Thursday, October 14, 2010

MiM Mailbag: Need some help (urgently)

Dear Mothers in Medicine,
I need your help. I am in a sudden mid-training crisis and after years of being absolutely sure of what step comes next… I now have choices and that leaves me in a panic. I’ve been reading this blog for about a year now and I respect and enjoy reading the posts that go up. So I need your help in the form of unbiased opinions about what to do with my life.

I’m an internal medicine resident in my second year, with a 19-month-old son and a loving husband. I’ve been interested in Endocrine casually for a while now but recently I’ve decided that I would like to specialize in it. The unfair thing is that the match application for fellowship occurs in December of the second year of residency… for a spot after the third year is over. So after the whirlwind of intern year, it seems like this crossroads comes up way too quickly. This is also the time that my program sends out the call for Chief Medical Resident applications (there are 4 chiefs every year for my program), again, for the year just after I graduate. I’ve been asked twice by one of the associate program directors to apply for CMR, which is both flattering and shocking to me. I want to stay at my current program for fellowship, but this is a year when 5 of my colleagues also are applying for Endo and 2 out of the 3 spots have already been promised to people. Basically, no reason to apply for the match this year. I’ve been told that if I did do CMR that I would be guaranteed a spot when I was done. I literally have to make a decision in 2 days (deadline for CMR). So I made pro/con list (or, sort of a stream of consciousness) for the jobs that I’m considering.

Endocrine Fellowship +/- Chief Medical Resident vs. Primary Care Internal Medicine


Pro: Focused on limited problem set - thyroid, pituitary, diabetes, PCOS... Overall nice colleagues. Maybe a little better salary than primary care... Don't have to deal with musculoskeletal issues or runny noses. Get to potentially see some really crazy pathology and treat thyroid cancer.

Con: Have to apply for fellowship, including a personal statement, letters of recommendation, trying to start and somehow make sense of a research project. Being stuck in a fellowship for 2 more years while not making a full salary. Possibly having to end up doing primary care anyway after 2 years of training (the market in my area of the state is completely saturated and full time endocrine jobs are extremely hard to come by from what I’ve been told).

Primary care...

Pro: Tons of jobs available. Weekends off, no more overnight call in-house EVER. Making a decent salary in less than 2 years. Happier husband. Potentially really nice patient-doctor relationships with the sane and reasonable patients.

Con: The overwhelming amount of follow up labs, etc. MSK complaints that I never know what to do with. The fear of missing a big diagnosis. The awful gyn complaints (though I think outside the VA where my continuity clinic is at, internal medicine primary care is probably a lot less gyn since women usually have their yearly pap by an OB/Gyn).

Chief Medical Resident. This is an esteemed position that comes as a bitter-sweet combination of administrative work, no clinical time, teaching, politics, and pretty much an 8-5 M-F schedule, and a few more bucks than a regular resident. It would be one more year past my 3 years of residency and would essentially guarantee a spot in my institution's Endocrine fellowship after I'm done. On my curriculum vitae it would be a plus for any future job application. What's one more year out of my life? Well, I think I'm hesitant for two reasons: 1) my husband is not a fan of making 1/2 the salary of an attending for one more year of delay to a real job 2) I don't want to have to deal with all the politics and new ACGME rules that are coming down the pike, i.e. the new rules of interns only working 16 hrs in a row (which is ridiculous, but I'm sure all the new interns for next year are happy about that). I think I would be a good chief and I've always liked mentoring along my younger colleagues (mainly medical students, at this point), teaching, realizing that I actually do know some medicine.

Here’s the rub… My husband has been in his career for 10 years. He is making great money… but he hates his job. He has stuck by me for years now… moved with me to medical school, moved back for residency, supporting me through the overwhelming debt I have from medical school and college, being the primary caretaker for our son last year when I was an intern. He would like nothing better than for me to finish IM residency, get a job in Primary Care, and start having a regular salary and consistent schedule. He’s sure, now more than ever, that he needs to change his career drastically for the sake of his happiness. I want this for him too. After all, he has been supporting me this whole time… when is it his turn? How long can he wait? We will both be in our late 30’s by the time I am really done if I continue onto fellowship.

So. Here I am. I feel like there are a few ways this could play out… and any of them I would find a way to be happy. That’s just who I am. That’s what makes this decision so tough… In any of these, I think I could be happy.

