After ID Fellowship, What Next?

Second year of infectious disease fellowship was supposed to be great. It being the last year of my medical training, I was going to relax, take it slow, complete and publish my research, find a job, and just chill. My, have I been mistaken. Second year is certainly easier than first year in terms of work schedule, patient care duties, and emotional issues from being stressed, overworked, and undervalued. But I underestimated the pain of the job search and the trials of completing research.

I’m so done with research by the way. I’m convinced that approach to academia is not for me. I simply don’t like the feeling of working on a project for years on end before it comes to fruition. Oh, but I will make it through this one!

The job search though has thrown me for a loop. There are just so many options. Do I want to stay in academics? If I stay in academics, what percent of my income will be generated by research vs. administrative duties vs. clinical care? Can I live on an academic salary?! It is often recited that infectious diseases physicians spend an extra two to four years in training (ID fellowship) only to end up making about the same or even less than their  internist counterparts who didn’t enter a fellowship program.

Do I want a pure infectious disease practice or do I want to mix in internal medicine to boost my income or keep up-to-date? Then, what kind of infectious diseases do I want to do? Inner-city infections? Surgical or trauma hospital infections? Rural town infections? Transplant hospital infections? A bit of all? What?! Oh, too many choices. Do I want an outpatient practice or do I just want inpatient consultations? If I have an outpatient practice do I want to be the primary physician for my patients especially my HIV patients?  Or do I just want to be strictly a consultant having someone else do the primary care and the hospital admissions?

Well once I thought I had figured all of that out, the next stage was fairly easy. Crafted my cover letter(s) and resume, perused the periodicals and sent my applications flying. The responses were robust. I found myself in a buyers market. There really is a great need for infectious diseases physicians out there….only that out there is truly out there! I had already made up my mind that for a truly decent chance at establishing myself I would leave my hot spots – the New York City’s, the Washington D.Cs, the Bostons etc. I would leave and be just fine in the boondocks somewhere. After all, I’m an introvert, a loner, I can manage on my own.

Miscalculation number one! True, I hardly came across job offers in these major cities, but am I ready to leave my comfort zone? Emotionally? Socially?

As, my job search narrows and I face relocation to small town America (Palin’s real America) I’m beginning to second-guess myself. O-h m-y g-o-o-d-n-e-s-s!!! What am I going to do with my lonesome self outside of the hospital?! Go moose hunting? Hmmm!

Interviewing itself has been fun. I have flown to Texas, Louisiana, Florida, Georgia, and Pennsylvania on my quest to finally begin life. Life in a warmer climate is the goal. Don’t ask how Pennsylvania ended up on the list. It would just be my luck if that’s where I end up too. All expenses paid, dined and wined to boot. I did say it was a buyers market. The financial offers have run the gamut from a few thousand dollars more than a fellows salary to twice or triple that. Some offers have had me downright scared that I could make that much money and actually see the light of day. No, I’m trying to have a life here not trying to kill myself working! Other offers have had me looking at the potential employer like “you’re kidding me right?”

But there’s one opportunity that really tugs at my heart and it’s actually academic. I would be THE Infectious Disease Attending supervising residents as they take care of HIV infected patients in several clinics per week. I would have my panel of HIV patients of course. I would also consult on the inpatient service – just bread and butter general infectious diseases – but lots of wounds in poorly controlled diabetic people. The opportunity is at a small community based hospital somewhere in Louisiana, not exactly rural but from the feel of it, it may as well be.

I felt like I had entered another world when I went there for my interview. I said to myself, dear, this is what you’ve been looking for. Academics but clinical with research at my discretion…HIV care as a significant portion…ethnic minorities (although in this case it was either country African-Americans or country White Americans)…the working poor…the disenfranchised. My ultimate preference of a patient population. Essentially, a resource-poor setting without leaving rich world America.

Sorry to say and truly disheartening if you think about it. That there are many areas here in the US where there is such a dearth of medical care and where only foreigners are willing to go to take care of patients. The doctors I saw there were all from foreign countries essentially even those who had established themselves there for the past 20 -30 years.

What happened to the drive to educate Americans from rural places so that they would return to their rural homes to practice? Ah yes, they couldn’t get into medical school in the first place as their primary and secondary education is so poor. Or perhaps, they did make it to medical school and then decided to better their own lives and that of their immediate family. They might be out there competing for what little jobs there are in the major metropolitan cities of America fighting turf wars along with everyone else. Sigh!

But back to me. I truly want to say yes to this opportunity. At the same time I am scared. But what is a job opportunity if the prospects of it doesn’t scare you a bit right? But, honestly I’m scared. Would there be enough of me to deal with the emotions that will definitely be generated from taking care of such a disenfranchised population? I’m not a stranger to taking care of disenfranchised people. In my third year of medical school I did all my rotations at the county hospital in Cleveland and not at the university hospital. Currently, my ID fellowship is at Boston’s city hospital full of “the indigent”, immigrants, refugees, and those for whom substance abuse and violence of any sort is the norm.

Would I be frazzled by the unfairness and inequalities driven by racism, prejudice, capitalism, and social ills? Will I be forced to burn out faster than ever as a result? Will I end up packing up my bags and checking myself into a mental institution from the burden of inequality in this country? Will I be able to handle it? Would I be able to live side by side with my patients sharing their experiences of cultural prejudice and racism but having a much larger wallet at my disposal? Will I be able to handle it?

Or would I just disappoint myself? Cop out to a much easier choice of a place where people think and reason like I do, where people are poor because of the bad choices that they have made and not because of an institution that has worked against them for centuries, where there are resources easily at hand for myself to help my patients, and where I can go home at night relatively emotionally intact?

Mind you, I’m asking myself all these questions while everyone else is reminding me that I’m not getting any younger and that I need to settle down and pop out some kids, ya know?! Can I handle it?

What is it going to be?