Sunday, July 3, 2016

3rd Year Chronicles: Medicine, Neurology, and Choosing a Specialty

Third year is officially over now, which means I’ve completed three more rotations without posting anything more on the blog. Which means it’s time to sit down and write something. I’ll try and briefly cover my internal medicine and neurology rotations in this post, and then emergency medicine (my last rotation of the year) will get its own post. 

Internal Medicine
How to Choose Your Specialty

Together with surgery, the internal medicine (or simply “medicine,” as it’s more frequently called) rotation forms the latter half of the third year gauntlet through which we all must pass. Ideally, after completing these rotations, one is expected to have a very rough idea of the expanse of medicine and at least a general idea of what they may want to do when they grow up. That may or may not be the case in actuality, but that’s another post entirely.

My medicine rotation was eight weeks long. The first half the rotation took place on the “wards” or “floors” at Loyola and the second half was at the VA hospital immediately next door (or at least a long walk away). The hours were fairly typical hospital hours but significantly better than surgery – we were there at 6 am to get sign out from the overnight team and, depending on which site we were at, how busy the day was, and whether or not our team was admitting new patients, would get out between 4 – 5:30 pm. The one weekend day we had to work was shorter – we’d usually be done by noon, sometimes a little later, sometimes sooner.

Most of the work happened in the morning. We’d get in, hear about any overnight events for our patients, round on them, and see any new admissions we knew about already. Depending on the morning, we might have a meeting or lecture, and if we were lucky we’d have a few minutes to touch base with our residents to talk about our plans before we rounded with the attending. Some of the attendings like to sit down talk through the patients first and then go see them (this was ideal, I thought, and typically a bit more efficient), while others liked to do bedside rounds. Either way, this process could take anywhere from an hour and a half on a good day to three hours or more on a… less good day. Once that was over, the rest of the day was spent seeing any more new patients that were admitted, writing notes, following up on consults, or whatever busywork was left over.

Each day was fairly routine. The medicine itself was sort of the “bread and butter” of hospital medicine. This was the biggest service in the hospital and accounted for the vast majority of the inpatients. Day-to-day work usually involved tweaking medications to achieve the desired result and seeing what happened or waiting on labs, imaging, or other workups while we were trying to get at a diagnosis. There was something nice about the predictableness of everything – there was a certain way everything was done and certain time to do everything. While it was busy at times, this was the service, more than any other (except for perhaps neurology), where our attendings loved to sit and discuss what was going on and what odd things might be (but probably weren’t) contributing to our patients’ current problems. This was also the first rotation for a long time where I didn’t have some form of clinic – everything was on the floors.

Since this is one of the third year “gauntlet” rotations, it was busy and when it came to studying I had to pick and choose which resources I actually could use. As usual, I started out the rotation with grand plans of getting through Step Up to Medicine, all of the UWorld medicine questions, and reading about individual patients. As it turned out, Step Up just put me to sleep after a long day on the wards and I didn’t have the time to get through even half of all my original goals as it was, so about three weeks in I just switched to reading about different patient problems on UptoDate and doing as many UWorld questions as I could (ended up getting through around half of them). That said, since I had had surgery first, that seemed to be sufficient to do well enough on the end of rotation shelf.

As with most rotations, I enjoyed medicine. I already know I wanted to practice the “breadth” of medicine, and general medicine certainly fits the bill. Also, doing an internal medicine residency is a fairly safe bet – this is the path you need to go down anyway to “unlock” many of the fellowships into medical subspecialties (think cardiology, gastroenterology, rheumatology, critical care, etc.). That being said… I am not a fan of rounding. There are certainly ways to make it less painful, but sitting around talking about patients for hours every day just isn’t my idea of a good time. I like seeing patients and doing things for them, but that only comprised a small portion of my day. The rest was spent mostly on the phone calling consults or on the computer chart reviewing or writing notes. Stuff that needed to be done, sure, and not exactly unique to medicine (emergency medicine certainly has more than its fair share of phone and computer time too), but that was all. day. long. I did appreciate the intellectual aspect of the field – medicine people like to sit around and talk about the endless possible etiologies or sequelae of a given disease process. And that’s not a bad thing – I enjoy learning or refreshing my memory about a given disease process as much as the next guy, and many of the residents and attendings I had the privilege of working with were incredibly intelligent and had a lot to teach (some, not so much, but hey – that’s life). Of course, all of this isn’t necessarily reflective of what one’s day-to-day would look like in one of the many possible subspecialties, but that’s a conversation for later. All in all, I feel like this is the field I might fall into if EM didn’t exist and I decided to not go down the family medicine path. I might consider doing a combined medicine-pediatrics residency if that were the case, though, because I really do enjoy seeing kids – not something you get to really do with a run of the mill IM residency.

Neurology

Once I crested the hill of the third year, fourth year and its fruits were in sight. My first taste was with neurology – a four week rotation that, by some odd design, was almost more “shadowing” than actual work. With medicine and surgery and most other third year rotations so far, I had been busy working as part of the team, seeing patients, and increasing my workload as much as I could (or at least pretending to do all of that, even if what we were doing wasn’t all that important). With neurology, things were a bit different. First off, instead of having maybe one or two other medical students on your team, there were five of us, which made for a bit of a different dynamic. Second, the residents weren’t quite sure what to do with us. Finally, we had all just made it through the hardest part of third year and were ok with relaxing at least a little bit. Regardless, there were no weekends with this rotation, which was beautiful, and we typically didn’t need to get to the hospital until 7 – 7:30 am, which was also beautiful. To top it off, the residents started looking at us funny if we were there past 4 pm, and often sent us home closer to 3 pm or so. This must be why all the fourth years look so happy.

