last updated: Thursday, November 6, 2008
first posted: Sunday, April 20, 2008
Choosing my medical specialty
I’ve been meaning to write some more about how I chose my
field in medicine, and what residency I’ll be starting in
June, but I’ve been a little hesitant to start, since it’s
a long story and I don’t think I’ve got enough time or
patience to sit down and spend hours and hours writing
about it. To solve that problem, I’ve decided to just start
writing from the beginning and will continue in
installments if I don’t get to finish in one post.
Okay, I'll be back later. Just kidding. Here’s some
background information:
I actually didn’t know what field I wanted to go into when
I started medical school. As a youth, if someone ever asked
me what kind of doctor I’d want to be if I ever became one,
I’d always say A pediatrician, because I like
children. Those who know better know there is a big
difference between liking children, and caring for
ill children, so that was a pretty uninformed
statement.
In high school, I really enjoyed activities like drafting,
needle crafts (knitting and sewing), and tinkering with
tiny tools and toys (taking apart watches and fiddling with
the gears, for example). I loved arts and crafts but wasn’t
particularly talented, and had a knack for languages and
math. I was pretty meticulous as a student, and was one of
those annoying people who liked to have everything neat and
organized (I suppose I still am, but this has become quite
a bit more difficult).
Sports-wise, I was a swimmer and a softball player early on
in elementary school, competing in the latter sport through
part of high school (and played in club softball in
college). Ninety percent of the time, I pitched, and the
rest of the time was pretty much split between shortstop or
second base. I also dabbled a bit in track and field during
junior high, running relay and competing in shot put. In
high school, I also picked up a tennis racquet for the
first time during sophomore year, eventually getting to
play on the varsity team during my senior year. Other than
taking swimming lessons within elementary school and during
the summers between those years, I didn’t have any other
formal lessons in sports or anything else for that matter.
I would have loved to take piano lessons or some other
music class, but that pretty much didn’t make the family
budget, nor was it something my father felt strongly about
(he was practical, and swimming lessons would keep us from
drowning; music lessons on the other hand, were not what he
would consider useful). It’s kind of a cultural thing – I
don’t think anyone took music classes where he grew up.
I guess the point of all this background information is to
try to see if I can come up with any signs of an early
preference for a particular field in medicine. I suppose
that my meticulous nature and interest in tinkering with
small parts sort of pointed me in the direction of some
sort of surgical field, which wouldn't have been a bad
guess back then if you had to bet money on which field I'd
go into. But it's actually way more complicated than that,
at least that's what I realized in the last year or so.
***
I started as a math major in college, but switched to
neurobiology and behavior in my junior year when I started
feeling like I wanted to study something a little more
broad, particularly in development and biology. I think I
had been sticking with math for so long since it was
something that made sense to me and that I was reasonably
good at. But once I started getting into the upper-level
math courses where number theory came into play and
suddenly 1+1 wasn’t always 2 anymore, I opted to try my
hand at something new. Math had always been an exact
science in my mind, and I kind of wanted to keep it that
way (silly, I know). I think I was also a little
intimidated by the lack of (or severe shortage) of women in
my field. And those upper level math folks were truly
something, and I really had to spin my wheels to keep up
with them.
In any case, I found myself being drawn to behavioral
science and neurobiology. I really enjoyed my introductory
psychology classes (I think most people did) and I took
some courses in developmental biology. I also worked in a
campus daycare (I participated in work-study throughout all
four years), and really enjoyed learning about child
development. During the summer between junior and senior
year, I spent several weeks as an extern at a major
children’s hospital in California (generously mentored by
an alumnus from my college), and decided that I’d consider
applying to medical school. At that point, I still hadn’t
completed all my prerequisites, nor had I taken the MCAT,
so I decided to take some time off after graduating to get
things in order, as well as pay off some of my school
loans.
To make a long story short(er), I worked in biotech and
then did neuroendocrine research before starting medical
school (you can read more about my application to medical
school here). I had
multiple jobs (at least four at one point, one of them
full-time), nearly paid off all my loans from college,
and helped my folks with their finances as well. When
I started medical school, I really didn’t have any
idea what field I wanted to go into, and decided I was
going to be “undeclared.” And I stayed that way for
nearly 2 years, when I finally decided that I needed
to at least make what most people advised as a
starting decision – surgery vs. medicine.
