Anyone want to listen to me ramble?

[Teufelhunden]

Well, if you read the title and clicked anyways...you've been warned.

So far, I have been really disappointed with medicine as an "intellectual" field. I am a very intellectual person, and medicine (so far) seems very un-intellectual.

Please don't misinterpret this statement. I by no means feel that I'm exceptionally intelligent. I'm actually woefully average in the IQ department. However, I am "intellectual" in the strict definition as I greatly enjoy the study, reflection, and speculation of a wide array of topics ranging from philosophy to religion and politics.

My favorite courses (as well as my strongest subjects) in college were all math related, i.e. Calculus, Physics, Discrete Math. I'm also one of the weird people who loved organic chem.

Conversely, I hated most Bio classes that involved rote memorization of facts. I mean, I'm the guy who set the curve in my math and physics classes, but barely got a C in Bio II because I couldn't memorize all that crap.

Okay....so y'all can probably imagine how much fun I had my first two years of medical school where rote memorization was rewarded above all other attributes. In fact, the only attribute awarded in medical school is rote memorization, which by the way I believe is partially an innate gift (that I don't possess), and partially a function of work ethic. As far as the latter goes...it was always a struggle for me to make myself study, because I HATED the type of studying you have to do to be successful on med school multiple-choice, fill-in-the-bubbles tests. I found that type of studying to be boring, above all else. And, when I find something boring, it takes an enormous amount of self-discipline to do it well.

Well, my performance tells the story. Although we don't rank in our school, my test scores pretty much hovered right above the mean. Keeping with that tradition, I scored in the 51st percentile on the COMLEX.

Now as a MS-III, I admit I'm much happier with my day-to-day; however, I still see very little "intellectual" work in medicine.

Here's are some observations I've made so far in my very short medical career. Please don't feel I'm attacking any of these fields...I admit my exposure has been very limited. Let's just say that these are my "first impressions" based on what I've witnesses thus far.

Surgery - A very egotistical bunch. Very mechanical, detail-oriented, abhor actual patient care, but love the OR. The surgeons I've witnessed actually seem to very much dislike many of their patients, as observed from their banter in the OR. Surgeons seems to be a very non-intellectual bunch. The talk in the OR seems centered on college sports and talk of how incompetent other doctors (read: non-surgeons) are. Surgeons seems to love the OR, but hate every other aspect of their job (pre- and post-op care, etc.) The residents bitch constantly about how over-worked they are, how they have no free time, how they never see their family; however, they seem to almost brag about these things as some sort of badge of honor. It's almost a "I can suffer more than you, therefore I am better than you" attitude.

Ortho - OMG! Take the ego factor of surgeons and multiply it by 1,000. The orthos at our hospital act like a H.S. football team, i.e. lots of locker-room humor. I've actually heard homophobic jokes made in the OR. They talk sports incessantly. The field itself seems to be the most mechanical. Seems they see their patients as just a means to an end, i.e. they seem them a opportunities to use their cool toys and make bucks. Also, the majority of my fellow students who want to be orthopods are egotistical, former athletes who are abrasive and insensitive.

Family Practice - For the most part, family docs seem genuinely interested in their patients' well-being. Very much "people persons." A high emotional intelligence ("EQ" as some call it) seems to be quality most of these docs possess. Many are family oriented, and value their time off. Many, however, are bitter as they feel the system is screwing them the hardest. I love the variety that an FP sees, and think I'd enjoy the broad knowledge base, i.e. being able to dx and at least start treating almost anything.

Anesthesia - Laid back. A lot of really cool personalities. Heavy physiology and pharmacology (which I like). However, they seem very removed from patient care. Heck, they even seem far removed from the actual practice of anesthesia as they seem to be more like "managers" of the anesthsia department than anything else, i.e. managing the CNRAs. Seem to be a happy lot, however not my idea of practicing medicine.

Internal Medicine - A really damn smart group of people, however they seem unhappy. These residents at my hospital are highly intelligent people who seem to hate every minute of their existence. Medicine seems very interesting and challenging, and appeals to me on many levels. However, I just can't get over how unhappy these people seem. I know the surgical residents are miserable, too, but at least their eyes light up when they get to cut. Conversely, I never see the medicine residents' eyes light up.