1. Primary care – as a career

2. Primary care for 4-5 years, then apply for Endocrine fellowship - my fear is that I become too comfortable in my current salary/job and just bag the whole idea of going back to training

3. Chief year, then Endocrine fellowship directly after – this is what I would choose in the alternate reality where I’m not a wife or a mom

Any comments or ideas I would greatly appreciate!



  1. Are you willing to move to a different location, or do you feel you must stay geographically where you are long term?

  2. I don't understand why you'd be essentially doing family medicine as a primary internist... wouldn't you just be doing general internal medicine?

  3. I think you should do primary care for a few years, then go back for fellowship. Or do a chief year, then hold off on a fellowship and do primary care.

    You aren't totally opposed to the idea of primary care, which makes a huge difference. I'm in primary care also (Med Peds) and it's actually quite enjoyable. There is a learning curve the first year, but you'll have that no matter what you do. Doing primary care for a few years will enable you to earn more money, allow your husband to change fields, and also allow you more time with your family. It's not a big deal to go back and do fellowship afterward. If you become comfortable and don't want to go back for fellowship, it's not the end of the world either. The key thing is that you have that option down the road. I think you should still consider the chief year, because that will be a great stepping stone if you ever decide to go back and do fellowship, or for that matter, just in terms of finding a good job. And it won't be too much of a delay in terms of your husband.

    My husband is like yours in the sense that he doesn't like his job, and he wants a career change. Except that my husband has no clue what he wants to do. Having lived with a spouse who is unhappy and unfulfilled at work, I totally understand what that's like. Since you are considering primary care as a viable option, I think you should seriously consider deferring fellowship for now to give him a chance to pursue his goals, and then you can get back on track if that's what you want.

    Interestingly, I had also considered an endocrine fellowship, but then decided I didn't want to do anymore training and just wanted to practice. Well, right now my plans are to practice for a few more years, and then I plan to go back and do an MPH and go into public health.

    Good luck in whatever you ultimately decide.

  4. Would definitely do Chief Resident year. It would get you the Endo fellowship if you so decide, and would give you administrative experience which opens more options if you do General IM.
    A decade from now, the extra year will seem like nothing. And the more training the better for General IM.
    I do general IM/adolescent med, and it includes LOTS of gyn. In the private world of med practice, specialists often turf stuff - so we've seen episiotomy infection 3 days postpartum, post-op 1 wk hysterectomy bleed ... because "nobody can see me today". General IM appointments are filled daily as the physician of last resort! We also do routine GYN on about half of our female patients, who no longer see GYN once finished with pregnancies.
    An additional problem is the big push by NP's and PA's to take over primary care medicine, and at lower salary. So, some large groups will hire the mid-levels preferentially. As medicine changes, you need something to differentiate yourself as a physician.
    Husband who is most concerned about immediate need for higher income has to be educated that your next few years will influence your career for the long haul.

  5. gcs15 - yes I am very much tied to my current location. Both mine and my husband's extended family is in this area, we bought a house, this is where we grew up, etc. So we're pretty much here to stay.

    Kelly - thank you so much for your thoughtful reply! it really helps.

    Dr.Nana - Interesting about the prevalence of gyn work-up in an internal medicine practice... I did not know this. Also, I agree that my husband is having a hard time understanding the benefit of chief year and even fellowship. He's a financial guy in his career and can't see past the numbers sometimes.

  6. NiqueKee -

    I haven't seen a ton of gyn in my primary care practice, so I think a lot of it is based on your area and your particular patient mix. I certainly have never seen the post op gyn stuff that Dr. Nana describes. The main things that I felt unprepared for were:

    1. Chronic pain patients. We're not taught what to do with patients with chronic pain issues who just want their Lortabs and Somas refilled. How to distinguish between true pain vs. drug seekers? When to refer to pain specialist? What if no pain specialist will accept their M'caid or they are self pay? etc etc.

    2. Mental illness, in particular chronic anxiety and panic attack patients who are on chronic benzos and want refills. Bipolar disorder and adult ADD are also huge areas where I don't feel qualified to diagnose.

    3. Outpatient procedures, such as toenail removals, foreign body removals, etc. I feel that our FP counterparts are a lot better trained at these than IM grads.

