Friday, April 16, 2010

Guest Post: Second-guessing career choices

As of today, I am one month from adding those long sought-after and hard-earned initials to my name, M.D..  I matched at my number one choice in a very competitive “lifestyle specialty,” have a fabulous husband who has helped me through the emotional turmoil that is medical school, and two young boys who make me laugh and smile every day.  I sit here, where I worked so hard to get, wondering if I made the right decisions.
My grandfather died from CML when I was 6, the years prior to his death being spent meeting his medical needs.  My experience of the impact of illness upon a family drew me toward medicine and at the age of 6 I embarked upon the road to becoming a physician.  While I could not understand this at 6, I suspect now, that I yearned for some power over illness and becoming a doctor seemed to meet this need.

In high school I decided upon pediatrics.  I continued to follow this path, volunteering with pediatric oncology programs and the like.  One summer during college I returned to my hometown and happened to find my way into a women’s health clinic where I served as an intern, counseling women on abortion procedures and birth control.  I loved every minute of it and was eager to learn more so that I could help my patients.  I got involved in activism in a way I hadn’t before.  From the day I started, I knew that Ob/Gyn was my calling.

Halfway through my third year of medical school, however,  I stood in the OR, 33 weeks pregnant, having held a bladder blade for who knows how long, thinking I just couldn’t do this anymore.  My ob/gyn rotation, the 6 weeks I had expected to confirm my career choice, left me wanting.  I hated the OR, I really didn’t want to be like the residents I was working with, I wanted to see my family, and I didn’t want to worry about the malpractice.  The 3 past weeks I had spent on the gyn service had been 3 of the most trying of my education to that point.  The next week I moved on to the OB portion of my rotation and absolutely loved it.  I loved following patients through prenatal care and delivery.  I loved the raw emotion and I never thought of it as work.  I was thrilled to be able to be part of my patient’s lives in such a real way.  Maybe I could do this after all.

My son was born at 37 weeks and after having a placental abruption, I was scared to death of ever being the doctor in charge of a delivery like my own.  I lumped together my loathing of operative gynecology with my new-found fear of the sudden twists a routine low-risk pregnancy can take and decided against ob/gyn.  This, despite my love of prenatal care, primary care, and procedures.  This despite the relative ease I had with the material, my true interest and passion in the field.  My decision was final, I didn’t think I had what it took to be an ob/gyn.  I set about finding another specialty and over the next year and a half (I took 5 years for medical school) flipped-flopped between fields.  My husband calls my decision making process the Hamlet approach, one which I do not suggest to other medical students choosing a specialty.  In the end, after much drama and many second guesses of myself, I landed a spot in Dermatology.  In the end, it was a well thought out, rational decision.   I was thrilled with my match for all the reasons I told myself I should be.   Dermatology offers a great combination of surgery and medicine, plenty of small, what I like to call non-scary surgeries, great pay, weekends to spend with my family, and the list goes on.

One week after my match, my second son was born.  Within a few days, I immediately felt that my decision to go into dermatology was the wrong one.   I felt an immense sadness knowing that I may never be involved in birth in such a personal way.  I cannot be sure what part of this to attribute to the fact that I may not have any more children myself and what to attribute to my second thoughts about my career choice.  I know teenagers can get emotional about acne and that skin cancer is a very real and serious problem, but I have a hard time getting emotional about accutane and imiquimod, in the way I get emotional about abortion and pregnancy.   I have begun to look at the medical journals that arrive in the mailbox in a completely different way.  While I want to read the articles on preterm birth, I feel I must force myself to concentrate on the newest treatments for lice and scabies.   

So it is that I sit here, wondering which would have been the more perfect decision, ob/gyn or dermatology.  Perhaps that is my problem, that I believe there was a perfect solution.   To be honest, my family came first in my decision to pursue dermatology over ob/gyn.  My husband has been a saint throughout my medical education, finding ways to occupy himself as I set about marathon study sessions most every weekend, taking on more than his fair share of childcare duties, and making numerous sacrifices in terms of his career, so that I may follow my dream of becoming a doctor.  I made the decision to become a dermatologist, in part to allow us to have a life with a bit more balance, where he will eventually be able to follow his own career goals.   But as I reflect upon my decision, I wonder if it was actually to his benefit and to that of my children.  Would I have been happier doing something where I did not have to convince myself that my work was important?  If I felt like I was making more of a difference with my work and truly loving it, would I be a better mother and role-model?  Or would the continuous strain on my family and relationship with my husband have outweighed this benefit?

