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.

Do you really want to be a doctor?

It takes a certain level of masochism to go into medicine. Something in your mind has to actually say that yes, I do think that getting the shit beat out of me on a regular basis sounds like a way to spend my life. Never in all my life have a felt stupider than when I'm taking care of patients. What's the patient's UA show? How do you explain this uric acid level? What are we doing for her renal failure? What medications do we have him on for blood pressure? What has her white count been doing for the past week?

I think that the great advantage attendings have over us lowly interns is that they can cherry pick. They can take aim at us from high above and we really have no recourse. It's wholly their right, since they take the heat if shit starts flying, but it certainly doesn't do much for the ego when your attending shoots a string of questions at you and the only one you can answer is that yes, she has been afebrile for the past 24 hours.

But it balances in ways. My senior has a habit of saying that I did a good job with this or that, and it's unbelievable, absolutely unbelievable how much I appreciate that. It's nice to have someone say, hey, good job, I think that's the right thing to do. One of my seniors questioned an order I wrote. I told him that the on call senior told me to do it and he laughed. He said to me that he knew it wasn't me. I was too smart to do something that dumb. I'm glad that others have such confidence in me, and I'm starting to think that I need to have some confidence in myself as well.

I'd love to talk to pre-meds in college. I'd love to tell them that this glorious career of medicine, it's not what they think. It's work, tough work. It's as blue collar as you can get for six figure salary. It's not noble. It's not honorable. It's work. And if that's your flavor then more power to you, but if I wanted to get some respect, I think that there are better ways.

I think the one beautiful thing about medicine is that despite what other people do to you, no matter how much the system beats you up and down, you can feel good about yourself if you can go home and say that you helped someone. You know, it's not often that you can go home, sip a beer, eat a pizza, and think to yourself that you made the last few hours of someone's life as pleasant and pain-free as medically possible.

A patient looked at me today and asked me what I would do in her shoes. I didn't have an answer. She wanted one but I didn't have one. What would I do? I dunno. Would I fight? Would I give up? I don't know. And sometimes, just knowing that this decision that she's been fighting with is a tough one, that's comforting to know. And so I can go home and sip on a beer and think that in spite of how lousy today was, I did okay.