Respectful Insolence

If you knew what you know now…

Hanging out last night, the final night of a three day holiday weekend, I was momentarily at a loss for what to write. For one thing, having spent a good chunk of the last three days unpacking the remaining stuff we’ve had in our basement in boxes for the last six or seven months, my wife and I had a pretty good sense of accomplishment but not a lot of energy left. So much for one of my analyses of a study or a medical issue.

I was also half-tempted to go back and listen again to the Science Friday last week because the antivaccinationist named Chantal who called in at the end was a perfect example of close-minded ideological blindness that rejects scientific observations, no matter how compelling, if they support the efficacy and, above all, safety of vaccines. But listening to Chantal again and transcribing some of her neuron-apoptosingly ignorant statements would have taken a lot of tedious effort, and, besides, Kevin Leitch has already taken care of it well enough, leaving me little to add. I had also thought about doing a sarcastic post making fun of Age of Autism’s laughably disingenuous and hypocritical response to my slapdown of Mark Blaxill for his outing of a regular reader of mine who comments using just initials (no, I will not link to AoA’s post on this issue). Why bother, though? Truly, the “staff” at AoA has revealed itself for what it is: a bunch of hypocrites on the issue of free speech. Indeed, it wasn’t long before J.B. Handley himself (at least, it appears to have his fingerprints all over it, if his past history is any indication) predictably dredged up yet another “outing” of me by republishing a remonstration from Dr. Jay Gordon complaining that I was being so, so very, very mean and unfair to him by characterizing him as “anti-vaccine” (or more accurately, as “parroting antivaccine canards”). Clearly, J.B. is too dense to realize that his reposting and “re-outing’ me confirmed my point for me (namely, that it is standard operating procedure of AoA to punish, intimidate, or otherwise seek retribution against pseudonymous critics who displease them too much by outing said critics) far, far better than anything I could ever have written. Great going, J.B.! I thank you from the bottom of my heart for reinforcing my point in such a timely fashion! You’re slipping, though. It took you two days; I figured you’d have done it in less than a day.

Given all the sturm und drang of the last week, believe it or not, I’m in the mood for a bit of navel-gazing, at least for today. Besides, it lets me just type what I think in the annoying stream-of-consciousness style that I sometimes affect and that allows me to blather on without having to plow into the depths of a paper or data. Don’t worry. I won’t make (too much of) a habit of it. In fact, I’m hoping to find a hardcore science paper or two to give my characteristic take on this week. In the meantime, Dr. Signout asked my input on the dreaded question that she received from a reader:

I know that what-ifs are horrible exercises of futility, and that denial and self-rationalization are crucial elements of happiness, but I was wondering anyway: would you do it over again knowing what you know now?


Dr. Signout is young and still in training; I’m a grizzled old fart. Well, not that old, but if I anticipate a total career spanning approximately 30 years or so, I’m rapidly approaching the end of the first third of my career and the beginning of the middle third, meaning that I’ll be entering what we in the biz call “mid-career.” Theoretically (and I do mean theoretically), this is supposed to be the most productive period of an academic medical career. Certainly, for clinical surgeons, it’s the part of the career when they are at the height of their game, the lack of confidence of early career gone and their surgical skills approaching their height, with no sign of ossification or decline yet. Given that I don’t feel all that “productive” at the moment, approaching as I am my first competitive renewal of my R01 and feeling the cold fear of not having published enough combined with the current lab-destroying funding climate, my perspective may be a bit warped. In addition, I can only speak for a relatively narrow part of the wild world of medicine: the world of academic surgery that includes actual translational research and running a lab.

So, if I knew then what I know now, would I do it all over again? The answer is not simple. I’d love to say, “definitely yes!” and certainly I can’t say “No way in hell!” The answer, as you might expect, is somewhere between the two. The question, of course, is: To which extreme would my answer be closest?

I came to my current career through a rather odd path. When I was in college, I knew I wanted to be a scientist, and I knew I wanted to do be a scientist, but I had little idea of specifics. I was, believe it or not, a chemistry major (indeed, my undergraduate degree is a B.S. in Chemistry) and for a while I thought I might want to be a chemist. When I took a graduate course in biochemistry during my junior year, my attentions moved in a more biological direction, and I started to think that I might want to pursue a career as a biochemist. In the meantime, however, an idea had been growing since my freshman year. It started out as a thought that I thought of mainly in terms of “what if” or “maybe it would be cool” and grew. It was the thought that maybe I wanted to be a doctor. The thought of not only being able to help patients but also to be able to take an active role in advancing medical care through research was very appealing to me. Then the thought grew that maybe I wanted to pursue a combined M.D./Ph.D. degree. It sounded like a good plan. Unfortunately, I didn’t make the cut, the first time in my life I didn’t achieve something really major that I had wanted to achieve. I did get into medical school (and an excellent one, at that), however, and reluctantly decided to go to medical school first and hope to find opportunities to gain research chops by other means. To that end, I volunteered in a biochemistry lab between my first and second year of medical school.

