The Light at the End of the Tunnel

                Yesterday I interviewed for a movement disorders fellowship at Rush University Medical Center in Chicago. 3 weeks ago, I interviewed for fellowship in UCLA. I really liked all of the faculty at Rush and I am impressed with the city of Chicago. I will rank Rush number one, and I will find out if I get the fellowship in 2 weeks.  Moving to a big city seems like the next step for me.  Chicago has great parks, culture, food, and the lake front is spectacular. The public transportation is good enough that I may not have to drive at all. And of course, I’d be a 6 hour drive from Cincinnati. (Of note, it was looking unlikely that UC would have a movement disorders fellowship opening next year so I did not formally apply).  Also, my talented girlfriend, who is a 4^th year medical student planning on going in to emergency medicine, would have plenty of options if she chooses to follow me to Chicago as there are lots of residency programs within a close proximity.

                But things in my life typically don’t go according to plan. 4 years ago I was planning on matching in to neurology in Indianapolis (just 90 minutes from Cincinnati), but I ended up in Chapel Hill. I had no close friends in North Carolina, but I learned to love the “Southern part of heaven” as my second home. The clear blue skies, the clean air, the low traffic, the beautiful UNC campus, and overall warmth and kindness of the people in Chapel Hill makes this the perfect place to live if you are 40 with 2 kids.

                My vision of moving to Chicago may be ruined by the fact that I misread my calendar and did not show up on time for my scheduled interview at Rush. Arrangements were made to postpone my interview 24hours, but that’s not the kind of first impression I wanted to make. I would imagine there are many people interviewing for just 1 spot. I know now that nothing is guaranteed.

                I have 10 months of neurology residency left.  Some days are good, but I often feel vulnerable. Some days I feel like I am being attacked by patients who make demands for narcotic medications they know I can’t give them. Some patients want paperwork and legitimate medication refills completed in a manner that is faster than I am able to finish as they do not realize I have many other work obligations.  Sometimes I feel attacked by some of my co-residents, who may seem nice on the surface but ultimately have motives to advance their careers sometimes by criticizing their peers to make themselves look good.  Other times I feel under attack from my supervising attending physicians, who often are quick to find fault in the plans I suggest or with trivial technicalities regarding the notes I write.  It can be very difficult to learn and practice neurology correctly when the people who supervise and provide your training can’t agree themselves on the appropriate way to manage neurologic diseases.

                But now I have no choice but to finish residency to the best of my ability. I am around $115,000 in debt and I have poured in thousands of hours that I have logged, and it will all be for nothing if I don’t finish now.  How is it fair that nurse practitioners and physicians assistants can do many of the same things I do and have spent less than half as much time and money on their training?  How is it right that we sometimes order screening MRIs for patients with MS which cost thousands of dollars and do not typically change the treatment course?  How is it practical that we often prescribe expensive medications like IVIG, natalizumab, and Botox which can also cost thousands of dollars but are not always indicated and can have potentially harmful side effects? Is it right to order 20 lab tests with results that are often difficult to interpret and even harder to explain to your patient when a neurologic diagnosis is unclear?  I know I’ve ordered tests that aren’t indicated and perhaps written for medications that are expensive and not helpful. Maybe it’s part of the learning process.  There have been a few stories where thousands of dollars in diagnostic testing have resulted in the diagnosis of rare and fascinating progressive neurodegenerative conditions with no treatment. However, I know that there have been a few success stories too where thousands of dollars in diagnostic tests and treatments have made the difference for my patients.

                I’m not sure if I will complete a fellowship, but I hope to finish residency as a profoundly intelligent neurologist with a firm grasp on neuroanatomy and the indications for ordering tests and medications. Also, I hope to be someone who can be smart enough to do nothing when nothing can be done rather than putting patients through thousands of dollars of diagnostic tests and treatments along with countless hours spent driving to and from the doctor’s office.  Neurology is ultimately a compromise because sometimes tests with soft indications have to be ordered either because a supervising attending physician wants it, or a patient insists on it.  Residents can become vulnerable as they are the face of patient care and are easy scapegoats when things don’t go according to plan. Also, residents are underappreciated, underpaid, and overworked. 

                In the near future I will figure out my plans after residency and the prestigious fellowship with better working hours or the high paying job in private practice may be the metaphorical “light at the end of the tunnel.”  Regardless of what is next, I think my career goals will always remain the same. One of my favorite attending cognitive neurologists tells his residents and medical students that there are three goals in medicine: 1) Deliver excellent patient care, 2) Have fun, and 3) Teach each other.  On some level I think I’ve accomplished all of these to the best of my abilities. Maybe after residency I will have more fun!