Choosing Your Specialty or Sub-Specialty

I just found out about your blog through Scrub Notes, where your topic “failure”was reposted. And I had more fun exploring the topics you’ve discussed especially about how you chose surgery. I am doing my post grad internship now and have (i think) ruled out surgery–but i keep on reading surgeon’s blogs! Would you have another topic about choosing your specialty?

I’ve had a lot of recent conversations with medical students and residents about how to choose a specialty (or subspecialty).  I have to admit, they have changed the way I think about this a little.   I’ve begun to realize that there are different forces at play, including some I used to discount.

The Philosophical View

Your work is to discover your work
And then with all your heart
To give yourself to it.

Buddha

In the ideal world, your speciality picks you.  (How to Choose Your Medical Specialty).  In a nutshell, I think if you are paying attention, you will be pulled towards the specialty that fits you best. If the pull towards a particular specialty is very strong, you really shouldn’t ignore it.  Some of the most miserable doctors I know picked their specialty based on income,“lifestyle” (more about that in a minute), or other “practical” issues…and then were miserable.

As I’ve thought about it more, and talked to more and more students and residents, it’s clear that the “pull” towards a specialty can be really strong… or not so strong.  So, how do you figure out what you should do if you don’t have a strong calling for a specific field of medicine?

I believe that most of us are either “surgical” or “medical” in the way we view our professional world.  It’s like the Yin-Yang symbol – the two halves that make up the whole.  There is no judgment here – patient care needs both medicine and surgery.  It’s not an either-or proposition, either –  just like the Yin-Yang symbol, there is some “medicine” in every good surgeon, and some “surgery” in every good internist or pediatrician.  So, the first step in deciding on your future career is to decide where you fit on the medical-surgical spectrum.  At one extreme, the most “surgical” specialties are general surgery, vascular surgery, cardiac surgery, and trauma surgery.  At the other end of the scale, the most “medical” specialties are general pediatrics and internal medicine, as well as many of the subspecialties in pediatrics and medicine (e.g. nephrology, rheumatology, etc).  There are surgical specialties that have more of a “medical” component (e.g. ophthalmology, ob-gyn) and medical specialties that have a significant “surgical” component (e.g. gastroenterology, invasive cardiology, interventional radiology). As you are exposed to specialties, think about where you fit on the “medical-surgical spectrum” and how wide your “bandwith” is i.e. is it a larger number of specialties that fit your personality and talents, or is it really a relative limited number of specialties?   It’s important, too, to realize that you will be exposed to only a small percentage of the 145 specialities in medicine.  Take time to learn about the specialties you haven’t heard about – one of them might be a perfect fit.

The second step in thinking about your future career is to decide if you want to work with adults, children or both.  If you have a strong pull towards (or against) working with children, it will narrow the specialties you are considering.  If you don’t feel strongly one way or another, keep an open mind as you go through pediatrics and family medicine.

If, at the end of this process, you find you have eliminated a few specialties but still have a list of possibilities, that’s ok.  You will end up choosing one and – it will be the right one.  All field of medicine are important and all of them allow you to impact the lives of other people.  As I’ve gotten more experience helping people through this process, I realize that there are some people that choose the work and then make it their passion (instead of the other way around).

What if you make the wrong choice?

There is nothing that is set in stone.  Despite your best effort to make a good choice, you may find that it’s just not a good fit.  There are plenty of examples of people who started in one field and realized that they had made the wrong choice.  This isn’t a personal failure!  The only failure would be staying in a field you really don’t like.  Yes, starting over will add some years.  But if it’s really clear that you should be in a different field, make the choice and move on.

The Practical Issues

As I’ve talked to more and more trainees, I’ve realized that practical issues are important to consider when you are choosing your specialty.  Practical issues cannot and should not be the only thing you consider though.  Please don’t talk yourself out of something you really love because you are worried about your talent for the field, money or lifestyle.

