Choosing a specialty? Now?

In a professional context, I was recently asked about my goals for medical school, and what specialty I'm considering...now.  Specialty choice?  I haven't even moved out of Schenectady, much less begun at AMC!  But as it stands, today, here are my thoughts:


Ideally, I'll ultimately find a specialty that will:

• provide me with professional and personal fulfillment/challenge with regard to the work itself, 
• afford me a lifestyle that will allow me sufficient flexibility to be a wife and mother, and 
• generate enough income so that my family and I will be able to live comfortably.

Other thoughts:

• I figure that my dad may want me to assume responsibility for his patients/take over his practice at some point.  (I am not sure about where I stand on that at the moment.  It's an established practice, which is helpful in a lot of ways and has its own merits, but I may not end up in OB/GYN.)
• To date, I have done major volunteer/internship work in an STD/ID free clinic, a peds private practice, L&D/maternity floors, and a peds ER.  By virtue of these experiences, I have some insight into those specific specialty areas.
• Purely in terms of interest, I have always felt attracted to specialties involving babies - specifically, fields involving neonates, and the field of obstetrics.  To that end, I may need to spend some time in a NICU in order to learn more about the practice of neonatal medicine.
• I am currently unsure about whether I want to pursue surgical training in whatever specialty I may choose, although I am certainly open to considering it.
• I would also like to explore my options in emergency medicine and critical care.

Time shall tell...

God shows up

It's important, especially in the midst of sorrow and trial, to remember the good things, too.

I just finished listening to a presentation on the history of physician involvement in prison torture.  I won't...can't...say much else except that there were visuals.  Which is why I'm grateful to God for what happened next:

I went upstairs and grabbed a table so that I could try to "emerge", so to speak...and had barely been sitting here for five minutes when another student approached me on his way out for lunch.  TP is a retired family medicine practitioner, silver-haired but still remarkably sharp, and I've found over the past week that he has contributed much to discussions simply by virtue of his extensive life experience.  I haven't spent much time actually talking to him.  But today, he gave me a bit of a shocker when he just walked up to me and said:

"So when you eventually become a doctor, just remember the old guy who was in a class with you once...because I'll be one of your patients pretty soon."  At this, I began to stammer in my self-deprecating way, whereupon he cut me off and continued: "I have to say that I'm really impressed with you - the way you answer questions, the compassion in your heart, your kindness toward everyone you meet."  "But you've only known me for a week!" I exclaimed.  His reply: "But I can tell already...and I can't wait to be your patient."

Wow.

Running

I'm in full flight...I have been, for a few days now.  Hiding, turtling, and then feeling alone - I wonder when that will make more sense to me.  For now, it just seems like the usual paradox.

I read this morning that "oftentimes when love hurts, we shut down and stop feeling.  We blame and get angry.  And in those times, we often miss the one thing that we ought to be doing.  Trusting in God that He will provide for our every need, knowing that He is in control of our lives even when our lives seem so very out of control.  Our issues do not shock him...it is okay to be angry.  It is okay to hurt.  It is even okay to be angry with God.  What is not okay is to sit in that anger; to remain in that place...when love hurts, where do you run to?  Where do you hide...is it in the promises of the One who created you and knows your every hurt, even when you aren't speaking to Him?  When love hurts, to whom do you run?"

Well, that pretty much sums it up.  I haven't been speaking to Him because prayer, at its core, is honesty about Him and me, with Him and me.  I don't feel ready to be honest, because this kind of honesty is something I imagine to be a Pandora's box of sorts - open one issue, and the whole lot come tumbling out.  Perhaps it will be better for me in the end, but right now...well, it's only been a month.  It's okay to grieve a loss (although I mustn't stay in this place forever, like D keeps saying.  I must not...yet it feels impossible to move.)

Father, I'm sorry.  You scare me.  Approaching You scares me.  Give me this day my daily bread...in time, I'll try harder to come back.  In the meantime, I count three people who I can talk to - thank You for these three.

Bearing all things

I've had nothing to say for the past few days...not to myself, not to anyone else, not to God, not to anyone.

It's been a month.  One long month.  I have a little more than a week left on campus, and exactly a month left in New York.  My eyelids are heavy...dim with tears and emotional exhaustion...so I'm trying to remember, as the hymn says, that there is "grace that is greater than all [my] sin".

