Greetings fellow Hamiltonians. I was invited by Vanessa Yap ’23 to write a column for students embarking on a pre-medical career pathway. I have recently retired after a 41-year career in the practice of medicine, and will try to give you a taste of the private practice of medicine—which is rapidly disappearing as large hospital systems continue to merge, grow, and become the primary providers. I will also venture to present a vision of what you may well encounter as you wind your way through years of education and training in the field of your choice.
I entered Hamilton in August 1967, without any clear idea of what I wanted to do. Clearly, I did not wish to go to Vietnam. Hamilton was a men’s college at that time, but fortunately the women arrived the next year, making the atmosphere much healthier. I majored in Spanish literature with healthy additions of courses in biology, chemistry, and physics. We had distribution requirements at that time in public speaking, the arts, English, history, and philosophy—though the spectrum of courses was nowhere as comprehensive as it has become today.
I played varsity soccer all four years and was co-captain my senior year. We were pretty good for those years and had winning seasons each year. Midway through college, I decided upon a career in medicine and entered medical school in New York City at Weill Cornell, where I earned my M.D. degree in June 1975.
Medical school was very competitive and arduous the first and second years, until we began to have patient contact and clinical instruction. Despite professing an interest in seeking diversity of race, gender, and college major while selecting the student body, Cornell admitted only one non-science major in a class of 95. But I soon discovered the value of a liberal arts background and Hamilton’s emphasis on clarity in written and spoken communication—promoting understanding, mindfulness, and humanity into meaningful interaction. Do not underestimate the value of studying subjects separate from your ultimate pursuits.
I met my future wife, who was a dance student enrolled at NYU, during the first week of medical school. She became a professional ballet dancer and had the talent to act and sing in summer stock productions in the Midwest. She has been my soulmate for 45 years. She joined me in Cleveland after she danced for a season with Twyla Tharp’s company and then joined Cleveland Ballet as a principal dancer.
I worked for five years as an intern, resident, and later a fellow in gastroenterology in clinical work and laboratory research at University Hospitals of Cleveland. I found the research interesting but lonely. My faculty adviser and I were mocked by others in the field for the preposterous notion that lowly bacteria might be involved in a larger microbiome, which could promote health, but also illness, if the populations were sufficiently altered. Not quite like being Galileo or Copernicus, but ultimately satisfying 30 years later, when the importance of the gut microbiome was recognized in viruses such as herpes and in contributing to maintenance of health and, if altered, in the development of disease.
Post-graduate training outside of medical school varies in its duration depending on the field, and can last for up to six or seven years in some surgical specialties. Just like my professors at Hamilton, most of my post-graduate mentors were excellent physicians and thinkers, and I gravitated toward the field of digestive and liver diseases and nutrition, which appealed to me since it combined clinical and surgical specialization. I had several attractive offers to work in academic positions in Cleveland, but wished to practice clinical medicine somewhere between Boston and New York. In 1980, most opportunities in my field were either hospital-based and more academic, especially if university-affiliated, or private group practices of varying size in one or more specialties. The latter involved more intense on-call schedules, particularly if there were no house staff trainees, as was the case in smaller sized hospitals.
The small group of three that I joined was located in Litchfield County, Connecticut, which was semi-rural and located about 90 miles from New York City. The hospital had 85 beds, but despite my snobbish academic background, I discovered that their level of care and skill was quite good. The first rule of practice is to know your limitations; those who know best are aware when they don’t know. Eventually, the hospital was affiliated with Columbia-Presbyterian in New York and ultimately with its much larger neighbor, Danbury Hospital, which has a house staff that made overnight calls much easier, since it did not require personally admitting several patients every fourth night and inevitable sleep deprivation. Most schedules in training have ceilings on work hours and hospital calls are easier now than many years ago. My training, however, did prepare me for long sleepless shifts and next-day fatigue. I recall never having a single moment during my year of internship until the very last night, when I climbed into a bunk bed at 6:30 am, met the bedbugs, and got out of bed 15 minutes later for good, scratching all over.
Enough biographical background; I would like to give you a glimpse of how medicine was, how it has evolved, and where it may be going. I may be wrong because the landscape is changing so rapidly.
Just like remote learning, technology, cell phones, electronic records, and easy retrieval of printed material on the internet, including reference works and journals, the speed of information technology has transformed medical practice into algorithms and lengthy time in front of the screen. Some of the time spent in analysis and explanation of differential diagnoses in the pathway of patient care has been lost in the cold light of the electronic medical record (EMR).
Medical practice has become much more centralized, primarily hospital-based and salaried rather than fee-for-service. Depending on your position, you might work primarily in an outpatient hospital-owned office or offices; there are ever-expanding networks as the larger and richer institutions, some academic-based and university-affiliated, gobble up smaller institutions trying to stay above water financially. Referrals come into the parent institution, which in turn scrutinizes individual performance goals, number of referrals, and number of studies (lab/x-ray, procedures) ordered or performed during salary negotiations. If I had wished to refer a patient to Yale, NYU, or the Mayo Clinic, I could—if the patient felt comfortable with that suggestion. That practice is no longer prevalent today.
