Sixteen Questions: The Emotions of Career Decisions in Medicine.

There were these days where I just disappeared into the shadows. I could be there, I could be gone, I could be standing there for the entire time those rounds lasted with my middle finger pointed straight in the direction of the attending or the senior resident and I feel certain -- quite certain -- that no one would have noticed.

Not a one.

"Are you the student joining our team?" my attending asked. His eyes looked nice. Well. As nice as eyes can look when covered with an entanglement of unruly salt and pepper eyebrows. When he said that, they furrowed down first and then raised up. Like two very surprised giant bi-colored caterpillars. Ick.

"Sir?" I answered. That was all I could really say because, actually, that was his second time saying that to me in the two weeks since I'd been there. Complete with eyebrow acrobatics both times.

"Don't worry! I'm one of the nice ones," my attending said to me with a chuckle. "You don't have to worry about me grilling you or anything." And he said that part after shaking my hand and introducing himself to me for the second time in two weeks.

If "grilling me" would mean paying attention to me then I'd take it. I would.

"I think she was here with us last week." This was what the resident said to counter that Groundhog Day-like introduction from my attending. Because, I swear, he said the exact same thing to me the first time. That resident didn't even look in my direction when he said it either. Perhaps he took it as some opportunity to one-up his attending which, I had noticed from my position in the shadows, was something he seemed to relish in doing.

You "think" I was here with you last week? You "think?" Wow.

The interns at this rotation site did sort of talk to me. I'll give them that. The intern on my team was more than happy to send me out on scut-tacular field trips to spin down urine and gram stain slobber. Particularly if said job needed to be done at midnight or later. There was another intern that was very pleasant to us students, but she always seemed so scared that she made me nervous. Then, of course, there were  these other two intern guys who were extremely friendly to my friends and me. Extremely. They taught us things and showed us EKGs and asked us if we wanted to have lunch with them and things like that. And yes, now that I am much older, I recognize that they were being part-medical student centric and part-fresh, and probably even recognized that then, but never really thought much about it. Because at least I wasn't invisible then.

I cannot recall a single teaching point made by that caterpillar-brow attending. I can only remember that he always showed up in a blazer and tie and not a white coat and that he seemed to take great care in picking out his perfectly round, albeit small, afro. Whenever we had attending rounds which, back then before duty hours reform and billing rules changed, was only a few times per week, I would just stand there daydreaming and waiting for it to end.

And that was how it was on my very first rotation as a third year medical student. The good news is that just a couple of weeks later, my next attending seemed far more engaged than that one. And who knows? Maybe the guy had some personal issues going on or was simply burnt out. I don't know. What I do know is that it wasn't one of my more cherished experiences in medical school, that's for sure. (Fortunately, most of my other experiences in medical school were worth cherishing, so note that this is not a dig at my beloved alma mater by any stretch.)

Yeah. I guess it's just so hard to believe that I actually chose to go into the very field connected to such an unpalatable experience. But I did.

Internal Medicine. Imagine that.

Initially, I was pretty certain that I'd go into surgery. In fact, I was rather enamored by transplant surgery and had it set in my head that I would do a general surgery residency followed by a fellowship in transplantation surgery. And then, as I often told people in one altruistic breath, I would get African-Americans to sign up to be organ donors and transplant kidneys into my people.

Yup.

You have to admit that it was a rather noble aspiration. At least I think it was. And honestly, my very next rotation -- surgery -- was the polar opposite of that Medicine rotation. Every attending knew exactly who and where we were as students at all times. They called us by name and had expectations of us. Which, now that I recall my experience on that first month of the Internal Medicine clerkship, I recognize as the problem. No one had any expectations of me. So I rose -- or rather sunk -- to that expectation. Nothing.

It only made sense that my academic advisor was a female surgeon. She was kind and attentive and smart. On most days, I wanted to be her. At least, the professional version of her. And I owe it to her for noticing how much I came alive when caring for our post-operative surgical patients on the wards. She pointed out to me that surgeons get excited by the OR. In fact, they can't live without it.

And that statement led to an epiphany for me. One that made it clear that my future career would not involve twirling into sterile gowns in operating rooms.

I chose a combined residency in Internal Medicine and Pediatrics. And never looked back.

I'm reflecting on this on this early morning because many of our students are choosing specialties right now. They're trying to make sense of all of it and working hard to separate the emotions connected to the specific experiences from the actual field itself. And that's hard.

The emotions I had on my Internal Medicine rotation were mostly negative. Not mattering enough to be remembered stung. And that overpowers nearly all of my memories of that time. So very early on, I was certain that no matter what I did, it wouldn't be that. Pediatrics was a mostly okay experience and my feelings working with the Pediatricians were positive. Still, I didn't necessarily feel my heart leaping at the thought of doing it exclusively for the rest of my life. Of all of those clinical experiences in third year, Surgery was, hands down, the one that I always look back upon with warm nostalgia.

Yep.

See, that's dangerous, too. It's dangerous because it can lead a student down a path that isn't theirs to follow. I know this for sure because now, thanks to that caterpillar-attending-dude, I bend over backwards to make certain that no learner on my team EVER feels ignored. EVER. And I recognize that noticing people makes them feel good and brings out the best in them. Which can lead to very positive emotions.

