It's less diagnostician and more proceduralist for sure. Look in the eye (or at the OCT/retinal image), see the problem, operate to fix it. Very little pontificating about differentials or waiting on any labs/imaging. But it is all yours start to finish - nobody else really knows how to use a slit lamp or lenses or interpret Ophtho imaging, so as easy as it might be to glance in and know what's wrong, it's only you that can do so. And then the procedures themselves are hella cool, even the bread and butter stuff like slurping out cataracts with phacoemulsifier is much cooler in my opinion than the bread and butter of most other surgery.
As you can probably tell I was considering Ophtho for a bit. Clinic was the dealbreaker for me, it's an absolute slog of 4-5 patients per hour for 8-9 hours, each one just a quick glance on the slit lamp and then entering all the values and a few sentences into the EMR.
I didn't realize that Ophthalmologists see so many patients in one day. This large patient volume was actually one of the things that tore me away from Family Medicine, as I don't enjoy writing copious notes while the patient is speaking to me.
Critical care does some procedures and you’re the primary physician for the patient (ie you do the work up and sometimes have to look for zebras). You’ll also feel like a part time palliative care doctor with all the family meetings and goals of care discussions.
any surgical field will involve some work up and a lot of uncertainty and decision making. I welcome the slam dunk appendix/gallbladder consult. A lot of my practice is going through less obvious presentations and deciding who needs surgery and who doesn’t. If I take someone to surgery too soon I can hurt them. If I wait too long they can become septic and or die. I wish it was as easy as you suggest with the diagnosis made before someone calls me. I’ve had to ask for a cardiac/pulmonary/Hepatology/hematology work up before taking someone to surgery.
also, most fields of medicine the diagnosis or at least diagnostic pathway isn’t so mysterious. You develop an approach to problem X and you order the pertinent work up and then the diagnosis is “made for you”. In surgical fields once we arrive at a diagnosis we at least get the fun of operating to reach a solution rather than just ordering a medication or another consult.
my advice: pick something based on the diseases you’ll see and “typical” workflow and maybe even outcomes. I’d never be happy as a rheumatologist or neurologist. I came to medical school thinking patients will come to me with a problem and leave “fixed”. Most medical specialties don’t cure problems they just manage them. I get to cure appendicitis, Cholecystitis, necrotizing soft tissue infections, perforated colons, perforated ulcers, small bowel obstructions, hernias, etc. Of course, I still see many patients who don’t have a “fix”, but I usually make my recommendations and leave if there’s nothing to fix surgically.
I rotated on a critical care service with lots of rounding and discussion of patient pathology. I found it fruitless after awhile however, as even after a lengthy conversation about a patient we would usually decide to slightly tweak the electrolytes or nutrition. The lack of progress of patient healing didn't appeal to me, and really turned me off of ICU.
Thank you so much for clearing up that misconception about surgery! I can see why diagnoses aren't all clear cut and decisions need to be made based on limited information. I like it.
I agree with the sentiment regarding being able to do something about the diagnosis once you find it. I'm concerned that the appeal of thinking through problems will become mechanical once I see them enough times, and being able to actually do something about it is huge.
By picking something based on diseases that I see, do you mean focusing on pathologies that I find genuinely interesting, or the solutions to the problems? I've loved the cardiovascular system from day 1, but I don't find managing HTN particularly interesting. While I don't see the prostate as the most interesting organ, TURP's are very satisfying to watch.
Thanks for your input!
So you like diagnostic workups, procedures, continuity of care, and seeing results from your treatment plans. It seems to me like you want to be some kind of proceduralist.
There are lots of specialties that fit this description, both surgical and non-surgical. The biggest decision you now have to make between surgical and non-surgical pathways to being a proceduralist is whether or not you are willing to continue overseeing the care of patients with vague symptoms of non-diagnostic nature (POTS, IBS, Fibromyalgia) or medical issues without a defined anatomical etiology.
