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Finding our place

By Kristen Thornton

The Greek philosopher Epictetus once stated, "First say to yourself what you would be; and then do what you have to do." As medical students, we have said to ourselves that we would be physicians. And we have spent much of our lives doing what we have to do to achieve that goal.

Medical students come to Dartmouth with a wide variety of experiences and interests, but with the uniform traits of being focused and goal-oriented. We all have worked hard to get into medical school. We have amassed a record of achievement in challenging premedical courses; we have earned strong scores on the MCAT, the Medical College Admission Test; and most of us have had relevant work or volunteer experience in the health-care arena. Once we get to medical school, we work even harder to learn all we need to know to be good doctors.

Vague: But having goals and achieving them before and during medical school are only part of what's required to become a physician. We must also choose a specialty in our third year of medical school so we can apply to the appropriate residency programs to continue our training. Some medical students are absolutely certain of their specialty interest from the outset and know, for instance, that they want to be a pediatrician or an orthopaedic surgeon. Others have vague goals, such as preferring primary care to the subspecialties. But most of us have had limited exposure to medical specialties and therefore have little idea what type of physician we'd like to be.

No matter how confident we appear to be, many of us become indecisive as we agonize over what specialty to choose. "I don't want to think about it," has been a common refrain among my classmates.

Fortunately, medical students do clerkships in a variety of clinical settings. These experiences are key to helping us narrow our choices. At Dartmouth Medical School, during our third year, we complete eight-week assignments in each of six areas‹pediatrics, ob-gyn/ women's health, surgery, medicine, family medicine, and psychiatry. In addition to

There are endless questions we must answer for ourselves, through our intuition as well as through our experiences.

learning about different health conditions and about how to care for patients, we gain insight into the daily responsibilities and challenges faced by physicians.

Inspiring: Many intangibles during the clerkships contribute to our understanding of whether a particular field feels like a good fit for us. For instance, students who had crossed off a career in general surgery may, after working with an inspiring surgeon, give the specialty serious consideration. Other students might be dissuaded from entering a field they were initially attracted to either because they did not feel challenged on that rotation or because they felt overwhelmed and confused.

I entered medical school with the intention of becoming a family physician. I was also interested in palliative care, behavioral medicine, geriatrics, endocrinology, and women's health. I had positive experiences in all of my clerkships and at various times was convinced I was going to be a psychiatrist, an internist, or a general surgeon.

My final clerkship was in family medicine, and I worked with a fantastic preceptor in rural Vermont. Over the course of each day, we would manage acute and chronic

illnesses, evaluate everything from orthopaedic to dermatologic problems, provide care for newborns and the elderly, make home visits, and do a great deal of counseling. I realized that I loved the breadth of family medicine as well as the holistic model through which it is practiced. I knew that I'd found my place.

But although the third-year clerkships can guide us in making choices, they can mislead us, too. They expose students to only a fraction of the different practice styles and to only a few specialties. We can take electives in our fourth year to explore other fields‹like anesthesiology or ophthalmology‹but we must apply to residency programs before we've had a chance to sample all the options.

Ambiguity: Choosing a specialty is not based solely on what organ systems or pathologies we find interesting. It demands that students also reflect on their personality, strengths and weaknesses, and ultimate goals. There are endless questions we must answer for ourselves, through our intuition as well as through our experiences. Do we prefer seeing immediate results of our care‹as in emergency medicine or surgery‹or are we content with seeing smaller gains over time‹as in primary care? How comfortable are we with ambiguity? Would we rather act as expert consultants or as coordinators of care? Do the choices that might help us achieve professional satisfaction align with our personal goals? How much time are we willing to devote to residency and fellowship training before we're out in practice? Will we have time to enjoy our interests outside of medicine? Striking a balance between one's professional and personal life is difficult yet critical to a physician's lifelong well-being.

The enormous number of specialty options awaiting medical students upon graduation is exciting but daunting. The choices we make are the culmination of lengthy introspection into where we feel we can best make a contribution to medicine, in a way that is rewarding both personally and professionally. However, when we remember the essence of what called us to enter medicine in the first place, the "what you have to do" requirement eventually reveals itself.

The "Student Notebook" essay shares word of the activities or opinions of students and trainees. Kristen Thornton is currently a fourth-year DMS student; just at press time, she learned she had matched to the Mayo Clinic's family medicine residency program.

If you'd like to offer feedback about this article, we'd welcome getting your comments at DartMed@Dartmouth.edu.

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