When I meet with students about their career choices, I tell them, "I want you to choose the field that is best for you. So know that it's okay if you change your mind because I did." And I say that part particularly to the ones who come to me with their sights set on Internal Medicine. Which, yes, is super awesome.

To me.

My rockstar-female-surgeon advisor gave me some good advice that changed the trajectory of my career. And I'm so glad she did. In the spirit of that advice, I have come up with a list of my own that I think could greatly help students who are muddling through the emotions-versus-specialty conundrum with career choices. (Perhaps a lot of this can even be applied to selecting a major in college, although we have several engineers and art history majors in our medical school.)

I bring you:

Dr. Manning's SWEET SIXTEEN questions  

for all medical students to consider 

when choosing (or not choosing) a specialty:

1. How do you feel about communicating with people? Do you enjoy explaining and discussing things? Do you mind challenging interactions? In other words, how do you feel about a career that involves a lot of talking?
2. When you went into the OR as a student, did you finally feel at home? Could you be okay with NOT being in an operating room? Does the thought of NOT being in an operating room make you break out in a cold sweat? Do you feel yourself longing to talk to the patient instead of cauterize their blood vessels? Are you okay with taking care of people who can't talk to you at all?
3. Do you have many, many different interests or a few interests that you spend significant time enjoying? In other words, is it more fun for you to hyperfocus on one area or broadly focus on many?
4. How do you feel about children? Particularly ones that aren't related to you? Do you see them in grocery stores with their parents and want to hold them? Are you the person who asks questions like, "How old is she?" or  "How long has he been walking?" not because they have stepped on your foot in line but because you genuinely want to know? Or do you run the other way and (though you hate to admit it) wish there was a "no kid" rule along with the no smoking rule at certain restaurants?
5. How do you feel about procedures? Do you like them? Does blood freak you out? Can you do with out anything that interrupts the skin's integrity or requires a consent form?
6. Are you willing to be on call? Specifically, would you be against someone calling you on a cell phone or pager in the middle of the night because your expertise is urgently needed?
7. Do you prefer longitudinal relationships with patients or are you okay with short glimpses into the lives of many people? For example, were you constantly wondering what happened to every single person you saw on Emergency Medicine and did you often find yourself reviewing the electronic medical record long after the encounter?
8. Do you like things that get your adrenaline pumping? Does the thought of jumping from a plane or bungee-diving from a bridge make you want to vomit? Or does that make you squeal with glee? Now--translate that to a specialty. How do you feel about high stakes, high paced medical care? Does it excite you or overwhelm you?
9. How confident are you? Some specialties require a lot of it. Just saying.
10. How do you feel about bodily fluids? Not just blood, but all of them? Totally, completely grossed out? Or "meh"? 
11. How do you feel about working with the nether regions? Oh--not clear enough? Does it completely mortify you to examine a tender testicle or to explore an agonizing anus? There is a lot of reward in making people feel better when they have problems below the waist line--but it ain't for everyone.
12. Do you love medicine? Not Internal Medicine, per say, just . . . medicine? Do you feel like it is what you were meant to do? Like, if you won the lottery and you were fully trained, would you go in to see patients the next day? Or would you give the office and hospital the same middle finger that I considered giving the caterpillar-attending way back when?
13. After answering number 12, ask yourself this: How hard are you willing to work? Is it your expectation to be gone every single day by 2PM? Are you (though you hate to admit it) kind of lazy? Or is your mantra "go hard or go home?" 
14. Are you okay with fields that involve high incidences of death? Are you okay with managing problems for which there is no known cure to date? 
15. How do you feel about research? How do you feel about teaching? For each of those things on a scale of one to ten for "OMG-yes-I-love-it"-ness, what would you give them?Also, how do you feel about practicing in rural or international settings? Apply that scale to that as well for both of those settings.
16. How do you feel about taking care of poor people? How do you feel about taking care of rich people? How do feel about taking care of very, very poor people? How do you feel about taking care of very, very rich people? (These are things you ask yourself and answer to yourself only.)

Oh, and you probably noticed the absence of the money-slash-earning potential questions on this list. My feeling is that, in general, all physicians make "good money." Now. How you define "good money" is personal. It's up to you to decide whether or not that will be factored into what you do. It wasn't a consideration for me, but I acknowledge that that's just me. I don't judge anyone who feels differently because at the end of the day, all anyone can be is happy.

Ya dig?

Now. After exploring these sixteen questions (which YES, I KNOW were far more than sixteen)-- you will find that voila! Some work environments and specialties will be narrowed down, nixed or frontrunners for you as a result. Next, schedule a meeting with a trusted advisor to help you explore this some more. The key is to tease the emotion away from the "real" parts. And yes, the emotions could be because of things on that list of questions, but you just want to be sure that -- good, bad or indifferent -- it isn't because of. . . . . well. . . people or a person. Especially the "indifferent" part. Does that make sense? I hope so.


Hmmmm.

You know what? I just realized something. That caterpillar-eyebrow attending did teach me something. He taught me what not to do with medical students. And now that I think of it, he changed the trajectory of my career, too.

That's all I've got this morning. Pass this on to a medical student. 'Cause you know I love the kids.

***
Happy Sunday.

Now playing on my mental iPod. . . ."Emotions" by Mariah Carey. And yeah, she was speaking of a different kind of emotion, but you get the picture.