7/30/2019 jamatext

1/2

A PIECEOFMYMIND

Considering Life Before Lifestyle

MY DAD HAS HAPPILY PRACTICED GENERAL PEDIATRICS

for the past 35 years, but according to my grand-mother 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 hebegan medical school in 1970, and so he could not pursue asurgical specialty. She explained it vividly, and it really musthave been terrifying: you had to place your hands in front ofyour body, fingers stretched taut, in front of a panel of robed,white-haired, pipe-smoking, surgicalprofessorsone quiver,youre finished.

I had serious suspicions about the actual existence of thesteady-hands test. By the time I was a teenager I concluded

that, in fact, my dad never wanted to become a surgeon; hegenuinely sought to care for children, help them meet theirmilestones, and treat them when they became sick. On manyoccasions he had told me how influential his own familydoctor hadbeen in his choice to become a pediatrician whenhe was still a child. Perhaps my grandmother had hoped forher son to become a surgeon, and I am certain that therewassignificant pressure for my father to followthrough withher wishes. Did she think he would have a superior life-style had he chosen to pursue a life in surgery?

Asforme,Iendedupbecomingaurologist,andrecentlystarteda fellowshipinkidney transplantation.Buthow didI gethere?What factors shapedmy choiceof specialty? I started medical

school 30 years after my dad, but the steadiness of my handswas not substantiated, and I was fortunate to befreeof the pa-rental pressure that my father likely endured. My classmatesandI experienced therequisitewelcoming ceremonies, andwewereadmonishedtostartourcareeragog,andagape,toallmedi-cine had to offer. We complied, albeit only for a week, and itseemed genuinelynoble to consider every facet of disease andhuman sufferingwith equal fervor.Butsoon I encounteredin-numerableexternalfactorsthatwouldinfluencemycareerpathin medicine. Most pervasive, and unsavory at times, was theconcept of lifestyle. On the surface it may seem that choos-ingonesfieldbasedonlifestylemakestotal sense.But what ex-actly does lifestyle mean in the context of a medical or surgi-

calspecialty? I couldnotrecalleverthinkingabout mylifestyleupto this point,but suddenlyit hadbecomea near-obsession.My classmates andI started to categorize oureventual choicesbased on a given specialtysratio of potentialmonetary returnandleisuretime,totheamountofeffortonewouldneedtoex-pend in his or her practice.

We waxed poetic about the so-calledlifestylespecialtiesradiology, ophthalmology, dermatology, emergency medi-cine, and anesthesiology. Family medicine, along with the

other primary care fields, has relatively decent hours, and awonderful scope of practice, but the pay is not as good. Thenthereare the surgical lifestyle specialtiesif you justcouldntresist being a surgeon but wanted to maximize the lifestyleratio, you considered orthopedics, urology, plastic sur-gery, and head and neck. You wouldnt want to do generalsurgery with falling incomes, perennial emergencies, andnever-ending hours. If, however, you could endure a neu-rosurgery residency and subsequent spine fellowship, therewards might be immense.

This was before we even had any real-life exposure; wewere still grappling with the Krebs cycle, the nerves of thebrachial plexus, and the pharmacokinetics of warfarin. We

had no idea what we were talking about. Leaving our booksbehind for an hour, we would clamor to attend the variousspecialty interest group meetingsthere would be somestale take-out food for dinner, maybe an attending physi-cian, and a couple of tired residents under the fluorescentlights of a classroom. After the standard introductions anda bit of background, we made circuitous inquiries in orderto get a better idea of the lifestyle in store for us.

Its embarrassing to admit, but I do remember sitting witha group of classmates late one night in the medical schoollibrary, crowded around a computer, looking at a websitethat ranked medical specialties by average income. Whywould we care? According to the Association of American

Medical Colleges, in 2010 78% of medical school gradu-ates had at least $100 000 in educational debt; 42% haddebtin excess of $150 000. Only 15% of medical school gradu-ates had not accrued educational debt.1 Medical school tu-ition is only increasing, and fewer parents are likely to beable to assist their children financially given the current stateof the economy. Merely being able to repay ones loans fac-tored heavily into the lifestyle equation. I felt this first-hand when I faced $225 000 of my own educational debt,and I would be dishonest if I did not admit I was thankfulthat my path had led to a highly paying specialty.

Figuring that lifestyle mania, and the compounding is-sue of indebtedness, had not waned in the seven years since

I selected urology, I decided to confirm my suspicions. Re-cently 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 point-blank about the current eminence of perceived lifestyleamong medical students today. Adam candidly said that dis-cussions of lifestyle and potential earnings are indeed ram-

A Piece of My Mind Section Editor: Roxanne K. Young, Associate Senior Editor.

2012 American Medical Association. All rights reserved. JAMA, May 23/30, 2012Vol 307, No. 20 2159

wnloaded From: http://jama.jamanetwork.com/ on 05/24/2012

7/30/2019 jamatext

2/2

pant. He knew that very website I used to look at in the li-brary. Adam had pondered his future lifestyle as well andwas strongly considering neurosurgery and maybe urol-ogyhe would experience both fields as elective rotationsfor a paltry seven days each. I looked over the top edge ofmy loupes and asked Adam, What is the difference be-

tween your life and your lifestyle? He understood the rhe-torical nature of my question and did not answer, but I couldtell that something might have clicked inside him.

