Introduction to "Pathways Through Medicine"
The First Installment of NextGen's "Pathways Through Medicine" Series
"Infinite Opportunities": The Decision Tree
One of medicine's many appealing characteristics as a field is the diversity of pathways that a life in medicine can take. Dr. Nancy Oriol, Dean of Student at Harvard Medical School, asserts that, "in medicine there are infinite opportunities to do anything you can imagine." However, understanding and navigating these pathways can be challenging. Medicine is a rapidly changing field, with new specialties and disciplines emerging as new breakthroughs in research and technology appear almost daily. Furthermore, the decisions made along the way to and through a career in medicine are not always intuitive, and the diversity of options open to medical professionals makes it difficult to map out or visualize all of the possibilities.
Nonetheless, the Next Generation's new series aims to demystify these pathways, laying out a "decision tree" with the help of medical school deans and professors, medical career advisors, physicians, and the student doctors still journeying along their particular pathways. Over time, we will fill in the decision tree with profiles of specialties, physician advisors shedding light on major junctions in the road, and students talking about their training experiences along their chosen path.
The basic structure of the decision tree is formed by at least three major junction points: choosing residency programs for medical specialties, entering fellowships for subspecialization, and finally, finding a career in the broad field of medicine. Throughout the lengthy process of education that links these junction points, student doctors learn about their choices in many ways--some better than others. Many choose to shadow physicians; others follow patients. Students interested in combining clinical practice with research can both shadow a physician-scientist in the clinic and work alongside him or her in the laboratory. Coursework, clinical clerkships and rotations within medical school introduce some specialties. Some new initatives such as Harvard Medical School's Premedical Institute and Mentored Clinical Casebook projects or the "narrative medicine" programs at several medical schools aim to provide students with a more realistic, in-depth, and reflective look at what it means to be a physician and what specialties might be most fulfilling. Finally, senior physicians acting as mentors can be medical students' best sources of experienced advice and insight; while the experiences of older physicians may not be directly relevant to the medicine of today, their years of experience in the practice of medicine make them valuable advisors to people just beginning a life in medicine.
The Problem of Planning Ahead
While different approaches will work for different individuals, Dr. Oriol emphasizes that in general the decision-making process in medical school and beyond is not always conducive to planning. Learning and career opportunities can arise unexpectedly, whether through connections with people in different careers or through new developments in the field of your interest and in medicine as a whole. In fact, it is commonly said that medical students generally change their mind about their specialty half a dozen times or more before finally choosing their field of practice.
Furthermore, many of the current ways students are exposed to fields of medicine may not show them what working in that field would actually be like. In traditional medical school curricula, the first and second years are devoted almost entirely to a kind of "extreme premedical education" through classroom-based science. During the first two years of medical school, students have doctor and patient contact to the extent of shadowing, taking histories, and learning the basics of interacting with patients. Medical school experiences may include either shadowing a doctor, following a particular patient, or occasionally both; however, the crucial patient-doctor relationship often remains poorly understood. By the time students begin to apply to residency at the end of their third year, they have typically experienced only one year of clerkships, and even these emphasize practice within a field more from the perspective of interns and residents than from the attending physicians who have worked in the field for years and are in charge of their team. Students may be drawn to the scientific and medical "content" of a particular field, but have little understanding of what their experiences would be as a physician in that specialty.
It might seem that advice from senior physicians would be invaluable in making these decisions, but ultimately it can only be one part of the puzzle. Dr. Oriol cautions that, due to the rapid "rate of change of reality" in the field of medicine, the experiences of professors and mentors may not relate to contemporary and future experiences in the same field. She relates a story from her own experience as an anesthesiologist, in which she and her fellow senior physicians were frustrated and resentful about the new requirements for doing paperwork; the interns, by contrast, took the task in stride as simply a part of how medical care was delivered because they had never experienced it any other way.
Serendipity, Reflection, and Exposure
If it is impossible to plan ahead or trust any single source of information while making decisions about what paths to take, how can students make sure they are making good decisions about their futures? Ultimately, Dr. Oriol stresses that openness to new opportunities and influences, and even to chance encounters, is essential. The "premed mentality" may lead students not only to plan everything out in advance but also to adhere to that plan blindly and stubbornly. Instead, student doctors must be flexible and reflective. Senior physicians, fellow students, friends, and family members may mean well when praising or criticizing a particular specialty, but in the end it is a student's own interests and desires that must be followed, and young doctors need to find ways to listen to themselves as well as to others. This often means being open to changing plans in response to serendipitous discoveries, such as when one student uncertain about her specialty choice suddenly realized that, a year later, she still remembered every bit of information from her obstetrics rotation because she had found it so fascinating.
