Dokter Blog: from the desk of Rahajeng Tunjungputri

Medicine et cetera by @ajengmd

Choosing Medical Specialty (and more on Internal medicine, infectious disease, and academic medicine)

By: Dr. Rahajeng

I recently stumbled on a very interesting publication of Lange, The Ultimate Guide to Choosing Medical Specialty by Brian Freeman.

For many, the decision of taking up a specialty is easy, for others it’s much more complicated. The best thing is of course to be able to choose based on your interest and the kind of life you want for yourself. I realized very early on that a certain medical specialty is not just about the kind of work that you have to do, but also about the commitment you have to make to a certain lifestyle. I was lucky to have had a real life experience about the field I am going to take up, as well as to have several mentors to introduce me to it.

What is sometimes not immediately anticipated for us Indonesian young medical doctors is that choosing a medical specialty is a decision of the family (and family sometimes means the whole extended family). This means you can’t really make your own decision. There’s mum, dad, grandparents (if they’re around), and maybe others that will have a say about the decision, and for some unlucky ones, the decision is not even yours anymore. For some, they never had a say in what they like, it’s always about what they have to take.

For example, a friend of mine had been pursuing his interest in surgery for a long time during medical school. Dad is a pediatrician, and mom is an ophthalmologist. He did express his interest of surgery to his parents, but dad took over the decision-making and told him that ob-gyn was the best choice for him. He agreed to it despite the fact that he had another choice. He thought that it was what’s best for the family.

For another guy, ob-gyn is a no-question choice, as many in the family (grandpa, uncles) was ob-gyn specialist and they already establish their own private hospital and clinics. Neither a bright nor dedicated student, by circumstances that many call luck, he is to take over the family business.

My own experience is by situation a more liberated one despite the family medical legacy. Grandpa from dad’s side was an orthopedic surgery professor, uncle is also an orthopedic surgeon and his son is now an orthopedic surgery resident. My father was briefly in surgical residency but he resigned and decided that being a company’s medical manager and acupuncture was more enjoyable. He worked for 25 years in a national oil mining company as medical manager and have started and now runs the first dermatology/ aesthetic acupuncture clinic in the city. Uncle from mom’s side is a psychiatrist. I had ob-gyn and pediatrics in mind for a short period. I was finally exposed to the wonders of internal medicine and infectious disease and eventually choosing infectious disease for myself two years ago, preferably in academic setting.

Back to the book, it also offers looking to MBTI personality types to see if you cut-out to be in certain specialty although for internal medicine, it is very flexible on who it is most suited for (Introverted–Intuitive–Feeling– Judging INFJ, Extroverted–Sensing–Feeling– Judging ESFJ, Introverted–Intuitive–Thinking– Judging INTJ, Extroverted–Intuitive–Thinking– Judging ENTJ). It doesn’t really matter I guess, as long as you have good access to yourself, knowing what you like and what you can be passionate about. I happen to be an ENFJ (sorry, you gotta find out what that is yourself).

I started thinking about these 4 years ago when I was still doing my preclinical years (naturally, without having a book to guide my thinking):

• What do you want to get out of your medical career? (intellectual and spiritual satisfaction)

• For whom do you want to work? (international academic institutions)

• Do you want to be a leader in your specialty? (i’d like that very much, so yes)

• How much time do you want to devote to research, teaching, or administrative work? (research and teaching: a lot of time. Administrative: naaah, not really into it)

And knowing that I’ve explored answers to these questions has definitely made me confident in the choices I make.

I have a vision of what career I want for myself, as well as very personal reasons of why I choose a certain path. But the thing is I always know what I like, not just the science but also the lifestyle. I like international travel, I like discussions, I like challenges of pursuing knowledge of the unknown. I like reading, writing and facing cerebral challenges. And I definitely like giving presentations in front of international audience, preferably about something I know a lot about. Those reasons above are part of the things that shape my choices.

And surprise surprise, my Keirsey profiling ended up being “teacher”.

*

These are selected excerpt from the book “The Ultimate Guide to Choosing Medical Specialty” by Brian Freeman

TO SUBSPECIALIZE OR NOT: THE FELLOWSHIP DECISION

Before considering their practice options, residents in every specialty have to decide whether or not to subspecialize. The additional time spent in fellowship training gives them advanced knowledge and skills—both of which are essential for practicing as an expert in a focused variety of specialty medicine.

