Kristin Prentiss Ott, M.D.

The Truth about Medical Specialties and “Specialism”

UPDATE:  This post was also published on KevinMD.com.  Since its publication, the Gomerblog article that it references (link below) was updated so it no longer draws parallels between my specialty and Joffrey Boratheon.  I take a little, tiny bit of credit for that.

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Medicine is plagued by a form of prejudice called “specialism” (yes, I just made up that word, but it fits).  In medical school we were united; we were all in the same boat; we were a team making our way through the gauntlet together.  And then it came time to choose a specialty.

A satirical article by “Lord Lockwell” circulated on social media recently called, “Medical Specialties as Game of Thrones Characters.” The runner-up character for my specialty was Jon Snow, the bastard of Winterfell.  The justification was:

“Because people love to tell you:  ‘You know nothing Jon Snow.’”

Can you guess my specialty?

Probably.

I practice Emergency Medicine.

The first character selection for EM was Joffrey Boratheon because:

“The entire hospital would enjoy seeing you die.” 

It’s okay.  Laugh.  It’s funny.

But what if we changed it to a race or a sex?  Just try it.

Not so funny now.

Specialty choice is a big deal and we make it so much bigger than choosing what we like to do.  We make it about who we are.

We are told to choose a specialty where we feel like we “fit in.”  I did that.  I chose the right specialty for my personality, but the wrong specialty for my life.

As an Ob/Gyn intern, I realized that specialties are, in fact just jobs.  I had seriously considered Emergency Medicine while in medical school, but didn’t think I fit “the type.”  I would rather stay in a 5-star beach resort than a tent in the Himalayas.  I’m not an adrenaline-seeking, black-and-white kind of person, but I liked the job so I switched.

Despite knowing my specialty doesn’t define me, the transition still sent me in to a little identity crisis because I didn’t fit the EM mold and someone in power literally told me:

“You’re not an Ob/Gyn anymore.  You’re one of us now.” 

One of us…

Us. 

Them. 

We divide ourselves into factions.  We say, “I am a gastroenterologist,” or “I am a plastic surgeon.”  Truly our specialty becomes part of how we see ourselves, how we define ourselves.  We go from all being in the same boat to separate ships navigating the same long hours and heavy responsibility with less togetherness.

I saw another article on generalizations about physicians by specialty called “The 30 Types of Doctors You Went to High School With.”  Ah, high school.  Kids.  Cliques.  Adults are so above that kind of behavior – oh…wait.

The halls of the hospital are lined with chart racks/computers instead of lockers, but packs of grown-ups all dressed alike still round together and are not above making comments about the “other” group down the hall wearing neck ties or surgical scrubs.

I don’t think the general public is aware of how we judge one another.  As people who generally revere knowledge and intelligence above all, status climbs with duration of training and competitiveness of the Match.  Plastic surgery, ENT, and dermatology held the top three spots for board scores of matched applicants in 2014.

Our colleagues who choose highly competitive residencies secure a lifetime of acknowledgment of their cerebral prowess.  This creates unfortunate pressure to choose more competitive residencies (because you can) and also the kind of bias (“specialism”) that leads to unfounded assumptions about our colleagues who choose less-competitive fields.

Physicians are judgmental people.  Within seconds, we judge our patients’ intelligence/educations levels, we judge their authenticity/theatrics, their honesty/dishonesty.  We judge their emotional stability/psychiatric soundness.

These subjective judgments are often supported by objective information like “this guy is totally crazy because he just peed in the corner,” or “those are alligator tears because I’ve seen this lady’s narcotic record and she was asleep when I walked in the room.”  Judgments like these can help us do our jobs when time is limited, but using the same kind of snap decisions about each other is unfair and harmful.

It only takes one time for a colleague to be wrong about something for us to think he isn’t very smart.  It only takes one time to hear someone be impatient with a medical student for us to think she’s a total b**ch.  We don’t give each other a lot of grace and “specialism” doesn’t help with this.

It is, I suppose, a very human thing to identify with a group and feel superior to other groups because of it.  Specialism says, “That Pediatrician didn’t even know the difference between a pilon fracture and a bi-mall fracture.”  It takes specialized knowledge and uses it to diminish others.  But I have seen the most secure Orthopedist suddenly insecure about treating a DVT in a pediatric patient.  I hear Internists deride Surgeons for their inability to handle “simple” medical conditions suddenly uncertain about the management of “simple” pathology on an abdominal CT.  We need each other.

When I call you about a patient in the ED, what I’m really saying is:

“Help!  I can’t do this alone!  Help!  This person needs more than me.” 

