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

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

, 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

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.

Olfactory Adjustments

There’s no question that one of the most difficult things to get used to about the hospital is the smell — or, rather, the smells. This is especially true on a surgery service where many patients undergo multiple operations. Some need a leg or foot amputated. Others need open abdominal surgery and can’t control their bowel movements afterwards. Some patients’ intestines cannot absorb fat, leading to oily stools which give off their own distinct and foul odor. And still others have abscesses, or deep bacterial infections, which need to be cut and drained. It’s impossible to know how to react to the offending smell. Mostly, in the presence of these stenches, I control my desire to run from the room and, stoically, attempt to breathe through my mouth. But the smells are potent and dehumanizing. Empathy for these patients is difficult to find when one’s visceral desire is to sever the olfactory nerve which transmits smells to the brain. One encounter in particular is burned into my memory.

The Emergency Department had called the surgical team to see a patient who had a deep abscess. An abscess initially develops with some kind of break in the skin: an insect bite or a cut. And these infections are usually caused by specific bacteria called Staphylococcus aureus, though other bacteria can be involved. Our body’s immune cells wall off the infection, thus creating a pocket of pus and inflammation. Because it is walled off, antibiotics can’t reach the site of infection, so the only treatment in most cases is an incision of the abscess, draining of the pus, and allowing the incision to heal. If the abscess goes untreated, the infection, despite being walled off, can still spread. Some of these bacteria infect and consume flesh and produce gas as they disseminate.

The patient in the Emergency Room had a severe abscess that was far advanced. He had noticed a fever and some tenderness and redness in his lower abdominal area a week earlier but had not thought much of it. As the week went on, however, this area of redness grew and he decided to come to the ER. I felt awful for this young man who had assumed whatever this was would go away.

On entering his room, the smell hit me. There is nothing comparable to it. It took every effort to restrain myself from coughing — my sympathetic flight response had been turned on: my heart began to beat faster, I began to sweat, and I wanted to run. Never in my life would I have guessed that such an uncontrollable visceral reaction could occur because of a smell.

Alas, this seems to be a common theme throughout the history of medicine. Louisa May Alcott, author of Little Women, volunteered as a nurse during the American Civil War and wrote Hospital Sketches, a compilation of reflections on her time in the hospitals. She explains exactly how it feels to deal with the potent smells: “The first thing I met was a regiment of the vilest odors that ever assaulted the human nose, and took it by storm. Cologne, with its seven and seventy evil savors, was a posy-bed to it; and the worst of this affliction was, every one had assured me that it was a chronic weakness of all hospitals, and I must bear it.”

Our patient’s skin in the affected area was lucid. I could peer through into his body and I watched as air bubbles and pus percolated in the tissue. Because of the diffuse infection, he had to be taken to the operating room immediately in order for the dead tissue to be cut out. This was the only possible treatment — even with the medical miracles we possess, the scalpel is often still the best treatment.

In the operating room (OR), we put our masks and gowns on and the nurses coated the front of our masks with Starburst-scented cream to overpower the stench. We were like Alcott: “…armed with lavender water, with which I so besprinkled myself and premises.” Four of us — two medical students and two upper-level surgical residents — huddled over the patient’s body, cutting away skin and fat and flesh as warm pus poured out of the infected area, which overpowered the smell of Starburst, rendering our substitute for lavender water completely useless. But, there was no “out” here, no excuse to leave the OR. It had to be done, as the situation, in Alcott’s words, “admonished me that I was there to work, not to wonder or weep; so I corked up my feelings, and returned to the path of duty, which was rather ‘a hard road to travel’ just then.”

Thankfully, the patient ended up being ok — no vital organs were touched by us or by the bacteria. We had come very, very close to the inside of the pelvis with its reproductive organs, but all was safe and well. However, the smell lingers in my memory. Now, whenever I encounter an unpleasant smell in the hospital I compare it to the abscess. No smell is quite as awful and dehumanizing as the shock of the first one. Perhaps it was the unexpectedness of it that caught me. And, of course, I remember Alcott and what she must have faced in an understaffed, overburdened Union Army hospital in 1862. Her words admonish me that I am here to learn and help where I can and not to wonder or weep.