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You're in 19th Grade: Time to Choose the Rest of Your Life

The NRMP can only be held off for so long, and H-hour is approaching.

Kate Hitchcock, MD, PhD

Disclosures

June 22, 2021

“Education is the path from cocky ignorance to miserable uncertainty."
   - Leo Rosten, 1985 (often falsely attributed to Mark Twain)

In the Northern Hemisphere, it’s that time of year when birds fill the air with love songs, flowers burst forth in their glory, and third-year medical students lapse into existential crisis. For those in the US who think they might want to match into a competitive specialty, it’s getting a bit late to set up away rotations. This is the time to hit up overcommitted attendings for letters of recommendation if there’s any desire to avoid thrilling eleventh-hour deliveries to the National Resident Matching Program (NRMP). Fourth-year schedules need to be shuffled to work in the right acting internships. In short, the decision of what they are going to do for the rest of their lives cannot be put off any longer.

For me, oncology came as a surprise. It wasn’t until well into my third year that I realized I wouldn’t be happy unless I practiced big, high-stakes medicine. My engineering PhD advisor guided me toward radiology, which would have fit so well with our work, but I tried it and discovered that the day-to-day routine of it just wasn’t for me.

The course of my entire professional life pivoted on a throwaway comment in a single conversation in December with my wife’s friend, who said that she really wished she had gone into radiation oncology. What on Earth was that? I went and found the “how to get into a good residency” book I’d been mauling in my anxiety over what to do. Sure enough, radiation oncology was down toward the bottom in the master list of possibilities, right there between pulmonary disease/critical care and reproductive endocrinology. I had read past it probably 50 times. Not sure how else to proceed, I emailed the residency coordinator in our hospital asking if I could shadow in the clinic on the days when my pediatric outpatient rotation wrapped up early. And promptly fell in love.

Many oncologists, if asked about their profession at a cocktail party, say they work at the city dump or feign an urgent need to use the restroom. If I fail to remember the wisdom of such maneuvers and my new acquaintance doesn’t lapse into awkward silence or ask me to look at the mole on her calf, she will generally next ask why I chose this.

I find it difficult to capture in a word count appropriate to the setting, but for me, oncology is a perfect mix of elements that suit me: I do life-and-death work every day but at a pace appropriate for my methodical brain. I get the satisfaction of working hard to maintain competency in a field that advances rapidly. I meet patients at a time in their lives when most are disposed to actually listen (to some extent, anyway) and participate in their own care. I enjoy the luxury of spending a lot of time with them and explaining what they should do. Teaching is deeply woven into the fabric of every professional activity. I am always free to creatively solve new, complicated problems in the way I think best, with lots of smart friends to ask for help. And my colleagues, in all of the oncologic specialties, are some of the most wonderful human beings I have ever met. Tumor boards are a heavenly mix of delightful puzzle solving and unmatchable company.

To the anxious medical students who have been popping up in my Zoom/office in the last few weeks, I also explain that they need to do some soul searching and be honest about whether they have certain qualities necessary to a good oncologist of any stripe:

They must actually enjoy, not just tolerate, digging into the medical literature. They should feel a drive to do their own research and move the science forward instead of accepting the status quo.

They need to be able to express humility and at least a bit of openness with their patients. Nothing sends a person with a new cancer diagnosis to the competing hospital faster than telling them that you’re the smart expert and they should just do as you say. An oncologist needs to be the sort of doctor who patiently teases details out of the history in order to fully understand the big picture; laziness in this regard could cost the patient her life.

They must, absolutely must, enjoy teaching because regardless of the location of their practice in an academic facility or private clinic, they will spend all day, every day teaching extremely complicated scientific concepts to folks who may or may not have had the benefit of much formal science education.

Finally, and I really emphasize this, they must be able to make important decisions based on incomplete evidence. Cancer doesn’t read textbooks, and medical technology is rarely all that we want it to be. If they dither over critical treatment choices because they lack knowledge of the unknowable, this is not the path for them. To paraphrase Leo Rosten's quote above, miserable uncertainty is the mark of an educated oncologist.

For those willing to brave a life in oncology, there is a bounty of reward, as you can see in the response to a recent tweet from @JoJoBirdHome.

https://twitter.com/JoJoBirdHome/status/1397050678892122118?s=19

How do you help medical students discover whether your specialty is right for them?

Please join the discussion below, but if you need to communicate with me offline, you can reach me at OncBlogMedscape@gmail.com.

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About Dr Kate Hitchcock
Kate Hitchcock, MD, PhD, is a radiation oncologist, biomedical engineer, and retired aircraft carrier driver who grew up as a Wyoming cowgirl. When she is not at the hospital, you can find her with Carolyn, Mary, Tyler, Nick, Marlee, and Colby the barking dog, enjoying the natural splendor of the great state of Florida. She thinks you should visit sometime and try to solve the puzzle of why the natives have so carefully shunted all of the tourists toward the House of Mouse. Connect with her on Twitter: @hitchcock_kate

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