SURGICAL PERSPECTIVE
“Go With Your Gut”—Reflections on Selecting a Surgical Subspecialty Christopher S. Graffeo, MD
M
y surgery clerkship director sat across his desk from me, eyes momentarily cast toward the window, turning my question over in his mind as he considered a response. I realized my breath was held, and I exhaled as our eyes met. “Well, you’re not alone . . . ” he intoned, pausing again. “I don’t want to seem flip, but there may not be a right answer.” My heart sank—another dead-end. “Try some things out, see what grabs you.” We shook hands as I rose and thanked him, and as I turned toward the door he sighed, “Go with your gut.” Spring was approaching in my third year of medical school, and selecting a specialty weighed more heavily on me each day. Like most of my classmates, I’d arrived unformed and moved through 3 prescribed years of classroom and clinical education, establishing a strong foundation of medical knowledge, but one that lacked depth in most subspecialties. The core clerkships had done their job, exposing me to broad categories of professional options, and I felt confident that I was heading toward a career in surgery. Still, I felt unequipped to discriminate further and realized I’d be making a tremendous decision on scant evidence. With all this in mind, I’d turned to my clerkship director— a long-standing advisor, and experienced medical educator—but our conversation highlighted a troubling mentorship gap. Although clerkship faculty and preceptors were able to offer broad advice about my aptitude, the next level of mentorship existed within the specialties— faculty and program directors—where bias might be unavoidable. Simultaneously, I felt anxious about appearing ambivalent to a potential mentor, letter writer, or decision maker. What follows is an account of how I negotiated the challenges of introspection and exploration that selecting a specialty demands. Many months and a decision later, I haven’t solved a basic problem confronting medical education, but my hope in framing these experiences is that future mentors and advisors might benefit from the insights of one student’s approach.
Formulating a Differential Diagnosis Knowing that my window of elective time was limited, my first task was to winnow the options to a manageable number, no more than 3 or 4. Foremost, I wanted to find a set of academic and clinical problems that would hold my attention, and I started by devouring anything I could think to read. Resident-level textbooks and operative videos were the most useful, offering a great mix of detailed case descriptions, a clear sense for each discipline’s territory, and an overview of management strategies. In contrast, specialty journals felt unwieldy, or too sophisticated for my level of training. I added guest lectures and grand rounds to the mix and found that they split the difference between an introductory From the Department of Neurologic Surgery, Mayo School of Graduate Medical Education, Rochester, MN. Disclosure: No funding was received in support of this work. The authors declare there are no conflicts of interest. Reprints: Christopher S. Graffeo, MD, Department of Neurologic Surgery, Mayo School of Graduate Medical Education, 200 First St SW, Rochester, MN 55905. E-mail: [email protected]. C 2014 Wolters Kluwer Health, Inc. All rights reserved. Copyright ISSN: 0003-4932/15/26201-0018 DOI: 10.1097/SLA.0000000000000943
18 | www.annalsofsurgery.com
textbook and a nuanced article, while also providing the opportunity to observe and contrast differences in the culture and mood of each specialty. Perhaps my most insightful early strategy was returning to anatomy, revisiting favorite textbooks, radiology reviews, and even the cadaver laboratory. Comparing the landmarks, techniques, and key structures in dissecting a neck, raising a flap, clipping an aneurysm, or fixing a fractured humerus quickly promoted certain fields in my mind—and ruled out others.
The Clinical Examination Having narrowed the field, I knew the insight needed to make a final decision would demand more exposure. Preliminarily, I’d scrubbed on procedures in as many specialties as possible during my general surgery clerkship, and though this had reinforced my initial leanings, it would take more than a case or 2 for me to appreciate the essential character of each field. With 4 possibilities in mind, I scheduled short electives, each of which proved immensely useful, giving me the opportunity to quickly survey the operating rooms, outpatient clinics, and personalities and attitudes of each. I was struck by how dominant the “bread-and-butter” operations were in each specialty, and I realized that—even though I would ultimately focus on one subset of patients—in reality, these cases would dominate much of my training, and my early, practice-building career. Even more importantly, I came to know each unique patient population—their diseases, prognoses, and treatment options. Many of the orthopedists, otolaryngologists, plastic surgeons, and general surgeons I met treated isolated problems in otherwise-healthy patients. In parallel, neurosurgeons, reconstructive surgeons, and oncological specialists took on complicated, long-term care of sick patients, and operations that risked significant morbidity. Although some specialists managed intensive care units and operated frequently, others maintained large outpatient practices and blended medical management with procedures. Each field offered surprising variability—one functional neurosurgeon I met followed patients with better prognoses than an orthopedist who specialized in bony tumors—yet these exceptions aside, becoming familiar with the most common patients and procedures in each specialty powerfully informed my decision. Perhaps even more importantly, meeting and seeking advice from several physicians in each department demonstrated the breadth of reasons why others had selected that field, and what they still considered to be its highlights and disadvantages. The most valuable advice was frequently personal, with mentors relating their own career trajectories in a way that allowed me to trace a range of potential paths I could take into their fields. Finally, I found that the attendings who best connected with me were also the most forthright, acknowledging the sensitivity of my position, and setting my concerns about indecision at ease by reassuring me that it was also in their best interest for me to make a careful, considered decision.
