Perfect Job, perfect specialty??

I remember how difficult it was for me to choose a specialty. Initially (as in before medical school), I wanted to be a dermatologist. I loved cosmetics and hair products, and as a college student I thought I'd go into some sort of 'beautifying' medical specialty.

Once in medical school they forced upon us that primary care crap tried to encourage us to consider careers in primary care. And I did...seriously. I really, really liked the idea of family practice. The doctor that sees the entire family, and watch the kids grow up, and have continuity of care, and keep the family healthy, yadda yadda yadda.

Then, I started having doubts. I met no one (even with all of this brainwashing exposure) who actually *enjoyed* family practice. It's a thankless job really. Anytime I asked a FP "do you like your job?" the response would start off "....wwweeellllll....". Not a good thing. And what followed was usually some combination of justification, hope, and regret.

So, I considered internal medicine. I guess I was stuck on this continuity of care issue, and thought that would make my practice worthwhile (you know, seeing the smiling faces of the patients I help, and eating the fresh baked muffins they'd bring with them to their office appointments to show their appreciation for my time and expertise). So, as a result of all the negative comments regarding primary care in general, I thought I would preserve my option of subspecializing (just in case the naysayers were right about primary care)...and internal medicine seemed better for that purpose than FP.

So, up until 4th year (FOURTH YEAR), I was all set to go into internal medicine. Then, in 4th year I did an elective anesthesia rotation. I thought about endless rounding that was internal medicine hospitalist care. I thought about the rushed office visits, and the lack of depth of knowledge (the "jack of all trades issue") and that kinda bothered me. What would I be doing all day as an internist? Rounding, taking call....clinic and referring? On the other hand...anesthesia pays well over $300,000 year, and you have only one patient at a time. There is no rounding, and the job is mostly low stress. And did I mention the over $300,000 yr salary??!!

I applied to BOTH internal medicine programs, AND anesthesia programs. I ranked anesthesia higher, and matched at my first choice spot. I did my prelim year in internal medicine...and off to anesthesia.

Well, I realized I hated anesthesia (at least my program sucked bigtime - which is no doubt detailed on this blog somewhere in another post). So now what do I do?

I didn't work this hard, for this long, and for this much debt to *hate* my job!!

I thought about my rotations as an intern. My ER rotation was the best. Not necessarily the most exciting specialty ever...but I just felt 'fulfilled' on that rotation. I felt healthier since I had time to get out in the sunshine on our days off. I felt disconnected (mentally and physically) with no beeper or hospital responsibilities on my time off...and the prospect of going back to work was exciting. Everyday I started with a clean plate. No inpatient ward 'rocks' or a patient that I was responsible for, yet someone else was just 'covering' for me. I enjoyed the 'we have a life' attitude of the ER residents. And I liked the fact that I could basically 'play doctor' with the patients until they became too complicated, or I became uninterested...then I could call someone else to take care of 'em.

So...I applied to EM programs (as a PGY2 anesthesia resident), AND internal medicine (in the case I didn't match in emergency medicine which was/is very competitive, I'd just finish up 2 more years in IM and be done). I guess you can say I decided on a EM career a bit late!! And even then, I *still* I wasn't completely sold...


I tell my story to demonstrate that choosing a speciality is very difficult indeed. With that said, I had a young woman send me a very thoughtful email:

I was telling my husband that I was really thinking about doing ER for the flexibility and the hours, because I'm really wanting to have kids...
...he responded by saying: I should do 'whatever I'm passionate about, no matter what the hours look like' because 'we didn't go through all of this to do something we're not passionate about'.

My Take -
Overall I think this is a very naive point of view. No, you don't wanna do something you hate. That wouldn't be fair...."after all of this time" you don't wanna go to a job everyday you *hate* (like me with anesthesia). But passion about a job.....??? I don't think that's a requirement at all, and if that's the *sole* determining factor in your specialty choice...you will be disappointed.

There is no way you'll *love*, say OB/Gyn if you cannot have your *dream life* because of it. Period. And, since being a 'part-time' OB is difficult....don't do it. It's kinda like buying a big house. Med students are basically telling themselves "you've worked hard...you deserve a mansion." So, you go buy a mansion....you're passionate about the house, and love the house....but after working 2-5 years around the clock, and never really having the opportunity to appreciate the home (or any other aspect of your life), you realize that you're just a slave to this house. Working to pay the mortgage....

