Choosing a specialty, part 3

So, this will be the last "choosing a specialty" post. I have been asked to render my opinion on emergency medicine, plastics, ortho, and someone couldn't help but pipe up about radiology. These four specialties probably accounted for the career goals of a third of my med school class. I can't stress enough that these are my opinions, and are likely in no way applicable to you.

The most important thing for me to say is that one should not go into ANY profession in medicine with your primary concerns being lifestyle and reimbursement. Those are shitty reasons to do any field of medicine. You should do what you love. You did not go through eight years (minimum) of school plus another three years (minimum) of training to do something that you hate. You'd be a fool.

I remember quite clearly in college I realized that I could actually do anything. It dawned on me that if I put my heart into it, I actually could do anything that I wanted to do with my life: scientist, doctor, engineer, lawyer. That is a privilege that extremely few people have. How dare you waste that privilege doing something just for the money and hours? If you do not want to make use of such a precious opportunity, there are millions of others who would make better use of it. Please, have a better reason for choosing a career than 'shift work.'

People make fun of ortho. Take the smartest and make em the dumbest. FOOBA. Honestly, I'm all right with ortho. I love ortho consults. I get to manage diabetes and high blood pressure, and I don't have to do a discharge summary? Excellent. I couldn't do ortho after I saw one procedure where they were hammering away at a femur. Felt like passing out. I like wood work. Not too crazy about sawing and hammering people.

Plastics is a funny one. Everyone thinks that plastic surgery is all boobs. In reality, the vast majority of plastics is wounds, skin grafts, minor reconstructions, and hands. If you are lucky, you can do some cosmetics, but you're not going to be on Dr. 90210. I still think it's really cool, but there's far more to plastics than making little ones bigger. But I'm no surgeon, so no plastics for me.

Someone mentioned how I knock radiology, which blew my mind. I actually like rads. I wish I could do it, but I needed the patient contact. What kills me about rads is that a lot of my med school colleagues went into rads for easy lifestyle, money, and 9 to 5 hours, and I loved rads far more than them. I was talking Houndsfield units and reviewing criteria for V/Q scans. They couldn't have cared less. And now, they're radiologists? It kills me.

Now, to emergency. I was trying not to comment on emergency medicine, since my opinion of emergency medicine is toxic at best. Keep in mind that my med school class was part of the "ER" tv show boom in emergency medicine interest. I quite clearly remember having ER parties on Thursday nights in college.

I wrote a very long tirade about ER docs, which had nothing to do with my reasons for not choosing emergency medicine, so I have created a separate post for it. I should mention that I do not counsel students at all about ER medicine. I point them as far away from me as possible.

Personally, I had no interest in ER because I liked having continuity of care, and I despise acute care. It was fun, but entirely without satisfaction for me. Also, what I did enjoy about ER was the primary care. Nearly everything I saw in ER was a primary care issue that if they had seen an internist a week before, they could've probably avoided going to the ER. Instead of leg edema, it was decompensated heart failure. Instead of exertional fatigue, it was acute MI. Instead of abscess, it was fasciitis. What ER made me realize is what these people needed wasn't more ER physicians, but they needed a primary care doc.

And so, here I am.

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.

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.