This is a story for those who struggle in finding their specialty. Sometimes it takes time to figure out your place in medicine. We may not always find it on our first try, but the journey in its pursuit is what influences us into becoming the kind of physicians we are meant to be.  

I. Uncertainty     

Towards the end of my third-year in medical school, my attending psychiatrist suggested I take an elective in psychiatry because it would teach me how to be better with people, a skill valuable for a budding surgeon. Because of him, in the month preceding the submission of ERAS, I met Kamil, a patient who showed me a new dimension of humanity.

During that rotation, I did not have access to the EMR and, because of that, I spent a lot of time with the patients. On my first day, I walked in and heard Johnny Cash playing. Following the sound to the dayroom, I saw the music therapist standing next to the stereo and three patients sitting around a table. There was Kamil, a person who left an indelible mark in my understanding of the human condition between drawing sessions, guitar jam-outs, psalm readings and conversations shared. 

Learning about the importance of ending the therapeutic relationship, I decided to prepare for it with Kamil in my last couple days of the rotation. At this time, he was emerging from an episode of bipolar depression and returning to himself. After recovering from an upsetting epiphany about where his life went wrong after hearing Harry Styles’ “As It Was” the day before, Kamil was visibly calmer and relaxed. On my penultimate day, I saw him in the dayroom drawing a conglomeration of faces in a Picasso-like style and took a seat.

Having completed my SICU, gen-surg sub-internship and now an inpatient psychiatry sub-internship, I found myself more enamored with psychiatry than anticipated. Yet I was still unable, or perhaps, unwilling to let go of surgery. Since my first panic-reaction during the middle of my first psychiatry rotation triggered by an encroaching reality in surgery, I remained unsure of which avenue to pursue. I cried, pondered and exhausted myself and everyone I could trust on the subject. 

Sitting before Kamil as we conversed about future plans as is customary in the planning for discharge discussion in psychiatry, I shared my upcoming surgery elective. Unintentionally,  my dilemma about deciding on a specialty came up. “I’m going to decide for you. Do psychiatry,” offered Kamil, point-blank. Taken aback, I fire back, “Kamil, you can’t make decisions for other people. You can only make decisions about your own life. Anyway, no one even listens to their psychiatrist. Do you listen to yours?” Internally acknowledging his own shortcomings with his psychiatrist, he can only muster, “…Well you’re good at it.” My mixed emotions could do nothing but reiterate my unsureness. 

Kamil — a patient whom I have seen tear-up at an old video of himself singing in the park, plead his case in court and lose, transcend with the guitar he was permitted to play, remove his shirt in act of aggression, lie in an uncomfortable position against the wall with drool dripping as he mused “I’m a deadman. I’m a deadman,” enter hypomania after a brief course on fluoxetine and gradually revert back to the person I first met — simplified this issue that had been distressing me terribly with one question. “Well, think about it like this. What’s going to make you happy; talking to people or cutting them open?” 

II. Decision  

With this new framework in mind for my surgical oncology rotation, I started turning a little more towards psychiatry and away from surgery. Being with true surgery-oriented fourth-year students had an effect of making me feel like the odd one out, as if we existed on different planes. While they were invested in discussing optimal time for reversal of a Hartman’s, I was more drawn to highlighting the importance of trauma-informed care to improve patient-physician communication. Despite starting to realize that I could not see myself in a surgical morbidity & mortality conference, I still was not completely ready to withdraw my applications in general surgery. 

Interview season was upon us and commencing by the time I began my fifth consecutive rotation and last general surgery elective in a hospital where nine years ago, I found my vocation. Whether it was a mixture of the metropolitan speed at which this hospital operated at, being in the place I have had dreams of returning to or feeling sentimental about nearing the end of my career as a student, it was a peculiar time. Having been transparent about my dual-applicant status throughout my fourth-year, I shared this with my attending surgeon, Dr. Chen, who seemed polite enough during our introductions.

Working on a sleeve gastrectomy with him that first Thursday, I was surprised by an opinion that paralyzed me more than a dose of rocuronium ever could. He said, “You know, I was thinking about it and I don’t think you should dual-apply. Don’t you have an advisor?” The resident, whom the day prior had been reprimanded for talking back, jumped in quickly to agree. Dr. Chen concluded by saying, “It’s time for you to make a decision.” 

