PEDIATRICS
The first thing they’ll tell you on your pediatrics rotations is, “They’re not just little adults.” And it’s true that since most of medicine is geared toward the adult patient, it takes some time to adjust your thinking to encompass the physiologic and developmental considerations of caring for peds patients. Suddenly all your drug dosages are in milligrams per kilogram, and your IV fluids have to be half their normal concentration. You quickly realize that taking a useful history from a four-year-old is tough and requires a lot of interpretation. Often too late, you discover that sick kids can be subtle and that they tend to look okay right up until the point they crash. Finally, you will lose your breath over the strength, composure, and attitude of kids with chronic and terminal illnesses. There is much we can learn from them, both as physicians and humans.
On the other hand, kids also tend to be healthy, don’t generally have self-destructive behaviors, and if they are sick they tend to get better. This is incredibly refreshing after you’ve spent six weeks caring for chronic alcoholics, obese hyperlipidemics recovering from their third heart attack, and lung-cancer patients who are still smoking and insist it has nothing to do with their disease. It’s gratifying to be able to soothe scared kids, to be able to explain an illness to the child and the family, and to help the little ones get better because of the therapies you instituted.
There is something of a cultural schism between the adult medical world and the pediatric medical world. If you’ve already done a series of adult rotations, be prepared to adopt the “peds view” for the next several weeks. Be sure to read the first few chapters of your review book of choice on how to approach the peds patient before you start the rotation. Keep at hand a good reference for drug dosages and common peds illnesses. Read in your spare time about the important differences between adult and pediatric versions of even common illnesses like diabetes. Immerse yourself in the peds world and, as with all rotations, you will grow and learn at a dramatic rate. Your peds rotation will follow a similar structure to that of your internal-medicine rotation. The bulk of your time will be spent on inpatient pediatric care, with a smaller portion going to clinic and various pediatric subspecialties. Try to make sure you cover a complete range of ages from neonatal through adolescent. Unfortunately this probably means you won’t spend enough time in any one area or age group to gain real comfort, but remember—your goal here is to survey the specialty. If you choose to specialize in pediatrics, you’ll have your entire residency to intensely study each age; if you’re going into something else, you’ll be well served by appreciating the very different diseases and needs of kids of all different ages.
Career considerations—pediatrics
Much like internal medicine, the bulk of pediatrics is practiced by primary-care pediatricians from their offices. Since kids less frequently require hospitalization, the majority of pediatric illnesses are managed on an outpatient basis. Unfortunately, since kids require less direct care and fewer procedures, the reimbursements from insurance and Medicaid are lower, and therefore pediatrics is historically one of the lower-compensated specialties. However, this shouldn’t dissuade you if your passion is taking care of the little ones, as the payoff comes in many ways.
There are also a broad range of subspecialties in pediatrics that mirror those in adult medicine. These include adolescent medicine, allergy and immunology, cardiology, critical care, emergency medicine, endocrinology, gastroenterology, genetics, hematology and oncology, infectious disease, neonatology, nephrology, neurology, and pulmonology. It should be noted that several of the pediatric subspecialties can be entered either by completing a general peds residency and then a peds fellowship or by completing a specialty-specific residency and then completing a peds-specific fellowship. Thus, training in pediatric emergency medicine can be achieved either via a peds residency and peds-emergency medicine fellowship, or via an emergency medicine residency with a peds-emergency medicine fellowship. Similarly, to become a pediatric surgeon you must complete a standard general-surgery residency and then go on to a pediatricsurgery fellowship. The pediatrics residency is three years, and most fellowships are one to three additional years.
If you’re considering pediatrics, you may feel frustrated by how many nonpediatric rotations you have to do.
Don’t be.
While peds aren’t little adults, there is much of adult medicine that applies to pediatrics, so any and all exposure will be helpful. Furthermore, many of the specialties you’ll rotate through will include pediatrics in their demographics. If you’re interested in peds, make sure you let this be known, and try to tailor your rotation to give you extra exposure to the pediatric patients of that specialty. Thus, by way of example, on your family-medicine clerkship you should request to spend more time on their newborn service, or while on surgery you should request to do a special week of pediatric surgery.
SURGERY
The lore of medical training is filled with horror stories of surgeons and surgical training. Medical students typically either dread or eagerly anticipate their surgery rotation, but either way they know it will be one of their most challenging and most memorable.
The surgeon’s day is long, and he usually gets a very early start (often doing initial walking rounds at 6:00 A.M. and prerounds even earlier). Surgeons are classically quick, decisive physicians who pride themselves on their intimate knowledge of anatomy, disease, and complex surgical techniques. They consider themselves experts not just of the physical act of surgery but of care for the critically ill.
