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Wednesday, May 8, 2013

Life at Grady: Picking (or not) a specialty

Initially, I was pretty certain that I'd go into surgery. In fact, I was rather enamored by transplant surgery and had it set in my head that I would do a general surgery residency followed by a fellowship in transplantation surgery. And then, as I often told people in one altruistic breath, I would get African-Americans to sign up to be organ donors and transplant kidneys into my people. Yup.

You have to admit that it was a rather noble aspiration. At least I think it was. And honestly, my surgery rotation was the polar opposite of my first internal medicine rotation. Every surgery attending knew exactly who and where we were as students at all times. They called us by name and had expectations of us. Which, now that I recall my experience on that first month of internal medicine clerkship, I recognize as the problem. No one had any expectations of me. So I rose--or rather sunk--to that expectation.

It only made sense that my academic advisor was a female surgeon. She was kind and attentive and smart. On most days, I wanted to be her. At least, the professional version of her. And I owe it to her for noticing how much I came alive when caring for our post-operative surgical patients on the wards. She pointed out to me that surgeons get excited by the OR. In fact, they can't live without it.

And that statement led to an epiphany for me. One that made it clear that my future career would not involve twirling into sterile gowns in operating rooms.

I chose a combined residency in Internal Medicine and Pediatrics. And never looked back.

I'm reflecting on this on this early morning because many of our students are choosing specialties now. They're trying to make sense of all of it and working hard to separate the emotions connected to the specific experiences from the actual field itself. And that's hard.

The emotions I had on my Internal Medicine rotation were mostly negative. And that overpowers nearly all of my memories of that time. So very early on, I was certain that no matter what I did, it wouldn't be that. Pediatrics was a mostly okay experience and my feelings working with the pediatricians were positive. Still, I didn't necessarily feel my heart leaping at the thought of doing it exclusively for the rest of my life. Of all of those clinical experiences in third year, Surgery was, hands down, the one that I always look back upon with warm nostalgia.

See, that's dangerous, too. It's dangerous because it can lead a student down a path that isn't theirs to follow. I know this for sure because now I bend over backwards to make certain that no learner on my team EVER feels ignored. EVER. And I recognize that noticing people makes them feel good and brings out the best in them. Which can lead to very positive emotions.

When I meet with students about their career choices, I tell them, "I want you to choose the field that is best for you. So know that it's okay if you change your mind, because I did." And I say that part particularly to the ones who come to me with their sights set on Internal Medicine. Which, yes, is super awesome.

My rockstar-female-surgeon advisor gave me some good advice that changed the trajectory of my career. And I'm so glad she did. In the spirit of that advice, I have come up with a list of my own that I think could greatly help students who are muddling through the emotions-versus-specialty conundrum with career choices.  I bring you:

Dr. Manning's SWEET SIXTEEN questions  for all medical students to consider when choosing (or not choosing) a specialty:

1.How do you feel about communicating with people? Do you enjoy explaining and discussing things? Do you mind challenging interactions? In other words, how do you feel about a career that involves a lot of talking?

2.When you went into the OR as a student, did you finally feel at home? Could you be okay with NOT being in an operating room? Does the thought of NOT being in an operating room make you break out in a cold sweat? Do you feel yourself longing to talk to the patient instead of cauterize their blood vessels? Are you okay with taking care of people who can't talk to you at all?

3.Do you have many, many different interests or a few interests that you spend significant time enjoying? In other words, is it more fun for you to hyperfocus on one area or broadly focus on many?

4.How do you feel about children? Particularly ones that aren't related to you? Do you see them in grocery stores with their parents and want to hold them? Are you the person who asks questions like, "How old is she?" or  "How long has he been walking?" not because they have stepped on your foot in line but because you genuinely want to know? Or do you run the other way and (though you hate to admit it) wish there was a "no kid" rule along with the no smoking rule at certain restaurants?

5.How do you feel about procedures? Do you like them? Does blood freak you out? Can you do without anything that interrupts the skin's integrity or requires a consent form?

6.Are you willing to be on call? Specifically, would you be against someone calling you on a cell phone or pager in the middle of the night because your expertise is urgently needed?
7.Do you prefer longitudinal relationships with patients or are you okay with short glimpses into the lives of many people? For example, were you constantly wondering what happened to every single person you saw on Emergency Medicine and did you often find yourself reviewing the electronic medical record long after the encounter?

8.Do you like things that get your adrenaline pumping? Does the thought of jumping from a plane or bungee-diving from a bridge make you want to vomit? Or does that make you squeal with glee? Now--translate that to a specialty. How do you feel about high-stakes, high-paced medical care? Does it excite you or overwhelm you?

9.How confident are you? Some specialties require a lot of it. Just saying.

10.How do you feel about bodily fluids? Not just blood, but all of them? Totally, completely grossed out? Or "meh"?

11.How do you feel about working with the nether regions? Oh--not clear enough? Does it completely mortify you to examine a tender testicle or to explore an agonizing anus? There is a lot of reward in making people feel better when they have problems below the waist line--but it ain't for everyone.

12.Do you love medicine? Not Internal Medicine, per say, just . . . medicine? Do you feel like it is what you were meant to do? Like, if you won the lottery and you were fully trained, would you go in to see patients the next day? Or would you give the office and hospital the middle finger?

13.After answering number 12, ask yourself this: How hard are you willing to work? Is it your expectation to be gone every single day by 2 PM? Are you (though you hate to admit it) kind of lazy? Or is your mantra "go hard or go home?"

14.Are you okay with fields that involve high incidences of death? Are you okay with managing problems for which there is no known cure to date?

15.How do you feel about research? How do you feel about teaching? For each of those things on a scale of one to ten for "OMG-yes-I-love-it"-ness, what would you give them?Also, how do you feel about practicing in rural or international settings? Apply that scale to that as well for both of those settings.

16.How do you feel about taking care of poor people? How do you feel about taking care of rich people? How do feel about taking care of very, very poor people? How do you feel about taking care of very, very rich people? (These are things you ask yourself and answer to yourself only.)

Oh, and you probably noticed the absence of the money-slash-earning potential questions on this list. My feeling is that, in general, all physicians make "good money." Now. How you define "good money" is personal. It's up to you to decide whether or not that will be factored into what you do. It wasn't a consideration for me, but I acknowledge that that's just me. I don't judge anyone who feels differently because at the end of the day, all anyone can be is happy.

Now. After exploring these sixteen questions (which YES, I KNOW were far more than sixteen)-- you will find that voila! Some work environments and specialties will be narrowed down, nixed or frontrunners for you as a result. Next, schedule a meeting with a trusted advisor to help you explore this more. The key is to tease the emotion away from the "real" parts. And yes, the emotions could be because of things on that list of questions, but you just want to be sure that --good, bad or indifferent --it isn't because of. . . . . well. . . people or a person.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from "Reflections of a Grady Doctor," Dr. Manning's blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals' privacy.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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