Today I met with the Administrator of the MSTP program. It was a great conversation. Very useful. And it confirmed some of the things I've been thinking about career-wise for myself lately.
The long and the short of it: How am I going to integrate my research career with clinical medicine? What type of residency / fellowship should I plan on doing? What programs have people who are interested in the types of problems I have been researching? What programs have jobs for people like me?
I know, graduation's still 4 years away (well, a little less now....). But I really do have to decide what type of residency to pursue well in advance of that.
Here's what my final year will look like:
Final Year of Program
Apr - wrap up dissertation
May - defend dissertation (c/b April)
Jun - clinical elective
Jul - clinical elective
Aug - clinical elective
Sep - clinical elective
Oct - elective? step 2 CS if not already done
Nov - Dean’s ltr out Nov 1; elective? research? interviewing? step 2 CK if not already done
Dec-Jan - interviewing (and elective? research?)
Feb-Apr - bioethics, CSI, elective? research? etc
May - graduate
I'd like to know a year in advance of the final year what type of residency I'd like to pursue. This is to give me the chance to do some clinical time on a regular basis with a faculty mentor in my field of choosing. The idea is a) that I will look like less of an idiot when I rejoin clinical medicine, and b) I'll have someone who would (I hope) be willing to write me a letter of recommendation. That choice needs to be made in less than 2 years. (One if I'm going to do the PhD in 3 yrs.... which is probably not going to happen, haha.)
!!!!
And how will I do that if I'm not actively in the clinics, you may ask? Well, I can go shadow, I can attend grand rounds and seminars in the departments I'm interested in, I can do something (shift? shadow? both?) in the ER or MICU, have coffee with various people who work in different departments, network, etc. My assignment from this meeting was to actually set something up for myself that is oriented towards figuring out what field I want to pursue each and every week.
AHHHHH!!!!!!
I think it's going to be a good idea, but I am a little terrified for some reason!
So let's do a quick rundown of the fields that are still on the table:
1. Neurology -- I love neurology. I love the nerds who go into it. I love the imaging, the path, the fact that there's a lot of medicine, but the focus is not on gout and CHF. I love the neuro exam and the anatomy. But the problem is, I'm not sure most neurologists really "get" what I do. I've talked to them, and told them what my research is in, and I get a "huh, I don't know what that is, and I don't care to" kind of attitude. I get this a little less with the clinical researchers, but even most of them are more basic science oriented. And while it's true that it means the field is wiiiiiiiddddeeeee open, it also means that there may not be any jobs available doing research in what I'm interested in. And THAT could be a big problem down the line.
2. Internal Medicine -- I loved my sub-i, but I did not love my medicine rotation. And unfortunately, it was mostly because of the people I worked with. Even more unfortunately, that trend has continued somewhat since I started my PhD. Sure, there are medicine people I really like, but a few of the fellows who do the specialty that I am most interested in my department seem to have gone out of their ways to be dicks to me. And I'm sorry, it's really a turn off. But on the "pro" side, I love taking a history, coming up with an assessment and plan, and then following the patient through a hospital stay. I love the social issues. I love that you have to know a bit about everything. And for my research -- my research IS general internal med research. I know for a fact that there are people who have the kinds of careers I want who are internists. There are jobs. And also? People in IM "get" what I do. That's a huge plus.
The next question with IM is: If I were to do IM, then what kind of fellowship would I do? Would I want to fast track (trade a year of residency for an extra research year in fellowship)? Can you even do that with critical care? Would I want to do a general internal med fellowship like my mentors from U Chicago did? And also, if I did any of this, would I like the people in IM better at other institutions? What institutions would that be?
3. Emergency Medicine -- Better lifestyle than IM, and the people are a lot of fun. I love being in the ED. I love being in the hospital at wacky hours. Also, there is a sh*t-ton of clinical research done by ED people who actually have the time to do it! The injury epi people in my department are some of the coolest people I've met at my institution, and I would love to collaborate with them, should my life go down that path. I also love that you do procedures in the ED, and that you see such a wide variety of patients. You have acuity, and you have primary care for poor people who can't get it elsewhere. You even have a bit of peds. The only issues are a) I like talking to my patients, and there's not so much time for that in the ED, b) they mostly stabilize and leaving a lot of the differential diagnosis part for the medicine folks upstairs. On the other hand, I love the pace. Something to think about anyway.