OBGYN - I've posted on other threads extensively on how I feel about OBGYN. It's probably the most intersting field to me, personally. However, the abysmal lifestyle, malpractice crisis, and trend of pt's to prefer a female OBGYN are all scaring me away from this field. BTW, the 'abysmal' lifestyle quote is directly from an OB attending. Not exactly a ringing endorsement.

Pain Management - I did a month of 'Pain' and absolutely loved it. I liked the procedures (epidurals, blocks, etc), and even enjoyed the office work and consult stuff. The pain docs I met had wonderful personalities and seemed driven by a genuine desire to alleviate patient suffering. I also enjoy the psychosocial aspects, and feel there's room in the field for an even more multi-disciplinary approach. Although, I'd never do anesthesia, I would consider a Pain fellowship via another route (PMR, Psych, maybe even neuro).

DERM - these residents are the happiest motherf*ckers in the hospital. Heck, why shouldn't they be? Great field, i.e. great pay, great hours. What else would you want. Too bad I'm not even close to being competitve enough for this field.

RADS - Another group of seemingly happy people. I like the math and physics aspect of rads. I think I'd really enjoy the procedures...and like pathologists, being an integral part of making diagnostic and prognostic decisions. But again, I'm not even in the ballpark of being competitive enough for this field.

Psychiatry - I'm on my Psych rotation right now. I'm on an inpatient service in an inner-city hospital, and so far, am blown away by how much I am enjoying it. I even enjoyed the PGY1 didactics the other day! I find the field fascinating, however....I've always had one big issue with psych: It seems like a waste of medical school. I mean, if I pursued psych as a career, 99% of everything I learned (and will continue to have to learn) becomes almost utterly worthless. Maybe I just don't understand the field, but it seems a general medical education is an enormous overkill. That time could have been much better spent studying pyschology (as a basis for understanding pyschotherapy). I don't have an issue so much with the MS-I and MS-II years as I do with III & IV. I mean, if you know you're going into psych, wtf is the point of a 4-week ortho rotation?

Anyway, of what I've seen thus far, Psych seems the most intellectual of all the fields. I'm not saying they're any smarter than anyone else, just that they definitely seem to fit the definition of "deep thinker" more than other specialties.

So, I'm starting to lean towards doing a combined residency in FP/Psych, although I'm not certain as to what sort of career that would lend me to. Could I split my practice between the two? Know anyone who does that?

It's funny, if you would have asked me two years ago what the two fields I was least likely to go into, I would have probably said FP & Psych.

Anyway, making a decision on which field to pursue is terrifying to me. I hear stories of people doing 2 years of some residency only to switch to another. Hell, in my own hospital I've already heard of two people who completed one residency, only to immediately start over in another (IM --> Derm & Surg --> OBGYN). I do not want to be one of these people. Heck, the psych intern I'm with did 6-mos of an OBGYN internship, quit, took a year off, and is now a psych PGY1. Hell, there's people on this forum, like Foxxy, who are thinking of jumping ship.

I just want to get this right the first time around. I'm too old (32) to be one of these resideny-switchers. So, I guess what I'm asking for is general advice. Given what I've said above, are there any fields besides FP & Psych that I'd probably be a good "fit" for? Maybe something I haven't even considered?

Maybe my expectations of medicine were unrealistic from the start. I think that's true for most of us in varying degrees. But, given that I'm already well invested in this process, I'm trying to find the field that is the perfect match.

I, very recently, btw had a paradigm shift in that I used to dismiss the lower-paying specialties. However, I now don't really care about the money. Life is too short to be miserable, and if I end up hating what I do everyday, all the money in the world isn't gonna help.

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[doctor4ever]

During my third year I made some of the same observations as you. I saw lots of docs working crazy hours making tons of money, but had no family life. Many divorced more than once. Some constantly talked about malpractice risks and lower compensation.

I'm applying to psych this year. If you're thinking about psych, you should do a rotation in outpatient. It's a good way to see what everyday psych is like.

 

[mpp]

Have you done a neurology rotation yet? It seems like you'll love it. From my limited experience it is very, very intellectual. Since you seem to like radiology, you'll look at a lot of films in neurology. You deal a lot with interesting patient care since many of the conditions are chronic. There are some 'procedures' such as EMG and EEG. The pay is decent, the hours are good (as an attending), and the demand is high. It is not all that competitive of a residency to get into. Good luck...