***
As part of my neuroendocrine research, I learned how to do
some stereotactic microsurgery (brain and vascular), which
I loved. It was very calming to spend a whole afternoon
performing these surgeries, and I really enjoyed trying to
come up with ways to improve the procedures and help with
recovery of my tiny rodent patients. After my mentor showed
me a couple of surgeries, I pretty much performed most of
the procedures in the lab for the next two years (I had
other duties of course, but this was one of my favorites).
Something about the tiny tools and meticulous details
really appealed to me. I was cannulating vessels that were
about 1 millimeter in diameter, and had to locate brain
locations to precise measurements, fractions of
millimeters. It was fascinating and I really enjoyed the
work.
Interestingly, it didn’t occur to me at that time that I
should pursue a career in surgery. For some reason, I kept
my research and medical goals separate in my mind, not ever
speculating (until my second year of school) on where I
should focus my goals. As I mentioned in my last post, I
decided to start by trying to identify whether I fit into
either one of the two commonly proposed paths (surgery vs.
medicine).
Of course, I had no idea how to go about doing this. The
medical school preclinical curriculum didn’t give me much
breadth into the vast number of specialties in medicine. I
didn’t have much of any idea what I wanted to go into. If
you forced me to try and pick something, I would have
possibly said “hand surgery” based off of one conversation
I had with a hand surgery fellow during one of my weekly
introductory clinical medicine sessions. Actually, now that
I think about it, my group attending was a retired general
surgeon, who was a phenomenal teacher. He taught me
everything I know about how to take a good history, as well
as appropriate bedside manner, which is kind of funny since
general surgeons aren’t often regarded as the best when it
comes to either of those two things.
In any case, it didn’t really occur to me when I started
medical school that I should consider surgery from the
start – I really wanted to keep an open mind.
***
Figuring I just needed to dive in and try something, I
decided to take a stab (no pun intended) at the world of
surgery. As a pre-clinical medical student, I never really
heard many positive things about surgery – the field is
widely portrayed in a very negative way. No time for family
or personal life, long work hours, terrible personalities
driven by ego – not a winning endorsement by any means.
So why did I decide to check out surgery first? My
reasoning was that I should see what it was all about, and
that I’d probably find out very quickly that I hated it,
and then I could cross it off my list and focus on
something else. Narrowing my decision choices would make it
easier to figure out what I wanted to do, or so I thought.
I’ve always been someone who is pretty much up for
anything, so it was actually hard for me to hone in on
something that I really wanted to pursue. It was much
easier to try to find out what I really didn’t like, and
choose by elimination. Whether or not this was a good way
to go about choosing a specialty (probably not the greatest
method), it was at least a start.
I started by meeting with my advisor. Let me point out that
while I really think my (appointed) advisor is a good
person, I never really felt like he really helped to guide
me and give me options. We had good discussions (which
probably helped in the sense that I could talk through
ideas with him) but I just felt like he was a bit out of
tune with either what was available to me, or my
indecisiveness, or both. In any case, after our
discussions, I figured there really wasn’t going to be any
easy way to get involved (I didn’t have any personal
contacts in the field, nor did I really know any
professionally either), so I ultimately decided to just to
start from the top.
***
I emailed the Chair of the Department of Surgery. In my
email, I wrote about how I was trying to decide what field
to go into and that I might be interested in surgery or a
surgical field. Fortunately, he was very enthusiastic about
medical students who were interested in surgery and agreed
to meet with me to discuss options. We chatted about what
kinds of things I was interested in and I honed in on two
subspecialties I found particularly fascinating – hand
surgery and pediatric surgery.
After a bit more discussion, I contacted the residency
director of the plastic surgery program at my school, who
was also a hand specialist. I knew that hand surgery was
pretty broad and could be done via various pathways. The
three most commonly known paths are through plastic
surgery, orthopedic surgery, and general surgery. These
days, it is less common (and not ideal) to go into hand
surgery through general surgery, so I decided to look into
orthopedic surgery and plastic surgery. Given my background
and interest in microsurgery, it seemed as though plastic
surgery was a better fit. I tried to imagine the types of
surgeries I would be performing, and in general, found that
I preferred working with free flaps and neurovascular
bundles than bones and joints.
The residency director and I chatted about my research
experience and gave me information about his own laboratory
and projects. He also gave me the names of other students
who have worked with him. All in all, it was a good
start.
***
I
decided to join his lab and worked part-time in his lab
over the next year and a half or so (while I was a full
time preclinical student) on a project that involved
microarrays and immunohistochemistry. Basic science
research is generally regarded as a plus in terms of being
a competitive applicant for plastic surgery residency
spots. My project was small, but perfectly sized for an
inexperienced medical student. Actually, I had some
background in immunohistochemistry from my previous years
in research before medical school, so at least I wasn’t
totally lost.
