Decision-Making I

I'm terrible at making decisions. And here, I don't think there's a perfect decision. Or at least, no clear cut choice. But I'm about three weeks behind schedule, and everyone's bugging me about what I want to be. Most of the time for these conundrums, I scrutinize everything as rationally as possible, but of course, rationality only captures part of it. There are so many other factors, the silent and unmentionables, the emotions and secret desires. In the end, I'll decide based on incomplete information, as most critical decisions are; such is life.

The decision is between internal medicine and anesthesia. But I have to define things more precisely than that. If I were to pursue medicine, I am nearly certain I'd subspecialize. I know it's all the rage these days, but I've thought about this quite a bit. I don't want to be an outpatient general internal medicine doctor, that I'm sure. The hospitalist role is a little closer to the realm of possibility but after imagining myself as a medicine attending, I don't think that's what I want. Although I like knowing a bit about everything, I like the idea of expertise even more.

The problem is that I don't know what kind of subspecialist I'd be. Cardiology has always been alluring, but the standard outpatient cardiology fare - atherosclerosis, coronary artery disease, hypertension, hyperlipidemia, atrial fibrillation - is simply "okay." I do like arrhythmias, congenital heart disease, and invasive stuff like intra-aortic balloon pumps, but I'm not sold on the specialty.

Infectious disease has also been attractive, but I'm afraid that the practice is less exciting than the idea of it. In my mind, I imagine ID to be filled with obscure great diagnoses like brucella or leptospirosis or non-Hodgkin lymphoma (that's why all the cultures have been negative) but in reality, I worry that I'll be doing hospital infection control, wrestling with other services over antibiotic use, and waiting for cultures. I don't know what outpatient ID is like.

Some other subspecialties - endocrinology, hematology, pulmonary critical care, and rheumatology - seem vaguely interesting, but not enough to convince me now. The problem is that if I pursue medicine, I'm investing 6 years of my life without being fully convinced that I'll find what I want.

As for anesthesia, I'm in a similar bind; I don't think general run-of-the-mill anesthesia is what I want to do. I think I might get bored of the cases, and I want to have particular expertise. Cardiac anesthesia attracts me; even though I only had a hint of it in my anesthesia rotation, I wanted more. I can see myself as a cardiac anesthesiologist a little more clearly than I can see myself as a cardiologist. The things I like about cardiology - the high intensity, sick patients, immediacy, and procedural nature - trickle over to cardiac anesthesia. Lastly, critical care is accessible from multiple venues, and anesthesia is as good a route as any.

One caveat is that our clinical rotations give us far less time in anesthesia and critical care than medicine, yet despite having only limited experiences, I feel a little more certain I'll find something I like. Even though I've had equally little experience with obstetric anesthesia and rheumatology, there's a little part of me that would want to do the former rather than the latter. Should I be listening to that instinct? And who knows? Maybe pediatric or transplant anesthesia might just catch my eye.

Anesthesia is nice in that it's 4 years, one of which will be internal medicine. Subspecialization is an additional year so it's a total of five, and intern year will sate some of that medicine drive.

This is day one of pondering.