...and you realize that you would be happier in a smaller house so you can work less and enjoy your life (and the small house) more. So, instead of finding joy swimming in your personal Olympic sized pool at your mansion (which you never had time to do anyway b/c you were working all the time)....you instead find joy swimming in the pool at the sports club you're a member of....and you actually have time to go and enjoy it.

Do you just absolutely LOVE your little house....??? Not necessarily. But, do you love your life...and the time this smaller home allows you to have free? Absolutely.

Do what you love. Love what you do!!


I don't like the lack of continuity with patients. I don't like not building relationships with families. I don't like the way it is in general...

My take -
I was very idealistic...."I wanna help people and build a relationship with them....". But, honestly, medicine isn't like that for most of us. Ask around...I think you'll find (I'm sure you'll find) that the *concept* of continuity of care is attractive, but the *practice* of continuity of care...sucks. You'll realize that, in your family medicine practice, you'll never see your "well patients" (the nice ones that do what you tell 'em to do...because they aren't sick frequently). And with all of your patients (in order to make a living) you can only spend 10-15 minutes with them (I get more time than that with my patients in the ER...and I actually probably get to know them better than their crazy-busy primary care doctor during their sometimes 6+ hr stay with me).

As a primary care doc you work long hours for little appreciation (and even less pay). And you realize that you'd rather have continuity of care with your own children, than with patients who don't listen to you, may actually sue you when they decide they have a bad outcome for not listening to you....and want it all for FREE!!

I say, continuity of care ideology is nice...but not the reality, and I wouldn't choose a specialty thinking that the continuity will be good thing.

I've never considered myself to be the type to gravitate toward "jack of all trades".

My Take-
Emergency medicine is the best of all worlds. No matter what area of medicine you go into, you will not be the most specialized person in the field. And doing the same thing everyday sounds very boring, doesn't it? If you're not a 'jack of all trades' you'll be seeing the same stuff your entire career.

"I don't think I'm an ER doctor type."

My Take-
Most of emergency is medicine is non-emergent stuff (so it's not like you'll be running around like on the TV show ER - of course depending on the hospital). In a given month (10-12 shifts) I may see 5 true emergencies. The rest is ruling out very unlikely things just to protect yourself (CYA), and urgent care/primary care things. I see these same people *way* more than I'd like - so there's the 'continuity of care' b/c they don't have access to primary doctors' offices.

Anyway, what is an 'ER type'? I think it's the type of person who values their time off...and realize that getting paid is important, and that life outside the hospital is more important to your health (sanity, and job satisfaction) than life inside the hospital. It's a person that realizes that having a dream life consists of balance, and that a job/career does not replace meaningful relationships (that require time and nurturing) with friends/family. That it is not necessary to become a martyr or forgo everything else to be a good doctor.

Now, what these ER types *do* with their time off...varies greatly (sometimes depending on gender).

Other pluses: you feel like a *real* doctor...not a technician or a pawn in a larger political game (at least not most of the time). And, you can always go work in a GP or walk-in clinic and see patients on an ongoing basis as a EM trained doctor.

Overall, it's important to remember (cuz lots of docs don't, and they are unhappy):
You don't have to LOVE (every aspect of) your job for it to be the PERFECT job.

*pictures from Life is Good Collection...it's an awesome collection. Check it out.


Toni Brayer MD said...

Great post. You really pegged the thought process we all go through in choosing a specialty and lots of doctors get it wrong. You have to really understand the long haul and after the thrill of finally doing medicine wears off, having some type of a personal life is what is the most fulfilling. As you said, having continuity with your own children is the most rewarding!!
There is the "idealized" practice and the reality. I'm a General Internist and the current health care environment makes the "ideal" far from obtainable.

MD 2 B said...

You never cease to amaze me in your ability to articulate what goes on in your head.

I hope to someday be able to write as eloquently as you do.


ERP said...

I went through the same decisions. I thought I would do internal medicine but then I realised how boring it was seeing patients with chronic problems and doing BP and Blood sugar checks. Also, you saw about a million patients in an afternoon - way to many to "build a relationship with" in my opinion. I liked anaesthesia - in theory. I liked the pharmacology and the procedures - but it too seemed to get monotonous, and at the time the thought was they would be all supplanted by CRNA's. I realised I only really liked medicine when the Sh** was hitting the fan. Then it dawned on me - the sh** hit the fan most often in the ER! And indeed although things annoy me in the ER as well(like right now I got a twofer with viral pharyngitis at 2am), I am bored the least- and I get free time to do all the other things I love.