4. Psychiatry -- You all know how I love this field. The quirky doctors AND the quirky patients. But it has some of the same problems as Neurology has. I also worry that I'd miss the rest of medicine.
5. Anesthesia -- Has fallen on my list somewhat. The problem is that I really like critical care, and most doctors who do this do it via IM. That is because, once you've trained to be an OR doc, why would you want to do 2 more years of fellowship to take a 100K pay cut and work longer hours. Also Anesthesiologists don't get to talk to their patients. Well, at least not how I want to talk to them. I do so love taking that history and writing that plan! And there's the problem of getting protected time to do your research. Since Anesthesia is so well reimbursed, hospitals tend to prefer that you spend your time in the OR rather than doing research. This isn't a universal truth, but it is true a lot of places.
And God, then we started talking about where in the country I would do residency/fellowship. While I network, I guess I also have to figure out where there are jobs. What institutions are interested in people who do the kinds of research I want to do.
Can I get another AHHHHHHHHHHHHHH!!!!!!!!!!!!!!
Of course this gets even more complicated with the husband in the picture, because we need to ultimately find him a job wherever I go as well. Ok, scary thoughts. I don't even want to think about it right now!
I really should get back to my SAS.
10 Pearls of Wisdom:
We do something similar with the clinical mentor at my program, given that most of us choose to do 3rd year before joining a lab. In fact, we're encouraged to pick a clinical mentor as soon as we're post-candidacy.
I'm with you on the specialty indecision as well. Right now it's great because all my classmates are picking and applying and I get to put it off!
Wait, you can leave IM residency a year early for fellowship?? I never heard of that. I might not have quit my IM residency if I could have done that....
Yep, it's called "fast tracking." You have to get admitted to the fellowship when you apply for residency though. I have several friends who are doing this. You end up doing an extra year of fellowship research. It's very popular among the mud-phuds.
You love the social issues in IM? Really? It really sounds like anesthesia would not be a field that you'd enjoy, because - honestly - most of us don't like to talk to patients that much. That's why we like them asleep or really gorked.
I know RAG. I also know you're not the only one who feels that way. It's been a reservation of mine for some time. I've been told that I should just give it time, and I will stop enjoying the patient interaction, but it hasn't happened yet. Hence the consideration of other fields.
I hesitate to comment because this way beyond my experience, but as a layperson, I imagine that MD/PhD's would be able to use both of their degrees to the max if they went into experimental medicine, which would benefit those patients who have tried everything else. That seems like an immensely gratifying endeavor because it's like you're on the cutting edge of medicine. If you succeed you publish papers. The dark-sided benefit is that if you fail, all those before you have as well.
I don't know too much about it, but it's now legal (or whatever the term is) for EM people to go into a critical care fellowship; they don't need to do IM first. I'm just saying!
If you find that you're liking the interactions, despite what everyone is telling you, then I think your going to like them no matter how long your involved. I wanted to do EM, Peds, Surgery, and once IM. It took me a while, but I figured out what I liked and didn't like about medicine. I wish I had more control over the OR and didn't have to be treated like an interchangeable cog in the OR at times, but I like having some interactions, but not entirely. I honestly like being able to take care of something right there and then - so anesthesia fit for me.
Though I will admit, what you're trying to do would scare the hell outta me. So much of my "suggestions" are more from the "What is that?" or "What grant?" type thinking. Basically ignorant...
From the psychiatry aspect, there are a lot of epidemiology questions and colleagues who will get what you want to do. You probably will miss the medicine aspect of it, but there ARE jobs. And people will LOVE you if you know the statistical models for epi research, although you might get frustrated that they DON'T. Just my 2cents.
I gotta put in a plug for emergency... I would actually argue that we do a huge amount of the interesting differential work downstairs and leave a lot of the boring management stuff to the hospitalist.
Just yesterday I had a 35 y/o guy crumping in one of our front rooms with low O2 sats and sudden onset of tachycardia. Slapped an ultrasound on his chest to find that he had acute right heart dilatation, which I guessed (correctly!) was due to a PE. By the time we got him up to CT after giving him lytics we realized how lucky we really were... he had thrown a massive saddle PE.
But yes, absolutely the downside to EM is that you can get so busy that you don't have time to talk to patients. On good days, though, it's the most rewarding field in the world. This morning in the peds ED I diagnosed one kid with omphalitis, and the next with acute appendicitis. Super interesting day.
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