Your talents.  “I really want to be a heart surgeon, but how can I know if I have the hands to do it?”  Physical skill, in my opinion, is a bell shaped curve.  There probably are 5% of people on the right side of the curve who are truly gifted when it comes to technical skills (and, yes, 100% of surgeons think they are in that 5%)  Likewise, there are 5% of people on the left side of the curve who simply won’t be able to do it. These people will self select out of a career that requires technical skill – they just aren’t comfortable with working with their hands (and never have been). Everyone else can absolutely learn the technical skills needed in their specialty.  Physical talents may be the most obvious talent we think about, but there are other talents that play a role as well.  How well can you sit still?  How easy is it for you to listen to other people’s stories and feel empathy for them?  Are you more comfortable knowing a smaller amount about a lot of things, or being a real master of a smaller area? It’s a good idea to consciously think about your talents and ask people close to you to help you with this task.

Money. The average amount of debt a medical student incurs is currently $160,000 Loans for medical education can only be deferred for 4-5 years, which means if you choose a career that requires 7 years of training, you will be paying back your loans on a resident’s salary.  The math is scary – and our system is flawed.  One of the best explanations of this problem is a post by Benjamin Brown, MD called The Deceptive Income of Physicians.  If you have a family to support, I understand that choosing something that requires more years of training is problematic.  If you are in this category, your issue is going to be how much to let financial considerations affect your decision… without letting them totally drive the decision.

Lifestyle.  I was talking to a colleague in pediatrics the other day who told me a great story about when she was an intern.  She had been taking calls from families and had a family call around 5pm about their baby.  After talking to them, she decided the baby probably had croup, but it was not dangerous.  The next morning, in morning report, the chief resident asked her how the baby was when she called back.  When he found out she hadn’t called, he responded “If a family calls you about croup at 5pm and you don’t call back at 9 or 10 to find out how the baby is doing you haven’t done your job.”  Medicine – no matter what your specialty – is not “easy”.  Every field has issues that will keep you up at night and working at times you wished you didn’t have to work.  There are some that are worse than others, but don’t confuse “lifestyle” (i.e. the ability to have a balanced life and be happy) with an idea that your specialty will be “easy”.

Starting Clinical Rotations: Practical Advice

Don’t sit in the back of the plane.

The basic sciences are important to learn the vocabulary and grammar of medicine.  Clinical rotations are different – it’s where you actually learn to be a physician.   If you use the analogy of learning to fly, in basic sciences you are studying the book on how to fly the plane.  In your clinical rotations you are in the plane, watching and learning from the pilot.  Which means you have to be in the cockpit.  You cannot learn to fly a plane by sitting in the back.

In every situation you encounter in the hospital, imagine that you are “flying the plane.”  When the resident starts to write the admission orders say “Do you mind if I write them and you show me how?”  On your surgery rotation, be in the holding area early and ask the anesthesia resident if he/she will explain how to intubate, show you how to intubate, or even let you try.  When you are writing an admission H&P on a baby in the ER, imagine you are the only doctor who will be seeing that patient.  Let the adrenaline of that thought guide you to the computer to look up more about the condition, how to treat it and what you would do if you were the only person making the decisions.

Yes, you need to be pushy and, yes, sometimes it will backfire.  Be reasonable, but stay engaged. If it’s not an appropriate time to be assertive, stay in the game mentally by asking yourself what they will do next, what you would do if you were making the decisions, or what complication might occur from the decisions being made.  Write down questions you will ask after the smoke clears if it’s not appropriate to ask during a stressful situation.

Know what you are expected to learn before you start.

I am not a fan of “learning objectives”.  If they are done well, they are very helpful, but most people don’t take the time to do them well (or don’t know how to do them).  For the rest of your professional life, you are going to have to define your own learning objectives.  So, in a way, learning how to do it early – during your core rotations – is also part of the skill set you need to know.  (Word of advice, though – even if they are very poorly written, you need to read any objectives you are given and make sure you accomplish them.)

Start with a basic textbook.  You will NOT be responsible for learning all the details in the textbook!  Textbooks are written for residents and practicing physicians.  But – a good textbook will give you an overview of the topics.