Although his way of communicating his opinion could have been done differently, he was right. Though in my heart, I no longer felt “in between” both specialties, I was sad to let go of surgery. It had spanned about a third of my entire clerkship time, twenty-two out of sixty-eight weeks. There were lots of feelings, lessons, experiences and memories attached to it as they occurred during my formative years of professional identity. As I lay on the couch when the night PA found me, I knew it was time to finalize an answer. 

Upon returning home the next morning, I received an email from the general surgery program at the hospital where I had just completed my surgical oncology elective. Staring back at the screen, I had to pinch myself to make sure I wasn’t having post-call illusions. It was the hardest rotation I had ever been on and because of that, this unexpected news made me believe that perhaps I was more capable than my fears led me to believe. Receiving this email of encouragement right after I was confronted with the need to decide gave me the confidence I needed to finally commit to psychiatry. 

III. Grief 

During my emergency medicine rotation, my last time as a medical student, I was having bouts of doubt whether I had chosen correctly. Between being unable to identify with psychiatrists, constantly having to explain the similarities I believed existed between psychiatry and surgery and being more drawn to codes and bedside ultrasounds than de-escalation techniques, I worried. 

Despite these concerns, my excitement towards graduation overrode any unease that was brewing until match day. Traditionally, match day is a celebratory event organized by your medical school where friends and families are invited to share in the milestone moment in the path towards physcianhood. It’s a day of high expectations that are hoped to be fulfilled. 

Dressed with my version of an academic Barbie with a striped black and white dress and softly curled curtain bangs, I shared the table with my friend Caterina and our families. The envelope with a trim of gold foil that held the information that would set the trajectory of the next four years sat before me. Between running my fingertips along the smooth edges, taking goofy selfies with Caterina, turning my head back to catch my friend Sammy’s eye for good luck and being prepared to text my mentors and resident friends where I’ll be, everything was poised for ecstasy. 

As we counted down in unison the final seconds as the clock struck twelve, everyone tore open their envelope carefully. As I opened the paper and scanned quickly to see where I would be, I had to blink twice because I couldn’t understand what it was saying. Speechless, I could only drop the paper and take a step back as I stood there in shock, registering what this meant for me and for my family. In medical school, we do a great job of worrying about getting into residency, but we aren’t prepared for what it means when you actually get in. And it’s something that I think no one can ever be prepared for because it’s an individualized experience that, like in surgery, can only be learned actively by doing. 

As best as I could, I kept myself together as we remained in the Great Hall, but upon leaving, all I could do was weep. The recurrent thought that broke my heart was having to leave my family and my complete powerlessness about it. I had an upcoming trip to my Argentinean Patagonia I had been planning since the start of my clerkship year but was no longer interested in. Between the unexpected costs of moving and feeling a lack of control, I couldn’t justify going anymore. At the same time, with all the changes that were coming, I needed at least one thing to stay the same. 

Seeing the Andes for the first time, a sudden wave of foreboding crashed through me. I was thousands of miles away from a new reality that awaited me. That night in our rented cabin outside El Bolsón, I stared at the ceiling asking myself, “What am I doing here?” After I opened my match letter, life had turned into a rapidly ticking clock where a day felt like a second. All I knew was that now more than ever, I wanted to be with the people I most loved. Although rightfully angry, my parents understood my desperation and we changed plans. We were to take the first flight the following morning back to Buenos Aires. Driving in the early morning that knows of only the sun’s first rays and a silence pierced only by the first stirrings of life, the Andes watched us go.

As we waited to board, daybreak arrived to reveal snow-capped mountains with an interweaving earthy, pastel haze. The freezing rain on the ground had been a snowfall thousands of meters above. As we ascended, I saw the mountains with their powdered peaks. While undeniably breathtaking, they looked so different from their bareness just over sixteen hours ago. It was hard to recognize them as the same. It was almost cosmic to see how much life mimicked nature, changing in the blink of an eye. But a blanket of snow is just a covering. The core remains unmalleable. 

IV. Depression 

In the first week of orientation, my co-interns and I decided to meet up over some beverages. As we shared our interview experiences, my co-intern, Drew, said something that caused great alarm regarding my perception of what the practice of psychiatry entailed. After recovering from that first hit, the second hit followed within minutes where the past few months of mental preparations for performing life-saving interventions were extinguished. I had mistakenly thought that the “E” in the name of my first rotation stood for emergency while it actually was indicative of the inpatient psychiatric service. 