Interestingly, old surgical adages like “It takes steel to heal” or ‘You’ve got to cut to cure” reveal in part why surgery is such a highintensity specialty and, concomitantly, such an intense rotation. While all physicians assume risk and responsibility as they prescribe therapies to their patients, nowhere is this risk more personal or apparent than in surgery. It’s one thing to misdose a medication or delay a diagnosis, it’s quite another to have personally opened up someone’s belly, knicked a bowel or blood vessel, and caused a potentially catastrophic complication with your own hands. The weight of responsibility rests heavy on the surgeon’s shoulders. They are able to achieve dramatic and rapid healing, but the complications that arise in their practices are often catastrophic.
Surgery is a tremendously broad field, so your rotation in general surgery will be only a fundamental introduction. Staying organized and being efficient are the keys to your surgical rotation. The service will tend to be busy and turn over fairly rapidly, so you will have to help to keep patients moving through. If you’ve just done other internal-medicine rotations, you may be accustomed to a more methodical, slower pace. You’ll be surprised by how focused a surgeon’s notes are. Surgeons are most interested in the problem at hand and the patient’s historical and pathophysiologic context. They are less. interested in an entire health history or major long-term preventative health strategies.
You should get some instruction on basic surgical techniques during your rotation. You won’t need to learn how to do operations, but you will be expected to know how to tie proper surgical knots, how to suture, and how to assist during procedures. Your time in the OR will be spent mostly watching and holding retractors. In fact, you may find yourself contorted into uncomfortable positions for exceedingly long periods of time holding a retractor in an operative field that you can’t even see from where you’re standing. The good news is that if you’re upbeat and eager, your efforts will get repaid with an invitation to close (i.e., close the incision with sutures and staples) or assist in more interesting ways on minor cases. Either way you will get to witness one of the most awesome sights in medicine—human anatomy in action. You’ll discover the vivid beating body lying open before you is a far cry from your Human Anatomy corpse. You’ll witness the dramatic impact of actual pathology on the body as you excise and repair disease. Finally, you’ll be astounded at the elegant and complex techniques that have been developed to address the sp
ectrum of surgical problems in human medicine. At the end of the rotation you will appreciate why a surgeon’s training is so long and hard.
Career considerations—surgery
It has been said that the only reason to go into surgery is because you literally cannot imagine doing anything else in your life. The path of surgical training is arduous, and the realities of your professional practice after training aren’t any easier. It is true that in this era of work-hour restrictions, surgical residents’ lives have become more palatable. However, these restrictions have also made it more difficult to acquire the body of knowledge and to attain the level of procedural experience required.
A general-surgery residency is typically five years in duration. This will prepare you to do common surgical procedures throughout much of the body, focusing on the abdomen and soft tissues of the extremities. There are myriad surgical subspecialties from neurosurgery to urology. Most of the subspecialties start after your second or third year of general-surgery residency, though some, like plastic surgery and pediatric surgery, require you to complete your generalsurgery residency before starting the fellowship.
Some surgeons are among the best-paid physicians in practice. The higher the level of training and the more complex the procedures, the higher the level of insurance reimbursement and, hence, the higher the salary. Neurosurgeons who spend seven or more years in training are among the highest paid. But to get there, you also have to commit seven years to living on a resident’s salary. This means forestalling family, free time, and repayment of debt for that many more years.
If you believe you’re interested in pursuing surgery, be sure to be appropriately vocal about it with your attendings and demonstrate it in your dedication to the rotation. This eagerness will likely open doors to more experiences for you. As you go through the rotation, examine closely the lives of your surgical colleagues. Can you see yourself doing what they do? Are they people that you want to spend a huge portion of your time with? Are you passionate enough about the subject matter and the opportunity to operate to dedicate yourself to the task—potentially at the cost of a personal life? If your answer is a resounding yes, then you will likely find the deepest rewards possible in your career.
“I came to realize about halfway through my required clinical rotations that I enjoyed being in the OR more than I enjoyed being on the wards,” Deb admits. “This really became apparent one time in the OR while I was on my neurology rotation. One of the residents remarked that I seemed much more upbeat than I did when I was on the floor. I realized he was right. I liked the focused one-on-one patient care—trying to remember who out of fifteen patients on the floor had a creatinine of 1.2 just wasn’t for me.”
OB/GYN
Obstetrics and gynecology is a unique specialty in that it encompasses everything from primary care to surgery. As opposed to the horizontal organization of internal medicine, which cares for all genders and all adult ages with a wide array of problems, ob/gyn takes a vertical approach and cares solely for women and their unique health issues. It is true that the focus of ob/gyn care is on pregnancy, fertility, and gynecologic problems. However, the necessity of an annual exam means many women turn to their ob/gyn for the majority of their primary care. This includes routine health maintenance as well as management of some chronic conditions like hypertension or diabetes. Most ob/gyns will, however, refer their patients to an internist for more complex nongynecologic medical issues that go beyond their training.