Meanwhile, the very nature of medical training started to grind on me. I’ve lamented time and time again about how poorly all too many physicians grasp the scientific method, leaving them to embrace “intelligent design” creationism or to fall into various forms of unscientific woo. If there’s a place where the groundwork for this failing is laid, it’s medical school. What I learned is that medical school is best characterized as a trade school. The goal of medical school is to provide students with the basic skills needed to be a doctor, not the scientific method. What this too often means is a lot of rote memorization and application of scientific principles taught to them to clinical problem-solving but little or no understanding of how those scientific principles came to be understood–in other words, little or no understanding of the science behind those principles. Students learn how to analyze blood gases, for instance, but not how we know what we know about them. They learn physical examination skills as rote skills to be applied. Of course, not all physicians need to be trained in hard core science. Indeed, only a minority of physicians will be academic; the vast majority will go into practice and do no research. Still, the lack of scientific stimulation grated on me.

Another sea change occurred during medical school. I originally thought I wanted to become an academic internist, probably an oncologist. That intent was tested first when I did my general surgery rotation as a third year medical student. To my utter shock, I liked it. More than liked it actually. Despite the grueling, inhuman hours of the pre-80 hour work week era (even for medical students, who didn’t spend as many hours as the surgery residents), I started to wonder if I wanted to become a surgeon. Still, I decided to wait until I did my internal medicine rotation before making any decisions. In retrospect, I needn’t have waited. When I did my internal medicine rotation, to my surprise I really didn’t like internal medicine much. While intellectually I liked the problem-solving and cogitation of internal medicine, I was frustrated by what I sometimes viewed as mental masturbation that went on too much of the time and missed the active approach of surgery. Over the course of several months, I decided to become a surgeon. I feared that this might ruin my chances for ever getting a Ph.D. or becoming a translational researcher, given the time demands of surgery.

It turns out that I needn’t have worried that much. Less than two years into my general surgery residency, an amazing opportunity came up. My chairman at the time wanted to see if he could manage to get one of his residents through a Ph.D. program during the residency. The resident from the year before me whom he originally had planned on supporting through a Ph.D. program bailed on him and decided to take a fellowship at the NIH during her research years. Seeing a golden opportunity to rectify my failure to get into an MD/PhD program, I seized the opportunity. And it was a sweet deal, too. Not only did I get a full ride, but I was paid as a resident, not as a graduate student, meaning I made more than twice what graduate students at the time did. I could get my Ph.D. and not have to be poor doing it. Ultimately that’s what happened. I got my Ph.D. and returned to my surgery residency, which I finished. I won’t say it wasn’t without some serious angst at a couple of points. The culture shock of returning from the rarified air of pure research to the hurly-burly, take-no-prisoners world of general surgery residency was profound. I seriously considered quitting on more than one occasion, especially during a particularly ugly stretch during my fourth year of every night call from home where I got called in nearly every night and on a couple of occasions went for a week with only a few hours of sleep total, caught here and there, often while sitting up.

I finished, though, and the rest, as they say, is history. I ended up gravitating towards cancer, and did a surgical oncology research fellowship. Ultimately I became primarily a breast cancer surgeon, built a lab, and became NIH-funded. The struggle was long and hard. It stressed me in ways I didn’t know I could be stressed. Many were the times I contemplated quitting, all of which brings us back to the question that started this meandering recitation of my history: Was it worth it? Would I do it again?

I answer: Yes, and I don’t know. (On a personal note, though, I do know that in the hypothetical realm where I could “do it all over again, if I didn’t, I’d never meet my wife, which would be unacceptable.)

Being a physician-scientist is one of the greatest callings there is. Not only can I have the satisfaction of eliminating cancer in individual patients, but I can have the additional satisfaction of trying to come up with more effective treatments for cancer. There is an unparalleled opportunity to take basic science research and craft it into something that helps patients. That being said, the reason for my answer to the second question of “I don’t know” is the sheer brutal toll the training took on me, as well as the number of years it took. I was 37 before I had my first “real” job, and I didn’t take any time off during my training, not to mention that I was also in considerable debt. It’s not for nothing that being a physician has been likened to joining the priesthood. It’s a professional calling that defines you forever and consumes your identity and–if you let it–your life. Like it or not, that’s just the way it is, and, given the importance of the work required, the way it arguably should be. Worse, the funding climate right now is at a soul- and career-crushing low. I spend nearly all my non-clinical time plotting how to keep my lab funded. Not only does my academic career depend on it, but so do my lab personnel.

