play with boobs all day. I saw a TRAM flap done and that was amazing. I also saw a bunch of cleft palate repairs. I think if I was a surgeon, I would do a million breast implants if it meant I could do some really meaningful surgeries gratis.

Anonymous said...

i just came across you blog today, very inspirational stuff...i hope you'll keep it up. i admire the realism of medicine that you reiterate, and yet, i appreciate more the love that you have displayed for your profession. you see, i am a general internist as well. just finished with my residency this past June (just like yourself i believe), but unlike you, i dread going to work every day. i hate getting dumped on, and i hate having to work overnights despite being done with residency. i love interacting with patients as well, but with the 10-15minutes that i have with a patient, it's hard to take interest in who they are when you have to go over their uncontrolled dm, htn, hyperlipidemia, cad, osteoarthritic pain, chronic back pain, urinary incontinence issues, cancer screening, and so on and so forth. On top of all that, deal with their non-compliance while keeping a smily face cause where i work, we get evaluated by our patients. i hope i'll find the passion that you have for this field one day. i truly hope you'll continue to inspire. have you thought about specializing?

cscgrl4life said...

This blog is awesome! It's nice to get an inside perspective that's also honest. I look forward to reading more :o)