Anonymous said...

I'm an ENT, and I always thought people chose their specialty based on what body fluids offend them the least. I don't mind snot, for example...

Julie said...

Love this post. It can be exactly the same thought process for nurses as they choose what area they want to work in and the type of people they want to work with.

It's a challenge being a professional woman (or man), raising a family, holding together a marriage, and finding time to be happy as a person.

cstew said...

I always thought that emergency medicine would be fun, but then when I shadowed an ER doc (admittedly not the friendliest), it seemed like all she did all night was dictate while the residents did all of the fun stuff. Is there any truth to that, I'm still considering it, but I wouldn't want to just dictate the rest of my life. Or does it depend on the hospital? The hospital I shadowed at was a large academic hospital.

Liberty Jennifer said...

I've been considering specialties, and always thought I'd want to do Pediatrics. Recently I've been considering ER and stumbling on your blog was a great insight into what an ER doc might suggest :)

I'm still waiting to see what Third year holds (I'm still an MS2), but I'm encouraged by your blog! I want to be a great doctor, and still have an enjoyable life OUTSIDE of medicine.

Anonymous said...

I think the lifestyle issue is key. I decided on emergency medicine when I realized that I really didn't value the continuity of care issue either. I'd much rather be your doctor when the shit hits the fan because you ignored your doctor's advice about your hypertension or diabetes all those years. I also had strong female role models when in medical school in our emergency departments. When I met with my chair, she said that one thing she was proud of was that despite the demands of her job as the Chair of an academic emergency department she had never missed one of her child's school events, recitals, etc. This crystallized it for me as often you were exposed to this attitude that being a doctor was the end all be all of your life but those people for whom it was true were the most miserable human beings in the world. Ten years later and I'm now the mom to two boys and I can fit my job around their schedule without difficulty. This is the best specialty for balancing life and work. As you said, when I'm not at work, I don't give it a thought.

Bostonian in NY said...

Gasp...you view medicine as a JOB and not the end-all-be-all of your existence on this planet???

great post!

Anonymous said...

I hope that it continues to work out for you. I am 10 years into my career at a busy community trauma center. I started with a core group of guys around the same time so we are at the same place in our careers.

The BS lawsuits have hit us all and are taking their toll. It has taken the enjoyment out of practice for everyone of us. Two docs have partnered with eachother to do real estate. One has transitioned into another career and 2 others are actively plotting other careers. Myself and another are transitioning more to administrative roles so we are less exposed to direct patient care and lawsuits.

That is the large downside of EM. You pooh pooh it until you start getting those BS filing notices.

ER doctor said...

Thanks for the show of understanding.

I can imagine what working in the ER after 10+ years must be like...and I do hope that the majority of my income is *not* obtained this way. I hope I'm not 'doing shifts' forever.

Anonymous said...

Wow. I'm so happy you love the ER! I hope if I ever need one that my ER is staffed with doctors who love what they do.

I'm also SO FREEKING HAPPY that you aren't a FP. My FP LOVES what he does, treats my whole family, is always pleased when he gets my labs back because his skill as a dr and his kindness as a human encourage me to do what he tells me to do.

I've actually asked him - don't you want to be a hospitalist? No headache of owning your own business, no employees, etc.? Don't you wish you had taken a higher paying specialty? (He graduated Rice/Baylor top of class - brilliant man) He always says no - he loves being able to be an active part of his patient's lives and watching us heal. He sure doesn't think what he does is "family practice crap" and neither do his patients - like me - who don't have to go to the ER because he's there to help keep us healthy.

WOW am I ever glad you're not a FP. What a sad, jaded outlook you have.

ER doctor said...

You're happy I'm not FP?!

I'm the one that's happy.

Very happy I didn't choose FP. I wish all PMDs were as "brilliant" as yours at keeping non-emergent patients out of my ER.

berto said...

If im in the situation of the owner of this blog. I dont know how to post this kind of topic. he has a nice idea.

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Dora Ali said...

I hope if I ever need one that my ER is staffed with doctors who love what they do.http://www.afu.ac.ae/en/handbooks/

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Thanks for the post! I'm MS3 and trying to decide on specialty. It really helped put things in perspective for me.

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