Interested in humanitarian medicine? How to choose a specialty.

A Daunting Choice

The decision to select a specialty in medical school is one of the most exciting and intimidating moments in our careers. Many factors and external influences weigh in, even among students planning for more conventional career paths than us with global health ambitions. In the context of global medicine, won’t your specialty have different presentations of disease and treatments, as well as potential projects for research? Certainly, your case list as a plastic surgeon in the U.S. will look quite different than in a developing country. Some specialties have been involved in the public health realm for decades, like pediatrics and infectious disease, while others are recently emerging as population needs have been brought to light, like surgical oncology. So how do we commit to just one specialty?

How We Did It: The Path to Specialty Isn’t Always a Straight Line

As Josh and I entered medical school, we had many discussions about our big-picture goals and what specialty we should choose. We talked about the fields with big impact factors, thinking seriously about fields like obstetrics and infectious disease, as these areas seemed to have an obvious impact on large populations and seemed to be popular choices for others interested in humanitarian projects. Like many students in our class, we attended all of the interest groups for medical specialties, largely for the usual free lunch offered, and I genuinely could see myself doing a variety of things as 3rd year approached. Once into my clinical rotations, I mostly felt happy and immersed in whatever rotation I was on, with a few notable exceptions. I preferred the hospital to clinic settings, and preferred high acuity to chronic illnesses. I enjoyed working fast with high intensity.

Because I had amazing mentors in the field, I decided to pursue cardiac surgery. At the same time, my husband was strongly favoring neurosurgery; he talked often about how he worried that his specialty would not be useful in underserved areas. My perspective was that we should just choose the fields we were most passionate about, and make a way to provide the care where it didn’t already exist.

We had many conversations that seemed to go round and round about these topics. Nearly every car ride lasting longer than 15 minutes, this was the discussion. What should we become? Was that choice consistent with our hope to become humanitarian physicians?

Our 4th year, Josh did a sub-I month at a Cure Hospital in Uganda, working with the neurosurgery staff. This rotation helped solidify his confidence that there was plenty of potential for global neurosurgery projects.

We both matched into our dream program at Mayo in Rochester, MN. He in neurosurgery and me in general surgery with intentions to pursue cardiac. I went on a trip to Ukraine with an amazing organization called Novick Cardiac Alliance, and I saw first hand a successful project to elevate care in an underserved country. They had similar projects all around the world, and I loved hearing the accounts from the nurses, intensivists, and surgeons, about their different locations. This experience was formative. It showed me first hand that sophisticated, cutting edge, and resource-intense surgical care was possible anywhere. However, the irony of this trip was that the actual cardiac surgery that was happening was less interesting to me than the bombing of the Ukrainian city of Donetsk 50 miles away, with possible traumatic injuries that needed tending, and the illusion of cardiac surgery as the perfect fit for me began to crack.

In the cath lab in Kharkiv, Ukraine.

Within the year, I decided, definitively, to switch to Trauma and Surgical Critical Care as my specialty. It’s a perfect fit for me for many reasons, and is certainly one of those fields that has relevance in any setting around the world. Trauma is emerging as a hot topic of discussion for global surgery funding and improvement projects, as it is the leading cause of death and disability among young people. I do admit that this is one of many aspects that attracted me.

One detail I would like to mention, but not dwell on (I’ll save the long story for another post), is that I personally experienced a traumatic injury in a motor vehicle accident in high school, which was extremely formative for me. It undoubtedly changes my perspective when caring for my patients. However, I resisted going into the field of trauma surgery for a long time even though it weighed heavily on my mind. Having pondered this for a while, I think that I was rebelling a little bit against the idea of letting this negative experience steer my life in such a way. Ultimately, I think that the influence of this incident will enrich my passion for the field and help me to connect with my patients on a personal level.

Another attractive aspect about my field is that because it encompasses trauma care, surgical critical care, acute care general surgery, and elective general surgery, I can be quite flexible in how I work. Not to mention where I work. I can vary my schedule, and every week can be a little bit different depending on if I’m in the ICU, covering Trauma, or doing elective cases. Personally, I think that any job that was the same schedule, 9-5, week in and week out, would lead to burn-out for me. I like variety.