We spent two weeks of the rotation on “wards,” or the neurology inpatient service, and two weeks on the neurology consult service with some clinic smattered in there once a week or so (which was actually one of the more useful parts of the rotation where I actually got to practice my neuro exam a bit and get some one on one time with an attending). I will say that most of the residents and a couple of the attendings (well, one) did try to take some time out of their day to teach us some useful things (reading MRIs, managing seizures, etc.) which is always helpful and appreciated by students.

Most of our patients were either on the floors or in the neuro ICU after having a stroke, being worked up for seizures, or having some other assorted neurological condition (multiple sclerosis flare, intractable migraines, etc.). This, above all else, is the rotation where people loved to stand around and talk about exactly what part of the central or peripheral nervous system was probably affected by some lesion, and then order or look at imaging or some other study where possible to confirm it. Unfortunately, unless you were an interventional neurologist (a fellowship that allows you to go in and pull out clots within a certain timeframe after a stroke), it felt like most of our energy was spent figuring out what was going on and then watching and waiting to see what happened. There were exceptions, of course, and obviously there are important things that need to be done or medications that need to be started to reduce the risk, for example, of having a future stroke or seizure, but overall I felt like time was the most important treatment for many things (“Oh, you had a stroke? Well, we have a clot-busting drug that may or may not actually work, depending on how long ago the stroke was and if you believe the industry-funded literature or not, and might cause harm, but we can try that. And then we’ll start some meds to hopefully prevent this from happening again, and see if time and physical therapy might fix some of your new deficits. Thanks bye.”). This isn’t to bash neurology – it’s an incredible field with many new developments coming down the pipeline, and many of its practitioners are incredibly intelligent with an amazing grasp of neurological anatomy and pathophysiology.

Again, though, I found myself missing the “rest” of medicine. I brushed up on my neuro exam, but I think I might have used my stethoscope maybe a handful of times the entire rotation. Overall, it’s not for me but I really do think it’s a great field with a lot of opportunities and some cool fellowships (for example, interventional neurology or movement disorders, where you really can change people’s – with Parkinson’s, for example – lives for the better).  

Some Thoughts on Choosing a Specialty

Figuring out what you want to do when you grow up is hard, and it doesn’t stop once you figure out “Hey, being a doctor seems like a good idea.” Then you have to sort out which niche in the house of medicine is the one you want to spend the rest (or at least most) of your career in.

Thankfully, there are enough different paths in the broad world of medicine for almost everyone to find something they can at least tolerate. It’s generally a good sign if you get through your preclinical years and especially your third year feeling like you enjoyed most things – if you’ve hated every day of your life up until this point, all hope isn’t lost but you may have to work a bit harder to seek out your field. There are a lot of things we don’t get exposed to in our core rotations, and a number of fields that we may not see in our entire medical school experience unless we actively seek them out. AAMC’s Careers in Medicine website is a good resource for exploring many of the possible branching paths in medicine that may be a helpful place to start.

Many people start with the “medicine vs. surgery” decision, and that’s a good place to begin. Another way to think about things is to consider if you want to be "the expert" in a particular field (e.g. a heavily subspecialized IM or surgical field). The downside to that is you spend your days doing just that. Or would you rather be comfortable with and deal with a lot of different things on a day to day basis (family medicine, general IM, med/peds, EM)? The downside there is you may be good at certain things (e.g. with family medicine - taking care of the “whole person,” etc.; in EM, you're an expert in working up an undifferentiated patient, managing every field's emergencies, etc.) but won't necessarily function at the level of an "expert" in whatever field you happen to be dabbling in that day. Do you want your life to be all or mostly medicine (e.g. a surgical field or some procedural-heavy medicine subspecialties) or do you want to do things outside of medicine (e.g. 9-5 office based practice, etc.)? And again, there's also lots of nooks and crannies in medicine that you don't really get exposed to until much later in school, if at all.

Also, (almost) every field has its “action hero” moments, but most of your time on a day-to-day basis will be bread-and-butter cases. It’s important to differentiate between the two and not pick a field with few-and-far-between “action hero” moments that you love but a daily grind that you hate. You need to find something that you can at least tolerate on a day-to-day basis or you’re going to hate life and burnout quickly. Using emergency medicine as an example, you get to do some cool stuff – run codes, intubate patients, maybe bring people back to life, do some awesome procedures, and maybe save some lives. But most every day, your shift will involve endless waves of chest pains that aren’t heart attacks, belly pains that aren’t emergencies, and the drunks who consume time and resources you don’t have. If you can’t do the grind, don’t do the field. The “awesome saves” in EM certainly aren’t happening every shift or even every month. But we can talk more about EM in the next post.

Bottom line: keep an open mind. Explore things. Talk to people. Try and arrange rotations or at least shadowing experiences in fields that you are interested in. Understand that you likely would be happy in more than one field. Don’t feel pressured to choose a field right when you start medical school, or even when you’re halfway through third year. Maybe start feeling a little pressure once fourth year is about to start, but beyond that… take your time finding your field, and choose it for you, not based on any expectations that you think your friends or family have. Don’t choose a field to impress, choose one that you truly enjoy.

And regardless of what you choose… maybe think about a Plan B, just in case. That’s life, sometimes.

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