Wewentforlunchaftertheoperation andcontinuedthecon-versation. Looking back it seems preposterous to decide on acareer based on a seven-day rotationmy attending likenedit to persuading someone to get a tattoo without much fore-thought. I agreed. Adam knew classmates who had hoped tobecomeprimarycarephysiciansbutwhoabruptlyswitchedtheirfocusto dermatology whentheyscoredastronomicallyhigh ontheUSMLEStep1exam;hesensedthattheyhadnotdevelopedasuddenpassionfortheimmunotherapyofpsoriasis,butratheran urgency to maximize theirlifestylenowthattheir probabil-ity of matching had improved. The situation reminded me of

something the great American composer Aaron Copland hadsaidaboutexperiencingmusic:Ifyouwantto understandmusicbetter, youcan do nothing more important than listen to it. IfearedthatAdamandhisclassmatesweretryingtoappraisesongswithoutever hearing them.I haddone thesame7 yearsbefore.

In a similar leap of faith, and with only two weeks worthof 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 as-sured there would be a good lifestyle. Five years into my resi-dency, happy that I still enjoyed urology, I faced the next bigdecisionwhat to do next? When I decided to pursue a fel-lowship in kidney transplantation, an unconventional choice

for a urologist these days, I was met with puzzled looks; mostcomments centered on the fact that I was effectively givingup the urology lifestylemy hours would be terrible, un-predictable! It was dej vuI wassuddenlythrown back intothe lifestyle game. Perhaps ironically,my wife ushered me to-ward a decision that would ultimately lead to less time to-gether; she simply pointed out how elated I was when I camehome from a long night of transplantsmuch more so thanwhen I went to deal with ureteral stones or hematuria.

This is notto say that physiciansshould not seek to achievebalance in their lives, to enjoy quality time with our fami-lies, and to have interests outside medicine. We need lei-sure time. But can you be truly happy at home if youre un-

fulfilled, or unhappy, at work?For those of us fortunate enoughto interact with andmen-tor medical students through this critical decision, how canwe help? I do not believe that any curricular overhaul wouldmitigate the lure of lifestyle. There are simply toomany spe-cialties to allow ample time for a truly informed decision.Can we somehow shift the focus from securing a great life-style to building a magnificent life? Residents and fellowsmust remember that in many ways, we are the most influ-

ential partythe students spend more time with us com-pared with our attendings. They gauge our happiness andour zeal for our calling. We should help medical studentsfind their professional soulmatethe right specialty, I be-lieve, 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 af-fords us. For our studentswhose passion resides with a rela-tively lower-earning specialty, encourage them to follow thatpassion while not discouraging them based on a lower po-tential income. Emphasize the tremendous value that all phy-sicians hold for both society andhumanity. Even the lowest-paid physicians will earn far more money than the averageAmerican; it is sobering to recall that the median annual sal-ary in the United States in 2010 was $26 363.2

Reflect on what makes your life as a physician great, yourlegacy enduring. Tell them why you happily jump into yourcarat4 AM, why you lookforward to the next day, and whycoming home from a vacation is not too painful to bear. Asthey rotate through our operating rooms, reading rooms,

and clinics, zero in on why you enjoy being there. Steer themto talk to your mentors who, despite being beyond retire-ment age, eagerly come to care for their patients as if theywere on their very first clinical rotation as a student.

Sharethelittlethingstoo:Ilovethatred-tapelineonthefloorinmostoperatingrooms,theonebythefrontdesk,beyondwhichyou must bein operating-room scrubsstepoverit andI passinto a different world, a point of no return where I know Imgoingtoseeamazingsightsandcandogreatthings.Ishakemyhead in wonder when we take a kidney from one human, sewit in to another, andwatch asit resumes itsrenalduties imme-diately, making urine before we can even sew the ureter intothebladder.For mydad its whollydifferentheloves running

intopatientswhomhehasknownfromthedaytheywereborn,who now have children of their own. He takes great pride inmakingthatdifficult,early,diagnosisofdiabetesinachild,andpartakingin thechallenges ofhisor hermedicalcare.Thereissimply no price and no monetary value for the moments thatmake us content, proud, and enthralled to be physicians.

And so we still face that panel of stern professors, albeitwithin our own minds, who test not the steadiness of ourhands, but rather the steadfastness of our true passion forour chosen medical field. Consider your lifebefore lifestylethe rest, as they say, will follow.

Jeremy M. Blumberg, MD

Author Affiliation: Departmentof Urology,KidneyTransplantProgram, David Gef-fen School of Medicine, University of California, Los Angeles (jblumberg@mednet.ucla.edu).Conflict of Interest Disclosures:Theauthor hascompleted andsubmittedthe ICMJEForm 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.

A PIECE OF MY MIND

2160 JAMA, May 23/30, 2012Vol 307, No. 20 2012 American Medical Association. All rights reserved.

wnloaded From: http://jama.jamanetwork.com/ on 05/24/2012