Final Rambling Conversation With a Lumbering Asian-Bear Mammal

Ever considered any other specialties?

Sure. Everyone does. It is the rare person who arrives at medical school with his future planned to the last detail. Even people who, perhaps through prior work or shadowing experience, arrive with an overwhelming desire for one particular specialty usually change their minds. Orthopedic surgery, as an example, is a specialty which seems so appealing to many first year medical students that it seems half your class plans on matching into it. Once they see the level of commitment required as well as the lifestyle of the residents most decide that their passion was actually a polite interest and match into something else.

I’m sure, for that matter, that everybody has an occasional bad day where the prospect of working at a specialty like Radiology, one with minimal patient contact, can seem very appealing. Now, I know that radiologists can see patients in some settings but if you divide the medical profession into those whose job requires them to routinely stick a finger in a patient’s rectum and those who don’t, radiology is the king of the non-probing careers.

You have to make up your mind about a specialty much sooner than many believe for the simple reason that some are fairly competetive and, all other things being equal, the the guy with the highest board scores is going to land one of the few highly coveted dermatology residency positions. This means that if you are even thinking about dermatology, otolaryngology, urology, or radiology you need to start studying hard from day one and get both excellent grades and exceptional board scores. Are there exception to this rule? Sure there are. I will no doubt be innundated with comments from people relating how a friend of a friend of somebody’s brother matched into dermatology at the bottom of his class after having taken Step 1 twice for failing it the first time.

I also know a guy who was struck by lightning. Spare me.

Let me state Panda’s Axiom Number 1: At the beginning of medical school, and allowing for the questionable admission who managed to matriculate through a combination of luck, computer error, and bureaucratic inertia, any medical student can match into any specialty. Medical school is not hard per se but merely long and tedious. Because (with the aforementioned exception) medical students are drawn from the top one percent of the population for intelligence, there is nothing keeping anybody in your class from being a neurosurgeon except the desire and the willingness to work for it. However, as there is a good deal of self-selection out of potential medical specialties, medical students tend (tend, damn it!) to tailor their efforts towards the level of competitiveness of the specialties that they feel would both interest them and for which they believe they have a reasonable shot with their study habits. I knew early on that I was not destined for a career in neurosurgery both because I had no interest in it and because the amount of work required to get excellent grades was more than I was willing to give. It’s mostly as simple as that.

I will confess my great ignorance when I was applying to medical school about the structure of the medical profesion. I had only a vague idea what specialties where available let alone an idea of what I wanted to do except the nebulous notion that I would end up in internal medicine or family practice. True to pre-med form, the salaries that these specialties promised, salaries that I would view as a personal failure today (see my adventures in Family Practice as detailed in previous articles), seemed a princely sum for a mere seven years of training. We underestimated, you understand, the amount of debt and exactly what it was we were getting into. I didn’t even know that Emergency Medicine was a distinct specialty and never even considered it until the end of third year when, one by one, I decided against every specialty in which I rotated.

Sometimes it’s a process of elimnation.

So what specialties were you sure you wouldn’t do?

Surgery, for one. I admire and respect surgeons but after two months of my third year surgery rotation any small desire to be a surgeon that I may have ever had was beaten out of me. Sure, it’s a cool specialty, perhaps the coolest of the bunch as it combines medicine with dramatic interventions but after seeing how the surgery residents were treated, not only by their attendings but by each other, I said, with gusto, no mas.

Surgeons eat their own. It’s part of their culture to treat each other disrespectfully during training. Whether this is necessary to train a surgeon cannot be known. It’s just the way the system has evolved and it seems to be structured to keep residents perpetually tired and irritated at everyone and everything. If I ask a neurology resident for his opinion on a patient, I will generally have a friendly conversation where he will impart not only his opinion but a little bit of knowledge which is commonplace to him but perhaps new to me. If I ask a surgery resident I am likely to get rolled eyes, condescension, and the not-so-subtle impression that I am an idiot for not knowing as much about abdominal surgery as I’m supposed to. This attitude is extended to their own subordinates. The mistreatment of surgical interns is legendary and if you see some unhappy miserable fellow skulking around the hospital he is probably one of theirs.

So you’re saying that surgery programs are malignant?

Residency programs are often labled as malignant but there is more to it than working long hours and pulling a lot of call. An important feature is how the residents treat each other. In my program, if an intern asks me for some guidance or help with a procedure I don’t cop an attitude and get snotty as I have often both seen and experienced while on surgery rotations. We do not hold it against somebody that they don’t know something and as long as they’re not asking stupid or repetitive questions, they deserve respectful consideration. To berate someone for not knowing something, to throw him to the wolves, so to speak, as appears common in surgery programs is to act contrary to the spirit of residency training which I am told is ideally supposed to be some kind of multi-orgasmic Socratic interlude.

Apparently, many surgery interns are so tired and beat down after the first few weeks of residency that they lose the ability to be civil even to each other. As the years go by they build up a stock of resentment and perpetuate the malignant tradition because it is human nature to validate our own suffering by making others suffer. It takes leadership to break this cycle and as medical schools neither select for nor make any particular effort to instill leadership, you basically have a bunch of people in charge of subordinates for the first time in their lives who haven’t a clue what to do.

