At the Beginning of the Long and Winding Road

Each day I learn a little bit more about many fields in medicine, and I walk a few more steps along the path to becoming a physician. Though I have flatly ruled out few possibilities, I have grown much more interested in some disciplines and much less interested in others.

I am currently of the opinion that I probably don’t want to join a front-line specialty: Family Medicine, Emergency Medicine, Pediatrics, etc. While there is some truth to the notion that these fields contribute the valuable skill of differentiating between life-threatening conditions and the usual background noise of non-urgent problems, I don’t think that I would necessarily find this task as intellectually interesting twenty years from now than I currently do (not having this skill yet). I may be wrong in my perception, but this task essentially is a high-precision form of triaging: determining the severity of a problem, determining whether or not I can solve the problem with my current skill set and available resources, and if necessary, refer the patient to a specialist or send them to the operating room or intensive care unit if I cannot solve the problem myself. In Emergency Medicine, this skill has to be particularly refined and quick, and it seems that there is less of an emphasis on being definitive in one’s diagnosis: the goal is to stabilize, and then either discharge or send the patients to the appropriate department. Though I have learned much from my handful of EM experiences so far, I don’t think that this relatively young field has built-in measures of satisfaction that suit me. The time spent with each patient is too small with the lack of follow-up, and I wonder if the constant, high-volume triaging would eventually numb my motivation and compassion. Family Medicine and Pediatrics theoretically enjoy more time spent with each patient due to the development of long-term relationships and multiple visits, but they have a lower probability of turning up intellectually interesting conditions or urgent care needs. There is satisfaction in developing long-term relationships and seeing improvement or maintenance of good health over long periods of time, but I might find the lack of urgency boring.

On the topic of urgency, I think I may have in mind one notion that partly explains why “proceduralists” (interventional specialties, surgeons, and emergency medicine physicians) are paid much more than “cognitive” physicians (physicians that don’t do procedures but instead focus on taking histories, doing physical examinations, and prescribing medications and lifestyle changes). That notion is time. Not the time that physicians spend with patients, but rather, the time that a patient has left to live. Many procedures (surgeries, angioplasties, bronchoscopies, etc.) serve as interventions that dramatically reduce morbidity (suffering and disability from a disease or condition) or save the life of a patient who would otherwise die in a short time. One reason why cardiologists try to convince patients with myocardial infarctions (heart attacks) to have a cardiac catheterization (i.e. balloon angioplasty, stent insertion) instead of taking medication to resolve the coronary artery blockages is because “time is muscle.” In other words, the longer it takes to open the coronary artery blockages, the more damage the heart muscle takes (i.e. more heart muscle cells die, and these cannot be regenerated), and the patient, although still likely to survive, will be much more severely disabled than if he/she had the blockages opened quickly with a balloon angioplasty. By contrast, physicians in cognitive specialties theoretically have more time to deal with a patient’s problem since they are usually addressing non-urgent acute conditions or the long-term management of chronic diseases. This does not mean that these health problems are less important, economically or with respect to the burden of disease, but our society places a great value on time because time is a limited resource. Time is money, and in medicine, many procedures serve as rapid interventions to acute problems that cannot be resolved by cognitive physicians. For some time, I wondered whether this differential payment was a result of the sensationalism of “saving a life” as opposed to less dramatic long-term management of disease. I think that beneath that sensationalism lies the truth: that we value time, and when you are sliding down a steep slope with little time left, only proceduralists can save you and give you a fighting chance at continuing to live a decent life. Not all procedures are immediately life-saving, but they still require extra skills to learn. The system may allow for proceduralists who lack the cognitive skills of cognitive physicians, but I doubt that these physicians are less intelligent: the best proceduralists I’ve met and worked with use both cognition and procedure in an equal balance (especially using cognitive techniques to guide the use of procedures). (In fact, the interventional cardiologist I shadowed frequently took on the role of an internist and picked up the slack for primary care physicians.) While I believe that there will always be a place for family medicine and other cognitive specialties in American health care and that these should be well-reimbursed, I don’t think that these physicians should necessarily receive the same compensation or better than proceduralists (interventional cardiologists, pulmonologists, gastroenterologists, surgeons, emergency medicine physicians, etc.) as some would like to dream.

At this time, I’m leaning toward Pulmonary and Critical Care Medicine and Interventional Cardiology. Both of these involve a mixture of cognitive medicine and procedural medicine. Furthermore, both may involve commanding a section of the hospital: pulmonologists typically direct intensive care units, and interventional cardiologists lead teams in catherization labs. I like the idea of being in command of one’s own ship (to some degree) rather than being a nomad in various wards. Neither are front-line specialties, and that’s fine by me: I would like my batting average to reflect that I could do something both tangible and meaningful for most of my patients.

Being an intensivist would have its own unique challenges, though, including the growing debate as to how people should die and to what extent the medical profession should attempt to prolong the transition between life and death. Medical bloggers (and other people in health care) like to pick on the ICU as being one symbol of what is wrong with our health care system: it is the most expensive unit in most hospitals, and it generates horrifying images of barely-brain-alive patients powered by machines and stories from patients’ family members who would plead on behalf of their dying loved ones to just let them die. At this point in time, I am sympathetic to both the perspectives of many physicians and patients who want to die: I would want to work as hard as I can to stabilize patients and help them substantially recover a chance at living a decent life (with medical support, yes, but not necessarily a miserable one), but I also have respect for the desires of patients and an ear to their reasons for wanting to die (by being taken off life support). It’s a matter of balance, and given that seeking balance is a core value of mine, I wonder if this would be an ideal profession for me. Although others might find the ICU depressing because of the high mortality rate (as much as 20%), I think that I might find some satisfaction in helping guide patients through their transition: back to a stable life (disabled, perhaps, but with reason to live) or toward a less painful and less sudden end.

Anyways, these are just some of my early musings. I have recently come to realize that while my choice in discipline is important for finding personal satisfaction in my career (as there are many differences in style between various fields), it is also important for me to realize that this is a long journey, and the journey is half of the fun. In some ways, picking a long journey with fixed, incremental endpoints (unlike graduate school) gives me a vast variety of experiences at a good pace that few others will ever encounter: from medical school, to residency, to fellowship, to practice, to research, to teaching, and so on. I am happy that I have picked a profession that can allow me to do so many different things, and I even if I may not be as interested in some things now, I may be more interested and more involved in the future (e.g. almost all of my lab instructors for Anatomy were former surgeons; I would love to spend my venerable years teaching students instead of sitting around in retirement and having nothing meaningful to do). With that in mind, I realize that it’s important to enjoy each stage and find value in each one rather than constantly looking toward the days when I can practice independently. Sure, each stage will have its frustrations and annoyances, but there’s also something unique and good about each as well. Rather than focusing on inadequacies, why not focus on what I can do and be? There are many milestones, and I’m happy to be what I am now: a kick-ass medical student that can do whatever I set my mind to.

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