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A PIECE OF MY MIND

Considering Life Before Lifestyle


for the past 35 years, but according to my grandmother this was not his intended career pathhe was supposed to become a surgeon. Nana, as we called her, told me that my father failed the steady-hands test when he began medical school in 1970, and so he could not pursue a surgical specialty. She explained it vividly, and it really must have been terrifying: you had to place your hands in front of your body, fingers stretched taut, in front of a panel of robed, white-haired, pipe-smoking, surgical professorsone quiver, youre finished. I had serious suspicions about the actual existence of the steady-hands test. By the time I was a teenager I concluded that, in fact, my dad never wanted to become a surgeon; he genuinely sought to care for children, help them meet their milestones, and treat them when they became sick. On many occasions he had told me how influential his own family doctor had been in his choice to become a pediatrician when he was still a child. Perhaps my grandmother had hoped for her son to become a surgeon, and I am certain that there was significant pressure for my father to follow through with her wishes. Did she think he would have a superior lifestyle had he chosen to pursue a life in surgery? Asforme,Iendedupbecomingaurologist,andrecentlystarted a fellowship in kidney transplantation. But how did I get here? What factors shaped my choice of specialty? I started medical school 30 years after my dad, but the steadiness of my hands was not substantiated, and I was fortunate to be free of the parental pressure that my father likely endured. My classmates and I experienced the requisite welcoming ceremonies, and we wereadmonishedtostartourcareeragog,andagape,toallmedicine had to offer. We complied, albeit only for a week, and it seemed genuinely noble to consider every facet of disease and human suffering with equal fervor. But soon I encountered innumerable external factors that would influence my career path in medicine. Most pervasive, and unsavory at times, was the concept of lifestyle. On the surface it may seem that choosing ones field based on lifestyle makes total sense. But what exactly does lifestyle mean in the context of a medical or surgical specialty? I could not recall ever thinking about my lifestyle up to this point, but suddenly it had become a near-obsession. My classmates and I started to categorize our eventual choices based on a given specialtys ratio of potential monetary return and leisure time, to the amount of effort one would need to expend in his or her practice. We waxed poetic about the so-called lifestyle specialties radiology, ophthalmology, dermatology, emergency medicine, and anesthesiology. Family medicine, along with the
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Y DAD HAS HAPPILY PRACTICED GENERAL PEDIATRICS

other primary care fields, has relatively decent hours, and a wonderful scope of practice, but the pay is not as good. Then there are the surgical lifestyle specialtiesif you just couldnt resist being a surgeon but wanted to maximize the lifestyle ratio, you considered orthopedics, urology, plastic surgery, and head and neck. You wouldnt want to do general surgery with falling incomes, perennial emergencies, and never-ending hours. If, however, you could endure a neurosurgery residency and subsequent spine fellowship, the rewards might be immense. This was before we even had any real-life exposure; we were still grappling with the Krebs cycle, the nerves of the brachial plexus, and the pharmacokinetics of warfarin. We had no idea what we were talking about. Leaving our books behind for an hour, we would clamor to attend the various specialty interest group meetingsthere would be some stale take-out food for dinner, maybe an attending physician, and a couple of tired residents under the fluorescent lights of a classroom. After the standard introductions and a bit of background, we made circuitous inquiries in order to get a better idea of the lifestyle in store for us. Its embarrassing to admit, but I do remember sitting with a group of classmates late one night in the medical school library, crowded around a computer, looking at a website that ranked medical specialties by average income. Why would we care? According to the Association of American Medical Colleges, in 2010 78% of medical school graduates had at least $100 000 in educational debt; 42% had debt in excess of $150 000. Only 15% of medical school graduates had not accrued educational debt.1 Medical school tuition is only increasing, and fewer parents are likely to be able to assist their children financially given the current state of the economy. Merely being able to repay ones loans factored heavily into the lifestyle equation. I felt this firsthand when I faced $225 000 of my own educational debt, and I would be dishonest if I did not admit I was thankful that my path had led to a highly paying specialty. Figuring that lifestyle mania, and the compounding issue of indebtedness, had not waned in the seven years since I selected urology, I decided to confirm my suspicions. Recently I met a third-year medical student, Ill call him Adam, who was doing an elective rotation on our urology service; he scrubbed into a kidney transplant. I asked him pointblank about the current eminence of perceived lifestyle among medical students today. Adam candidly said that discussions of lifestyle and potential earnings are indeed ramA Piece of My Mind Section Editor: Roxanne K. Young, Associate Senior Editor. JAMA, May 23/30, 2012Vol 307, No. 20 2159

