Choosing Residencies

Just when you thought that your decision to pursue a medical education was challenging enough, medical school introduces you to a whole new set of possibilities and life decisions to be made. Last time, we spoke with Dr. Nancy Oriol, the Dean of Students at Harvard Medical School, who helped us grasp the complexity of the decision tree and understand the need to stay flexible and open to new experiences that might help us discover possible career paths we might not have previously considered. This time, we spoke with eight medical students, residents and physicians who discussed with us the experiences that brought them to their residency programs and to their fields of medical practice.

Developing Interest

"General surgery appealed to me from a young age," states Dante Foster, a fourth year medical student at Harvard who is currently rotating with the transplant team at the University of Washington in Seattle. Having been hospitalized for traumatic pancreatitis during her youth, Dante was deeply impressed by the care given to her by the surgeons. Sarah Billmeier, another fourth year medical student at Harvard, was also introduced to surgery from the patient's perspective as an athlete and an amputee.

On the other hand, many physicians don't find a specific field that suits them until they embark on clinical rotations, a portion of the medical school curriculum that typically occurs during the third and fourth years of medical school. Wally Bethune, a fourth year medical student at Harvard who is entering an anesthesiology residency program, says that rotations give "as accurate an idea as you can possibly get without actually practicing in each field. During medical school rotations, you do a combination of shadowing, supervised reading and research, and actual help with clinical work - including interacting with real patients. So you're usually pretty sheltered from some of the nitty-gritty and from some of the more unpleasant 'scutwork' tasks that interns and residents have to do, but overall you do get a pretty reasonable idea, in broad strokes, of what each specialty is about."

Wally continues, "The third year of medical school is key! Before then, you think you know what different fields are like, but you really don't. Only during third year clinical rotations, when you actually spend time with residents and attendings practicing in each field, do you finally start to appreciate the many nuances of life in various specialties." Anne-Marie Wills, an M.D. from Columbia University's College of Physicians and Surgeons and a graduate from a neurology residency coordinated by the Massachusetts General Hospital and Brigham and Women's Hospital, suggests spending at least one month rotating through every field that you have any interest in. Furthermore, both Anne-Marie and Wally emphasize that the process of elimination is useful in selecting a field of medicine to pursue.

It is important for prospective medical students to realize that there are always people who are willing to help them along the way. All eight of the physicians and physicians-in-training we interviewed expressed great admiration and gratitude toward their mentors in medical school. Sarah says, "Mentors both on the attending and resident level have been extremely valuable in helping to navigate through the sometimes difficult process of deciding what direction to choose." Dante describes those who guided her: "I was blessed with three excellent mentors. The first is a giant in the field who stopped operating approximately 10 years ago. His vigor and passion are still very much in action, and I benefited from his tutelage while a part of the Cambridge Integrated Clerkship last year. The second is an active general surgeon whose love for her job and family are equally obvious. She was a gracious teacher and honest role model who took time to discuss the challenge of balancing family and surgery. The third was actually a primary care physician whose commitment to teaching and feedback did two things. First, he gave me the best primary care experience possible. Second, he pushed my physical exam and diagnostic skills to new levels while encouraging me to maintain diagnostic and therapeutic vigilance no matter what field I end up in. Each of these people contributed to my decision making process and was equally supportive of the various possibilities I entertained. They are all happy with the decision I ended up making."

Keeping an Open Mind

Medical school holds many surprises, and it's important to keep an open mind. Clinical rotations, by themselves, are not reliable as a singular source from which to determine one's interests, asserts Jennifer Pippins, a recent graduate from a combined internal medicine-pediatrics residency program at Brigham and Women's Hospital in Boston. "While overall very helpful, they do fall somewhat short in giving students a true sense of what a career in that field will be like. During rotations, one spends a lot more time in inpatient settings, and one's models are often physicians-in-training. It is important to balance this experience with exposure to physicians in the field who have completed their training, and with exposure to physicians who practice in a variety of settings, in order to make a truly informed choice." Furthermore, the opportunities that best fit your interests may be difficult to find at first: Jennifer had strong interests in both internal medicine and pediatrics, and she struggled with the prospect of making a decision between the two disciplines. However, Jennifer's persistent interests paid off: "It all finally came together when I did my internal medicine sub-internship at the end of my third year of medical school; my senior resident was in the combined internal medicine-pediatrics program. She was a wonderful role model and this prompted me to settle on combined internal medicine-pediatrics as a specialty choice."