It was tough balancing preclinical classes and working in
the lab. I spent much of my spare time there (this was
obviously started before I had children) and spent many
weekends and late nights in the lab as well. Part of my
project involved surgical sample collection and timely
tissue processing, so I made sure to be available in the
operating room every Friday morning to collect data. In
addition, I had an open invitation to observe and operate
with my now research advisor, which was usually at 7am on
Thursdays.
We actually decided to try for a baby soon after I started
working in the lab, and I actually spent much of my
pregnancy on this schedule. Looking back, I think it was a
bit much (and I’m not even sure I could do it again), but I
guess that’s all in the past now. After my son was born, I
took a break from the lab for a few months (but I was still
going to school full-time; more about this story later) and
started finishing up the project in the spring before
starting on the wards (when I was also trying to study for
the board exams). That period of time was hectic – it was
late spring and we had not yet gotten off the wait list for
full-time daycare and I was frantically trying to finish my
research. I had submitted an abstract for a poster at a
major plastic surgery conference, and to my complete
surprise and horror, had it accepted as a talk instead. If
any one is interested in hearing about that, I’ve got lots
to share – but for now, I will try to focus on how I chose
my specialty.
***
So, to the meat of the matter, and the whole reason why I
started this post. How did I end up choosing? Well, I
thought about each rotation I had done and eliminated ones
that I either didn’t like, or didn’t like enough to make my
top five list.
First, I eliminated Internal Medicine. I
actually thought this would be something I would like,
since it basically encompasses most of what we were
taught in medical school. But I had such a negative
experience on this rotation people-wise, that it
completely turned me off to the whole field. Obviously
I realize that you can’t judge a whole field by just a
couple of bad seeds, but I think it was so
traumatizing that I could never look at it in a
positive light again, unless I did another rotation
somewhere else and loved it more than anything (which
I highly doubted would happen, since I had some pretty
good contenders in my top five already).
So, why was my medicine rotation so terrible?
I think a lot of experiences on the wards are very
circumstantial. The people on your team (as well as the
people you interact with) and the schedule that you get can
be quite random and uncontrollable. And while one student
may have had the best experience ever, another might have
wanted to quit medical school after the experience they had
on the very same rotation. It’s too bad - despite what you
think you are interested in (or not interested in), an
enthusiastic teacher or an uninspiring one can make or
break all that. I guess it works both ways though, since
often times you’ll be exposed to something you never
thought you’d like (but end up loving) just because you had
the good fortune of meeting someone who inspired you to
want to be just like them.
It was my very first rotation as a clinical student, and
while I had a pretty good first month at one site, my
second month was, in my mind, a disaster. Looking back, I
think it was a reality check that clearly showed how
doctors do not necessarily make good teachers. In fact,
most of the time, I really felt that was the case.
***
I really enjoyed my general surgery and
ob/gyn
rotations, as well as my pediatrics rotation. In fact,
for the most part (and with the exception of internal medicine), I
pretty much liked all of my rotations.
My research, however, was basic science work in plastic
surgery. I really liked hand surgery. Hand anatomy made
sense to me, and I really liked microsurgery. In addition,
I liked the fact that hand pathology wasn’t usually
life-threatening, and the improvement of function could be
quite significant. And in more minor details, hand surgeons
generally liked to sit down while operating, and because of
tourniquets, the surgeries were not very bloody. It’s not
that I get queasy at the sight of blood – it’s just nice to
have a clear surgical field when you are trying to operate.
So that was my working plan for the end of my preclinical
years and the beginning of my clinical years. I knew it was
going to be an uphill battle, since plastic surgery
residency spots were extremely competitive (fewer than 80
positions each year), and the training could be pretty
brutal. While hand injuries aren’t usually life
threatening, they do often happen at all hours of the day
and night. Vehicle trauma, work-related injuries, you name
it. So I knew the calls were going to be horrendous. And
most plastic surgery programs were 6 or 7 years long, and
then a hand fellowship was another two more. It was going
to be a long road.