So my answer remains: I don’t know. I love what I do, but it’s a lot harder than I could ever have imagined when I first undertook this long journey. To any medical students contemplating a career in medicine, you have to ask yourself: How much does it mean to you? If you’re involved in patient care and especially if you take care of really sick patients, it will take over your life. You need to do everything you can to find out whether you truly love what it involves. It’s true that you can never truly know what medicine entails until you actually immerse yourself in its practice, but you can get an idea. Patients deserve the best possible care, and ultimately physicians who love what they’re doing will be more likely to provide that care. If you think you might want to be a physician, you should not proceed if there’s significant doubt that medicine represents a passion for you that demands satisfaction, even at the cost of a considerable chunk of what are considered the best years of your life and, depending on your specialty, a large chunk of your identity and the rest of your life. This goes double for academic medicine and triple for academic surgery.

Comments

  1. #1 Signout
    September 2, 2008

    Thanks, Orac, for the thoughtful and sobering view. I’ve left a pointer to your post in the comments section over at Signout.

  2. #2 Gary Godfrey
    September 2, 2008

    Orac,

    Thank you for the insight.

    A couple of questions (from a non-scientist, non-MD):

    1. Is the sacrifice necessary, or is it just because of the US system? When you talk to other physicians or researchers around the world, do they share the same stresses?

    2. This is orthogonal to your post. I believe (not a strong belief) that the long hours that physicians experience during residency is a good thing. This is based on the theory that the best way to learn something is when you’re wide awake and well rested. The best time to reinforce learning is during the most adverse circumstances. By forcing residents to work in their sleep, they become able to work in their sleep. Thoughts?

  3. #3 daedalus2u
    September 2, 2008

    Orac, I suspect that the level of intensity that you experience while practicing medicine isn’t about the practice of medicine, it is about you. No matter what career you chose (or which chose you), I suspect you would approach it with the same level of intensity and focus. The degree of difficulty isn’t in the career, it is in you.

    Gary, I think there is physiology behind the imposition of stress during the formative years of a person’s career. High stress causes low NO, which fosters short range functional connectivity which is necessary for looking at the details of what is learned as it is being learned. High stress forces you to look at the individual trees in the forest. Later, when one’s stress level is lower, NO levels increase and cause longer range functional connectivity allowing one to see and appreciate the forest while not losing sight of individual trees.

    I think this is the archetypal path by which heroes and other mythic figures occur.

    http://en.wikipedia.org/wiki/The_Hero_with_a_Thousand_Faces

    Low NO during formative years followed by high NO. The disintegration of the heroes ego is due to low NO decreasing the functional connectivity (i.e. the fMRI BOLD signal is mediated through NO), the reintegration of it is due to high NO. The low NO of acute stress causes disintegration, the high NO of loving relationship causes reintegration but now with a focus on giving back.

    I think this is how most of the paradigm shifting technologies were developed; by the “Einsteins” of the time (low NO causes the Asperger phenotype). They were thought of as magic because all sufficiently advanced technology is indistinguishable from magic.

  4. #4 DLC
    September 2, 2008

    If you knew then what you know now, would you still be where you are ? No.

  5. #5 Legal Eagle
    September 3, 2008

    Keep in mind that doctors screw up. By the AMA’s own stats, they kill well over 100,000 a year.

    100.000

    When you throw in hospital and pharaceutical errors, its closer to 200,000. And these are not just old people who weren’t going to make it, they are largely people who should have made it.

    Thats over twice the number killed in car wrecks every year, twice the number of Americans killed in the entire Vietnam war.

    And of course we can ignore the million and a half subhumans aborted by doctors every year.

    I have no sympathy for their “stress”, and if doctors knew how many times people wanted to sue doctors but the lawyer told them it wasn’t economically feasible they would be shocked.

  6. #6 sea creature
    September 3, 2008

    Thank you Orac for taking the time to write this. When I have been hospitalized (or a loved one has) it has been easy to be impatient with physicians when dealing with them in that hectic environment. Yet I have often been touched by displays of caring from them when I knew they had worked more hours and slept little, and I in the same place would have been barely able to be civil.

  7. #7 Tercel
    September 4, 2008

    Yes, doctors make mistakes. What are you suggesting? Do you think we would be better off without them? How many would die every year if that were the case?

    You cannot take a lack of perfection as a lack of effectiveness or competence. And it is a bit disgusting to attack people who do so much good simply because they don’t do more than they are humanly able. Its like being given a million dollars, and calling your benefactor a thief because he didn’t give you 1.1 million. Except in this case it is worse. You are talking about death, and the doctors who inevitably feel guilty enough as it is.

    If you have so little sympathy for their stress, and so little appreciation for what they do, then maybe you should avoid them next time you are ill.

  8. #8 SC
    September 4, 2008

    republishing a remonstration from Dr. Jay Gordon complaining that I was being so, so very, very mean and unfair to him by characterizing him as “anti-vaccine” (or more accurately, as “parroting antivaccine canards”).

    Well, I feel slighted. I had unpleasant truths aplenty for Dr. Jay on that thread. But do I get a sniffle in his little poutifesto? Not a one. Harumph.

    (Nice glasses, btw.)

  9. #9 Legal Eagle
    September 6, 2008

    Tercel, I do. And I am suggesting that if they had a little more humility, people would not hate them so much.

    I sued a doctor today.

    It felt good.

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