That night, I needed to talk to Caterina whose objectivity I desperately needed. As I cried into the phone and told her of a hasty and  ill-conceived plan of reapplying into internal medicine, she gave me her family-famous reality checks. By virtue of her Czech wisdom, she reassured me by stating, “Every resident goes through a challenge unique to them, ” and advised me to give psychiatry a year, experience internal medicine to see if I would like it and then reassess. 

During this time, we were assigned to do a series of four training calls. One Thursday evening at the crisis intervention unit, I sat with Nina, a co-intern, as we waited for our senior resident. Knowing Nina had her mother staying over during this transitioning period, I wished my mother to be with me also. “But I don’t want my mother to come, for what? There is nothing here for her,” I whispered to Nina. With the tears pooling in my eyes, Nina suggested we go outside and get some air. 

We made it as far as the little solid cement ledges fencing the skinny tree at the front of the entrance before sitting down. I didn’t know Nina well, but something about her reserved nature made her seem trustworthy. And with that, I shared with her the story of my sadness. Telling her my truest feelings was a tremendous unburdening because I no longer had to pretend to be something I was not. After my own admission, Nina herself felt safe enough to share her own hardships. Bonded in the safekeeping of each other, a friendship was forged, and our plights alleviated. 

It was difficult to accept that my life was here in Albany, away from everyone I knew and loved. It was a time of many firsts for me. The transition from medical student to intern is already such a drastic one. When that is compounded by leaving home for the first time, moving to a new city and being completely alone, it can become too much. For the first time in my life, dark and unpleasant thoughts ran through my mind. A recurrent theme was questioning the meaning in all of this. I just felt so detached from everything and so far removed from myself. What I felt had to be more than a problem with adjusting. 

There were many signs that something was really wrong and they all revolved around unhappiness with work. I felt alien to my co-residents. I couldn’t treat the conditions I wanted to treat. I couldn’t get into learning about the topics that I would be dedicating my life to. I couldn’t find that sense of purpose I once had. The gravest sign of all was a dissolution of empathy towards my patients. I had become emotionally numb towards everything, including myself. I couldn’t recognize what I had become. Thinking back on Caterina’s words, it was true that I had been homesick, shell-shocked and lonely while learning how to manage all the newness. But there was something else going on that was separating this from a normal and an abnormally dysphoric reaction. 

V.  Rekindling   

During my second week on the inpatient psychiatric service, I was preparing a patient for discharge and needed to visit the orthopedics unit to fetch some surgical supplies for suture removal. The lacerations he had sustained on his palms were deep and some knots had crusted over while others buried into the tissue. Though a little rusty at first, my patient and I persevered. My trusty four-by-four gauze was halved and placed over the wound, secured by a singular piece of tape. 

That day on the behavioral medicine unit, for the first time in a long while, I felt like myself. Some of the comfort could have been from the nostalgia of familiarity, but a bigger part was a sense of satisfaction in interacting with the patient beyond words. It was the ritual of sitting down and bringing forth the aspect of touch in examination of a patient, the pillar of the physician and patient relationship, that made me feel like the me I was before the dawning of a reality of a career in psychiatry. 

Taking advantage of that wave of reignition that cleared my head, I needed to reconsider my future in psychiatry. I asked Drew why he chose psychiatry and he said that for him, the pain he is made to confront gives him perspective about the things in life that really matter. Up until that moment, the only other specialty that I could relate to something similar was surgery. It made me overcome my fears that were inhibiting both my personal and professional life. 

The following evening sitting at my desk, I made a table of the things I liked and disliked about each specialty, and after ten minutes, I stopped because there was nothing more to think about. My heart belonged in surgery and this time, I did not want to talk myself out of it. The moment I decided to reapply, I felt the panorama of my life change. Most importantly, there was a resurgence of light, a renewed sense of hope that revitalized my weakened spirit. I told myself, “This time, I’m going to get it right.” 

As excited as I was in making my way back to where I thought I wanted to be during the next few weeks, there were three things that seeded guilt in this career-altering decision. Number one, I didn’t tell Caterina until the end because I was afraid of what she would say. Number two, the few times I glanced at some of the general surgery programs curriculum online, I felt a familiar but low grade surge of anxiety. Number three, when my mentor, Dr. McLaughlin, who I trust because of his characteristic way of communicating certain truths, said, “You cannot switch specialties a third time.” 