Residents who become inspired by a particular organ system or a complex problem within their specialty should seriously consider pursuing a fellowship. The training provides sophisticated knowledge and skills, making you an expert to whom colleagues look for advice and teaching. Knowing one narrow area very well can enhance your career satisfaction and build your professional confidence. With an emphasis on research and scholarly endeavors, fellowships are also great preparation for careers in academic medicine.

Are there any disadvantages to pursuing a fellowship? Just one—the temporary financial sacrifice. You will have to wait several more years before paying off all those big educational debts hanging over your head.

Private Practice: Delivering the Best Patient Care

Most of you will enter private practice after completing residency or fellowship. In the private sector, physicians either work by themselves or with others, providing high-quality medical care to all types of patients. Because they are not tied strictly to the large academic medical centers, private practitioners have the flexibility to set up shop anywhere in the country—urban, suburban, or rural. Depending on the specialty, you may be working in the office-clinic (dermatology, rheumatology, allergy medicine), the hospital (anesthesiology, radiology, pathology), or both (internal medicine, surgery, pediatrics). Some private practitioners also make rounds at other places, like nursing homes (geriatricians, internists), state facilities (psychiatrists), and prisons (internists, family practitioners).

Academic Medicine: Shaping the Future of Your Specialty

Medical students who want to be leaders in their specialty should consider a career in academic medicine. A much smaller percentage of physicians work at university hospitals than in the private sector. Academicians serve as medical school faculty members in their specialty’s department and also provide patient care at their affiliated teaching hospital. With less emphasis on patient volume and turnover, the pace of academic medicine is more relaxed than that of private practice. Although the job market for new faculty physicians is quite strong, the tertiary care medical centers are usually in major metropolitan areas. This limitation means that academic physicians—whether pediatricians or interventional radiologists—have less geographic flexibility than their counterparts in the private

sector.

Whereas private practitioners deliver patient care to the masses, academic physicians in every specialty and subspecialty have a set of three universal—and equally important—responsibilities.

1. Teaching: Every doctor receives residency training in a teaching hospital. By staying there to practice, academic physicians instruct generation after generation of specialists. Much of this time is spent supervising and teaching fellows, residents, and medical students. Through hours of mentorship, academic physicians can make a meaningful difference in their charges’ professional lives by shaping their formative years of clinical training. These inexperienced young doctors will pepper you with lots of probing questions, keeping you sharp in your specialty. Most faculty members recruited out of residency or fellowship start teaching at the level of Assistant Professor. Promotion and tenure—just like in nonmedical fields—are directly related to your ability to teach and conduct ground-breaking research.

2. Research: Through cutting-edge clinical and basic science research, academic physicians are responsible for advancing their specialty. They generate new knowledge, develop procedures and drugs, and evaluate the efficacy of different types of treatment. For instance, a general surgeon might conduct a study looking at the best time to take out a chest tube, and an internist investigates the outcomes of treating diabetic and renal failure patients with ACE inhibitors. Academic physicians also have to teach their colleagues in private practice about the latest advances in their specialty.

They do so by writing up their findings in medical journals and giving lectures at national conferences. To carry out any research project, academic physicians have to obtain the necessary funding—by submitting grants themselves or by receiving money from their department. In the world of academia, the number of papers published and amount of federal research grants received confers prestige on a university medical center. (In a certain weekly news magazine, the formula used to rank US hospitals and medical schools gives the greatest weight to research awards from the National Institutes of Health.)

3. Patient care: In every specialty, academic physicians provide the latest and most innovative medical care. Tertiary medical centers draw a diverse mix of patients, from the indigent (most teaching hospitals are historically located in underserved city neighborhoods) to the very wealthy (e.g., Saudi princes who fly in for the most advanced treatment). Most patients receive care directly from residents and fellows, who are supervised by their attending physicians, of course. Compared to private practitioners, full-time faculty members generally take less call, devote fewer hours to patient care, and earn less money. All revenue generated from clinical practice goes directly to the medical center instead of counting as personal income. In turn, the hospital pays each faculty physician a fixed salary that is directly proportional to the type and volume of medicine he or she practices. This is why academic pediatricians earn less than an academic cardiothoracic surgeon.