    4. How to get along with other "old school" doctors who don't know about EBM and have no interest in that. (I could contribute a whole blog entry about the woes I've had with this.) A lot of times those of us trained in EBM have an attitude of moral superiority with regards to using evidence, and it can really make it hard to get along with other doctors.

  7. I would definitely consider primary care +/- CMR. You will still have the option of going back for a fellowship down the road. And if staying in your current location is that important to you, you will have a lot more job opportunities in primary care. There is such as need for primary care docs anyway. As a FP resident I still feel unprepared for a lot of the things you describe, but I just assume I will get more comfortable with those things as I get more experience. So far that has been the case in residency - I have been enjoying it more and more the less I suck at it. Good luck with your decision!

  8. Not all of us interns for next year are excited about the ACGME changes. It will greatly impact our education and place a strain on programs who have less that a year to figure out a solution, without increasing their resident class size. We didn't ask for this and I often worry about the relationship between upper level residents and the new incoming interns (myself) due to them having to pick up my slack. You may be fortunate to escape, but we are stuck at the mercy of the system. Please don't generalize that "the incoming interns will be happy about not having call".

  9. I'm a current chief resident in medicine and I agree with many of the other posters who say do the chief year! It gives you the option to do your fellowship, gives you a year to "ease into" being an attending, administrative and teaching experience, and if you're planning to stay in the area gives you a huge opportunity to build a reputation and network. The new duty hour rules go into effect this coming July (2011) so I hope for your sake things have been worked out by the time you are a chief! (Other than redesigning my residency program to meet those new duty hour rules, I'm having a blast as a chief!)

    For your husband, can he make a career change while you're still in training? My husband made a huge career change involving a second bachelor's degree while I was in medical school, and it was tough but doable. I don't know your financial situation, etc, but something worth thinking about.

  10. It's kind of stupid that IM residency prepares you so poorly to do primary care, when that's what a large number of IM residents end up doing.

    Have you ever thought about hospitalist work? That's becoming a more popular option recently... pays very well and gives you lots of days off.

  11. I was also wondering why you're not considering hospitalist work. I'm a hospitalist and it's a very popular choice for people who want to work for a year between residency and fellowship. Primary care can be hard to leave after a year--often you are obligated to work for a few years or have to pay money back to an affiliate hospital.

    Pro: set hours, lots of time off, making a LOT of money before you go back to a piddly fellowship salary, easy to leave

    Cons: Working nights/weekends (though this may be less if your group has nocturnists), higher stress level. I don't think lack of continuity is an issue here since you're only planning for a year anyway.

  12. I agree with those who ask you to consider the Chief year, as the leadership experience will look great on your CV and may benefit you in many ways, might give you some time to decide about the fellowship.

    Also interesting that a commenter (I think it was Fizzy) mentioned hospitalist work. This is an excellent choice for a mommy doc because it is basically shift work.

    In the end, please know that whatever path you choose will be right for you. You may not recognize that for a few years, but in hindsight you'll see that all of the pieces fell into place in just the right order.

    Please keep us posted!

  13. You absolutely have to consider compromising for your husband's happiness. As you said, when is it time to be about him? He is 1/2 of your marriage and if he is not happy, you will not be happy, and as a couple, you will not be good parents for your child. Doing the chief year and delaying fellowship sounds like a reasonable compromise.

    I am a Peds intern with a husband and two young children, so I too know the struggle of having our medical schedules dictate our family's lives. Now that you will have more of a choice than you did with med school and the match, it's time for it to be about your husband's career for a while, or you may regret it later.

    Good luck -- tough decisions!


  14. Hard to add anything to all the great advice you received above. Just wanted to let you know I was wishing you good luck with your decision. Also echo to work with spouse - if you make decisions that compromise their happiness it is easy to rationalize that you can fix it, or make it up later. Easier said than done.

  15. Everyone, thank you for your thoughts. It's really helped to get some outside opinions. Still not sure what the future ultimately holds, but I'm going to apply for CMR at least... but now leaning more towards taking a few years after CMR/before fellowship so the hubby can do his thing. Did give some thought to the hospitalist route, but I'm concerned that the high stress and long days when I'm on would burn out the husband at home with the kid. We'll see what happens!


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