 

[willow212]

Interesting post!

I was also disappointed during some 3rd year rotations at the lack of opportunities to use intellectual power.

I didn't expect medicine to be as protocol-based as it is. And I didn't know to what extent radiologic and laboratory studies make careful differential diagnosis and physical exam less important.

Be that as it may, I think that most jobs (inside or outside medicine) will become intellectually routine after a point in time (and perhaps should, as patients want your clinical decisions to be made without much agonizing thought...) Becoming involved in research, teaching, etc. in any field seems like a good way to stave off boredom.

But you're right - I think some fields lend themselves more towards creative thought, if that's what your looking for. One of my priorities in choosing a specialty was intellectual challenge, and for me, psychiatry meets that need very well.

At risk of sounding defensive, I thought I would address your concern about wasting your medical education if you become a psychiatrist.

When I first thought about doing psychiatry, I myself struggled with this question. After having gone through several rotations and speaking to other people in the field, I feel much less concerned about this issue. Sure, I'm not going to need to know the details of every rotation I did during med school. But there are reasons that psychiatrists go to medical school.

Part of it is so that you understand pharmacological treatment of other diseases and potential interactions with psychiatric meds. Another part is so that you can create a good differential diagnosis for patients who present with psychiatric symptoms (some of whom may have a purely "medical" cause for these symptoms). And of course, there are fields like consult-liaison where you need to know a lot of medicine.

Granted, some psychiatrists choose to become full-time analysts or to practice only psychotherapy in other forms; these few might better have spent their time studying psychology. But I don't think this is the majority of psychiatrists.

More intangible is the thought process that we develop through the medical school process. How many of us use the knowledge we learned in our undergraduate classes? Yet most of us would say that our ways of thinking were very much affected by the experiences we had in college. So while I can't explain exactly how my ortho/ob-gyn/etc rotations will be helpful in my practice as a psychiatrist, I'm not sorry to have gone through them.

As far as FP/psych, don't know much about it - it would be interesting to e-mail some recently graduated (or about-to-graduate) residents at a combined program and see what their experiences and opportunities are. With other specialties, I know even less, but my guess is that the current residents at your school would be happy to talk with you about their own decision-making processes.

Good luck with deciding on a specialty - definitely a scary process! Don't know if it will be reassuring to you, but I found that after doing a few additional rotations in different fields, the decision was easier to make than I thought it would be. Also, it was great to talk to residents about the process, as many of them had similar anxieties and can remember what it was like to be in my shoes.

 

[bartholomew]

I would suggest you explore MPP's suggestion regarding Neurology...While it isn't focused upon the psycho-social elements of psychiatry or family practice, in my opinion, it seems considerably more intellectually fulfilling. Physical diagnosis is incredible in this field, you review radiological films as an integral part of your practice, and your foundational knowledge encompasses a great deal of medicine in general.

 

[Gator05]

***SPOILER ALERT-House of God***

I'm reminded of the last portions of the book, where everyone is leaving medicine for, um, another specialty listed by the Marine. They're all so gleefully happy with that decision. I wonder how many Deans across the country scratch their head in wonder each Fall when they sit down with the MS4's?

Has anyone else noticed how little the appelation of these specialties can depend on the actual specialty itself? Moreoever, it seems to depend on who you're working with, the work environment itself, and your patient population.

My biased opinion towards anesthesiology is that it's worth another look. It's one of those specialties that affords you as much or as little time as you like to interact with patients. There's a constant intellectual challenge with each case and patient, as to how you will optimize your "art" to keep them as comfortable and safe as humanly possible. For routine, ambulatory cases, this more towards comfort; for larger peds and cardiac cases, I'm still amazed that the patients survive after what we do to them In addition, the basic concepts of pain and conciousness seem to undergo a dynamic reevaluation whenever new agents or combinations are brought to practice.

In the end, I guess it's all of what you make of it. A friend opined that there is probably more than one specialty out there that is suitable for each of us; this is comforting. Finally, as we keep moving through different life stages, the benefits and detractors may change quite radically.

