EPTNeurology:
Certainly one of the more intellectual specialties. There are a lot of tools that you get to use. These tools are typically carried by attendings in those archetypal black doctor's bags. No one else carries those bags. So that's a plus. You do lots of things on physical exam to gather clues, and then you try to correlate those findings to areas of the brain where the problem might be. Kind of cool from the perspective of a medical student.
I feel like the people who go into this specialty have to really find enjoyment in the intellectual aspect, because diseases of the brain tend to be pretty depressing and difficulty to treat. Lots of stuff that is insidiously progressing and debilitating. I saw someone get a diagnosis of ALS (Lou Gehrig's disease) and the poor guy admirably tried to keep a brave face and search for a silver lining somewhere, anywhere. But there was none to be found. Basically, good luck living out Tuesdays with Morrie. (1)
Alzheimer's is probably as bad or even worse. Same with Parkinson's. Multiple sclerosis. There are so many stroke cases that our inpatient service is divided into "Stroke" and "Non-stroke." Even the more benign stuff like Guillain-Barre syndrome can take years to rehab. Basically the only quick fix that I can remember now is a type of vertigo called BPPV. (2)
Why would anyone want to be a neurologist? Well, it's nice to specialize in one part of the human body. You worry about that alone, and leave the heart failure, pneumonia, hypertension, diabetes, spinal stenosis, COPD, etc. to the fine internist. (3) Secondly, if you have an affinity for radiology (and for any number of valid reasons, are not a radiologist), this is probably the closest you will get to using your own impressions of CT scans and MRIs to make a plan. Third, as I alluded to earlier, there are some mighty interesting and intellectually satisfying aspects in studying the brain. Lots of potential for research and breakthroughs.
Also relatively non-competitive in terms of getting into a residency.
Psychiatry:
How many psychiatrists does it take to change a light bulb? Just one, but the lightbulb has to really want to change.
I rather liked my psychiatry rotation. I spent the entire six weeks on consult-liaison, which means that other services in the hospital (like medicine or neurology) called us whenever there was a vaguely psych-sounding complaint.(4) Lots of suicidal ideation and depression. A decent amount of evaluating competency. Substance dependence. Anxiety. The more acute stuff, like schizophrenic episodes, were on the inpatient psychiatry service, and thus out of my realm of authority. (5)
Certainly it can be quite interesting listening to people's life stories. One particularly memorable one was a prisoner who had been transferred from jail to be evaluated for psychiatry issues. He was very quiet and solemn, talking about being in the shoe and how he had, at most, an hour a day outside his tiny cell in solitary. How he could scarcely take the solitude anymore and was hearing voices telling him to hurt himself. How he felt trapped because jails don't place a premium on taking care of mental health issues.
He was very articulate and quite the sympathetic figure. A little too articulate actually. Articulate enough to be extremely manipulative, an indication of antisocial personality disorder. Watching him talk with the resident was like watching a boxing match between two seasoned veterans. Each one would toss a few jabs out there to see how the other would react. There would be some dancing around the real issues. They were using all their best techniques. The prisoner wanted to establish a level of comfort, so that the resident would feel guilty for not helping him. He wanted to be believed because that was the first step to get out of the shoe. The resident wanted to build a relationship without ceding control of the conversation or being swayed by his attempts at manipulation. Pretty cool stuff, really.
Psychiatry is exhausting. A 9 to 5 day of talking to people for hours and hours about their problems was more draining than a 6 to 6 day in Peds. (6) There are also some very tiring cat-and-mouse games with people who seem to just want to have a bed to sleep in for the night. Can you really prove 100% than Mr. James is NOT suicidal and that you should not admit him? The answer is often no, and with the threat of litigation always hanging in the air, some patients get to treat the hospital like their own hostel.
Lots of pharmacology in psychiatry, and most of them work for reasons that are unclear. Again, the brain is a complicated thing.
All in all, I'm glad I did the rotation because I learned a lot. (7) The psychiatric history and "physical" is really detailed and complete compared to pretty much any other service. (8) However, you have to really like, or at least be skilled at, talking to people. A LOT. Most people shy away from it. There is a huge psychiatrist shortage pretty much everywhere.
Footnotes:
(1) What happens when you receive a death sentence? A sentence that says you will slowly lose muscle function until you are but a tragic figure, a shell of your former self? And that the ones you love will be suffering along right with you, watching you deteriorate until the merciful end? How do you not go home and immediately start drinking heavily and contemplate other ways out?
(2) To treat BPPV, you actually just lie the patient down and twist their head around like an amateur chiropractor to dislodge some schmutz from their ear canals. It's wild. And it actually works. Imagine breaking that one out at a dinner party. Talk about panty-dropping.
(3) The more I contemplate this, the less enthusiastic I feel about jumping on the internal medicine mothership. It is staggering how much you have to know to be a good internist. More on this in a later post.
(4) This is a source of much contention. Basically, a decent number of these "consults" were really just medical problems in disguise, i.e. delirium secondary to a pathologic process. The perception is that these services would rather relieve themselves of extra responsibility when possible. Whether this is true or not is probably moot. Suffice it to say that it's very easy to see why doctors from different specialties can tend not to get along.
(5) Sarcasm detected.
(6) This is not even mentioning that students regurgitate this story to the resident, who then regurgitates the story to the attending. I knew more about these patients than all but my closest friends.
(7) Like how to respond when a homeless crack addict going through alcohol withdrawl asks you for a handjob. Wait, I still don't know what to do.
(8) Helloooo, seven page admissions notes.