Like learning a foreign language, getting past superficial understandings of medicine and its specialties requires an immersion experience. Dr. Oriol paraphrases the famous adage, saying that to understand a doctor's life you must "walk a mile" in his or her shoes. New programs are responding to this need by providing a more profound introduction to the subtleties and complexities of medical careers. The Harvard Premedical Institute, a pilot program for high school and college students, provided these students with an intense immersion experience through a week of realistic simulations using a robotic mannequin designed to mimic the human body's appearance, functions, and responses. Students kept personal journals for extensive reflection on their experiences. Harvard's Mentored Clinical Casebook program matches first year students with a single doctor-patient pair to follow throughout the year; they learn everything possible about the patient and then write a book addressing every aspect of the patient's health and life circumstances and how they interrelate, including the basic science and the influences of the patient's family, insurance, employment, and more. Narrative medicine programs in several medical schools encourage students to reflect on their medical experiences through writing, gaining deeper insight (See Narrative Medicine with Rita Charon). Finally, "enrichment projects" available at many school provide credit and/or pay for research projects in basic and clinical science or even relevant community service experiences. A project like working in a clinic in rural and other physician-need areas or volunteering for national and international community public health projects may be as close as a medical student can get to experiencing life as a physician before they get their M.D.
The medical field encompasses a wide variety of career possibilities, and students who are interested in taking their future careers into fields beyond clinical practice may wonder how to go about bridging between medical school's scientific and clinical training and other areas such as policy, industry, teaching, administration, business, government, or law. The answer, Dr. Oriol says, is to "invent your pathway." While getting joint degrees, either by applying to joint degree programs when beginning medical school or pursuing additional degrees after finishing an M.D., obviously provides the knowledge and experience necessary to enter combined fields, these programs also provide invaluable connections to people in the field a student will work with, learn from, and discover new opportunities through. Even students pursuing just an M.D. or M.D.-PhD., however, should not feel they are cutting themselves off from the possibility of branching out in the future by making connections with people working in fields beyond medicine: as a physician, Dr. Oriol notes, "your world collides with these people," and being exposed to new career possibilities can be an ongoing process for a physician.
Navigating Along the Decision Tree
The network of pathways through medicine as we have introduced it here is undeniably complex, and as the Decision Tree is filled in readers will be able to watch the myriad options unfold at every step. There is no one way to approach this decision-making process that is right for everyone, but there are a few things that any future doctor can do during his or her medical training to make the process of exploring pathways through medicine a fruitful one.
First, it is important to reemphasize the value of keeping one's eyes open to all possibilities and opportunities during medical school and beyond. Dr. Oriol feels that it is all right to develop a strong, impulsive inclination towards something--heeding "gut feelings," after all, is a way of listening to your own instincts about yourself--and it is okay to make decisions based upon these strongly felt impulses and interests. However, she says, after the decision is made one must be able to "wipe away the fantasy" to be able to see the reality for what it is, rather than blindly following along on a particular path without engaging in sufficient self-reflection at each step. This self-reflection is an important chance to become aware of one's own interests, feelings, and desires, not just the well meaning but potentially misleading advice of family members, friends, senior physicians, and fellow students who may view choices from their perspective rather than from yours.
Second, recognize that the pathways through medicine are not set in stone, and that changing one's mind down the road is neither impossible nor a total waste of time. While ideally you will have made wise decisions and chosen the pathway for you the first time around, it is possible to change fields and specialties later on, and while you may lose some time in backtracking you will never lose the knowledge you have already gained. You may even gain an advantage by becoming a unique commodity with your combination of knowledge and training: for example, a general surgeon who has extensive previous experience with pediatric physiology may be especially well prepared for a career in pediatric surgery.
Finally, be aware that the field of medicine is changing rapidly, and adapt accordingly. It is easy to be disappointed when your experiences of a field are very different from what a senior physician had described, but being able to recognize the role of change and to be flexible with your plans and expectations will allow you to find the field that is truly right for you, whether or not it is the one you thought you wanted to enter all along. Ultimately, no one source, including this series on Pathways Through Medicine, has all the information you will need to make these decisions. Our goal is to offer you as much information and advice as possible from as many sources as possible; after that, it is up to you to discover which pathway is the best match for you.
Click here to visit the decision tree.
Miya Bernson is an Associate Editor of the Next Generation and a member of the Harvard College Class of 2006. Lester Leung is the Editor-in-Chief of the Next Generation and is also a member of the Harvard College Class of 2006.
Nancy Oriol, M.D. is the Dean of Students at Harvard Medical School, addressing issues such as the professional development of medical students, including career path and choice of specialty. She was the director of obstetric anesthesia at Beth Israel Deaconess Medical Center in Boston for fifteen years, and remains an active member of the department. She is also an associate professor of anesthesia at HMS. Other professional activities include the founding and leadership of the Family Van, a mobile public health outreach program serving economically disadvantaged areas of Boston, and research and innovation in obstetrics.