Tef, enjoyed reading your post, and look forward to reading about future thoughts by you.

 

[augmel]

I've talked to a few people about combined programs in psych and medicine or fp. All of them have said the same thing, and that is it is too difficult to stay current in two very different fields unless you want to spend all your free time reading journals. Their other, and maybe more significant, complaint is that you end up being an fp who is really good at the psychosocial aspects of that field, or a psychiatrist that is great at dealing with medical comorbidities of their patients. There may be a few jobs out there that allow you to really practice the full breadth of both fields, but no one around here knows about them.

 

[prominence]

Teufelhunden, as a current MSIII, I fully agree with your observations. I too am considering pain management. Good luck with your application process.

 

[beyond all hope]

Dear folks,

I had come to very similar conclusions during med school. You have to realize that the first time you hear your internal medicine professor explain congestive heart failure it sounds fascinating, but the 1000th time you give Lasix and O2 for someone who forgot to take their meds it's not so interesting. 90-99% of anything you do is simple repetition.

As you get experience, you start to see patterns in anything you do. That means that you're more qualified to treat the patient, but the experience is less novel to you because you've seen it a thousand times before. This is true for all specialties, including psych and neurology and IM. A facial nerve palsy is only new for the first hundred times.

Even supposedly intellectual fields, such as philosophy, engineering, and math, have mostly repetitive chores to perform. Only a small fraction of the time are you doing anything new requiring serious creativity or brainpower.

It's a terrible disillusionment for a lot of us, but once you realize that will be the case for ANY field you persue, it's liberating. There is no perfect job where you come up with creative solutions to important problems every day, are persued by hordes of beautiful men/women, get the respect and devotion of your collegues, and come home to your beautiful family every night.

We all just slog through our day like any janitor or advertising executive or telemarketer, have occasional heartbreaks and setbacks, and the even rarer victories. Medicine is no more glorified or intellectual than selling toothbrushes over the internet.

Medicine is a job. It can be intellectual, heroic and uplifting. It can also be dull, mundane and backbreaking. What you make of it is up to you.

If you like being intellectual, find yourself a nice cush university setting and teach. If you're a good teacher, you can make Orthopedic Surgery intellectual (a challenge, I'll grant, but I've seen it done.) Do lots of research, read all of the journals, and challenge the hegemony whenever you can. That will give you intellectual arguments to keep you going for a long time.

 

[RADRULES]

Radiology clearly is the one of the most intellectually challenging fields. Sure, in private practice it is all about churning out the work. But if you stay in academia you could do lots of very cool research. If you like physics even better, and many cutting edge aspects of radiology like MRI and PET are the brainchild of medical physicists. You can do a lot of cool research and still read films as a radiologist.

 

[Gator05]

I thought the purpose of extensive training throughout residency WAS to make patient care mundane and routine! Experience is a double edged sword; it makes us good, but it also makes the work, well, routine.

From this month's ASA Newsletter: Good judgment comes from experience. Experience, well, that comes from bad judgment.

 

[notstudying]

Great observations! I had a very similar feeling about 1st and 2nd years, and was very happy to get to the clinical years. I do agree with those who recommended neurology-many intellectual types find it very rewarding.

You have to be a little careful about generalizing your experiences with different specialties to those at other schools. I think many of your observations were right on, but some could vary. I have heard FPs in some parts of the country are very much in demand, and respected, and so might be happier. You didn't mention peds; in some places it has the reputation of being not intellectual, but I'm at a fairly academic institution, and I have been so impressed with the focus placed on thinking and learning at our program. Similarly, I think there are places where medicine residents are actually happy (I've heard the rumor, though I haven't seen one myself ).

Bottom line, do what makes you light up when a patient enters the room, or when you sit down to discuss a case with a colleague.

Good luck!

 

[supercut]

I think there are more highly intellectual aspects of any field. It depends were and how you practice. If you are in academia and running a lab, I'm sure you will find the intellectual stimulation you feel you lack. EVERY field has it's own reseach. Much of immunology research, for example, is done by surgeons... transplantation requires control of the immune system, after all. Also many issues in critical care are immune system dysfunction.
Like primary care? There's still a lot to learn about diabetes, hypertension, obesity.... to name a few.