The strategy:

1.     Make a list of the topics covered in a general textbook.  There are usually 2-3 good textbooks for every specialty.  Ask other students or residents which one(s) they recommend.  You will probably rotate on sub-specialty services during your core rotation, but don’t get bogged down in looking in sub-specialty textbooks.  Stay with the general textbook.

2.     Plan to skim and make notes on every major topic.  These should be “big picture” notes, not every detail.  If there are 60 chapters in the book and your rotation is 2 months long, you should be shooting for one chapter a day.  Keep track and make sure you get them all covered during the rotation (not after).  When you are done with the rotation, these notes should be all you will need to review for the shelf exam.

3.     Don’t read the chapters in order – read them as you see patients (see below). But, make sure that all the chapters are covered since it’s unlikely you will see patients with every disease in the book.

Practice being professional.

It’s really important to be professional and to be seen as professional in all your interactions.  First of all, it’s the right thing to do.  Secondly, a bad interaction with a nurse on the floor can lead to a poor evaluation by your attending.  Make learning how to behave as a professional one of your learning objectives.  Learn from those around you.  Which residents and attendings are the most professional?  Why?  When you see bad behavior (and you will), think about it – what would you have done differently?

Learn from every single patient you see.

Use every patient to learn about their specific disease.  Even if it’s the 30th patient with appendicitis you’ve seen you’ll still learn something new.  (or use it to learn about their hypertension instead)

The strategy:

1.     Keep a notebook with an entry for every patient you see.  You can use 3×5 cards or an electronic equivlaent, if you prefer.  In fact, many hospitals have 3×5 cards with the patient info available in the patient’s chart for docs to take. (Remember HIPAA – it is better to do this without any protected information!)

2.     Make yourself read something about every patient you see.  If you haven’t read the textbook chapter on the subject, that’s where you start.  If you have read the textbook, review your notes and read something new (UpToDate or PubMed for example)

3.     Make yourself write down a minimum of 3 things you learned from the patient in your notebook (or on your 3×5 card).

Be the doctor for patients that are assigned to you.

You will be assigned patients to follow during your rotations.  When this happens, make up your mind that you are going to “wear the white coat”.   What if you were the only doctor taking care of Mr. Smith after his surgery?  In addition to reading (see above), ask the residents to help you write all the orders.  Write a daily note and make sure your notes are at the level of the residents (ask them to review and critique your notes).  When a drug is prescribed, know the dose you are giving, the effects of the drug and the potential side effects.  When a x-ray is ordered, be the first person to actually see the image and know the result (and make sure you call the resident as soon as you do!).  Don’t get any information second hand – make sure you see the results and the images yourself.  At any point in time, if the attending asks, you should be able to present your patient as though you are his/her only doctor, which means how they presented, their past history, social issues, test results, procedures performed and how they are doing now.

Prepare for conferences.

Every service has at least one or two weekly teaching conferences.  In most cases, the topic (or cases) are known before the conference.  Ask your residents or attendings the day before the conference for the topics and/or cases that are going to be discussed.  Use the strategy outlined above to prepare e.g. consider these “vicarious” patients and learn from them as if they were a patient assigned to you.

Come early, stay late and keep moving.

Taking care of patients in the hospital is a team sport.  The best medical students become part of the team early and are appreciated and – therefore – taught more.  It’s just human nature and it’s just the way it works.  Don’t brown nose, don’t show off…. just show up.   If there are labs to look up before morning rounds, be there 10 minutes early and look them up for the residents. If you don’t know the answer to a question the best response is “I don’t know, but I’ll find out!” If there is scut work to be done that you can help with, volunteer to help before you go home. Anytime you can, make the residents look good. It’s particularly important not to try to one-up the residents.  You will have more time to read than the residents, so you may actually know more than they do about a specific topic.  But, if the attending asks a question and the resident gets it wrong, don’t correct them in front of the attending.  (Unless it’s a critical issue and you think the patient might suffer in which case you have to speak up!)  Whenever you can, set up the resident to succeed.  “A rising tide floats all boats” – if you help them look good, you will look good and the team will look good. Don’t ever sit in the lounge waiting for someone to come tell you what to do.  There are patients to see, conferences to attend, rounds to do, labs to look up… the hospital never sleeps!