The obstetrics portion of ob/gyn is focused on fertility, management of normal and abnormal pregnancies, and delivery of babies. On the gynecology side, ob/gyn physicians manage female hormone cycles, contraception, sexually transmitted diseases and other infections of the pelvis, gynecologic cancers, urinary complications, and all sorts of other pelvic disorders. This may sound like a lot to take in, and it is, but you will probably be surprised by how focused this specialty actually is, and how narrow the differentials often are. Ob/gyns have chosen a complex arena of anatomy and physiology, but they’ve developed a logical and highly structured approach to it that makes it comprehensible.
Your rotation in ob/gyn will be most similar to your surgery rotation. Like surgery, the service can be large and tends to turn over quickly. Your time will likely be divided between the ob side and the gyn side. During your ob weeks, you will start early and preround on the newly delivered postpartum patients. Your exam and notes will be strictly focused on complications associated with the delivery, making your rounds and note writing particularly quick. After you’ve seen your patients, you’ll have quick work rounds with the senior ob resident and review the service. Many patients will be ready for discharge that day, so you will likely help prepare discharge instructions and get people ready to go. From there you will either go to the ob clinic and begin seeing women for outpatient preand postnatal care or you will go to the labor deck and help with deliveries. The clinic time will be pretty typical for most clinic work, but again you will be focused specifically on their obstetric history and current pregnancy.
Your time on the labor deck will be some of the most exciting experiences you’ll have in medical school. You will primarily assist with vaginal deliveries, and by the end of your rotation you will likely be doing these almost completely without assistance (though an attending or a resident will be in the room with you). While it’s generally a fairly straightforward procedure (remember women have been birthing babies at home without a doctor’s help for centuries), it is nonetheless tremendously exciting and a great honor to be there and be able to help out. Furthermore, not every delivery goes smoothly, so you will also assist your team in complicated vaginal deliveries and emergent or scheduled cesarean sections in the adjacent OR.
During the gynecologic portion of your rotation, you will also divide your time between clinic and the wards, this time spending a much greater portion of your day in the OR. You will see everything from common infections to dysfunctional uterine bleeding to severe gynecologic cancers. Your clinic time will be spent with mostly preand postop patients. Your OR time will be spent assisting with various pelvic surgeries. Unfortunately the pelvis is a very difficult place to access surgically, so many of the procedures are done transvaginally (e.g., a transvaginal hysterectomy) or via minimal low abdominal incisions done in narrow spaces with minimal exposure. You’ll have an attending and a senior resident already hunched over the small space being held open by your retractor, so your chances of getting a really clear view of the proceedings are fairly slim.
Many people have strong reactions to their ob/gyn rotation—they either love it or they hate it. Some are fascinated by the pathology, by the anatomy, and by the awesome process of giving birth. Others find the field too focused, get tired of doing so many pelvic exams, and find the surgery tedious. It will be a rotation you work hard on, but likely one you get a sense of accomplishment from since you can more easily grasp the spectrum of pathology and feel at least somewhat knowledgeable when pimped on rounds.
Career considerations—ob/gyn
As discussed, ob/gyns tend to have busy surgical and obstetrical practices that involve fairly high volumes of patients. Because they perform a wide variety of procedures, they tend to be well reimbursed. However, their practice is also fraught with risk. Complications associated with childbirth remain among the most highly rewarded malpractice cases since they are almost inevitably tragic. This produces staggeringly high malpractice insurance premiums that are among the largest in medicine, which can take a huge cut out of the bottom line.
For most of the last century ob/gyn, like every other field of medicine, was dominated by men. The last twenty to thirty years, however, has seen a reversal of that trend and a swing toward a predominance of women entering obstetrics and gynecology. While some female patients feel a woman practitioner may be more in tune with their needs and problems, others are more comfortable with a male physician, and still others don’t care either way. It is true, however, that many male ob
/gyn graduates are reporting increasing challenges in finding positions with an existing practice. As this is an emerging trend, if you are a male med student looking for placement in an ob/gyn practice, it is probably best to discuss strategy with your chief resident or attending.
The life of the ob/gyn doc is an arduous one, more akin to that of a surgeon. Most babies seem to be born in the wee hours of the morning, not conveniently at 3:30 in the afternoon (after you’re done seeing your clinic patients). And, like their general-surgery colleagues, the complications of their procedures, both obstetrical and gynecologic, can carry a heavy toll. Nonetheless, most ob/gyns find their work tremendously rewarding and really enjoy the spectrum of diseases they see and the ability to spread their time between pure clinical medicine and the OR.
EMERGENCY MEDICINE
Emergency medicine is a relatively new field. As such, it has recently entered the mainstream and is only now becoming a required rotation at many medical schools. Emergency care was traditionally provided by internists, surgeons, pediatricians, and family-practice doctors, and the ER was just a place you either staffed occasionally to handle walk-ins or a place where you met your patients when you were going to admit them. Doctors in the ER were there either because they were required to be or because, for whatever reason, they had no independent practice of their own. With the advent of emergency medical systems in the 1960s, the modern ER began to take shape, and a few people found themselves drawn to the field as an independent specialty. Those initial heretics are now the forefathers (and foremothers) of the field, and the specialty is now a cornerstone of medical care in any community.
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