Decisions IV

The competing specialty is internal medicine, that quintessential cognitive specialty. My dad is a general internal medicine doctor, but the field didn't really make it onto my radar until I came to medical school. UCSF has a strong focus on internal medicine. Many of the best teachers we see are internal medicine generalists or subspecialists. The curriculum of the first two years heavily emphasizes medicine over other fields; we get less anatomy than other schools and the ob/gyn and pediatrics exposure comes really late in the second year. The medicine came easily to me. I loved the systems based learning and each system represented to me a facet of internal medicine. The mentors I have here, my Foundations of Patient Care facilitators and key players in my formative years (I almost say that jokingly) were all internal medicine trained. They were brilliant, compassionate, supportive, and encouraging.

What really got me was clinical problem solving; I even bought a book of NEJM cases. I absolutely love that strange idea of taking a story and figuring it out. That thought process fascinates me; how do we learn to do pattern recognition? How do we figure out what a diagnosis is? I got so wrapped up in the differential diagnosis that I even made a website for my own learning (http://caseoftheday.blogspot.com/) and still take two hours each weekend reading more. That feeling when a case clicks and all falls together is addicting and intoxicating. And clinical problem solving is far more than that: I like learning about the sensitivities and specificities of signs, symptoms, and tests; I like framing these questions in terms of pre-test and post-test probabilities.

My favorite third year rotation was medicine. I loved the sick inpatients, the acuity, the diversity of diseases, the mystery cases. I loved the EKGs, the chest X-rays, the physical finding rounds. My attendings and residents impressed me so much with their finesse and deduction. Then they turned around and told me I should do medicine as well; they seemed to recognize in me some unbeknownst talent.

There are aspects of internal medicine that give me pause. My dad warns me that general internal medicine as a practice is not as fun as it seems now; common things are common and the bulk of the work is not all that intellectually stimulating. I also think management is a plus-minus; although it's certainly important and fundamental to medicine today, I could be just as happy in an Oslerian world were we diagnose things but have little to offer. Medicine offers a wide range of specialties, including those that are procedural and interventional, those that are completely cognitive, and those that are in between. It is almost like delaying a decision on what kind of doctor I want to be. At this point, I think the most interesting fields would be cardiology (especially clinical cardiac electrophysiology) and infectious disease.