I always think to this lovely comic by Michelle Au when I think about specialties. I wish she’d make a panel for ENT but I’m not sure what it would say…Probably something about ear wax and boogers.
Close to the end of Third Year, and closing in on the time when I will need to choose a specialty, I realize that I’ve come to judge each specialty based on what seems to bring people job satisfaction. It is unfair to talk about all the physicians of a given specialty in broad strokes but I cannot help but come to some prejudices.
For example, this past month I was on neurology – a subject that I have never been particularly interested in from a basic science standpoint. So many people are “fascinated by the brain” but for some inexplicable reason, I am not one of them. My disinterest was further elucidated this past month, when, for the nth time, I sat around a round table, debating again the localization of the stroke based on the exam before and after viewing an MRI that stood in defiance of all the tricks of the physical exam. Following this was another hour long conversation about whether to use aspirin or Plavix or both, even though our poor patient was not represented by the inclusion criteria of any of the 3-10 major trials in the past decade, each of which shows that the risk of stroke was decreased by mere percentage points. We know too little about the human brain and while some people find this fascinating, I find it a huge obstacle in the way of patient care.
It wasn’t that I couldn’t appreciate the need to prevent strokes, or that I could not identify with the physicians I worked with – on the contrary, I found the residents and attendings charming, thoughtful, as well as extremely thorough in their work. It’s just that I didn’t get the same “job satisfaction” from their daily tasks.
A sentiment expressed by many of the neurologists I worked with is that one of the best things about neurology is the intellectual challenge of the physical exam and the localization of disease. Every demonstration of these principles seemed to brighten up the neurology residents during table rounds. Thinking about the beauty of the problem appeared to be enough.
As much as I love the evidence-based medicine that neurologists respect, I think that I don’t love data or elegant proofs in and of themselves without an actionable end. Part of my personality drives me to believe that the means justify the ends, and I am driven crazy when I realize that sometimes there isn’t much of an “end” (i.e. 3 weeks or 3 months of aspirin after a stroke? No one actually knows). In neurology, there seems to be so much emphasis on the means. I know that fortune cookies and wiser men say that it’s the journey that matters, not the destination, but as I stand during the 3rd hour of rounds, I can’t help but think that I went into medicine because I want to help patients reach a destination. In contrast, I petulantly imagine that it didn’t seem to matter all that much to a patient’s next stroke how long I thought about putting him on dual antiplatelets and yet here I was again, mentally mastrubating through decades old data.
I know it isn’t this simple because people have some flexibility to construct their own careers and job descriptions change over time, but given limited information, these observations are all I have. They are certainly not objective because they are too often contaminated by my own visceral reactions (maybe it wasn’t an hour long debate on antiplatelets but it sure felt like all morning). But I have some confidence in these observations and think that they do represent broad trends. So this is how I’ve decided to think about the specialties I’ve rotated in and about how to pick a field, but I wish there was more data on this. A search of pubmed reviews far more papers on “burnout” than on predictors of “job satisfaction” in different specialties. Unfortunately, these papers are mostly survey studies that reveal information that might seem obvious: physicians are burned out because of large patient loads, long work hours, too much paperwork; physicians enjoy some control over schedule and hours worked.
I guess that is the entire point of the third year experience and what makes it so frustrating at times. We are set loose to not only learn about each field (very briefly so that lay people won’t be any the wiser that going to medical school does not imbue anybody with many hard skills to ail suffering), but more importantly for us to draw our own understanding of what makes us happy, and how we can find a field where we can find others who are excited about the same part of patient care. My friend who wants to go into radiology is most excited about the diagnostics and the technology and the more definitive “physical exam” provided by the CT scans. I prefer to diagnose things that I can quickly fix – with meds, with my hands. When we entered medical school, we all said that 1) we love science (or social science?) and 2) we want to help people, so 1+2 means that medicine will be a great fit. But the real equation is so much more complicated than that, and no one has all the data but we have one year to collect some circumstantial evidence for ourselves, about ourselves.
Sometimes the data is troubling. In a prior post, I wrote about my frustration with not having seen death. Two weeks ago, I had a lovely patient who used to looked around the room of doctors in the morning and ask for “my T”. She died, arguably a few weeks or months too early, because the team was too curious about her diagnosis – some of the attendings were certain that she had an untreatable brain disease but others thought that there was still a small chance that it was something else as the lab results for our leading diagnosis came back negative. Her baseline health was poor and we knew that there was a chance that she wouldn’t tolerate a brain biopsy. As a neurology team though, it was hard for us to weigh all the risks of the procedure and the anesthesia against our thirst to know what was causing her mysterious imaging findings. Maybe no one could have been able to say with confidence that she, with her past CABG and 5 cardiac stents, would go into respiratory failure after the procedure. But a part of me thinks that we all knew that her chances of tolerating the brain biopsy were worse than the slim chance that she did not have progressive, terminal diagnosis. Four days after her biopsy, her family made her “comfort measures only” and she was extubated and all nutrition was stopped. Five days afterwards, I visited her in the ICU and saw her family gathered around her – they smiled as I mumbled that their mother was a special person. “We know,” her daughter said softly after a solemn pause, and I blushed and left them to their vigil. Seven days afterwards, I thought about checking in her medical records to see whether she had passed away when a small thought wormed itself into my head: what does it matter? I mean, wasn’t it all over as soon as we put her under for her biopsy? I quashed this thought with shame but this made me think of how harshly I had judged my neurology colleagues. I had to admit there were times when thinking about the problem, and about the patient, is about all we can do. I am thankful that there are people in medicine who are constantly thinking about the less actionable items that I so dislike and, hopefully, finding some job satisfaction.