Assessment and Plan Reflecting on my rotations, each specialty had surprised me, and frequently I found that what proved most appealing wasn’t what I’d anticipated. As my clerkship director had forecast, I knew that Annals of Surgery r Volume 262, Number 1, 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 262, Number 1, 2015
I could find a fulfilling career in several fields—a thought that had once seemed intimidating, but that now felt comforting. However, thinking through my conversations with dozens of surgeons, I finally understood that each specialty was colored by its own distinctive ethos, and that I would ultimately feel most at home in one community. Assembling my experiences into a clear perspective was the last and most nuanced challenge, and almost certainly the stage where insightful mentorship will be the most valuable. Attendings can help shepherd students through the process by providing a more experienced perspective. On the one hand, students will benefit from an open discussion of all the factors that should influence the decision: areas of interests, personal commitments, research opportunities, and many more. Simultaneously, a gentle reminder to not overemphasize “lifestyle” considerations—hours, call obligations, and compensation—may be necessary, as students frequently do not realize that surgeons with diverse practices exist in every field. Although it may seem almost patronizing, third-year clerks will benefit from hearing that attendings have considerable autonomy and flexibility, and that finding an interesting and exciting work environ-
C 2015 Wolters Kluwer Health, Inc. All rights reserved.
Go With Your Gut
ment should be their priority—especially considering today’s changing health care climate. In the end, the most effective mentors enabled me to answer the question “Is this me?” with as much honesty and self-awareness as I could muster. They encouraged me to talk about my impressions with everyone—my wife, my friends, my family—but also to ultimately trust my instincts and consider whether they dwelled on certain themes, or repeatedly returned to one specialty after brief romances elsewhere. Indeed, I felt a sense of rightness and relief when I imagined becoming a neurosurgeon, and even more importantly, I knew that those doctors were the ones I would be most at home working with and learning from, day-in and day-out. In parallel to so much of what we learn in medical school, you can help your students reach their own right answers through a familiar strategy: read as much as they can, do an examination, and look for patterns. They’ll never have all the information they might want, but they’ll have more than enough to make a decision with confidence. In other words, if you’re giving your students great mentorship, the best advice you can add really might be “go with your gut”—it’s what they’ve been trained to do.
www.annalsofsurgery.com | 19
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
“Go With Your Gut”—Reflections on Selecting a Surgical Subspecialty Christopher S. Graffeo, MD
M
y surgery clerkship director sat across his desk from me, eyes momentarily cast toward the window, turning my question over in his mind as he considered a response. I realized my breath was held, and I exhaled as our eyes met. “Well, you’re not alone . . . ” he intoned, pausing again. “I don’t want to seem flip, but there may not be a right answer.” My heart sank—another dead-end. “Try some things out, see what grabs you.” We shook hands as I rose and thanked him, and as I turned toward the door he sighed, “Go with your gut.” Spring was approaching in my third year of medical school, and selecting a specialty weighed more heavily on me each day. Like most of my classmates, I’d arrived unformed and moved through 3 prescribed years of classroom and clinical education, establishing a strong foundation of medical knowledge, but one that lacked depth in most subspecialties. The core clerkships had done their job, exposing me to broad categories of professional options, and I felt confident that I was heading toward a career in surgery. Still, I felt unequipped to discriminate further and realized I’d be making a tremendous decision on scant evidence. With all this in mind, I’d turned to my clerkship director— a long-standing advisor, and experienced medical educator—but our conversation highlighted a troubling mentorship gap. Although clerkship faculty and preceptors were able to offer broad advice about my aptitude, the next level of mentorship existed within the specialties— faculty and program directors—where bias might be unavoidable. Simultaneously, I felt anxious about appearing ambivalent to a potential mentor, letter writer, or decision maker. What follows is an account of how I negotiated the challenges of introspection and exploration that selecting a specialty demands. Many months and a decision later, I haven’t solved a basic problem confronting medical education, but my hope in framing these experiences is that future mentors and advisors might benefit from the insights of one student’s approach.
