1. Contemplating how choice of a medical specialty will impact her personal life and satisfaction in the future
2. Making an ER career better by blending it with something else
Q: I'm a rising fourth-year med student and am struggling to decide on a specialty. I started late in the game, after I had my children, so I have been focused on specialties with shorter residencies. Also, because I worked briefly as an EMT before medical school and really enjoyed it, I always had in the back of my mind that I would probably end up in Emergency Medicine. Lately, however, after reading the book Something for the Pain written by an EM doc, I have been having second thoughts. The threads on the EM forum at studentdoctor.net have likewise been discouraging. My main worries are stress (because I tend to be high-strung, and also I have a diagnosis of bipolar disorder, and have read that I should choose a low stress career to avoid mood triggers), and the sleep issue. When I was reading Something for the Pain, it struck me that half the chapters seem to be about his sleep issues caused by rotating shifts, and all the personal/relationship problems associated with them.
My Step 1 score is high, as are my grades (multiple honors in core rotations, and several evaluations with statements like “This is the hardest working student I have had so far”) so I feel I am in the running for a competitive specialty if I wanted it. In the past few weeks I have started thinking about radiology. I had an MRI of my knee done, and I spent hours looking at it. I began to be able to see it, me as a radiologist. I also write creatively, and been published several pieces, one written during my first year of med school. I think radiology might give me that extra time to pursue some of my other interests, like writing. I have two major problems with radiology, however:
- I won't be a 'real' doctor, which is the whole reason I went to medical school. I saw myself elbow deep in it, saving lives. I am having trouble letting go of this idea of myself. Also the practical reality of it: if I am on a 747 at 37000 feet, and someone begins choking, or having an MI, even after all those years of training I will be useless. That just seems crazy to me! Because of my nature—high-strung and always worrying about various scenarios—I have always looked forward to the days when I would have an EM doc 'with me' at all times.
- I am struggling with the idea of how others will perceive me, not others in the medical profession, but family and friends. For some reason I care, and I don't know if I want my kids to say to people, “My mom is a radiologist” as opposed to “My mom is an EM doc, my mom is a surgeon,” etc. I can't put my finger on exactly why that is. I never cared much what people thought throughout my life and have lived unconventionally in many ways.
I know that may sound ridiculous. And I know I cannot have everything, that I have to decide at some point what is most important to me, and then make my decision and let go of the rest. I am just having a lot of trouble with it as the time to apply for residencies approaches.
Thanks so much.
Answer by Kevin Pezzi, MD: Ah yes, the nightmarish sleep issue that continues to plague me years after I got out of emergency medicine. I woke up well before 4 AM today, hours before I wanted to get up, primarily because I did not take anything for sleep. I've found various natural substances that are very conducive to sleep and have other beneficial side effects (such as feeling like a million dollars the next day, blissful mood, resistance to stress, enhanced creativity, and even heightened libido and sensation), but their effects are optimal when I don't take them every day. Since you're a smart medical student (BTW, congratulations on your achievement!), I needn't explain why, but for the rest of the audience, I'll give a clue: tachyphylaxis.
No one can fully understand the noxiousness and debilitating effects of chronic sleep deprivation that often result from shift work—especially when coupled with a high-stress career that makes it difficult to unwind after working. I've previously written about what that lack of sleep did to me, such as being so tired on some of my days off that I would sit in a chair and stare at a wall for hours, too exhausted to do anything, and so mentally drained that I didn't give a hoot about my lack of productivity.
I was practically the Energizer Bunny before I entered medical school, and now—decades later—I still am most days, although a broken neck has imposed some very annoying limitations on what I can do. Although I am tired now, the mentally debilitating effects of sleep deprivation from one bad night of sleep are nothing like they once were, when virtually every night was a bad night that snowballed into chronic sleep deprivation so severe I could fall asleep at the wheel while traveling 70 mph on a freeway or drive through an intersection on my way home from the hospital and haven't the slightest idea if the light I'd just passed through was red, yellow, or green. If I were that comatose minutes after leaving the ER, was I truly alert enough to perform optimally as a doctor? No way. Dr. Paul Austin writes about that in his book, Something for the Pain: One Doctor's Account of Life and Death in the ER. I haven't yet read the book, but judging from its reviews and what you wrote, I suspect his pain stems from sleep deprivation and the myriad problems traceable to it.
Therefore, you are wise to consider how your choice of specialty might impact your personal life.
Ever see the classic movie The Graduate? In it, Mr. McGuire put his arm around the graduate before giving him some terse career advice: “Plastics . . . There's a great future in plastics. Think about it.”
If I could put my arm around you and deliver similar avuncular advice, I would say “Urgent Care.” The optimal path to Urgent Care is paved with an emergency medicine residency. As an Urgent Care doctor, you'll do many things that ER doctors do, but with fewer stresses and humane working hours—rarely in the night.
I'm going to give you a bit of advice I've never yet divulged: supplement your Urgent Care job by occasionally working in an ER, perhaps one day per week—enough to maintain your EM skills, but not enough to sap the joy out of your life or cause you to wonder about the color of the traffic light you just passed through (something I did as a resident; see Resident Fatigue, Stress Trigger Motor Vehicle Incidents). That occasional ER shift will indelibly give you the sense of being a 'real' doctor (something you might miss in an Urgent Care center that sees few high-octane cases) and it will give you a tremendous marketing edge. In my state, and perhaps others, Urgent Care centers can now be staffed by Physician Assistants (PAs). PAs are simply not a substitute for a doctor. When I think of even the best PA I've known, would I want him treating me instead of a doctor?
No. Frigging. Way.