Practice having a balanced life.

Compassion fatigue is a constant threat to practicing physicians.  Taking care of yourself, staying connected to family, friends and the outside work are all critical components of preventing compassion fatigue.  This, too, is a skill you need to learn during your rotations so you can carry it with you into your residency and your practice.

Enjoy!  You are finally a “real” doctor!’’

Your experiences on your clinical rotations will be among the most special of your life. Buy a new journal and take time to jot down the funny and not-so funny occurrences of daily life in the hospital.  You will see some extraordinarily beautiful moments of human life.. and some horrendous examples of what people can do to other people. We all learn to deal with these extremes by telling stories. Write down these stories when you can.  It’s also special to record your “firsts”… the first time you set a fracture or hear a murmur of aortic stenosis will be the only “first time” you have.  It’s a special world you are entering.   You’ll want to remember it by taking notes, recording stories and with pictures of your team and unique sights around the hospital. (No patients, though – remember HIPPA!)

Congratulations! You are well on your way to the privilege and joy of practicing medicine.

Starting Clinical Rotations: Wear the White Coat

Every year, I end up counseling a student who, from day one, was absolutely certain they wanted to go into surgery.  They scheduled their rotations to put surgery last, so they would get really good evaluations.  They cruised through pediatrics, medicine, ob-gyn, etc as observers, rather than real participants, because they were so sure they were going to be a surgeon.  Finally, the big day arrives – they start their surgery rotation.  Within a few weeks they begin to realize….. they hate surgery.  Now they are really stuck.  What kind of doctor should they be?

There is an easy way to prevent this from happening.

Wear the white coat.

When you start your pediatrics rotation, be a pediatrician. When the residents and attendings ask what you are interested in, tell them you think pediatrics is really interesting.  It will be true, if you are “trying on the white coat”.  (It will also inevitably lead to better evaluations, by the way, but that is secondary gain.)  When you are on medicine, be an internist.  When you are on surgery, be a surgeon.  You get the idea.  Really immerse yourself in the field, imagine it will be your future.  It’s necessary, but not sufficient to learn what you need to know for the shelf exam.  If you are going to wear the white coat, you have to go beyond what you learn from patients and about patient care.  How does an internist think?  What makes a particular case in surgery more challenging than another?  How does an obstetrician deal with a difficulty delivery at 2am?  What defines the culture of pediatrics?  Does the “coat” of a neurologist fit you?

Over 80% of students change their mind about what specialty they want to pursue as they go through their rotations. Choosing your specialty is not hard, but you have to genuinely keep an open mind as you “try on” all the specialties.  One of them will fit better than others, but it’s probably not the one you expected!

Creating Your “Peripheral Brain”

My last post was about how to keep track of the information you are learning on different services.  http://wellnessrounds.org/learning-clinical-medicine-tips-for-the-hospital-and-clinic/

A related, but slightly different issue is the best way to create a “peripheral brain” for your clinical work.  Every medical student and resident creates their own “peripheral brain” to access reference material that they use on a regular basis.  In it’s simplest form, it can be a list of phone numbers for the rotation, faculty dictation numbers, etc.  In a more advanced form, it can include normograms for drug dosing, tables for probability of survival in the ICU,  lists of attending preferences for patient care, etc.

The internet has become a vast  “peripheral brain” for everyone in medicine.  We all use it to find information.   But it’s not ideal because it’s not specific for your needs.  For reference material you need over and over,  it’s more effecient to have it with you.   Unlike the system I described for studying (which is based on 3×5 cards), your peripheral brain should be digital.  My current recommendation for students and residents is to use Evernote.