For those who have lived through this decision, what are your thoughts?  If you had it to do over again, would you?  Have any of you switched specialties after your initial match?  How have your spouses and children dealt with the continuous demands of your career in medicine?


  1. I take it you are in the US? Is there any chance of you switching to family medicine and being able to deliver babies, do abortions, women's health etc through that route? Here in Canada that is my perfect route...definitely recommended. I feel your pain.

  2. Thanks for sharing. Congrats on a great match!

    I think everyone second guesses many of their major life choices. That being said, a very wise woman on here switched specialties (it was Fizzy, right?) and thinks it was the best decision ever.

    I think if you have pangs of regret, then it's normal. Can you give it a year, and see what you think?

  3. Congrats on a super competitive match and for a great post!
    I took of the past year to stay home with my baby and it totally changed my life and career focus as well.

    I was planning on going into obgyn to the extent that I even interviewed at 10 programs in addition to Family Med. I ultimately decided on FM because of the flexible lifestyle (my husband is also a physician) but also because I was very frustrated by the way obstetrics is currently being practiced in the USA. Many programs/hospitals I interviewed at a 40%+ c/s rate and at one place a resident said, "we AROM and pit everyone here, regardless" As much as I love ob, I know I'd get tired of practicing defensive medicine and being indoctrinated into a field where the best interest of the patients are (routinely) not placed first.

    I loved, loved gyn surgery and will miss that but feel family med will give me great options. I was very active in MSFC, did a fantastic externship, and am psyched to be going to a program where elective abortion is directly incorporated into my program. Moreover, I'm excited to be able to expand my interest in reproductive health to adolescents and do office based procedures that don't carry the risk or responsibility of major surgery.

    Needless to say, my husband is psyched I'm not doing obgyn. We'll see if I made the right choice in June.

  4. Hard place to be, but you are cursed by an abundance of blessings (children, career) and you'll have these choices for many years to come. Some more subtle.

    I am 11 years out of medical school. In med school I was certain I would become an orthopedic surgeon. I had done mechanical engineering as an undergrad, did tons of research in med school in biomechanics. I was certain. Then I had a change of heart. Mostly because I was bored in the OR, and I found out I loved caring for patients. I also decided I did not want to struggle in a man's field (again). Part of my decision was based on the idea that I would probably struggle to be able to work part-time and be with my kids if I stayed in that field. So I did medicine. While in residency I decided I had to have the EXCITEMENT of the ICU so I was going to do pulmonary. It did not feel right. I knew that being with my kids was always going to be most important (no kids at that point). So I went into hospital medicine.

    Now with 3 kids and a job that allows me to have flexible hours, do QI research work largely at home, part-time, I know I dodged a few bullets.

    Here is what I learned (for myself):
    1. caring for patients is always interesting to me. they don't have to be really sick, or have exotic illnesses, I don't have to do CPR or remove a big tumor-it is still alawys interesting, everyday. Meeting new people, helping them, caring for them-this is what brings me joy. So glad I did not do pulmonary/CC as I really don't enjoy the ICU at all anymore. So glad I did not do ortho! Dermatologists take care of people, maybe they don't save lives everyday, I think this becomes less important as you get away from med school. All MDs (and RNs, etc) play an important role in the caring of people. I enjoy the 5th sweet old man with UTI and delirium as much as the patient with HSV encephalitis.

    2. When I have time to reflect, the only thing I ever regret is time away from my kids/family. Life is about compromise, I do not believe in the idea that you can do everything (well). I am sure I could be the head of a department or a famous surgeon. I have made compromises in my career, I am part-time, I will not advance as quickly. I have accepted that my own need to achieve (ego) is less important than the joy I get from time with my kids, so I accept this compromise. I have had both (great career accomplishments and more time at home, I prefer the time at home!)