Canh Vu, who finished his residency in psychiatry last year and is now an attending physician at Beth Israel Deaconess Medical Center in Boston, originally thought he wanted to practice in cardiology or internal medicine. He found that he didn't like what either set of doctors did. On the other hand, Canh describes his first rotation in psychiatry as part of a consultation service as a "disaster of a time," spent studying patient records and attempting to help patients without spending much time speaking with them. However, during his second month in psychiatry, Canh was assigned to an inpatient unit, and he found that he greatly enjoyed talking to patients without the immediacy of life-and-death issues found in other fields. It was only a small part of his rotation experience, but it was enough to draw him in: "You may not find something that you love every aspect of, but it may be that several little things combine to make the job rewarding." Later, discovering that medical schools are often willing to accommodate students who are seeking new opportunities and taking the initiative, Canh requested that his school create a clinical elective in outpatient psychiatry to continue developing his interests.

Furthermore, many attractive aspects of a field may not factor into one's preconceived notions of that discipline. Wally didn't know anything about anesthesiology before he was exposed to it briefly during a surgical rotation. He explains, "Some people think that if you're an anesthesiologist, you don't have to be good with people because all your patients are asleep. Nothing could be further from the truth! Just think; if you were about to undergo a big operation and you were meeting the person who would be taking care of you while you were unconscious and helpless, wouldn't you want that person to be someone you were comfortable with? In order to allay patients' fears and anxiety before operations, anesthesiologists must be not only knowledgeable and able to answer people's questions about what to expect before, during and after various operations, but they also should be generally calming and reassuring types."

The "Me" in Medicine

While most students who enter medical school bring with them a strong desire to help others in need, it is also important for medical students to be reflective and attuned to their own interests and needs. Each discipline has a different approach to the delivery of medicine and deals with different uncertainties.

Madina Gerasimov, a third year medical student at New York University School of Medicine, plans to apply for a residency program in cardiology, a field that matches her approach to other challenges in life: "The reward is either almost immediate or is very tangible and concrete. Of course, the price of a mistake is devastating, but I know I will be making a difference in a major way." Furthermore, Madina admired the attitudes of cardiologists: "I felt some sort of camaraderie with the cardiologists because of their extremely aggressive attitude towards the disease. I knew I would feel at home with people who want to get the results and get them fast. Their mentality, even the criteria the cardiologists use to assess the outcomes of the pharmacological interventions (e.g. Do we make people live longer? Do we make people live better lives?) were close to my ideas of what medicine is about. Their promises to the patients resonated with my own goals."

Anne-Marie found her fascination in the way the brain works to be a driving force in her decision to pursue neurology: "The brain is by far, hands down, the most complicated, important, and miraculous part of the human body. Studying the brain is like a concrete, scientific version of studying philosophy and art, since everything we perceive and think and do is through this organ. It's really gee-whiz stuff, like people who have strokes and don't realize that half of their body is theirs, or people who see imaginary creatures when their sight is gone. Other things that I like about it: I think the brain is beautiful when you see images of it, especially with these high-Tesla MRI's that we now have. I also like the fact that we have a lot of treatments for a lot of diseases."

Michael Singer, currently a resident at the Massachusetts Eye and Ear Infirmary, was disillusioned as a third year medical student with the lifestyles of doctors he observed. During his surgery rotation, he was required to be on call every third night, and he spent most of that time doing menial tasks. However, a colleague suggested he consider ophthalmology, and Michael found that ophthalmologists were said to be the happiest of doctors. He thus chose to do a rotation in ophthalmology, and this experience solidified his decision to pursue a residency in this field. Michael emphasizes, "It's not just an academic decision, it's a lifestyle decision. See how happy people are [in the disciplines you are considering]." Sarah, reflecting on her choice to pursue general surgery, suggests, "Lifestyle considerations are important; however, I would rather work hard and love what I am doing than have more free time and a less satisfying career."

Marta Gorczyca is a Writer of the Next Generation and a member of the Harvard College Class of 2007. Lester Leung is the Editor-in-Chief of the Next Generation and a member of the Harvard College Class of 2006.

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