With that in mind, as I was nearing the application
process, I knew I needed to figure out if that was indeed
what I wanted to do, and at the cost that it was going to
be. I had been quite involved in all things surgical during
my medical school years. I had led the student surgical
interest group for two years. I knew the Chair (and he knew
me) as well as a lot of other influential people in the
Department of Surgery at my school. I didn’t know that many
people in the Department of Plastic Surgery, but I knew a
few who really mattered, including the person whose lab I
had worked in. I had the rare opportunity (at least as a
medical student) to present at a major plastics conference
and published first-authorship basic science research in a
reputable journal. Everything was lined up just right for
me to at least match somewhere (the thing about applying
into plastics is that you really can’t guarantee where
you’ll end up), which is not always easy to say. Fifty
percent of people do not match. And while I was worried
that I could go unmatched, I think for the most part we
didn’t think that was going to happen. Rather, it was more
likely we’d have to move to a more remote part of the
country.
***
I thought about other options that might be more flexible
in terms of location. Statistically, I had a pretty good
chance of matching to one of my top choices if I applied
into a general surgery program, and then I could consider
pediatric surgery or plastic surgery through the
traditional route from there. But that meant at least 9
more years of training and I wasn’t so sure that was going
to be my best option. In 9 years, my kids would be 12 and
10 years old. And it wasn’t that I minded becoming an
attending at that time – it was more that I would be
extraordinarily busy for the majority of their childhood.
At twelve, I might only have a few years (if that) before
my kids would probably stop wanting to hang around me very
much anymore.
So, it was a dilemma. I knew when we had kids that I would
constantly have to make decisions concerning work vs.
family. In general, I think that during medical school, I
was able to devote to both equally (which often felt like I
was doing a mediocre job at both). But that was really only
a temporary solution, since it wasn’t always ideal.
My husband had always said that he thought I’d make a great
surgeon and that he’d be happy being the primary parent in
our household. Of course, that was much easier said than
done, and I found that at the end of my more demanding
rotations, he was just as burnt out as I was.
Over my clinical years, I started noticing a pattern to the
workings of our household. Whenever I was on an easy month,
things ran smoothly and everyone seemed to be quite
content. When I was on busy rotations, we argued more and
everyone ended up being on edge toward the end of the
month. We had a burnout time limit of about 6 weeks, which
really worried me since residency was going to be at least
forty times as long and every bit as hard if not more so.
Additionally, there were aspects of a career in surgery
that I wasn’t thrilled about either. Besides the long
hours, I was also sensitive to the fact that surgery is
generally not considered to be one of the friendlier
specialties. And while there are always abrasive
personalities in medicine, there do seem to be more in
surgery.
I sought advice from lots of people. I asked everyone I
encountered about how they picked their field and if they
wished they had done anything differently. Some told me
that the people really mattered. Some told me they didn’t
and that I should just pick what I love to do (these tended
to be surgeons). As a side note, the funny thing about
soliciting advice is that as long as you ask enough people,
you will probably get all possible answers. I wasn’t sure
if I was looking for confirmation of what I already knew or
if I just wanted someone to make the decision for
me.
***
When it comes to making decisions, I’m the kind of person
who tends to obsess about the possibilities. I often wish I
could make decisions based on gut instinct, and be right
most of the time, like many people I know are able to do.
My hunch is that if I went with my gut instinct, it would
be the right decision for me most of the time. And yet I
still obsess. I had classmates who were in similar
situations, and made lots of detailed charts, graphs and
lists to help them make a decision (I’m not that
meticulous). Granted, many of these decisions were
regarding where to rank their number one choice for the
residency match rather than what to apply in, but the point
is that students often tend to agonize over their choices.
Often times, I find that many people like to create
uncertainty where there isn’t any (myself included). We all
know someone who has come to us for advice, offering their
pros and cons for each side, when in fact the best decision
is pretty clear. I wanted to find such clarity in my
dilemma too.
I did a lot of soul-searching and really sat down and
thought. Many late nights I spent sitting and thinking
about what I should do. It wasn’t easy and even now, nearly
a third into my intern year, I still occasionally wonder if
I made the right decision. But deep down inside, I’m pretty
sure I did.
What became pretty clear to me was how important each of
the components of my dilemma was to me. And really, this
came down to my career choices and my family. It’s actually
a lot more complicated than this and some would argue that
it’s not fair to pit one against the other, but in reality,
these two entities are often in opposition regardless of
career choice. And unfortunately, medicine is not really a
place where you can merge the two and make a happy medium
(at least not when you have to include residency training
and potentially fellowship into the equation). Many people
told me that you have to look beyond training, because that
period of time during residency is finite. And while I
understand that point, I don’t feel it’s fair to discount
that whole period of time, since it pretty much runs
through a prime period in my life. Sure, as an attending in
any field, I can probably have a more flexible schedule,
but I can’t just pretend that working eighty hours each
week for three to potentially nine years of training
wouldn’t count as a cost. Let’s just say I became an
attending in six years. My kids would be 10 and 8 when I
finished training and became an attending. That’s just a
step away from them growing up to be young teens and
adults, and then they move away and start their own
independent lives. Of course, I’m being dramatic, but these
last four years have gone by so quickly that I sometimes
wish they could be little newborns again.