He was a very smart professional, but his knowledge base was not as deep or broad as what doctors possess. All that time you've spent in school, and all those years you're about to invest, are filled acquiring information and experience that will later prove priceless. In speaking the truth about PAs (such as in my first Men's Health magazine interview), I said things that triggered an incandescent response and even threats from some PAs, which I discussed at length on my other ER site; the discussion begins with a topic entitled, Treated by a Physician Assistant (PA) in an ER.
I think PAs have a role in medicine, but I don't think that an average PA knows enough to be a superb Urgent Care practitioner. Frankly, even after all of your emergency medicine training, even you (and others) could greatly benefit from knowing more. That applies to me, too, so I spend a few hours per day learning new information that goes well beyond the CME requirements.
I won't broaden this discussion too much since I have hungry chickens to feed, but I will say that anyone who truly cares about the optimal health and happiness of patients will think of medical school and residency as just half of their education. Medicine focuses on treating diseases and conditions; it does not center on optimizing health, intelligence, creativity, appearance, or longevity.
Want to see stunned silence? Ask a typical physician or PA what you could do to feel even better even though you now feel OK with no specific complaints. Or ask what you could do to make your children transcend their current intellectual potential, or what you could do to be attractive enough in your fifties or sixties that men much younger than you ask you out on dates, thinking you're of comparable age, and so hot they couldn't resist asking.
Whether he or she has MD or PA after their name, an average practitioner—and even most superb ones—won't be able to answer such questions, or will offer trite advice that most people already know or could find out in seconds by reading a magazine or searching on the Web. In contrast, I could talk for months in responding to such questions, but only because I've devoted so many years to learning about health instead of disease. Had I spent an equivalent time in school, I could have earned a few more doctorate degrees, or had I spent that time working, I'd now be rich.
Once word spreads that your Urgent Care center is staffed by a 'real' ER doctor who is also phenomenally knowledgeable about health, you are bound to be very successful, and your children will be justifiably very proud of you. Incidentally, one of the projects I'm developing is a database that will enable practitioners to give priceless health advice without spending years acquiring that info. I will likely give free access to that knowledge base, hoping to help many millions of people enjoy a quantum leap in health and brainpower, and hoping to pick up a few ad clicks here and there.
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As I discussed on some other pages, radiologists in the United States will increasingly face competition from doctors in other countries, such as India, who are very competent but willing to work for much less than U.S. physicians. Thanks to the Internet, the bits of data that form radiological images can be zipped around the globe in a split-second. In my opinion, there is no substitute for having a doctor present, but in today's political environment in which cutting costs is paramount, some American radiologists will find that their many years of training will be rewarded by standing in an unemployment line.
In closing, I'd like to comment on what one reviewer wrote about Something for the Pain:
“As a former ER doc, one of the things that drives me insane is reading books where the physicians are so compassionate, I wouldn't recognize them among the dozens (hundreds?) of docs I've worked with over the years.”
Read the rest of that review
I wish that doctor posted a review of my ER book (soon to be ER books). Too many readers, not cognizant of how hellacious it can be to work as a full-time doc in a high-acuity ER, have blasted me for my lack of compassion without thinking of why I lost the compassion I once had (and have since regained, now that I'm out of the ER). Add an MD after someone's name, and he or she is still a human being, susceptible to sleep deprivation and otherwise being slowly ground down by the many stresses of working in an emergency department. That was one of my goals in writing True Emergency Room Stories: to show the grueling effects of working in an ER, but that point was lost on readers who either didn't care (perhaps thinking that a reasonably fat paycheck should make ER docs happy even when they are whacked around like a piñata) or couldn't care because he or she couldn't read between the lines (the type of reader who thinks Animal Farm is about animals).
Speaking of animals, it's time to give my chickens a joyous start to their day! :-)
UPDATE: I discussed one of her concerns (Can ER doctors avoid mood triggers?) on a new page.
UPDATE #2: I fully understand your concern about being a 'real' doctor, but helping patients is what medicine is all about. If you can help more patients by doing X instead of Y, why not do X? For example, I will help considerably more patients (and people in general) by doing what I'm now doing—inventing—than I could in emergency medicine.
A 'real' doctor is usually perceived as one with diverse knowledge enabling him or her to intervene in emergencies, such as the medical crisis on a jet that you mentioned. However, those opportunities to help are too infrequent to base one's career decision on them.
Since I've been a doctor, the only medical crisis I recall outside a hospital was when a waitress collapsed in an overly warm, busy restaurant because she hadn't eaten that day, may have been pregnant, and may have done something else (I won't say what) to heighten her risk of syncope (fainting). By the time I saw her, she was conscious, talking, had a normal pulse, respiratory rate, color, and neurological exam. When her mother arrived minutes later, I sensed there was tension between them; the Mom seemed more angry and annoyed than concerned.
What would I have done if she weren't breathing and had no pulse? Do CPR and tell someone to call 911. I'm good at intubating (evidently better than one of my bosses), but I couldn't insert what laymen call a “breathing tube” in her because I didn't have an endotracheal tube or associated equipment. Nor did I have a cardiac monitor, IV, drugs, or a nurse to help me—optimally coding patients requires at least two people; five is even better. Doctors without equipment or assistants are severely limited in what they can do, similar to soldiers without weapons or comrades.
Considering this, if you maintain your BLS and ACLS skills (with the latter applicable for rare instances such as on jets with some medical supplies onboard), what you could do as a radiologist isn't much different from what 'real' doctors could do.
Most of the ability of doctors to help people depends on them working within the system. Take them out of that system, and their ability to help largely vanishes. Yes, I can do emergency surgery with a kitchen knife, Bic® pen, or drill from Home Depot, but those MacGyver-like skills are very rarely needed.
Ready to build something, or perform emergency neurological surgery?