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FORUM The Mirror of Medical Training Photo by Graham Ramsay Perhaps the final great challenge of medical school is to decide on a specialty--a choice each student must make often only weeks after the end of the third year. The decision then guides the selection of residency programs, a process culminating in the announcement of residency matches on Match Day. This event took place on March 18 for my classmates and me. Homing in on a field, however, began last year with our headlong plunge into the foreign place of the wards. We realized we scarcely spoke the language and knew even less about the culture of medicine. Yet we had no choice but to stumble forward. In time, we learned to be useful in the rush of morning rounds, to un-abashedly ask questions we never would in polite society, and to examine our patients' bodies with skill. We all had our first overpowering experience of the suddenness of death. This time it was our patient, someone who had been so real to us just a few short hours before. We couldn't speak for a moment; maybe we choked back tears and tried to return to our mundane paperwork with minds far away. Witnessing so much human emotion, we struggled to find a delicate balance between connectedness and boundaries with our patients and their families. Many considerations may influence the choices of graduating students, including intellectual and practice activities, the experiences of the clinical years, prior exposure to a field, and financial concerns. --Alisa Land While learning about medicine, perhaps we learned even more about ourselves. Future surgeons and emergency doctors longed for the hands-on work of the emergency department and operating room while those destined for medicine and pediatrics enjoyed the clinical care of patients over a period of time. Would-be psychiatrists sought a healing role in mental health, while others preferred clinical problem-solving through radiology or pathology. Some decided to specialize while others wanted the breadth of a general practice. And not every graduate would choose clinical work at all--some would pursue research or health policy, and others would leave medicine altogether. Yet I often felt the arbitrariness of these decisions: were these choices really what we wanted or more the reflection of a few short weeks in a given field? Did the physicians we happened to encounter in any one specialty care enough to teach and encourage us in their field? Did they seem happy in their choice? Could I connect with these patients, this medical culture, and these fellow doctors enough to make this my field? And could I be the person I wanted to be if I chose this specialty? The Rise of the Residency Residency training itself is a relatively new trend in medical education. In the early 1900s, medical school alone was considered sufficient preparation for general practice. New scientific discoveries by the 1920s prompted a required year of internship. Specialty training was also begun at this time. In the 1930s, the lack of standardization was addressed by establishing many specialty boards. In the 1950s, residency developments included salaries and a match plan, and by the 1970s, internship and residency merged, increasing possibilities for specialty and fellowship training. With all these new options, many medical students struggle to balance conflicting goals and interests. The most striking recent trend has been an increasing shift of applicants away from certain primary medical fields--OB/GYN, internal medicine, and family practice--in favor of specialties such as radiology, dermatology, psychiatry, anesthesiology, and ophthalmology. Many considerations may influence the choices of graduating students, including the experiences of the clinical years, prior exposure to a field, and financial concerns. There are also intangibles such as the social culture of a field and concerns about the altruistic possibilities of practice. The burden of significant debt, in particular, has been demonstrated to negatively influence entry into primary care fields. Recent studies suggest that some of the most compelling issues driving residency decisions are those that influence lifestyle. An increasing proportion of seniors are putting priority on a career that affords a "controllable lifestyle" in terms of manageable work hours, shorter residency training periods, fewer nights on call, an ability to integrate childbirth and family plans into training, and a reasonable future income. To many, these considerations outweigh the focus on specific skills, prestige, and financial security that has driven specialty selection in the past. Understandably, concern has been expressed about the implications of these trends for the future. Physicians and health care policymakers alike lament the potential maldistribution of physicians among specialties. Balancing Medicine I respect these concerns and suggest that solutions must be developed that include revised educational strategies during medical school and residency, as well as changes in the professional environment, hours, and remuneration to enable all physicians some level of well-being and balance throughout their careers. Especially in a culture with high rates of physician burnout, such reforms represent a vital means of encouraging doctors to enter underrepresented fields and remain in practice longer with greater contentment and job satisfaction. This, in turn, not only affirms the physician's sense of calling, but enables him or her to serve as a real mentor for the next generation. My fellow students and I entered medicine with a desire to serve and contribute to the lives of others. This commitment has supported each of us through the difficult times and reminded us that though we have chosen a challenging path, it is also one with great rewards. Self-sacrifice cannot be to the detriment of our own humanity, however. We can only hope that coming changes to medical training and practice may enable more balance and a greater sense of possibility for future students as they, too, look in the mirror and choose their identities as physicians. --Alisa Land, a fourth-year medical student at HMS, who matched at UCLA in psychiatry The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.