In a nutshell, here’s how Evernote works:

1.  It’s free. (You can pay $5/month for the Premium version to have your data encrypted and to increase your storage, but you probably won’t need it)

2.  You create “notes” that are stored on a server by Evernote in your account.

3.  “Notes” on Evernote are more than just notes you type – they can also be photos you take, voice recordings, websites, clippings from websites or articles (tables, graphs, normograms, etc), pdfs, scanned images or text.. you get the idea.  Anything that can be stored digitally is a “note” in Evernote.

3.  You can access your notes on any computer, on your desktop (i.e. separate from the internet) and on your smart phone.

4.  You can search your notes.  This is by far the most amazing part of Evernote.  In essence it converts your notes to your own personal “Google”.  Evernote has text recognition for photos which really increases your ability to search.  For example, if you take a picture of a business card, you can search for it by any word that is on the card.

One big caveat.  Do NOT put any information about patients on Evernote.  Even if you pay for the encrypted version, it does not meet HIPPA requirements and you are breaking the law.

Here’s some links to more information about using Evernote:

http://academiclifeinem.blogspot.com/2010/02/evernote-redefining-my-organizational.html

http://computersoftware.suite101.com/article.cfm/why-evernote-is-made-for-medical-students

http://www.healthline.com/blogs/medical_devices/2008/09/evernote-for-doctors-revisited-privacy.html

http://efficientmd.blogspot.com/2008/08/how-doctors-can-use-evernote-as.html

http://www.screencast.com/users/rmacdona/folders/Default/media/63f89060-271d-405e-a544-d463ee267a2c

Learning Clinical Medicine: Tips for the Hospital and Clinic

“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.”   William Osler.

Every day you are in the hospital or clinic is a day you will learn something new.  You will see patients with conditions that are new to you and procedures you have never seen.  You will attend conferences and lectures on topics that will be new to you.   It’s a huge amount of information.   A year later (or even a day or two later), most of this new information will be gone if you don’t develop a system to review and learn it.

Keeping track of what you are learning in clinical situations is a simple database problem – You need a simple way to record the information and a way to file it so you can find it again.  Whatever system you devise has to be carried in a white coat pocket and has to be easy to use “on the job.”   Technology will prevail, I’m sure, and an electronic based system that meets those criteria will be possible in the future.   Until then, this is a system that will work.

Where do you learn new information as a clinician?  On any given day, you will likely

  • Interview a patient with a disease you have never seen before
  • See a procedure that will be done in a way you have never seen before
  • Attend a formal lecture, like grand rounds
  • Attend a teaching conference, like a tumor board
  • Read a chapter in a textbook
  • Read an article pertaining to one of your patients

The system described here is cheap, portable, and it works.  It lets you take information from this wide variety of sources and collate it into a usable database.  It starts with buying unlined 3×5 cards and putting them in your pocket.   3×5 cards work the best because they fit in a shirt pocket.  Larger cards tend to get left behind.  When you buy the cards, buy a file box (at least 8-12 inches long) to store them, as well as a set of alphabetized file markers for the box.

When you pull out a card to make notes, start by putting a small rectangular box in the upper left hand corner.  This box will be used (for a label) to file the card later.  You can develop your own system, but for most people the easiest way to label the cards is an anatomic system e.g. “Biliary tract, gallbladder, cholecystitis” or “Lung, pneumonia.”  There will be a few exceptions – there’s not a good organ to file general information about bacteria or antibiotics, for example, so you’ll want to use “ID, bacteria, gram negative, Pseudomonas” or “ID, antibiotics, aminoglycosides, gentamicin”.   You’ll most likely fill in the information on your card in pen, but you may want to fill in the label box in pencil.  As you progress in your career, you’ll realize that you originally filed leukemia under “Oncology”, but you really rather have it as “Blood, white cell, leukemia”. If it’s in pencil, it’s easy to change.