Josh has never waivered from his decision of neurosurgery, and he has had the benefit of observing one of his former chief residents, Will Copeland, MD, move his family to Kenya to work at Tenwek Hospital. Dr. Copeland is doing outstanding work there and is a great role model for Josh.

Observations

As I was discussing this post with Josh, he quickly surmised, “I think I know someone in every surgical subspecialty doing humanitarian work.” We are lucky to be in a place where our colleagues and friends have these shared ambitions and have launched into humanitarian careers around the world.

I’ve also benefited from many connections in social media, particularly Twitter, where countless organizations representing the full variety of medical specialties are represented. Online journal clubs are becoming more common, as are twitter-hosted journal club discussions (@MayoGlobalSurgJC for one example). To see the many excellent accounts I follow on twitter, see my list under my profile at @IndieDocs1.

Summary

In the end, I chose the specialty that suited my personality and interests, as did Josh. The simplest way I can describe my decision is that I chose what sounded like the most fun to me, and I’m very happy and confident with the choice. I took into consideration personal as well as professional goals. There is no doubt that we will both have abundant opportunities to serve patients and elevate local surgical care if we remain dedicated to that cause. Therefore, the answer to the topic, “How to choose a specialty,” is both simple and complex. Pay attention to the little thoughts and reflexes in your mind as you encounter diseases and treatments in each field, and be honest with yourself about what truly interests you. Allow your past experiences to form the type of doctor you are going to be. Be open minded about the possibilities of providing advanced-level medical and surgical care in low and middle income countries. Seek mentors and role models, but don’t choose a specialty solely because you like or are encouraged by your mentor. Pick what you can do all day every day, and also what will allow you to have a sustainable lifestyle and work schedule.  Don’t be afraid to change directions as you obtain new experiences and perspective. If you choose a specialty in which you can work passionately and sustainably, you will undoubtedly have a significant impact as you serve your community.

What weighs into your decision for pursuing a specialty?

Do you have any additional insight or suggestions for young trainees?

Please comment below!

How to start a global health interest group at your institution

Despite having a huge campus, state of the art healthcare, and an amazingly diverse group of employees, my hospital did not have a Global Surgery “group.” There were surgeons, nurses, scrub technicians, and even pharmacist going on medical and surgery missions projects and lots of individual efforts going on. We have a fund available to us as residents for competitive scholarships to various locations for humanitarian health endeavors. But no one was getting together to have discussions and provide wisdom and support to the group. No one was addressing the enthusiasm of our medical students for this field. And no one was promoting education of the larger group of employees regarding all the potential benefits of participating in humanitarian projects. I could imagine an amazing Global Surgery department at our hospital, much like what I explored via the internet sites from Harvard and Stanford.

I tried to think of the most basic first step. What was the move that would be completely without controversy, free, and easy for this one person to pull off? The answer: Organize a journal club. Journal clubs are ubiquitous, 100% educational and therefore in line with the mission of my program, and flexible. I could design it to meet when and where was convenient for me (I hosted the first few), and also drum up enthusiasm and support from others that might want to participate.

So that’s what I did, and we just decided to see what might happen next…

We had a small group of highly enthusiastic participants, including medical students. We met at the homes of group members and enjoyed very wonderful home made food. I was thrilled that some of our attending physicians agreed to host!

I was committed to meeting monthly with the exception of December and selected articles that tried to set the groundwork for understand the current state of the Global Surgery arena. We started with the Lancet publications (see http://www.lancetglobalsurgery.org/) and ended up talking through various publications from this series for the first 3 meetings. We branched out to publications featured on the Lifebox website (see http://www.lifebox.org/professional/publications/).

Group members started to undertake fantastic research projects and promotion of humanitarian missions. As a group, we brainstormed about how to establish a Global Surgery center, which is our current active goal.

Perhaps most importantly, we became a close-knit and defined group of Global Surgery enthusiasts, and there is tremendous motivation in having this support from peers and mentors.

Starting a Global Surgery, or medicine, or pharmacy, or simply global health, journal club, is a quick and easy first step for starting the fire at your institution. With consistency, you can build an alliance of folks looking for camaraderie and practical advice. There are no downsides!

Let me know if you’ve had a successful strategy for starting a humanitarian medicine group of any subspecialty at your institution in the comments below. It would be great to share strategies for success!

Why “Indie Docs?”