Academic medicine is perfect for doctors inspired by working with some of medicine’s greatest minds the authors of well-known textbooks, the renowned researchers who develop new drugs and vaccines, the innovators who figured out how to surgically separate two newborns sharing the same brain. Because teaching hospitals are part of major referral centers, academic physicians are the ones who manage most of the rare and complicated cases. You will take care of diseases and conditions on a level that few physicians ever surpass. This career path, therefore, gives you the autonomy to become a true leader in your specialty.

The book also features profiles of every specialty. And here I will only put up what is obviously my pick: Internal medicine (and a little bit more about infectious disease).

READY TO EXERCISE YOUR BRAIN?

Internal medicine is perhaps the most cerebral of all specialties. It requires a high level of critical thinking. Many students are drawn to internal medicine for the intellectual stimulation. There are always interesting cases that require a lot of problem solving and interpretation of signs, symptoms, and other pieces of data.

Internists are very intellectually curious doctors. They always like to ask questions of themselves and others during the differential diagnosis process. Fascinated by the science of medicine, internists love exploring details—like the mechanisms of drug therapy or the pathophysiology of disease. To make the best diagnosis, internists tend to read quite a bit. Keeping abreast of the latest advances in general medicine requires a career-long commitment to reading journals such as JAMA or The New England Journal of Medicine.

Critical thinking is necessary because internists take a scientific approach to being master diagnosticians. They thrive on making a great diagnosis, analyzing a fascinating big case, and solving complex medical problems. Internists love to sit around and discuss disease. They get excited by putting together a patient’s signs, symptoms, and laboratory findings and trying to come up with a long list of possible differential diagnoses. Unfortunately, sometimes the daily activity in internal medicine is perceived as lots of thinking and talking but little action. In particular, academic inpatient rounds can perpetuate the stereotype of internal medicine as mental masturbation. This is because internists are thorough individuals who make sure not to leave out any possible diagnoses. Students who love to solve problems and mental puzzles find internal medicine a fascinating specialty. Internists are experts at taking patient histories and performing physical examinations. It is with the information derived from the H&P that they make most diagnoses. After talking to the patient, the internist constructs a list of differential diagnoses for each of the patient’s problems. This process allows them to clearly organize in their minds what is going on with the patient and how to address each issue; many patients have multiple medical problems or complaints. To finalize a diagnosis from a list of many, the internist relies on a great deal of critical thinking and deductive reasoning from the data at hand. They take pieces of evidence from the history, physical, laboratory data, and imaging studies to rule in or rule out various disease states. It is kind of like mental detective work. An internist in academics commented that “figuring out how all the pieces to a patients’ clinical puzzle fit together is extremely rewarding.” With a confident diagnosis in hand, the internist then moves on to treating the patient. Across the subspecialties of internal medicine, therapeutic interventions take the form of either pharmacologic agents or procedures. General internists, for instance, keep up with the advances in treating high blood pressure with the newest medications and are experts at figuring out the proper antibiotic for a patient with bacterial meningitis. Although this specialty requires thorough, organized thought, internists are more than just thinkers; they are also proficient in many technical skills essential for the diagnosis and treatment of illness. These skills include a number of inpatient procedures, such as thoracentesis, paracentesis, lumbar puncture, and central line placement, and outpatient procedures like flexible sigmoidoscopy, endometrial biopsy, and intra-articular injections.

WHAT MAKES A GOOD INTERNIST?

Likes physical diagnosis, pharmacology, and physiology.

Is a thorough, cautious problem- solver.

Can interact well with people and maintain long-term relationships.

Likes working with his or her mind.

Is a good, patient listener.

FELLOWSHIPS AND SUBSPECIALTY TRAINING

Internal medicine is comprised of many subspecialties. In 2000, roughly half of

all graduates from internal medicine residency programs sought fellowship training.

Currently there are 10 possible areas of subspecialization. Before jumping into one of these disciplines, take a moment for some honest self-evaluation. It is essential that you give some thought to

your field of interest and the type of personality most suited to it.

