I still feel like the same guy who got here back in September except maybe a bit more comfortable, a bit more able to put pieces and clues together, a bit more able to pick up on nuances, a bit more able to ask the important questions, a bit more able to figure out what's actually going on... maybe just a bit more competent.
It's an odd feeling. All along the way outside of rare occurences where I scream to myself "I just studied that!", I don't actually feel like I'm actively learning. When I see patients though, it doesn't feel as much like a giant question mark anymore. I now recognize more medications than I have to double-check on my iPhone. I'm getting some pimping questions... correct?
The days don't seem as long anymore. A 12-hour shift in the ER, a full day of surgery or a long clinic day don't seem as daunting. Don't get as much sleep as I'd like in one night? Meh! As I just told Brad, it feels like when you're training. At first when you begin to run (or swim or play that sport), you want to die. You don't feel like you'll ever get used to the rigors only to catch yourself breezing through spending more time than not at work and with less sleep than I usually get to boot.
Even more, I'm astounded as to how fortunate I am to have gone through my third year here in Hinton. The patients rave about the physicians I work with, it has an excellent setup for a town of ~10,000 people, and the medicine that passes through those hospital and clinic doors have not disappointed. I have a hard time thinking of what I have missed out on in the city minus the "weird and wonderful" that is not really what is important in third year when I'm trying to establish my foundation in medicine. I have seen the pediatrics, the obstetrics, the internal medicine, the surgery, the psychiatry, and of course what family medicine should really be like. What's more, my preceptors are more genuine friends than bosses, and outside of James have been my main outlets for support AND social out here... and I know will be people I keep in touch with in the future, and not for the purpose of reference letters. I honestly could not think of a better learning environment.
As to the golden question: what do I want to do next? A lot of doors still seem to be open, and I don't feel particularly rushed to say I'm drawn by any of them. In fact, there could be some opening in the corner of my eye too. There is a "big three" that has always been around, and the winner of the race probably won't be revealed until very close to the end barring an exceptional experience somewhere, or the lack of one. In descending order...
3. Emergency Medicine - It made a strong push maybe about halfway through the year as I was starting to feel a lot more comfortable with assessing and making decisions regarding patients and has always been the vehicle through which I have learned the most in the approach to the sick patient. I liked its versatility - you never know what's coming through the door and that satisfies my very short attention span. The fact that I can also do things with my hands is a dimension the other two don't have much of in either quantity or variety. With that said, doing things with my hands is not what I want my career to be centered around which is why I have essentially knocked any of the surgery specialties off my list. The three letters "NYD" (not yet diagnosed) is also troublesome - I don't deal well with unsolved problems, and continuous care and building relationships with patients are both important to me. Finally, the biggest knock against it, at least from my point-of-view is the shift work. I know a lot of people don't really mind it, but growing up with two parents who both did shift work, I generate a slight personal bias against it.
2. (Rural?) Family Medicine - I can't picture a better working environment, should I decide to go down the Family Medicine path, than the Hinton Medical Clinic. Everything including the support staff, the set-up, the other physicians was almost as good as I could imagine a family medicine clinic being. The HMC played a massive part in a late push by Family Medicine. Building relationships and the variety of problems are both positives, but I do remember that if I ever had more than 5 days in a row of just straight clinic, I started to get incredibly bored. I do enjoy the versatility and the fact that literally any type of medicine can walk through the door (similar to EM above), and as a result, one's practice can be moulded as they see fit (also similar to EM above). A significant part of me though does want to be a relative "expert" in a field I work - where I can be looked to by colleagues for consultations or answers to questions. It may come off as egotistical, but I see it more as a challenge because if I am relied on in that way, it forces me to stay diligent.
1. Internal Medicine - the incumbent leader that never really had been unseated outside of feeling great after one Emergency shift back in January. I love the complexity of its cases, and at least a few of the subspecialties I feel can overcome my ADD-ish tendencies... maybe. Continued care is also a real possibility with a number of the specialties. Interestingly enough though, throughout this year I have further realized two major concerns exist:
(a) the patient demographics are relatively narrow, I'm sure people over the age of 60 make up over 80% of the people treated by internists. Comorbidities abound - many of the solutions for people on 30+ meds... is to put them on more medication. Sure, some may live longer, but what about their quality of life? Diseases may be diagnosed, and that can be rewarding, but a lot of patients they deal with are sick... and stay sick, or feel worse in the name of maybe living slightly longer. It can be argued though that yes, internists do see patients when they are at their worst. When they've hit rock bottom... and many of them don't make it out of that, but I'm sure it is incredibly rewarding to see them come out of it (eventually) much better. No pain, no gain, right?
(b) my hands will either be in my pockets or writing orders. Outside of physical exams, the two main exceptions are interventional cardiologists and gastroenterologists, but even they do a relatively limited number of procedures which are incredibly competitive to get training for and land a job. Sure, I'm sure my brain will be tickled and puzzled a lot of my time, but I fear my hands will grow to resent me... I guess that's what art and hobbies are for, hey?
So that's where I stand. It's almost 00:30 and I'm too tired to make a dramatic or insightful conclusion from this rambly essay. Somewhere in Edmonton, Ms. Tuba is cringing.