General rules for the 3×5 card system

  • Always have cards with you
  • Never make notes with the intention of putting them on cards later.  Always take the notes directly on the cards.  If they are really messy and you want to redo them, great – but have at least one set of cards with the info to start with.
  • Always put the date you made the card and the source
  • File them when you get home

Most of the cards you’ll make will come from these 6 sources:

1.  Lectures or grand rounds.  Depending on the lecture, you may end up with 5 or 6 cards.  Number them to keep them in order. When you look them over later, you may want to highlight the 2 or 3 most important concepts you learned.  Even better,  you may want to make a separate card with those key concepts.

2. “Pearls” cards.  On rounds when the attending gives you the 6 reasons a fistula doesn’t close, write it down on a card.  Put the name of the attending and the date at the bottom.  In the operating room, when the chief resident pimps you on the critical anatomy for deciding if a hernia is direct or indirect, remember it – and then at the end of the case make a card.  If on rounds you get assigned something to look up at home, make the card and have it in your pocket the next day.  This is also a great way to record mnemonics.  It’s hard to remember lists of things, so use mnemonics liberally when faced with a list to memorize.  For example, the 6 reasons a fistula does not close spontaneously can be remembered by “FRIEND” : Foreign body, Radiation, Infection/Inflammation, Epithelialization, Neoplasm and Distal obstruction. There are many famous mnemonic in medicine, some of which you couldn’t repeat to your mother.  If there is not a common usage mnemonic, make one up yourself.  They really work.

http://www.medicalmnemonics.com

http://www.doctorslounge.com/studlounge/mnemonics/

    3.  Patient information.  This is probably the most important card you will make.  Put the patient sticker on the end of the card, or at least write down their number and date of birth.  You want to be conscious of patient confidentiality, so, be careful about information that could identify the patient if the card was accidentally lost.  Put the “hooks” that will make you remember this specific patient.  If your patient is an 80 year old lady who knit you a red hat, make sure that goes on the card.  Then put what you learned about the patient’s disease from this specific patient.  How many days did she have symptoms?  What did she report that was different from the textbook”?  What treatment did you use?  Did it work?

    4.  Procedures.  I must have watched 30 or 40 different people repair an inguinal hernia.  Each of them had some minor variation or “trick” that make the exposure easier, or the results better.  When you watch a procedure, try to find those details and then write them down.  Consider this a “procedural patient card”.  Put the same memory “hooks” on this card – details that will let you remember this specific case.  You can do this for any procedure, not just surgical procedures – lumbar punctures, central lines, radiological procedures, cardiac catheterizations, etc. etc.

    5. Chapters.  When you admit a patient with Crohn’s disease (for example), read the chapter.  And then carefully and completely summarize the key points on 3×5 cards.  As you do your annual reading of the textbook, make your notes on 3×5 cards. Do it once, compulsively, and you don’t ever have to do it again.  When it’s time to review for an exam, you can just use your cards.

    6. Articles. When you take the time to pull articles for a presentation, or just to better understand a patient you are caring for, make cards.   Most articles will have an introduction that summarizes  what has been written before that will serve the same purpose as a chapter in a textbook.  But the reason they are publishing is because they are adding something new to the literature.  Make a list of the 2 or 3 key points they are making in the article.

            It is incredible how many cards you will add in a week to your “database.” In an average day, you may see 3 new patients, attend a lecture, learn 3 key new points on rounds and sit through a teaching conference.  At the end of the day you will have made 10-20 new cards.  With almost no effort, you have added substantially to your file.   When it comes time for exams, particularly if you have been diligent about making notes from a textbook, you can use the cards to study. More importantly, as time goes by, it adds to your ability to teach.  Let’s say that overnight your team admits a gentleman with diabetic ketoacidosis.  You have teaching rounds that afternoon so, in the morning, you go to your file and pull out all your cards on diabetes and DKA to bring with you to work.  You have, in your pocket, clipped together, notes from 2 grand rounds, 5 patients you admitted and cared for, 4 articles you read, and a chapter.  During the day, you can spend 5 minutes here and there reviewing your notes.   You’ll have a real grasp on the topic and the important points.  You’ll look like a star on rounds!