    I still provide an important service as a doctor and care for lots of patients.

    Good luck!

  5. I think in deciding on a specialty in medicine, the important factors are these: what *kind* of patients you will be seeing every day (young, old, men, women, transexuals, etc.), what *things* you will be doing every day (clinic only, clinic and surgery, inpatient only, clinic procedures, lab work, desk/computer work etc.) and finally *who* you will be working with every day.

    I think second guessing is normal. And I think your path will be clear during your intern year. OB-GYN departments can be toxic (I know this because I am an OB-GYN resident and I avoided every residency program with a wiff of toxicity). But there are many departments out there with a mentoring, nurturing culture.

    In the end, I think the only way you know you've made the right decision is when you know you can be happy with what you're doing, who you're seeing and who you're working alongside.

    Finally, we spend too much of our waking hours working and while I think its difficult to balance life outside of work and work itself I HAVE to believe it can be done and I absolutely CANNOT spend my many working hours doing something I don't love with patient's I'm not passionate about and with colleagues I don't like. My kids (currently imaginary), my husband (very real) and my friends will not like me.

  6. I saw a dermatologist from ages 10-20. To this day, my mom runs into her regularly and she asks about me, and I ask about her. She was one of my teenage heroines- pretty, smart, was married and had kids and this neat career, and she knew so much and was so sweet and understanding.

    To this day, I always thought if I were ever going to be a doctor, I'd want to be a dermatologist, because of Dr. LaCasse. Plus, skin stuff's really neat.

  7. I agree with MomTFH above - you can always go from derm to OB but the other way? Seems like it would be tough. Why not just give it a year and see how you feel? The drama of the decision-making moment will wear off and you will have better perspective.

    My drama was choosing something I loved and seemed naturally good at (pathology) over a "sexy" hard-won specialty - ophthalmology. I think I would have been happy doing either, but the choice that led to a stable residency environment so I could have more time for my kids was definitely the right one for me. I have no regrets.

    I always thought that if I was pigeon-holed into any specialty by unseen outside forces I could find an upside and a way to happiness - simply because I would be doing medicine.

  8. I just wanted to let you know how much I appreciated your post. I too have matched into Derm and for many reasons, I chose to pursue it so avidly because of the lifestyle it offers. Now s/p match, the anxiety of 'will I match?' gone, I've managed to replace it with another worry- 'did I make the right decision?' Am I simply so programmed to live in a state of constant self-doubt and anxiety, that I have to make up things to feel worried about?
    Or is it simply the nature of the derm match (and probably all of the match) that there is little room for self reflection during the chaos of the interviewing/ranking/matching process that the fall out is intense? I haven't figured it all out.

    But I do remember after labor and delivery that my emotions were bright technicolor. Not that was a bad thing- the bonding, the thrill of having gone through child birth and mostly delirious excitement of having a new baby. But they were intense. I'm trying to picture that intensity overlaid with wondering if I've chosen wisely... hmm wow. In no way, am I writing it off your post as merely postpartum hormones, I guess I just would reiterate the same thing I repeat to myself, 'Breathe. Let's see what this derm thing is all about before making any decisions.'

    You are not alone.

  9. Hey and Aussie Doc here,
    Love this blog,
    Things are a bit different here but I also recently gave birth to my second baby, a boy.
    I am training to be a General Practitioner (I think this is similar to family medicine) even though I thought I would be a Paediatrician. I have decided to make a lifestyle choice.
    Down the track I will move to a rural area and do a diploma in Obstetrics which will enable me to do low risk deliveries and I'll have the option of learning C-sections.
    I am also planning to take 8 years or so to complete my 4 year training program.
    My thoughts are that down the track if peads is still my passioN i'll go back but I will never get these years with my kids back. These years where its cool to hang out with Mum and jump in puddles, sing and dance.
    I love being a doctor and hopefully will always get great satisfaction from my job, meeting new people, getting to know their stories but being a Mum has blown every other experience out of the water.
    Like others have said, give Derm time, there is always a way of changing your mind, even if its not easy. But one year in Derm will be one year with more time to spend with your family and I don't think you will regret those magical moments!
    Good luck

