How Doctors Choose a Specialty

People sometimes assume that every doctor feels a calling or has a special
skill for one area of medicine or another. But the truth is very
different for most doctors.

Old operating theater in London
Wikimedia Commons (Mike Peel, CC BY-SA 4.0)

When students begin medical school they don’t actually know what medicine entails. Maybe they’ve followed physicians around or worked in a lab. But that is completely distinct from being
in a hospital for twelve to fourteen hours a day writing notes, calling
consults, rounding on patients, operating, or delivering babies. And even
when young students do see these things, they
usually watch from afar and don’t fully understand what’s going on. The
hierarchy, the language, and the rapid exchange of information remain a
mystery.

Nevertheless, matriculating medical students still have ideas about what
specialties they want to practice. Walk around an auditorium during an
orientation and most budding physicians will say they’re interested in one
field or another. This is completely understandable; something motivates
people to apply to medical school. I thought seriously about
becoming an emergency-medicine doctor. I had worked as an EMT in New York and loved the excitement of
emergencies, the rush of adrenaline, and the range of patient presentations.
But I didn’t really know what it was like to work in an emergency room for
a twelve-hour shift.

Once medical school starts, things slowly change. As they study the
biological systems and dissect in the anatomy lab, some students realize
that they now feel dispassionate towards what they once loved. Suddenly, the eye
or the heart or the skin is not as interesting as the lungs or the brain or
the intestinal system. Granted, this is all still theoretical — it
is early, and the students have not been inside the hospital yet. But inklings
arise and ideas take hold. I enjoyed many of the educational blocks during
medical school and even had a particular affinity for hematology and

gastroenterology
, while taking a dislike, surprisingly, toward neurology (I am now a
neurology resident).

It is during the

third year of medical school
when professional ambitions take shape, as students work in the hospital and
clinic. They rotate through general surgery, psychiatry, emergency
medicine, and neurology, among other specialties, getting a quick but deep
sense about how these areas work. They participate in surgeries, clinic
appointments, and

hospital codes
. Decisions about a future specialty often form during these samplings.

But there is often much more to those decisions. I liked nearly everything during third year. I found the
operating room fascinating. You stand at the operating table and
assist the surgery residents and attending as they open up the
patient and take out parts of the intestine or the gallbladder. You
peer into a living human body in real time. You see the problem; you fix or
remove it; and then you sew the patient’s skin back together. Other
specialties are similarly awe-inspiring. On my obstetrics rotation I

delivered babies
. In the emergency room, I participated in

trauma codes
and watched the effects of

treating drug overdoses
. There is so much to marvel at in medicine that each rotation is appealing
in some way. How can a student settle on one specialty?

When faced with this impasse, another deciding factor is often
a teacher or mentor.
After all, the word “doctor” comes from the Latin verb docere, which means “to teach.” The degrees we receive when we graduate from
medical school read M.D., or Medicinae Doctor — “teacher
of medicine.” So when we speak of a

doctor’s purpose
 it is implied in the word that the purpose is not just to heal the sick but to teach the
next generation of doctors, and also one’s patients. Notice this passage from the

Hippocratic Oath
:

I swear by Apollo The Healer…. To hold my teacher in this art equal to my
own parents; to make him partner in my livelihood; when he is in need of
money to share mine with him; to consider his family as my own brothers,
and to teach them this art, if they want to learn it, without fee or
indenture; to impart precept, oral instruction, and all other instruction
to my own sons, the sons of my teacher, and to indentured pupils who have
taken the physician’s oath, but to nobody else.

Image via Flickr

These lines that deal with the doctor-student relationship come before the parts about
the doctor-patient relationship. It is one of the few professions left in this country that
still functions as an apprenticeship (somewhat similar, in a few respects, to being a Ph.D.
student under an adviser). One studies a specific topic very intensely for
an extended period of time with a group of professionals who teach you how
to do what they do. This means that who teaches you matters as much as what you’re
taught.

When I rotated through neurology, the subject area excited me, but I was particularly impressed by everything about
the doctors. They took the time to explain things to students, which in the
busy context of the hospital and clinic isn’t always a priority. They
treated patients with great respect and kindness. They knew an impressive
amount about the subject and beyond. I felt inspired. Though many
other physicians in internal medicine, pediatrics, and elsewhere were
similarly impressive, my experiences were more mixed in those departments.
This at least was my unique experience; colleagues of
mine reached different conclusions.

The physician teachers also affect the culture of each department. For example, emergency medicine doctors are frequently seen as adrenaline
junkies. They love going rock climbing, bungee jumping, racing in triathlons,
and so forth. This is not true across the board, but one likely finds a
higher proportion of people who have those hobbies in emergency medicine. Specialties fit certain personalities or interests. I found that more
neurologists shared my interests — many of them study human consciousness,
autonomy, and free will, which tie into my fascination with the humanities.

The last element that helps medical students choose a specialty is
lifestyle, or how much time one has outside of the hospital. Surgeons
seemingly live at work even when they’ve graduated from residency programs.
Surgeries can be long and tedious; unexpected disasters occur during
operations; patients need emergency surgeries; and many post-operative
patients need close monitoring to make sure there are no complications. Pediatricians, by contrast,
tend to have much more normal lifestyles. They can work in an outpatient clinic
from, say, 8 a.m. to 5 p.m. Any child with an emergency goes to the emergency room, not
to the outpatient clinic, and pediatric patients tend not to have as many
chronic, difficult-to-manage illnesses as adults (like heart disease or high blood
pressure). Pediatricians focus more on preventative measures,
such as well visits and vaccines. As a pediatrician it is much easier to keep up with
family or hobbies outside of medicine. I loved surgery, but I could not see
myself putting in the hours to do it every single day for the rest of my
life. Neurology, on the other hand, like pediatrics, often involves a more
balanced lifestyle.