In academia, opportunites exist for both basic science and clinical research. In clinical research, you could be the one who develops the protocols that then become the standard of care that everyone follows.

Perhaps you should take some time perusing the journals. You might find something that floats your boat. Talk to your attendings about what kind of research is going on in their departments.

As I'm sure you have learned from reading the forums here, choosing what to do is difficult. As is choosing where to do it. Remember that nothing is carved in stone. There will always be a way to change if you discover you made the wrong choice. Try not to put too much pressure on yourself, and keep an open mind

 

[kungfufishing]

I had similar observations 3rd year. The conclusion I came to is that you probably arent going to find a field that allows you to exercise your own creative intellect in the way you really want to. however, the intellectual interests are yours when you are working or not, so perhaps the best thing to do is pick a specialty that has work you enjoy at least somewhat and that will also offer you enough free time to pursue other interests.

 

[Sessamoid]

You've hit upon the downside to practicing medicine pretty well. No matter what field, nothing is going to be terribly intellectually stimulating (unless you're in research). The actual practice of medicine is mostly routine, even in the "intellectual" fields, and that's actually what we strive for. To get good at something, you have to do it with great frequency, which is naturally going to get boring after a while. If you're an intellectual, then you'll probably have to find your mental stimulation outside of work. It's at least more challenging than many other fields.

The observations you've made about the various specialties are pretty accurate as an average in my opinion, but you'll always be able to find exceptions to the rule. A couple of the trauma surgeons I used to work with were pretty well-read, and had some interesting and well thought-out views on a number of topics.

 

[Finally M3]

Glad to see you found something that interests you...

Here's an interesting link to an article from the Washington Post, posted by Loves Chai in the PM&R board...

http://www.washingtonpost.com/wp-dy...-2003Dec28.html

Although the procedural (and hence, financial) considerations of an interventional pain practice seem attractive, the patient set, and the medical-legal climate (did you know you can be sued for undertreating pain as well as being prosecuted by the FDA for overtreating?), I wouldn't touch chronic pain patients with a ten foot pole and a geiger counter.

 

[Nikiforos]

Treating chronic pain patients can be a very ugly experience. Most patients in an anesthesiology pain practice ARE CHRONIC pain patients. At least half of them (probably more) are mentally ill. For many, their mental illness predated any "pain" issues. Their "pain" allows them to seek treatment for a socially acceptable complaint. Our culture still frowns on seeking treatment for mental illness.

It is very disturbing to see pain management specialists doing repeated procedures on these patients. It seems like they are trying to treat mental illness with a spinal injection. Sadly, performing procedures is paid for, treating mental illness is not (or is paid for at a much lower reibursement.)

 

[Tenesma]

nikiforos: it is all about patient selection for your practice

 

[Teufelhunden]

Originally posted by Nikiforos
Treating chronic pain patients can be a very ugly experience. Most patients in an anesthesiology pain practice ARE CHRONIC pain patients. At least half of them (probably more) are mentally ill. For many, their mental illness predated any "pain" issues. Their "pain" allows them to seek treatment for a socially acceptable complaint. Our culture still frowns on seeking treatment for mental illness.

It is very disturbing to see pain management specialists doing repeated procedures on these patients. It seems like they are trying to treat mental illness with a spinal injection. Sadly, performing procedures is paid for, treating mental illness is not (or is paid for at a much lower reibursement.)

This is where I think a Pain Fellowship trained Psychiatrist would come in handy (and why my Pain Mgmt attending thought this will be a new trend, i.e. Psych/Pain). We might be able to eliminate unnecessary procedures and overtreating with pain meds if we'd do a better job treating these patients' concomitant mental illness. In addition, a Psych/Pain doc might be better able to deal with addiction issues if they arise.

 

[Foxxy Cleopatra]

Originally posted by Nikiforos
Treating chronic pain patients can be a very ugly experience. Most patients in an anesthesiology pain practice ARE CHRONIC pain patients. At least half of them (probably more) are mentally ill. For many, their mental illness predated any "pain" issues. Their "pain" allows them to seek treatment for a socially acceptable complaint. Our culture still frowns on seeking treatment for mental illness.

It is very disturbing to see pain management specialists doing repeated procedures on these patients. It seems like they are trying to treat mental illness with a spinal injection. Sadly, performing procedures is paid for, treating mental illness is not (or is paid for at a much lower reibursement.)

