A month and a half into third year, I am currently having conflicted notions about my desired career path into medicine. I am very much in love with medicine so far: the issue is that the pathway I thought I would pursue within medicine is now being challenged by a new passion. There are many factors that might inspire a medical student to select one field or another. Given my background of my mother’s cancer, it might seem natural for me to select Hematology-Oncology. However, despite my interest in caring for very sick patients and dealing with end-of-life issues, Heme-Onc never seemed to rest comfortably in my concept of a career for reasons of which I still may not be fully aware. Later, finding personal experience as a motivation (e.g. childhood asthma), gaining knowledge through basic science research in the field, and finding inspiration in the doctor-patient relationships exhibited by one very talented pulmonologist and her patients, I was drawn to Pulmonary-Critical Care Medicine as a potential career path. I can relate very well to patients who do not take easy breaths for granted, and the Critical Care aspect intrigues me with respect to the procedural aspects and the constant imperative to provide some level of care to one’s patients. Additionally, there also was the added amusement and benefit of being able to introduce myself as “Dr. L(e)ung!” At the same time, my shadowing experiences with an Interventional Cardiologist attracted my desire for immediate gratification in the ability to save lives by performing direct, hands-on interventions (balloon angioplasty and stenting).
However, each of the fields, although interesting, do not quite stimulate my sense of wonder. To my surprise (and almost to my chagrin), I have recently fallen in love with many aspects of the field of Neurology. I chose to do Neurology as my first rotation so that I could “get it out of the way” and cut my teeth on a field to which I was not particularly attracted. In truth, however, I have always found many subjects in Neurology fascinating but have repressed my interests and avoided the field due to a very poor quality course in Behavioral Science during my undergraduate years and very disorganized coursework in Medical Neuroscience. Furthermore, I was turned off by the (wrong) assumption that there are few treatment modalities available in a neurologist’s arsenal for treating neurological diseases as compared to other fields (primarily, cardiology and pulmonology). However, my recent tour on my hospital’s new Stroke Service has convinced me otherwise. Indeed, neurovascular diseases fascinate me more so than any other area within Neurology. Nonetheless, trying to catch patients in the 3-hour window within which tPA can be used to dissolve blood clots seems to be an intervention with many non-medical impediments. For my attending physician, trying to streamline that road from a patient’s first symptoms to her arrival in the Stroke Unit is a logical and meaningful objective at this time. However, what would be the great battles to fight 6-10 years from now when I first enter the field as a fully-trained specialist or subspecialist?
Taking a page out of the book of my fiancée, I have found one potential answer to my search for the perfect field and fit: a synthesis of several of my interests – Interventional Neurology. The field involves the treatment of neurovascular disorders with percutaneous interventions such as carotid stenting (to revascularize occluded carotid arteries), aneurysm coiling (to seal off potentially hemorrhagic vessel wall dilations), and intra-arterial thrombolysis and direct clot removal (to treat thrombotic or embolic strokes after the 3 hour tPA administration window, thus increasing the time available to directly treat ischemic strokes). This is a very new field with many names, and most trainees come from Neurosurgery or Neuroradiology backgrounds. However, there is an emergence of the notion that Neurologists with interventional training can also contribute greatly to the multidisciplinary field by providing the knowledge to treat and manage the neurological/medical aspects of neurovascular diseases as well as the preoperative and postoperative needs of these patients (e.g. neurocritical care background not provided by Neurosurgery or Neuroradiology). Interventional Neurology, recently approved in 2006 by the Accreditation Council for Graduate Medical Education (ACGME) as Endovascular Surgical Neuroradiology, was developed to include Neurology trainees as well as Neurosurgery and Neuroradiology-trained physicians. From the Neurology entry point, the fellowship would require:
3 years of Neurology
2 years of Neurocritical Care (or 1 year of vascular/stroke fellowship)
1 preliminary year of Neuroradiology* (may be incorporated into the ESN fellowship)
3 months of Neurosurgery
The fellowship itself is usually a 1-2 year program. That does mean my training would last 7 years, but if it is for something about which I am madly passionate, I think it would be well worth it. This new field appeals to me for a variety of reasons:
1. The (neurovascular) diseases are intellectually stimulating and fascinating. Furthermore, stroke is the leading cause of long term disability in the U.S. and around the world, and in the future may replace cardiovascular disease as the number one killer worldwide.
2. The critical care background would give me the knowledge and training to work in Intensive Care Unit settings, one of the areas in hospitals in which I feel most at home. I like working with very sick patients, I am not turned off by the presence of ventilators or the process of dying, and I like the team work in ICUs (especially the ICU nurses who are pretty awesome).
3. Performing direct interventions excites me, especially since it would give me the opportunity for me to use my hands without forcing me down a surgical path. Furthermore, endovascular intervention seems to be the logical next step in the advancement of the treatment of cerebrovascular diseases like stroke. Given the success Cardiology has found with angioplasty and stenting, Neurology seems poised for great advances, hopefully in the form of Interventional Neurology.
4. The field is very, very new. This hopefully would give me numerous opportunities to teach and train other physicians in the science and procedural aspects of the field as well as opportunities to research and develop new methods and principles of treatment.
5. While I don’t like the idea of excessive pride in physicians, I would still like to be proud of the work I do. While I would find pride in other fields, there is something incredibly compelling about the brain and its growing primacy in our developing understanding of life and consciousness. As Dr. Wiese noted: in acute care situations in Medicine, the lungs and the heart provide vital functions to provide oxygen to brain. The lungs and heart are incredibly important organs without which a person cannot live. However, they are still supporting players to the brain, the captain of the team. I have not neglected to notice that Neurologists are paid less than Pulmonologists and Cardiologists, partly based on that very idea of what can be done for the patient (with procedures and imaging being reimbursed for more than pharmacological treatment or physical examination). I would be proud of any efforts I might take to demonstrate and establish the truth that Neurologists can do incredible things, including interventional treatments, for their patients, as much as any Cardiologist or Pulmonologist.
Of course, two months ago I was fairly comfortable with the notion of going into Pulmonary-Critical Care Medicine. Will Interventional Neurology be a fleeting passion, or will it even be a plausible path? If nothing else, the idea excites me. A lot.