I am not saying that length of residency determined my
career choice alone, but I’ll be honest and say that it
played a role. Unfortunately for me, my top choices for
residency didn’t include the “lifestyle” specialties (ROAD
= radiology, ophthalmology, anesthesiology, dermatology).
Believe me, I tried hard as a student to want to enjoy them
as career choices, but they just weren’t right for me. In
fact, many specialties exist where the call schedule
significantly lightens up after one year (I have a friend
who only has call once a week as an intern and won’t have
any more call after this year). But my top choices were all
in what I’d consider primary care or a surgical
subspecialty. I liked (in no particular order) Obstetrics
and Gynecology, General Surgery, Plastic Surgery, Pediatric
Surgery, and Pediatrics. Nothing in that line-up is
particularly well-known for being family-friendly. And none
of those have cushy residency training
programs.
***
Now that I had my “top five,” I started getting down to
business. I scheduled a couple of sub-intern rotations and
electives that would hopefully give me a better idea about
what I wanted to do. Looking back, I now feel that even
those experiences are pretty random, and it’s probably no
best to make a snap decision based on one rotation.
Actually, if that were the case, I wouldn’t be in the
program I am in now.
I first revisited hand surgery. I did an elective, which
was run by both the Plastic Surgery and Orthopedic Surgery
Departments. It was hard work. Lots of overnight trauma
(paint gun injuries, chainsaw injuries, SUV rollover
injuries). And my research advisor – well it just so
happens that he was now the chief of the department. He was
very well known in his field and widely respected. And for
the most part, I think he liked me – however there were
definitely times when I thought otherwise. He is probably
one of the most meticulous people I know, and someone I
would have no second thoughts about recommending as a
surgeon. Having seen him operate, I realized how much
attention he paid to the tiniest of details, chastising
residents who were rushing through because he really
expected perfection. Of course, it’s hard to meet such
expectations, but I tend to agree with over-training
someone so that when they develop their own style, they’ll
have all the necessary tools to understand what they should
and should not do. He was definitely talked about as being
very hard on his residents, but at the same time, he had
their respect. I have mixed feelings about this of course,
since I do feel that a more sympathetic method of teaching
can also be beneficial. After talking to more people, I
realized he was sort of like a really strict father up
front, but was the kind of guy who gushes about how proud
he is of his kids to other people. This came up once when I
lamented to a resident that I thought my attending didn’t
like me because I was so slow to finish writing up my paper
(and had mentioned that to me). This resident exclaimed
Are you kidding? Do you know what he says to us? He
always bugs the residents about time management, saying he
has a med student who had two kids in school and is now
giving an oral presentation the major research
conference!
I do often wish that I had the wherewithal to have gone
straight to medical school right after college. I might
have had more flexibility in terms of what I wanted to
pursue and when I wanted to have kids. If I had picked a
training program that was only three years, I might have
been able to wait until I was an attending to have kids.
I’m not sure if that would have been better though, or if I
would just find myself in a different dilemma, as someone
who had planned to do fellowship but was having second
thoughts because of family planning issues.
I have a really good friend from medical school who had an
8 and 13 year old when he started. His path was so
different from most – he pretty much lived a whole segment
of “real life” before going back to school. He had owned a
home (possibly several), worked for his own company, and
wasn’t planning on having any more children. He was
extremely bright and ended up pursing a career in
orthopedic surgery. Interestingly, despite the fact that he
was a truly stellar candidate (crazy high boards scores
too, not to mention a top notch guy), he didn’t have as
many interviews as I thought he would and ultimately went
to a smaller program out in the East Coast. I can’t help
but think that his unique circumstances and age played a
large role (he was 41 when he graduated I think).
Unfortunately, he also went through a divorce during school
as well.
I have another friend who was essentially the youngest
person in the class. He was 25 when he graduated and is
pursuing a career in neurosurgery at one of the top
training programs in the country. He’s never considered
otherwise, and prior to graduating had also just recently
starting dating someone in another medical school class.
It’ll be interesting to see how that pans out.
(to be continued)