This is a very interesting point. Having rotated through neurosurgery, this very much fits the description of many of the chronic back/body pain patients. It is much more socially acceptable to have body aches/pains/"malaise" than to be labeled as depressed, anxious, etc. Makes perfect sense.

Then there's the request for Lortab. Gotta love it when the patients know more about p.o. rx pain meds than the doctor. Makes me feel like the candy doctor when they come to clinic looking for more.

 

[Teufelhunden]

Originally posted by kungfufishing
I had similar observations 3rd year. The conclusion I came to is that you probably arent going to find a field that allows you to exercise your own creative intellect in the way you really want to. however, the intellectual interests are yours when you are working or not, so perhaps the best thing to do is pick a specialty that has work you enjoy at least somewhat and that will also offer you enough free time to pursue other interests.

I'm coming to that same conclusion. Now the challenge is finding a specialty that will give me enough free time to pursue those other interests.

More and more, I'm starting to lean towards FP (the field I swore I'd never go into).

 

[tinwindow33]

if you're looking for time, try physical medicine and rehab, emergency medicine, or anesthesia. If you're a very competitive candidate, try optho, rads, etc.

 

[DoctorDoom]

DevilDog,

You can also pursue some research. Just because the people around you tend to focus in on rote activities (and surgeons often fall prey to the trap of perfecting previously determined technique rather than developing new thought) doesn't mean you have to do the same. Push the frontiers of whatever field you choose by being a thinker and intellectual in that field, if that is what you desire.

 

[Navy Dive Doc]

TH,
Specialty choice was extremely tough for me, I've been there. I thought I wanted to do the FP route, but wasn't sure, liked some other things but nothing struck me as "the one true thing" like a few of my classmates and fellow interns had happen. I did a transitional year with the intention of going to the fleet for a couple of years to figure out what to do. I even tuned down a strong hint that I'd get a residency spot if I applied as an intern. I would highly recommend that same pathway to you, since you have that option with the Navy. Escape the grips of academic medicine, relax and enjoy your 4th year electives knowing you don't have to decide. Do a transitional or an FP internship, the transitional can be built to mimic FP, the FP year counts as a base year for other non-surgical specialties. I'd recommend Trans over FP due to the size of the teaching hospitals. Go to the fleet as a GMO/FS/DMO where you will essentially be practicing FP. See what it's really like, see how the clinic abuses the FP docs. Read how ugly it is in the civilian world in the land of declining reimbursement and the q10-15 min office visit. If you still want to do FP after your time in the fleet, great, you'll be welcomed with open arms. If not, as most of us discover, you're not locked in to a specialty and can pick whatever you like.

I beg you to consider a tour in the fleet after internship, it made all the difference in my life. Be sure your really want to do FP, I admire those who are willing to do it these days but am thankful that I am not one of them. Just my $.02 from the other side of the pipeline.
DD

 

[The White Coat Investor]

I find the intellectual challenge in medicine comes with the "why" I do these routine things, rather than doing the routine things. Every patient with a decent chest pain story that walks into my ED gets an EKG, CXR, an ASA, O2, Nitro, and morphine. It doesn't take much brain power to order that. But interpreting the EKG etc and putting it together with the story to determine if its safe to send the patient home, treadmill her, admit her for a r/o, or call the Cath fellow I find very intellectual. Ad nauseum for dozens of other complaints.

If you think you'll get bored with routine stuff, choose a broad field such as FP, EM, IM, or possibly Gen Surg. If you also want time to pursue your intellectual pursuits, only one of those fields will give it to you.

It sounds to me like you're the research type. Give it a try, you never know, you might like it.

 

[Galaxian]

There is no "perfect" field to go into as far as medicine is concerned. The sooner you stop questing for that holy grail, the sooner you will find something that you can be content with, and that, to me at least, is all that matters.

One thing I would like to add, however, is that I think that the AAMC should really try to create some kind of fundamental change in the curriculum so that students have a better idea of what exactly these fields involve when they are 4th years so that they can make some informed decisions. I really felt like I was making a major life decision based on a rickety database. BTW, I didn't feel like the AAMC's careers in medicine website was all that helpful either.