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A PIECE OF MY MIND

pant. He knew that very website I used to look at in the library. Adam had pondered his future lifestyle as well and was strongly considering neurosurgery and maybe urologyhe would experience both fields as elective rotations for a paltry seven days each. I looked over the top edge of my loupes and asked Adam, What is the difference between your life and your lifestyle? He understood the rhetorical nature of my question and did not answer, but I could tell that something might have clicked inside him. We went for lunch after the operation and continued the conversation. Looking back it seems preposterous to decide on a career based on a seven-day rotationmy attending likened it to persuading someone to get a tattoo without much forethought. I agreed. Adam knew classmates who had hoped to becomeprimarycarephysiciansbutwhoabruptlyswitchedtheir focus to dermatology when they scored astronomically high on the USMLE Step 1 exam; he sensed that they had not developed a sudden passion for the immunotherapy of psoriasis, but rather an urgency to maximize their lifestyle now that their probability of matching had improved. The situation reminded me of something the great American composer Aaron Copland had saidaboutexperiencingmusic:Ifyouwanttounderstandmusic better, you can do nothing more important than listen to it. I fearedthatAdamandhisclassmatesweretryingtoappraisesongs without ever hearing them. I had done the same 7 years before. In a similar leap of faith, and with only two weeks worth of experience, I decided on a life in urology. I loved surgery, I found the diseases of the genitourinary system fascinating, the residents and attendings seemed happy, and I was assured there would be a good lifestyle. Five years into my residency, happy that I still enjoyed urology, I faced the next big decisionwhat to do next? When I decided to pursue a fellowship in kidney transplantation, an unconventional choice for a urologist these days, I was met with puzzled looks; most comments centered on the fact that I was effectively giving up the urology lifestylemy hours would be terrible, unpredictable! It was de j vuI was suddenly thrown back into the lifestyle game. Perhaps ironically, my wife ushered me toward a decision that would ultimately lead to less time together; she simply pointed out how elated I was when I came home from a long night of transplantsmuch more so than when I went to deal with ureteral stones or hematuria. This is not to say that physicians should not seek to achieve balance in their lives, to enjoy quality time with our families, and to have interests outside medicine. We need leisure time. But can you be truly happy at home if youre unfulfilled, or unhappy, at work? For those of us fortunate enough to interact with and mentor medical students through this critical decision, how can we help? I do not believe that any curricular overhaul would mitigate the lure of lifestyle. There are simply too many specialties to allow ample time for a truly informed decision. Can we somehow shift the focus from securing a great lifestyle to building a magnificent life? Residents and fellows must remember that in many ways, we are the most influ2160 JAMA, May 23/30, 2012Vol 307, No. 20

ential partythe students spend more time with us compared with our attendings. They gauge our happiness and our zeal for our calling. We should help medical students find their professional soulmatethe right specialty, I believe, is out there for all of us. When counseling medical students, let us focus on our life as physicians, not on the lifestyle that our specialty affords us. For our students whose passion resides with a relatively lower-earning specialty, encourage them to follow that passion while not discouraging them based on a lower potential income. Emphasize the tremendous value that all physicians hold for both society and humanity. Even the lowestpaid physicians will earn far more money than the average American; it is sobering to recall that the median annual salary in the United States in 2010 was $26 363.2 Reflect on what makes your life as a physician great, your legacy enduring. Tell them why you happily jump into your car at 4 AM, why you look forward to the next day, and why coming home from a vacation is not too painful to bear. As they rotate through our operating rooms, reading rooms, and clinics, zero in on why you enjoy being there. Steer them to talk to your mentors who, despite being beyond retirement age, eagerly come to care for their patients as if they were on their very first clinical rotation as a student. Share the little things too: I love that red-tape line on the floor inmostoperatingrooms,theonebythefrontdesk,beyondwhich you must be in operating-room scrubsstep over it and I pass into a different world, a point of no return where I know Im going to see amazing sights and can do great things. I shake my head in wonder when we take a kidney from one human, sew it in to another, and watch as it resumes its renal duties immediately, making urine before we can even sew the ureter into the bladder. For my dad its wholly differenthe loves running into patients whom he has known from the day they were born, who now have children of their own. He takes great pride in making that difficult, early, diagnosis of diabetes in a child, and partaking in the challenges of his or her medical care. There is simply no price and no monetary value for the moments that make us content, proud, and enthralled to be physicians. And so we still face that panel of stern professors, albeit within our own minds, who test not the steadiness of our hands, but rather the steadfastness of our true passion for our chosen medical field. Consider your life before lifestyle the rest, as they say, will follow.
Jeremy M. Blumberg, MD
Author Affiliation: Department of Urology, Kidney Transplant Program, David Geffen School of Medicine, University of California, Los Angeles (jblumberg@mednet .ucla.edu). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

1. Medical student debt. American Medical Association, 2011. http://www .ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections /medical-student-section/advocacy-policy/medical-student-debt/background .page. Accessed January 3, 2012. 2. Wage statistics for 2010: Social Security Administration, 2012. http://www .ssa.gov/cgi-bin/netcomp.cgi?year=2010. Accessed April 2, 2012.

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