It doesn’t mean I’m stupid or lazy, or give you any right to laugh at the idea of enjoying my death. Specialism is different than racism or sexism because there is some choice involved, but it is not the kind of choice that justifies a lifetime of shallow assumptions.  The best way to fight all forms of prejudice is always to make it personal.  If an Orthopedist becomes a friend, he is no longer “an insensitive jock.”  He’s Dave.

Face-to-face conversations are a good starting point.  They help us see each other as people.  Because in the end, I’m not an EM doctor.  I’m Kristin.  I am the mother of two pre-schoolers.  I like Game of Thrones and dinners that feel like events.

Even if we don’t have parenthood or outside interests in common, we have a lot in common.  At one point we all convinced admissions personnel that we cared about people, that we liked helping people, and for most of us it was easy because it was true.  We were all in the same boat once.  Remember that?  We may have left the short white-coats behind, but we’re still on the same team.

Our jobs are hard enough; why are we making them harder by being hard on each other?  We should want to help each other!  Our patients aren’t the only people worthy of compassion and respect.  We’re people too.  Remember?

 

Photo credits:  flikr: Sean and Lauren/cruise ship, Dawn Endico/battle ship, writing added, creative commons license.

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Kristin Prentiss Ott, M.D.

Author of the viral post: 10 Things to Know Before Your Next Visit to the Emergency Department. Board certified emergency medicine physician, wife, mother, aspiring novelist.
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3 Comments

  1. Kassi

    Doctor Ott,
    I did not respond to this article immediately because I am not a doctor, and I do not in any way want to ‘pile on’ and complain.
    But I feel I must thank you personally for your well written article regarding physians learning to help one another. It’s been on my mind since the first day you wrote it.
    As a consumer, not a physician, I can only use my 92 year old mom as my personal case study.
    I have become leery of taking her to the hospital for anything from arythmia to Pnemonia to a broken ankle.
    This is not the way I used to feel. I always thought the hospital was the safest place she could be.
    The problems that have occurred (complete changes in her medicine, by each different specialist, meds that interact with other meds., meds creating Dilirium) have resulted in my need to spent a great deal of time with her pharmacist, helping me figure out which drugs are causing her new symptoms.
    I had long assumed that, not only were too many doctors in the mix, but that they didn’t understand the so called ‘old’ old.
    After reading your article, I understood completely what you are saying. As I have long suspected, but found hard to believe, each specialist she sees in the hospital appears not to have consulted with the other specialists. From the wildly conflicting reports and medication changes, I fear they may have not bothered to read what has been written by other specialists.
    I have been in tears trying to speak with one or another specialist outside her hospital door, only to be rebuffed each time as someone not worthy of their time.
    Please understand, I am not anti-medicine, not anti doctor, not anti specialist. And I am only speaking about my mother’s experiences over the past 5 to 7 years.
    Your compassionate letter to other doctors about sharing, about seeing each other, made a deep impact on me.
    Changes such as you speak of would make the entire medical system hum much more smoothly, for doctors and patients as well. Crying in the hallway of the hospital is not my best look, or the best way to allow a physician to see me rationally.
    So, again, I really hope your article gets the widespread attention it deserves.
    Doctors need each other, as those of us who are sick or worried need to feel heard.
    My hope is that your voice will echo throughout the halls of medical practices everywhere, and the result will be happier, more assured doctors, resulting in better patient care.
    Thank You,
    Not a Doctor.

  2. Natalie Britt

    Kristin… yes, yes and yes! As you know, specialism among colleagues starts in medical school. In 3rd year, we quickly learn how to fit it on our rotations by adopting the jargon and persona of the specialty, and their attitudes toward other specialties. By the end of 3rd year, we have all chosen our specialties, and suddenly we hear things like, “you’re too smart for family medicine” (which to me sounds as silly as “you’re too athletic for football”) or “you’re too social for radiology” or “oh, you’re doing ortho now… gunner.” As you said, we are so much more than our specialty, and there is so much more that goes into choosing our futures than just a personality fit. And I’ve also learned (like you) that there probably is no single specialty that is “the one” for me. I could probably be professionally content and fulfilled in a number of specialties, but there are so many factors that go into the decision. I’m not going with a back-up plan because I’ve chosen to become a family doctor. And as a future family doctor, I don’t want the specialists that I consult to look down on me or make assumptions about my intellect. The fact is, the pts that I send to a specialist likely have multiple comorbidities that I will be managing as their primary care provider, and in order for them to give my pt the best chance at a good outcome, I have to be doing my job as well as they are doing theirs. Thanks for articulating this so well! I look forward to sharing with my classmates!

  3. Stacy

    Another beautiful blog. I see and hear what you describe here all the time! The hospital is totally Bayside High. 😉

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