Come on now. Isn’t “Leadership” heavily stressed by medical school admission committess?

Leadership is a buzzword, nothing more. Most extracurricular activities are really hobbies in which no one is really in charge of anything. In other words, if your decisions have no consequences for anyone, and show me an extracurricular activity where the participants had anything important at stake, you are not a leader but an enthusiastic participant.

As for other specialties, I decided against OB-Gyn pretty early. It’s a decent specialty but the hours and lifestyle, even after residency, are ridiculous. The only attendings in a hospital at all hours of the day and night are the Emergency Medicine attendings and the obstetricians. But the EM guys are working shifts. The obstetrician has a day job to which he must go after staying up all night delivering babies. Like pediatrics (which suffers from low pay), OB-Gyn almost has to be a calling. You can be a Family Physician or an internist and treat it like a nine-to-five job but you have to love your specialty to be happy as an obstetrician.

Not to mention that they get sued like nobody’s business which has to hurt, especially when some of the mothers suing for bad outcomes smoke, drink, do drugs, and otherwise take no responsibility at all for their contribution to the outcome. Obstetricians are doctors, not miracle workers. Bad protoplasm combined with ignorance is a deadly combination for babies, both in and ex-utero.

I never considered pediatrics. Having my own children has given me a running start at disliking other people’s children so I just don’t have the temperament for private pediatric practice. We see pediatric patients in the Emergency Department but the focus is more on making sure they have no serious illnesses than building a relationship with the parents, something that is essential for private practice pediatricians. To be honest, many of the parents we see are totally unsuited to raise hamsters let alone children and it makes my blood run cold just thinking about it. Unfortunately, the predominantly single polybabydadic mothers who we see, themselves the third or fourth generation of teenage single mothers, haven’t a clue about good parenting. Parenting skills have to be taught and there is a huge knowledge gap which is getting larger every generation.

I’m talking basic stuff like how to roast a chicken and cook up a mess o’ greens instead of raising the little bastards on Froot Loops and Pop-Tarts.

My favorite lie is the insistence that, despite their sociopathic son having gone on a crime spree often involving murder and rape, everybody is a good parent and it is some random act of nature that makes some children into criminals.

Anything you don’t like about Emergency Medicine?

Naw. It’s pretty cool. But I am early in my career and sometimes it’s hard to separate the trials and tribulations of residency from the specialty. As you know, I am a new second year resident so I still get a lot of guidance from our attendings. This is both necessary and appreciated (and we have stellar attendings at my program including some of the pioneers of Emergency Medicine) but I can sense that I will enjoy my job a lot more on that day when I become an attending myself and am granted the double-edged sword of complete responsibility. One of the worst aspects of residency (but necessary, I repeat) is the constant supervision and criticism. Compound this with a work environment where everybody from the janitor to the patient to the attending has a front-row seat to our screw-ups and you can see that working as a resident in the Emergency Department can be like being in a pressure cooker.

The things that many people cite as reasons to dislike Emergency Medicine are actually part of the appeal of the field to me. My creationist friends would love our specialty because we prove Darwin wrong every day. Survival of the fittest my ass.

Any advice to people considering a career in medicine?

My whole blog. Other than that I’d think about it carefully and try to get beyond the undeniable coolness factor of the profession. It’s a hard road and maybe you won’t like it. Hell, you won’t like a lot of it. My wife once explained to me why a lot of marriages don’t work, namely that the person you are attracted to when you are 18 is not necessarily the same kind of person you will be attracted to when you are thirty. It’s kind of the same in medicine. Because of the convoluted admission process, most people have to commit to a medical career shortly after high-school. But you are going to be a different person when you are in your early thirties and finally finished with training.

There are, in fact, other perfectly decent careers out there to which you may find yourself better suited. I highly recommend both the military and engineering which I know from personal experience to be both honorable and useful and neither of which require anything close to the training time. As for other medical careers, I guess we’re supposed to spout the conventional wisdom that being some kind of mid-level providor is just as good as being a physician but I won’t because I don’t believe it. Personally, and this is one of the few times you will hear me issue a caveat, personally, meaning me personally and not you, the idea of being anything other than a physician never occured to me. If you strip away the scope and responsibility of being a physician it’s just a trade, not a profession, and I would have as soon stayed in engineering.

20 thoughts on “Final Rambling Conversation With a Lumbering Asian-Bear Mammal

  1. I’ve lurked here for a long time. Usually not a big contributor, but today I need to give you an apology in advance: I’ll be appropriating the term “polybabydadic” from today forward. Frequently. I’ll cite your blog, of course.

    Keep up the great work!

  2. This post was good, no doubt, but it wasn’t nearly long enough. I’m trying to procrastinate here. Help me out, will ya?

  3. “Unsuited to raise hamsters, let alone children . . .” Heck yeah. I’m just thinking about one of the newborns I had on peds who was abandoned by mom for 3 weeks. I too will be incorporating ‘polybabydadic’ into my vocabulary.

