It is 2 a.m. The hospital is running on a skeleton crew. Alexi is sleeping at home, while I have just finished my evening rounds and am heading to sleep until 5 a.m. or until the nurses page me—whichever comes first. As I get settled into my call room, I hear the overhead buzzer: "Code Blue—Tower Code Team, 14 D Delta." Within minutes, those of us still in the hospital are on the 14th floor and by a patient's bedside. Including the nurses, there are upward of 50 of us. One individual, known as the "Medical ICU Senior Resident" is responsible for "running" the code. This is a role revered—and feared—by most house staff. There will be a time for all of us to run a code while still residents. Yet there are those who run it brilliantly; Tracy, who directed last night's code, is one of them. Relief washes over us when we see her at the helm, standing at the foot of the patient's bed. She has done more MICU time than I even care to consider and has the air of a well-seasoned veteran as she gives orders to the motley crew of half-awake physicians and nurses, most of whom have never met this patient.
When I later ask her to recount the events of our 2 a.m. rendezvous, she describes it as follows: "The guy last night was found unresponsive. His ECG strip went from first degree AV block, to second degree, and finally into complete heart block over the course of a few seconds! Pretty neat!" Tracy, as one might imagine, is destined to be a cardiologist. She gets her jollies from correcting advancing heart block.
Being a cardiologist is not exactly a cushy 9 to 5 lifestyle. In fact, it's rare that my attending physician in the CCU is not present and attentive throughout the day and well into the night. Similarly, the attending physicians I've worked with in other subspecialties, such as oncology, renal, infectious disease, and pulmonary/critical care, as well as general medicine, work hours that put me to shame. These doctors, who are opting to pursue their passion, regardless of a difficult lifestyle, are bucking a new and rather unnerving trend within medicine—a move toward what we interns call "The ROAD."
The ROAD is an acronym that refers to a collection of subspecialties (radiology, ophthalmology, anesthesiology, and dermatology) that offer more manageable lifestyles. A few weeks ago, at a particularly vulnerable moment—I had just worked 36 hours and was on my way home in the dark—I received a brief note from my father, along with an article about the move many medical students are making toward these "lifestyle" fields. Most medical students, at some point during their four years, consider opting for one of them. Many eventually do.
Ever since I decided to leave the liberal arts world and pursue a career in medicine, my father has been gently trying to direct me toward a field with a better lifestyle than the one he chose. As a pulmonologist, he still takes call (albeit from home) and works weekends. Much like his own father, who was a surgeon in a solo practice, he loves what he does and only rarely seems to be bothered by the long hours. Still, he has hopes of making my life a little easier, so he encouraged me to become fascinated by acne.
Unfortunately, the more skin disorders I saw, the more repelled I became. With each new pustule, I found myself reaching for the doorknob. I soon realized that every physician finds something repellant—for some it's the smell of vomit, or examining crusty feet, but for me it was unhealthy skin. There is something about an oozing pimple ready to explode that sends me reeling.
Those of us in fields that demand more of our time often find ourselves getting a bit haughty about our decision. When I call for a dermatologist to consult on my patient, and he or she returns my call from a cell phone while birds are tweeting in the background, I become highly self-righteous. "Fresh air is overrated anyway," I think to myself.
As it turns out, I've decided to pursue internal medicine in spite of the long hours. This field of medicine thinks of the person as a whole, as the sum of his or her parts, rather than as each part by itself. We take people as they are, with whatever ails them, and try to heal them—without augmenting, lifting, deconstructing, or reconstructing them in any way. Giving medications and coming up with diagnoses are integral to what we do, but these are not the components of internal medicine that inspire me. While physicians who choose the ROAD don't have extensive interactions with their patients—radiologists don't see patients, ophthalmologists and dermatologists tend to only see patients for specific complaints, and anesthesiologists rarely see patients when they are awake—internists are the first to see a patient for any ailment, no matter how small. We are there for the problems that range from the run-of-mill to the rare, and being this kind of constant in a patient's life leads to incredibly rich interactions. Our patients stick with us, and we with them. We mentally take our patients home with us at night, reading up on rare diagnoses, or thinking about challenges they are facing. Our encounters are important to the patients as well; many send holiday cards, photographs, or even flowers months after we've seen them.
In the end, the ROAD has the cachet, the hours, and the dollars—but if I were to take this ROAD so often traveled, it would be rare that I would hear those three important words a patient uses when he or she introduces me to her friends and family: "Here's my Doc." In the end, isn't that what it is all about?