The idea for this website emerged from feeling completely overwhelmed by all the decisions and seemingly difficult lifestyle demands of pursuing humanitarian medicine. Josh and I talked about options for full time missions, part time missions, advanced degree programs, traveling fellowships, how we would raise our daughter…the challenges seemed infinite.

I thought about this website and blog as a means to organize the vast information and generate discussion among a like-minded community, and for months I waited for the right domain name to pop into my head. I was frustrated that I couldn’t come up with something that encompassed all the ideas behind humanitarianism, global medicine, travel, professional independence, and philanthropy. Luckily, my husband has a habit of solving these types of problems, and on a long car ride I explained to him all the ideas I was trying to tie together. His face brightened up, eyebrows raised, and he said, “Hey, what about “Indie Docs?” My response: Yeah, good one! After all, physicians pursuing global and/or humanitarian projects need independence, both professional and financial, and a willingness to go against the mainstream. There is also a spirit of fun in the name. It doesn’t emphasize philanthropy or humanitarianism overtly, but I think this broadens our purpose a bit while still providing room for these motivations behind pursuing one’s professional ambitions as a physician, whatever they might be.

Of course I would be dishonest if I didn’t share our love of Indie music as a big influencer in the moniker. Josh and I fell in love at a Christian Indie-rock music festival in Memphis, TN, 15 years ago, and we’ve been bonding over great music ever since. The year before we had our first baby, we decided to go to every music show possible for a year, which despite our demanding residency schedules, was quite a few shows in our area near Minneapolis, MN, one of the best indie music cities in the country (thanks in part to the amazing 89.3 TheCURRENT radio station), and some shows in Nashville, TN. We rocked out to Wilco, Dr. Dog, Feist, Trampled by Turtles, Lucius, Father John Misty, Benjamin Booker, Houndmouth, and maybe a dozen other awesome indie bands. We went to Festival Palamino (VIP tickets!) and Eaux Claires music festival (put on by Justin Vernon of Bon Iver fame).

She’s ready for the show.

Why is indie music special? Without writing a tome on the subject, the artists work hard to simply make and promote good freakin’ music and challenge themselves creatively. Indie musicians have created an amazing community of artists and fans who share their ideals of loving the music rather than chasing commercial appeal and financial success. (For instance, FEIST refused to play her most commercially successful single, “1-2-3-4,” at both of her shows that we saw. Given the chance, I would request at least a performance of the Sesame Street version, “Counting to 4,” which my daughter absolutely loves).

My mom recently paid me one of the highest compliments of my life when she said she listens to Lucius’s “On the Run,” with tears in her eyes thinking of Josh and me. I can’t even count how many times I’ve listened to that song with a little mist in my eyes thinking of the exhausting effort of this path and all the hurting people I can’t reach.

So, if the Indie revolutions in  music, journalism, film making, and other creative fields occurred because the talented artists wanted to take back control of what they produced, give it to the people who needed and appreciated it most, and embrace the idealism that filled their young imaginations in the first place, the medical field might be similarly primed for this same transformation. Rumblings of discontent are growing in the medical community-at-large due to the endless pressures to increase billing and revenue at the expense of spending quality time with our patients. We see small pockets of counter-culture movements, including boutique healthcare, as a response, but there is definitely  a major grassroots movement of many idealistic (no longer a dirty word) physicians towards working in the global health and humanitarian arena.

Cliche as it may be, we went to med school to help people. Doctors have worked too hard and sacrificed too much to get to the end of training and face an unfulfilling career they never imagined or desired. As the oft-quoted study in JACR concludes, participating in global health projects reduces burnout,* and for anyone who has participated in even the smallest humanitarian mission, it’s easy to remember that pure joy of working with clear and present purpose and feeling effective. It is my hope that Indiedocs.org becomes a place for professionals to connect, encourage one another, and share the tips and tricks to maximize our ability to change all the little worlds we can reach with the hardest-working kind of love.

Happy Trails,

Joy

-On the Run-

“And now we pass so many people on the road
They could come along, I wish they’d been told
They may call it a shot in the dark
From what we know, it’s not unheard of

And we’ll one day tell our story
Of how we made something of ourselves now.”Lucius

 

*https://www.jacr.org/article/S1546-1440(17)31353-4/fulltext

http://www.thecurrent.org