For aspiring physicians who prefer direct primary patient care, general internal

medicine is the place to be. Specialists tend to be much more scientifically oriented

and enjoy more complex and difficult cases. They serve as consultants to the general internist, directing medical care for a specific organ system and often teaching the general internist about the patients’ disease process. For certain specialties, like cardiology, gastroenterology, and critical care, more time is spent caring for patients in the hospital environment than in the office setting. No matter whether you choose cardiology or rheumatology, all subspecialists are, at heart, excellent general internists. You will still be required to have high-quality history and physical examination skills, as well as the ability to interpret laboratory and radiographic findings, to produce a comprehensive differential diagnosis. In every subspecialty, all internists take care of very sick adult patients who have many medical problems.

Infectious Disease

If you love studying bacteria, viruses, parasites, and fungi, then the subspecialty of infectious disease is for you. These physicians take the basic science of microbiology and apply it to clinical situations. In their diagnostic workup, they approach the patient’s disease process by taking into consideration recent travel, geographic region, country of origin, and cultural practice. They are experts in the proper collection and analysis of culture specimens, plus a variety of laboratory tests, such as antibiotic sensitivity tests, CD4 counts, and infectious serologies.

Their treatment regimens are largely pharmacologic and draw on the latest developments in antibiotic therapy. Through the use of vaccines, they practice a great deal of preventive medicine. Most patients who require the expertise of these clinicians have diseases that are short-term in nature. Thus, infectious disease specialists typically serve as consultants for other physicians. In the summer of 2002, they were on the front lines of the West Nile virus outbreak in the United States. They consult on patients in the hospital for diagnostic challenges (e.g., fever of unknown origin) and for treatment regimens of specific infectious diseases (e.g., bacterial endocarditis, meningitis, cellulitis, sepsis). Many infectious disease physicians maintain longer relationships with patients suffering from chronic diseases, such as HIV/AIDS and tuberculosis, who require extensive follow up. Some practice travel medicine, serving as consultants to patients preparing for international travel and to those who acquired illnesses while overseas. Other areas of expertise include infection control within health care settings, international public health, and the prevention of antibiotic resistance through education and research. They also are involved in the tracking and epidemiology of certain communicable diseases. As the threat of biological attack becomes a growing concern, the prevention, recognition, and treatment of bioterrorism are now focal points of infectious disease. Fellowships require 2 years of training after residency.

Semarang, 7-6-2009

*

Reference:

Freeman B. The Ultimate Guide to Choosing Medical Specialty. Lange 2007.

Filed under: miscelaneous, , , , ,

6 Responses

  1. Indri H Putri says:

    What a post! I’ve been thinking my self what kind of doctor I wanna be. I find it difficult to choose… Maybe it’s easier for you because you already know what you want and you already see the way to pursue it. I hope soon, I’ll figure it out… Success with your PTT. I was so lucky to meet you at that day…

    Salute,
    Indri

  2. dokterblog says:

    Dear Indri: we shud chat again whenerver you want. Coass is another lifetime (and definitely another lifestyle). It was easy for me only after I went to Radboud. But you’ll figure it out when ur a coass, plenty of time!
    Thanks a bunch for visiting!
    Groets,
    ajeng

  3. Fanti says:

    Inspiring!
    It’s not always easy to decide ‘what you LIKE’ Or specifically what kind of doctor i wanna be. I’ve been dealing with those questions. I hope 2010 is the time I re-write my story🙂

    • dokterblog says:

      To Mbak Dokter Fanti,
      It’s about knowing what you like, and then it’s about finding the strength, courage and opportunity to do it.
      Keep living the dream and making it happen🙂

      Warm regards,
      ajeng

  4. a colleague says:

    Hi. how do you do? salute to your self determination and your activities. your analysis on choosing a specialty in indonesian society is agreeable. i’m on that condition too. Your review of this book is very interesting also. I am very much interested as well to this book. Does this book sell in Indonesia? Can you tell me where can i have this book? thank you very much for your answer.

    • @ajengmd says:


      Dear Colleague,
      Thank you for stopping by! I’m still learning so I feel privileged for these opportunities. I got it as an e-book in pdf format, perhaps you can google the title and see if it’s available for Indonesia. I wish you all the best in exploring your options for specialty in Indonesia. It’s as much as a lifestyle choice as it is a financial and academic one.

      Best regards,
      Rahajeng

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Disclaimer

Medicine is a growing field, and information presented here is reflective of the time of posting. Please refer to your physician for direct medical consultation. My views do not reflect those of my employers. --
Regards, Rahajeng

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