I found in private practice a delight in face-to-face interaction, often without time constraints. There also was the challenge and pleasure of listening intently to the patient’s history and prodding its direction, without interrupting and while thinking critically. My practice was demanding, but afforded me the opportunity to be part of a community where we raised a family and continue to live today, in the same home we bought in 1980 when we left Cleveland for Connecticut.
Certainly, there are many careers other than primary care, whether it be medical or surgical. Pathology, radiology, nursing, research, PA or NP, and development of medical technology are all full of opportunities.
If possible, I encourage you to consider taking the opportunity to develop interests outside the healthcare field and perhaps take a few courses in areas which you have the time and opportunity to explore now. Foreign study is always a good experience. Today you have a wide range of programs available, though the pandemic has handcuffed our travels considerably. We had only a limited ability to travel for study abroad when I attended Hamilton College; instead, Saturday classes in the first two years were intended to keep us glued to the campus. I did also manage to spend a month after graduation traveling by train with a backpack in Europe before entering medical school.
For a short time, we had a 4-1-4 curriculum my final two years on the Hill. The single month of January was devoted to one subject, usually with two to three classes per week. It was graded with a pass/fail/ honor grade. The first year, I chose a course in Russian literature taught by Professor Adler. He wore a bow tie and had no sense of humor, but the discussions of novels by Turgenev, Dostoevsky, Tolstoy and plays of Chekhov made for a very memorable month. I have only recently had the time to re-explore some of that literature as well as the works of Dickens. The second year, I did an independent study of the late piano sonatas of Beethoven. I studied piano literature, but not to the technical level required to play any of those works. The paper seemed hot stuff to me, but Steven Bonta, professor of music, stuffed me with a “Pass” instead. Interest in the arts will likely provide you solace and break from the constant attention to detail required in the vast field you are preparing for.
Now, most pertinent to your interests is a glimpse of what lies ahead in medicine as it quickly moves forward.
Expect demanding standards in learning a new medical language, with much memory required. You are already on that pathway, and should find few obstacles. Your teachers will have more sympathy and empathy than those few precious souls who were kind and considerate during my medical training. In fact, when I started my internship in Cleveland, I was surprised that the medical students and house staff were treated respectfully, rather different from the attitude prevalent in New York. But as much as one might love NYC, realize that there are many excellent programs away from the coasts.
The evolution of computers, cellphones, creation of the EMR, and the ability to rapidly communicate by text speeds up the whole practice of medicine. Information is available in digital form rather than in 35 kg. two-volume textbooks. Artificial intelligence is already coming to various fields to assist in improving performance and patient care, and algorithms are constantly changing the management of many clinical problems and diseases. Technologically, you are already capable of adapting to these changes. There have been rapid advances in drug therapies in treatment of various cancers, in some neurologic diseases and surgical and endosurgical procedures. Telemedicine visits make it possible to visit and sometimes examine patients remotely. The EMR keeps a “datebook” for patient reminders about screening procedures from mammograms to colonoscopies and low-energy CT scans to detect early lung cancers in smokers and vaccination records and schedules. Fortunately, you have lots of gray matter left with which to store all this data.
The field of genetic mapping will give us a blueprint soon enough to direct more intense screening and surveillance where the importance of early detection is paramount. As you have witnessed, recent experiences with Zika virus and Ebola enabled a rapid response and development of the COVID-19 vaccine.
You will most likely do postgraduate study in a medium to large city; the current structure of medical care involves working for a hospital system as a salaried employee. This has benefits in limiting the length of the work week, and including scheduled vacation time and insurance coverage. If you are a primary provider, whether an MD, DO, PA, NP, or RN, you will be able to target the area where you would prefer to live. You could choose instead to join a private practice, which also pays a salary. My practice came with the uncertainty of when a day’s work would end, and with phone, pager, and then cell phone interruptions when I had “call”—which was practically every day. Inevitably, this led to disruptions in participating in family events. My wife has fortunately been a source of great understanding and forgiveness. That type of practice is disappearing, but it has the advantages of connection to place, family, and community to offer.
If you were to choose research or perhaps product development/tech, obviously the jobs will lure you to those geographical regions. Lifestyle can clearly be determined by choice of medical specialty; dermatology, radiology, ophthalmology, rheumatology and pathology all have few emergencies compared to gastroenterology, cardiology, and many surgical subspecialties, and have a more predictable schedule and working hours. Advances in medical care will hopefully contribute to longer and healthier lives, and demand for both disease treatment and prevention will allow you to find your “sweet spot” for location, quality of life, and work satisfaction.
I wish you all success in your chosen pathway. You are already on your journey and have excellent faculty and interesting and talented classmates at Hamilton. But don’t forget to explore some of the side streets on your way.