And this is how we choose: subject material, mentor and teacher experiences,
department personalities, and lifestyle. But the truth is that
many of us who go into medicine could be happy in a number of specialties,
which is an important perspective to have. It means that we love, broadly,
the subject and practice of medicine, and that our curiosity about disease
processes and treatments does not start and stop in one specialized silo or
another, just as most diseases do not stop in one body part or another. It’s what makes medicine such an enthralling and difficult field.

Residents and Rounds

Doctors practice “grand rounds,” ca. 1920s.
(National Library of Medicine)

This post is meant to provide a bit of background about how the day works and how a medical team functions so the references I make in future posts are clear. Let’s begin with the team. Nearly every medical team at an academic hospital consists of an attending physician, residents, interns, and medical school students. While these terms might sound familiar to anyone who has watched medical dramas on TV, it’s likely that most people don’t know what they mean. The attending physician is a bit like a tenured professor. He or she has the most experience and training in the operating room and the clinic, and has graduated from medical school, residency, and, in most cases, a fellowship program.

The residents, having graduated from medical school, are also physicians but, being less experienced, are “attendings-in-training,” learning the craft of a specialty via instruction from an attending physician. Residents are classified by the number of years they’ve spent in training, and different specialties will require a shorter or longer residency: there are chief residents (the most experienced residents), fourth-year residents, third-year residents, and so forth. Then there are the interns, physicians who have just finished medical school and are spending their first year out of school rotating through different specialties, learning how to enter orders for medications, writing progress notes on patient care and discharge notes to release patients from the hospital, and responding to immediate issues that arise during the course of the day. To do this an intern must know each patient in order to respond to questions about treatment from the patient and nurses.

Third-year medical students comprise the lowest rung of this ladder. We have little to contribute and plenty to learn. Frequently, we are assigned to follow a few patients and come to know as much as we possibly can about them. Once we know everything about our patients, it will be easier for us to think about what is most important regarding each patient’s care. We learn to pay attention to important details.

This team hierarchy, though it may seem stilted, is actually integral to the process of rounds, where the medical team visits each patient in its care. Rounding provides an opportunity for the healthcare team to speak with patients about how they are doing, to look at and physically examine them. The physical part of the exam is fundamental to healthcare. The abdomen, for example, can feel distended or stiff if there is a certain pathological problem, such as a bowel obstruction. Only by palpating — touching the patient’s body — can we know this. One cannot assess a patient’s progress until one examines a patient.

There are two official times to round during the day. One is immediately upon arrival at the hospital without the attending physician. This involves residents and medical students. And the other is with the attending physician later in the morning. While shuffling between different floors and patients, the hierarchy remains eminently clear. The attending physician leads the charge and behind him or her follows, in order of experience, everyone else: the third-year, the second-year, then the interns, then the medical students. There are usually about eight of us rounding together; to an untrained observer, we might look like the motorcade of a foreign diplomat. We all squeeze into each patient’s hospital room as the attending physician conducts the interview with the patient, assesses the patient, and tells the patient what the team’s plan is over the course of the day: Will a new medication be prescribed? Will the patient finally be able to eat food? Can the patient only drink liquids? As the attending explains this to the patient, one of the interns runs over to the computer inside the patient’s room and enters in the new medication orders or dietary orders. And on to the next patient. Over the course of the day, the new orders are confirmed and reconfirmed with the attending and upper level residents,

This daily pattern of rounding is actually a tradition as old as the American hospital system itself. In earlier days, there was a system of apprenticeship. So, if you wanted to be a physician in late-eighteenth-century America, you would be apprenticed to a doctor who would teach you all that you needed to know. You would then probably be offered a partnership with your teacher. But as the hospital and medical school system took root in the early nineteenth century, students pursued learning opportunities in hospitals in order to receive a more thorough practical education en masse. Individual physicians, after all, had very little time to apprentice aspiring doctors, and frequently the knowledge you received depended solely on one person. In order to teach medicine, hospitals created special programs where students would, as they do today, pay a fee for a basic science education (meaning anatomy, physiology, and pathology) and, eventually, a clinical one as well. Students rounded with residents (also known as house staff) and attendings in order to receive this practical experience in patient care. One description of rounds in Massachusetts General Hospital by Dr. James C. White in the 1850s sounds eerily familiar to me:

[The attending physicians] pass from bed to bed in the large wards, the students following. The house [officer] narrates any incidents in each patient’s condition during the previous twenty-four hours; the physician asks questions, makes the necessary explanations, and directs treatment. Over new and interesting questions much time is spent…. Students have nothing to do with the investigation of cases; they have only to look and listen.

My theory about this process as an educational tool is that it is suited to the role of each member of the team. The upper-level resident should be learning how to dictate orders and take charge of the team because soon he or she will be in that position. The attending, who knows this process well, educates the upper-level resident on whether the plan of care is correct and guides the fourth-year or chief resident. The mid-level resident follows closely on the heels of the upper level because he or she will soon occupy that position. And the interns need to learn how to manage patient care on a detailed level, writing notes and orders to improve at compounding a ton of information into a paragraph or two and assessing doses and units of medications.

And we, the medical students, observe and listen and ask questions when we can. Our purpose is to learn the language by observing patterns in patient care and disease. Thus far, it’s difficult to tell whether this strategy is working; it sometimes feels like I am back in French class on the very first day, listening to a language I’ve never heard before regarding dosages, plans of care, boluses, IV infusion rates, and so forth. But it is also comforting to know that this process has worked for more than a century and a half, and so perhaps we third-year medical students are right where we should be.