Grace, grace, God's grace
Grace that will pardon and cleanse within
Grace, grace, God's grace
Grace that is greater than all our sin


I know that if I ask for Your pardon, You will give it, and give it freely...for that, I'm grateful.  I wish it meant something more than just a Biblical truth, though.  D says that even after you've asked for and received forgiveness, you may still have to live with the consequences of your actions.  That's pretty much where I am...I need Your forgiveness to mean something in my heart, in my bones.  Help me, please...show me that You're more than words, more than verses and ink on page after page.  You have to be more than that, right?  Father God, I read and hear and understand (sometimes) that love bears all things...and I would concede these things, give you my yoke and take your burden (or whatever the verse says), if I trusted that You have my best interests at heart.  I confess that I don't trust You like I should...I don't love You like I should.  My greatest love is reserved for people, and that's wrong...so I need You to help me change that, because loving people - loving a person, caring through pain and awful ache - is hurting my heart.  And that's not how friendship is supposed to work.  It's not supposed to hurt like this.

Medicine = art

Today, Prof. V spent some time talking about how “modern” medicine used to strive for the objective judgment of fact; medical professionals used to believe that medical science held all of the answers about what therapy might be best for any particular patient in any particular situation.  I think that there is some comfort in this kind of scientism, but am glad that things are moving toward a more complex view of patient care.  Scientific inquiry begets facts, which I think should be relegated to objective thought – not the subjective decisions that characterize patient care.

I agree with Prof. V in that therapeutic choices are, by nature and necessity, value judgments.  It’s easy to criticize physicians who take aggressive or even unpopular approaches to patient care on the grounds that they should only be making strictly evidence-based judgments.  But if that’s all physicians were allowed to do, I would suggest that that’s cookbook medicine.  Patient care must not be reduced to flowcharts and algorithms…and I don’t say that just to make myself feel better about the huge investment of time and effort involved in my career choice.  I say it because medicine is, first and foremost, an art.  It’s an art of making responsible, considered value judgments that maximize benefit and minimize (or at least, manage) risk, all the while with patient care retaining top priority.

Prof. V made one distinction today which bothered me a bit; he spoke about the complexities of what defines a patient’s well-being, namely the different “spheres” (i.e. physical, mental, emotional, spiritual, social).  He posed the following question: is the physician’s goal and duty to maximize a patient’s physical health, or his total welfare?  I understand that focusing on the latter seems to put the physician beyond his sphere of expertise...that for example, a chaplain could be a more appropriate professional to consult about matters of spirituality.  However, a sole focus on physical issues feels like a cop-out.  Just because a holistic approach to care is more difficult doesn’t mean the physician should avoid it; in fact, I think that that’s the most responsible way to practice medicine.  People are more than just their bodies, and a physician’s duty, in my eyes, is to care for the whole person.  I realize that this may be a naïve, idealistic goal, given the economic and time constraints of practicing in the US, but even if I can’t achieve this end, I’m definitely planning to aim for it.

I believe Prof. M to be the most effective lecturer of this seminar (so far); generally speaking, his talks feel most applicable to my career trajectory, and I find that no other professor has been as good as he is at teaching me to formulate, substantiate, and defend my arguments.  I am learning a great deal from him and feel that he is a great asset to this class.

Prof. M made the valid (albeit loaded) assertion today that the idea of rationing healthcare violates the ethical principle of integrity – that is, practicing medicine according to intellectual standards of evidence-based medicine that put the patient’s interests above all else.  My immediate reaction to this was, “How does one then respond to the argument that rationing is necessary in a society like ours, where resources are limited?  That’s a nice ideal toward which to strive, but what do we do in real life?”  I was impressed with the answer I received: that instead of focusing on rationing and its pros and cons, healthcare professionals should be focusing their energy on reducing waste and minimizing regional variation in patient care.  His comments on how we should be studying medical processes with the people executing said processes (in order to reduce spending overall) reminded me of Atul Gawande’s The Checklist Manifesto: How to Get Things Right.  In this brilliant book, Gawande informs us about how he used a tool as simple as a checklist to bring various processes of patient care under scientific discipline.[1]  Indeed, this is candor at work; medical professionals would do well to take a step back once in a while, look at their failures without judgment, and subject said shortcomings to scientific inquiry in order to improve patient care.

In discussing the ethical principle of compassion, I raised my concern about emotional distance…and true to form, Prof. M reminded me of Gregory’s emphases on “steadiness” and “tenderness”.  I don’t think that I will have any problem treating my future patients with tenderness, but steadiness is a different story; I will have to work actively to cultivate that virtue, and I can already tell that this will be an uphill battle.  Even the film (i.e. not a firsthand encounter) about Dax Cowart’s pain and suffering left me significantly shaken.  I wonder how experience will teach me the practical distinction between hard-heartedness and necessary distance, as well as the one between debilitation and empathy.

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[1] Gawande, Atul.  The Checklist Manifesto: How to Get Things Right.  New York: Metropolitan, 2010.