Formulating a Differential Diagnosis Knowing that my window of elective time was limited, my first task was to winnow the options to a manageable number, no more than 3 or 4. Foremost, I wanted to find a set of academic and clinical problems that would hold my attention, and I started by devouring anything I could think to read. Resident-level textbooks and operative videos were the most useful, offering a great mix of detailed case descriptions, a clear sense for each discipline’s territory, and an overview of management strategies. In contrast, specialty journals felt unwieldy, or too sophisticated for my level of training. I added guest lectures and grand rounds to the mix and found that they split the difference between an introductory From the Department of Neurologic Surgery, Mayo School of Graduate Medical Education, Rochester, MN. Disclosure: No funding was received in support of this work. The authors declare there are no conflicts of interest. Reprints: Christopher S. Graffeo, MD, Department of Neurologic Surgery, Mayo School of Graduate Medical Education, 200 First St SW, Rochester, MN 55905. E-mail: [email protected]. C 2014 Wolters Kluwer Health, Inc. All rights reserved. Copyright ISSN: 0003-4932/15/26201-0018 DOI: 10.1097/SLA.0000000000000943
18 | www.annalsofsurgery.com
textbook and a nuanced article, while also providing the opportunity to observe and contrast differences in the culture and mood of each specialty. Perhaps my most insightful early strategy was returning to anatomy, revisiting favorite textbooks, radiology reviews, and even the cadaver laboratory. Comparing the landmarks, techniques, and key structures in dissecting a neck, raising a flap, clipping an aneurysm, or fixing a fractured humerus quickly promoted certain fields in my mind—and ruled out others.
The Clinical Examination Having narrowed the field, I knew the insight needed to make a final decision would demand more exposure. Preliminarily, I’d scrubbed on procedures in as many specialties as possible during my general surgery clerkship, and though this had reinforced my initial leanings, it would take more than a case or 2 for me to appreciate the essential character of each field. With 4 possibilities in mind, I scheduled short electives, each of which proved immensely useful, giving me the opportunity to quickly survey the operating rooms, outpatient clinics, and personalities and attitudes of each. I was struck by how dominant the “bread-and-butter” operations were in each specialty, and I realized that—even though I would ultimately focus on one subset of patients—in reality, these cases would dominate much of my training, and my early, practice-building career. Even more importantly, I came to know each unique patient population—their diseases, prognoses, and treatment options. Many of the orthopedists, otolaryngologists, plastic surgeons, and general surgeons I met treated isolated problems in otherwise-healthy patients. In parallel, neurosurgeons, reconstructive surgeons, and oncological specialists took on complicated, long-term care of sick patients, and operations that risked significant morbidity. Although some specialists managed intensive care units and operated frequently, others maintained large outpatient practices and blended medical management with procedures. Each field offered surprising variability—one functional neurosurgeon I met followed patients with better prognoses than an orthopedist who specialized in bony tumors—yet these exceptions aside, becoming familiar with the most common patients and procedures in each specialty powerfully informed my decision. Perhaps even more importantly, meeting and seeking advice from several physicians in each department demonstrated the breadth of reasons why others had selected that field, and what they still considered to be its highlights and disadvantages. The most valuable advice was frequently personal, with mentors relating their own career trajectories in a way that allowed me to trace a range of potential paths I could take into their fields. Finally, I found that the attendings who best connected with me were also the most forthright, acknowledging the sensitivity of my position, and setting my concerns about indecision at ease by reassuring me that it was also in their best interest for me to make a careful, considered decision.
Assessment and Plan Reflecting on my rotations, each specialty had surprised me, and frequently I found that what proved most appealing wasn’t what I’d anticipated. As my clerkship director had forecast, I knew that Annals of Surgery r Volume 262, Number 1, 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 262, Number 1, 2015
I could find a fulfilling career in several fields—a thought that had once seemed intimidating, but that now felt comforting. However, thinking through my conversations with dozens of surgeons, I finally understood that each specialty was colored by its own distinctive ethos, and that I would ultimately feel most at home in one community. Assembling my experiences into a clear perspective was the last and most nuanced challenge, and almost certainly the stage where insightful mentorship will be the most valuable. Attendings can help shepherd students through the process by providing a more experienced perspective. On the one hand, students will benefit from an open discussion of all the factors that should influence the decision: areas of interests, personal commitments, research opportunities, and many more. Simultaneously, a gentle reminder to not overemphasize “lifestyle” considerations—hours, call obligations, and compensation—may be necessary, as students frequently do not realize that surgeons with diverse practices exist in every field. Although it may seem almost patronizing, third-year clerks will benefit from hearing that attendings have considerable autonomy and flexibility, and that finding an interesting and exciting work environ-
C 2015 Wolters Kluwer Health, Inc. All rights reserved.
Go With Your Gut
ment should be their priority—especially considering today’s changing health care climate. In the end, the most effective mentors enabled me to answer the question “Is this me?” with as much honesty and self-awareness as I could muster. They encouraged me to talk about my impressions with everyone—my wife, my friends, my family—but also to ultimately trust my instincts and consider whether they dwelled on certain themes, or repeatedly returned to one specialty after brief romances elsewhere. Indeed, I felt a sense of rightness and relief when I imagined becoming a neurosurgeon, and even more importantly, I knew that those doctors were the ones I would be most at home working with and learning from, day-in and day-out. In parallel to so much of what we learn in medical school, you can help your students reach their own right answers through a familiar strategy: read as much as they can, do an examination, and look for patterns. They’ll never have all the information they might want, but they’ll have more than enough to make a decision with confidence. In other words, if you’re giving your students great mentorship, the best advice you can add really might be “go with your gut”—it’s what they’ve been trained to do.
www.annalsofsurgery.com | 19
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