I remained steadfast in reapplying to general surgery up until ten days before applications were due. I had gone home for a golden weekend and had gotten a haircut that was different from the prior ones I had loved so much. That night, I couldn’t find a wink of sleep and woke up in a panic. My tendency of thinking more emotionally than rationally can be a double-edged sword. For the past few months, as much as the prospects of switching into surgery had buoyed me, the story I was telling myself was flawed. My idea of surgery was understood through rose-tinted sunglasses rather than the clear frames of protective eyewear. There was a reason I withdrew my applications the first time around. That morning, my subconscious told me it was time to stop. 

VI. Reconstruction 

Whether surgery was a connection to my former life or a part instead of all of me, it was not my future. But it was a significant part of my medical school experience that shaped me to become the kind of physician I aspire to be. I thought to myself, “If it’s not surgery and not psychiatry, it has to be something else.” With that, I decided to take a chance on internal medicine. It is the foundation of medicine and something you cannot go wrong with. It was also the way back to the only place where I ever truly did feel at home, the intensive care unit. 

The week before applications were due, I did a complete 180 and got the new one ready in time. The day before it was due, it happened to be my first day on the internal medicine service. Feeling sadness of letting go of a potential in surgery forever and having to say goodbye to a position I held in psychiatry, I was scared. In the afternoon, face streaked with tears, I ran into one of the consultant-liaison psychiatrists, Dr. Milner, and told him how stuck I felt. He said, “Well, first, think about why you wanted to become a doctor. Then, think, where do you feel you can best do that?” 

Walking back home that evening talking to my co-intern friend, Minita, on the phone, I tried justifying reasons to either stay in psychiatry or dual-apply to surgery and medicine. Feeling bad over my friend’s kindness in hearing me talk in circles, we hung up and called the night early, needing to rest my mind. The next day, I went calmly into work and upon returning home, prepared myself máte to drink as I submitted my single application to internal medicine programs. 

I have been incredibly at peace and believe without a doubt that it was the right decision for me. Doing eight weeks consecutive of internal medicine was hard, but I was happy. Though I did cry because it’s impossible to not in residency, they were stress-tears, I’m tired-tears, my patient has brain cancer but I need to be hold them back-tears, my patient told me to not worry about him because he wants to die and the next day he actually deteriorated and died-tears, my senior is frustrated with me and I can’t get anything right-tears. But these were the normal tears, the ones you are supposed to have. Amidst the multitude of emotions experienced during that time, when it was over, I missed it and couldn’t wait to get back. 

On the interview trail, you meet different people across programs and hear some messages that may stick with you, reframe some thoughts and form new connections that hadn’t been clear before. As stressful as they can be, you learn a lot about yourself because as much as you prepare answers, it is natural to improvise when faced with a question you hadn’t expected. Certain questions as simple as “Where do you want to be in five years?”, “Why did you like psychiatry?” and “Why did you want to be a doctor?” were enlightening. For me, besides wanting to run my own ICU, I want to be at a person’s bedside. I love talking to people and hearing their stories. I want to help sick patients. The more concrete the answer, the closer it is to the truth. Aside from figuring out the place in medicine that best encompasses your interests, the most important thing I learned in finding your specialty is about being honest with yourself. 

Epilogue

The first time I met the Catskills and Adirondacks was when I began driving north along the New York State Thruway towards Albany, the city I was moving to for residency. They were domineering and silent presences that accompanied me. For those 90 miles, I was in their territory, subject to their whims. Little did I know that their untouched wilderness would become  a reservoir of answers. My relationship with these immense structures changed along the course of these past seven months. Before I felt an overwhelming despair as the Earth curved upwards. But now when I see them, all I can do is smile, the soft kind mustered up after a long battle. No longer are they a reminder of my distress but rather a means to overcome it. The struggles from the past few months have culminated in a sense of clarity, similar to the feeling of looking out at a vast clearing from a mountain’s apex, where things can be seen from all directions. I have always believed in paths and mine has been as non-linear as the ravines that erode into the earth, sculpting the landscape. I am grateful for all the people I have met along the way who have guided me towards finding my place in medicine. My experience in residency has been different from what I had been preparing for, but it is exactly where I was supposed to be.

 

Image Credit: “Through the looking glass” (CC BY 2.0) by bluesmoon