As a surgeon, you will almost always have the ability to say "no." For example, a patient gets referred to a surgeon for abdominal pain/diarrhea/nausea/etc of unfound etiology. Without a clear cut anatomical cause or procedure that could address the issue, a surgeon can sign off care, stating that there is no procedure to be done. Surgeons perform diagnostic workups and procedures for anatomical issues, establishing continuity of care for mostly post-operative patients only, and frequently see results from your treatments.
As a non-surgeon, you will more frequently have to continue caring for patients with vague symptoms or undiagnosed medical issues. Once you prescribe a medication for a problem, you are the physician overseeing that patient's issue, even if there is no diagnostic or anatomical basis for it. While a gastroenterologist gets to do procedures, they see many patients with medical issues not initially treated with surgery. While this gives you the ability to perform diagnostic workups, and establishes continuity of care, it potentially removes the gratification of seeing your treatments work.
TLDR:
If pursuing a specialty with procedures, surgeons can say no to overseeing the care of patients with vague medical issues for which there is no surgical treatment. Non-surgeon specialties that do procedures see more patients with chronic issues for which there are no procedures to fix them.
I'd definitely prefer to see patients with a specific pathology that I can either manage to an imperceptible level or outright cure.
I get the sense that although I do enjoy making differentials and workups, it ultimately becomes mechanical over time, which is why I'd like both a significant mind and brain component to the specialty I pursue. Mechanical thinking gets old after awhile, however, there's a certain satisfaction of performing a mechanical activity with the hands that I find really satisfying.
I didn't even think about the ability to say "no". Autonomy is something I greatly value.
Thank you!
I'm an internal medicine resident starting a primary care job in a few months, so this is definitely biased, but it sounds like internal medicine may be a good fit for you, particularly primary care if you really value having long-term relationships with patients. As an outpatient medicine physician, you often are the first to encounter an undifferentiated patient and have the ability to work them up and treat them to your heart's desire until you are out of your wheelhouse and need specialist input. Even if they end up under the care of a specialist, you continue to follow that patient, because they are ultimately your patient. Oftentimes, after the specialist starts treatment and the patient is stabilized, they will punt them back to you to continue managing that specific problem. You follow them through initial work-up, diagnosis, treatment, and, if it comes to it, end of life planning. Procedures are there if you want them, though admittedly not as much as, say, a surgeon would do. Still, small office-based stuff like I&Ds, arthrocentesis, skin biopsies, etc. are easy enough to pick up if you target your rotations/training right and the office you end up in is supportive of it.
Honestly, I think the best part about it all is those appointments where you have a patient you know coming in for a routine follow-up with not much going on, and you just spend 15 minutes shooting the **** with them about their grandkids or whatever.
While I do enjoy relationships with patients, I also really like to fix serious problems that the patient may have. I think my love of problem solving and fixing outweighs my love of longterm patient relationships at this moment. This of course could change in the future though! Thank you for your help!
Can you clarify what you're looking for a little bit? Workup-treatment-results-followup sounds like basically all of medicine. The only fields that come to mind that don't fit that are radiology and pathology and I guess PM&R. Every service that offers a treatment also works up conditions that require that treatment—that's the beauty of being the expert in your field.
Could you provide some examples of what you don't want to go into?
Here are some that I've rotated through and decided they weren't for me:
Psychiatry: Lots of patient interaction, however, psychiatric disorders did not seem very interesting to me. I enjoy fixing things using pathophysiology of the disease, but psychiatric conditions bore me.
Neurology: Great ability to workup a condition, but not much you can do in terms of treatment. Once someone has a TBI or stroke chances are they'll never be the same. If I can't fix or significantly help the health problems of the patient's that I see I'll feel like a failure.
Family Medicine: Lots of patient interaction, however, far too many patients in one day for most places. Also, patient compliance is a huge issue, and if a patient doesn't see something actively causing them distress their compliance decreases.