  10. I need to give my honest opinion here:

    I've known a few people who actually enjoyed dermatology. I had a classmate and good friend who had a severe skin condition as a child and it was always her goal to be a dermatologist. But she couldn't match because it's so damn competitive, so she had to settle for another field she didn't love nearly as much. While I completely understand making choices because of lifestyle, it upsets me that people go into a competitive field that BORES them just for lifestyle, making it impossible for people to match who love derm but don't have the grades for it. I really don't mean to be on the offensive, but I keep picturing my friend in tears on match day and it angers me to hear all these other people whining that they made a huge mistake by choosing derm.

    Anyway, putting that aside, have you ever considered doing family med and specializing in women's health? It's a pretty good lifestyle although not as high pay as derm. (But money isn't everything.)

  11. Believe me you will save lives and positively effect lives in dermatology. Just last week I spent 45minutes with an erythrodermic mycosis fungoides patient and his wife discussing his diagnosis, prognosis, and treatment options. On the same day I saw a woman with recalcitrent pemphigus vulgaris who has now finally been clear for 6months after I put her on a course of rituxan.

    The day before I saw a 6month old baby who had had a large infantile hemangioma obstructing her vision and deforming her nose. However, after 5months of propranolol it is barely visible anymore. She looks like a normal child and her eyesight will develop normally.

    Yesterday my last patient of the morning thanked me for saving his life. He had come in for a scalp rash a few weeks ago and I found and treated a melanoma on his neck.

    When I was an exchange student I watched as my host sister died from a mysterious disease that caused her skin to swell, turn bright red and peel off. Her parents were well off and she went to the best doctors, but even her Harvard-trained physician could not diagnosis her disease. Later when I was doing my derm residency, I realized that she died from DRESS syndrome from a recently started anti-seizure medication. So it was very satisfying when I was able to diagnose someone who had been in and out of the ER for weeks with this condition within minutes of him walking through my door. The only reason he wasn't in the ICU yet was that even though they didn't know what he had they had been giving him prednisone off and on. Undoubtedly I saved his life that day.

    And don't downplay acne treatment. Bad acne and scarring during puberty is an awful disease - physically and psychologically. You are effecting someone's self-image, confidence, and esteem for the rest of their lives when you treat them.

    Believe me you will find dermatology satisfying on so many levels and as you age you will really appreciated being able to sleep all night every night and being able to spend time with your family. I have 3 young children who I get to see every morning and put to bed every night. That is huge.

  12. As one of the fellow residents I work with said about Ob/gyn ( we are both currently trainees): if you love it you'll never be happy doing anything else.

    that moment when a new born turns pink from the middle out... I could never settle elsewhere...

  13. I seriously considered general surgery during medical school, b/c I absolutely loved the OR and cutting and fixing, etc. I sat down w/ the one and only female general surgeon on staff and discussed the decision. Despite her love of her job, she told me something that eventually swayed me from surgery. She told me how hard surgery was/is and how time-consuming and how often she was away from home and kids, but also how much satisfaction and enjoyment she got from her job. She said, "Surgery is very hard. You go into it if you can't see yourself doing anything else. But if you think you could be happy in another field, you should go into the other field. Because over time, the sacrifices you have to make for your job can overcome your love of the job, and you'll start thinking about what else you could have/should have done."
    I ended up deciding that I could be happy out of the OR as well, and I've never regretted the decision.

  14. I'm sorry for sounding harsh... but... seriously????

    You just said you did not like the surgical aspects of OB/GYN. That should just about kill that choice. Then you said that you chose derm for your family-you sacrificed.


    I'm only a student, but I'm fairly certain that nobody likes 100% of their occupation. Derm will grow on you. You will find things that excite you. You will change countless lives. You will get paid handsomely, get the opportunity to spends LOTS of time with your kids, and live a fulfilled like. And remember, few people get to get their cake AND eat it ravenously... you will. Why do I suspect that you will have cake AND eat it? Because you will likely seek out ways to volunteer in obstetric clinics etc.


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