    Excellent post. As an aspiring EM physician, I would love to hear some of the questions I should be asking on my residency search.

  4. And the best part of graduating from a General Surgery residency is that you’ll live an only slightly less shitty lifestyle for the rest of your professional life.

  5. what you’re saying somehow applies to my story! I finished my internship 2 yrs ago, joined a paediatrics residency program (that i was planning to join along time ago), I couldnt stand the first 2 weeks of being on call every other day.. children screeming or crying at night and my room is just next to that.. I quit. Joined a dermatology residency program, now that i’m almost done with year 1 and almost forgot everything i studied in my medical school, I regreted joining this program. Went to see my advisor regarding joining the internal medicine residency program, he was abit upset “you have to know what you want!”, I coundt and still not sure of what I want to be honest, I’m lost. I know that i will never be a surgeon, gynecologist, or paediatrician.. however, i cant decide what do i want.

  6. Nora,

    What are you on? You got into derm and have finished a year and want to do IM? The story is hardly believable but if it is true you should check into a psych ward.

    I also couldn’t make up my mind which is part of the reason I ended up in EM but stay in your own green pasture.

  7. Hey Dr. P! I’ve been enjoying your blog for a few months now; is your plan to eventually edit your entries into a book?

    Since you chose Emergency Medicine as your specialty and not private practice, I was wondering if you will be faced with a mandatory retirement age? Or can you continue working until you’re ready for the rocking chair and the golf condo? (Sorry if that’s a naif question.)

    When I told my ophthalmologist that I planned to apply for med school next year he winced, paused, and asked “Why don’t you just chew on some barbed wire that’s been coated with hot sauce instead…?”

    Viable option?

    (Yes.  Totally viable.  The pain will only last a few hours and with proper medical care, you should make a complete recovery.  Depending on how old you are, I would give the other more painful option some serious thought.  Maybe it’s not fair asking me because I can just now see the light at the end of the tunnel but, at the risk of stirring up the usual hornets, if I knew eight years ago what I know now I might not have been so gung ho.  There is no worse feeling than to be an intern on your first rotation and realize that you have as many years ahead of you as you have behind you. At that time, for me anyways, it seemed that the clocks were running so slow that I was sure the lying devices were running backwards.

    On your other question, Emergency Medicine is usually private practice.  You work for a group that contracts with a hospital.  Some physicians have even opened up private emergency rooms which, since they don’t take medicare or medicaid are not bound by EMTALA.  I suppose it’s up to your group (of which you may be a partner) whether you can work past 65.-PB)

  8. Funny, but I trained in those bad old days of unregulated hours; not rare to be at the hospital for two straight weeks. When I was Chief Resident on the Trauma Service, I was there for two straight months. Sure, we were tired sometimes. But as opposed to the place that panda describes, we helped each other out. Residents senior to me, and then I when I was senior, helped those below willingly and with rare exceptions, gracefully and generously. There were some attendings who were jerks, no doubt about it. But there was a kinship we trainees felt that made it more than tolerable. Just sayin’. Not all training programs, evidently, are created equal.

    (I’m not implying that they are.  And my experience is limited to the four or five surgery programs where I have rotated and even then it was as an outsider.  Still, the look of contempt on my chief resident’s face when I asked him a simple medical question at the beginning of my first surgery rotation as a third year medical student spoke volumes to me about at least his attitude which I found to bne not uncommon.-PB)

  9. I agree with Doc Schwab. Surgery residents are probably tighter than most specialties. I suppose it’s that whole “shared suffering” thing. Duplicitous, asshole residents are quickly tagged and ostracized.

    Interestingly, at my program, the medical student award for best resident teacher routinely went to a surgical resident.

    In surgery, there’s a higher degree of accountability when you’re a resident or even a med student on service. Expectations are higher. Simply showing up as a third year student, asking “what’s a whipple” will certainly earn you a condescending rolling of the eyes from the chief resident. A lot of the learning is self-motivated. We expect it out of each other. There’s no daily morning didactic session where you can learn via osmosis.

  10. “Duplicitous, asshole residents are quickly tagged and ostracized.”

    Except of course when they’re the Chief Resident, or an attending.

  11. in practice some years now. i do not know any happy surgeons. i do know plenty of happy plastic surgeons, but they are all on the cosmetic side now. ent guys seem okay too but the rest are bitter and burned.

  12. Does “final” mean “final in this series of conversations,” or “final” as in “I’m not posting anymore?”

    I ask because Bloglines encountered an error in trying to fetch the latest version of the blog feed.

    Are you done altogether, or just done with the topic. Please don’t stop blogging.

  13. I love the “self-directed” learning attitude surgery has. A friend of mine (we’re both 3rd years) is on surgery, and he doesn’t eat when he gets home. Just goes straight to bed and then wakes up and goes to work. He’s just trying to stay awake, much less memorize the history and practice of surgery in half an hour per night.

  14. the process of elimination only begins once you’re in medschool… which I’m not yet 🙁

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