Should I Stay or Should I Go? Falling Out of Love With My Dream Specialty
A PGY3 Critical Care Senior Resident Medical Officer (SRMO) weighs up his options to continue down the path of anesthesiology or try something new before it's too late.
"Do you have any allergies?" "Have you had an anaesthetic before?" I'm asking these questions mostly as a formality. I've already taken the liberty of looking up his old anaesthetic chart. I already know old mate had a Lap Chole in 2017 and was a Grade IIa view with BURP. I already know he had a bad time with pethidine in the 80s. I already know he'll get the same basic anaesthetic as 90% of the cases I've seen. As he tells me about his allergy to pethidine I find myself focussing more on his dentition and mouth opening than what he's saying.
I launch into the spiel — my perfectly crafted, layperson friendly account of what we will be doing to him; long and detailed enough to fulfill the requirements for informed consent, short and abstract enough that they aren't freaked out. While I'm on autopilot, my mind wanders around the bay. It lingers on the whistle of air rushing through gaps in the bay doors, on the sickly aroma of diathermy smoke and sevoflurane that hangs in the theatre air.
It’s a niggling indication that my passion for this job has waned; that the excitement and enthusiasm I once held had been supplanted by anhedonia and dread; that as a resident poised to make the leap to an Anaesthetic Registrar, I had fallen out of love with my dream speciality.
Having declared myself as “anaesthetics keen” as a medical student, over the next 5 years I built myself into the perfect candidate. My CV was honed to precision. I had invested hundreds of hours into teaching, audits and good-old-fashioned brown nosing, not to mention thousands of dollars into extra training. I interned at a hospital with a robust anaesthetic department and a strong culture of hiring from within, had scored a resident term in PGY2, and leveraged that into a coveted Critical Care Senior Resident Medical Officer (SRMO) job with back-to-back anaesthetic terms just prior to interview season. I had followed the roadmap to success, only now to find myself getting cold feet at the starting line.
Truth be told, I did love anaesthetics at first. Every day presented new challenges and opportunities to hone my skills. My consultants were involved, supportive and personable; enthusiastic to take me under their wing and usher me into their chosen specialty. But in hindsight, I never felt like I fit in. At first I chalked this up to being the “new guy,” but as I became more accustomed to the job I felt more and more out of place. I found the theatre environment to be daunting and uncomfortable. I asked every boss I met what drew them to anaesthetics, hoping to find common ground. But all I found were reasons that didn't resonate with me: "I am excited by the constant pursuit of perfection,"... "I love working in theatres, it's much more controlled than working in ED or ICU," and perhaps the most honest answer, "it pays well.” None of these answers sounded authentically like me, and I found it harder and harder to see myself in this role long term. The excitement I once had to come to work morphed slowly into apathy. I still enjoyed inducing patients – I was getting good at it, and could do most simple anaesthetics independently, but I found the remaining 90% of the job uninspiring. I found myself dragging my feet in the morning getting ready for work – every day hoping the list would go quickly and I could leave early. At one point I found myself hoping I would wake up with a sniffle or a sore throat so I could get a Covid-19 swab and score a few days off work.
Dissecting my decision
Despite this growing discontent, I still intended to apply for an anaesthetics job. I had come so far, it seemed like a waste to give up. It was not an easy road ahead – anaesthetics training would dominate the next 6 years of my life (at a minimum). Gruelling exams and a packed work schedule would leave me little time for a life outside of work.
With the dreaded annual recruitment period fast approaching – I had to decide. Not an easy task, as my dread had festered into despondence, and had begun to take refuge in the distraction of procrastination. I broke it down to its simplest form - a pros and cons list (or more aptly, should I stay or should I go?) What I ended up with was a laundry list of reasons to go, and no substantial reasons to stay. I still have that list buried under a stack of paper in my desk drawer. I dug it up while writing this article to keep myself anchored.
1 Sunk Costs
2 Wasting my one chance
3 Quitting my dream
Looking back, this list reads as a searing indictment of the current medical training crisis: the pressure placed on pre-vocational trainees to commit to training early, the potentially deleterious effects of having “one bad year,” and the impacts these factors can have on decision making when it comes to choosing a career.
In essence, sunk costs are money/time/effort that has already been invested and cannot be recovered. The sunk cost fallacy has fascinating implications in human decision making, and effects domains from investment to relationships to (you guessed it) career. Sunk costs cause strong emotional commitment to an existing “investment,” causing us to make suboptimal future decisions, which will ultimately yield lower overall satisfaction, simply because we don’t want our investment to be “wasted”.
I certainly felt the weight of my 5-year investment when making my decision – not just the time and money, but the reputation I had built within the department as an “anaesthetic hopeful.” I felt embarrassed to change lanes after such a dramatic run-up.
I had followed the roadmap to success, only now to find myself getting cold feet at the starting line.
Deciding in a time of the medical training crisis
The growing training bottleneck created by the tsunami of medical graduates in the past decade, compounded further by the Coronavirus pandemic, has greatly exacerbated the impact of the sunk cost fallacy. Hopeful applicants for competitive training programs need to stand out from the crowd, calling for an earlier commitment to one’s chosen path, more research, more courses, more time – and more sunk costs. In my case, many of my sunk costs were accumulated before I even got a real taste of anaesthetics – my early experiences and expectations were shaped by the sunk cost fallacy, and I had created an echo chamber in which I was unwilling to entertain alternatives to pursuing anaesthetics at full tilt.
Unfortunately, the current generation of junior doctors does not have the luxury of time to try on different hats and decide on a specialty through experience. Gaps in work history, multiple unsuccessful applications or too many years spent running in place as a SRMO are viewed unfavourably, and competitive programs demand early and unwavering commitment. “Failures” are tossed aside and left to “settle” for less desirable career paths. I viewed this as my “one chance” to pursue anaesthetics – and my options boiled down to either an anaesthetics job, or an ICU position (a well-recognised “back-door” to anaesthetic training). I was unwilling and unable to entertain any alternatives, taking a year off, working in remote Australia, or simply taking another SRMO year to figure out an alternative path were all unthinkable.
Having picked the brains of many of my seniors, there was a prevailing perception that you could only “fall backwards.” You could quit anaesthetics training and pursue a “lower level” career, but going the other way was not possible. I could continue this path with an exit strategy already mapped out. I pondered this for some time. Could I really start down this path half-heartedly? I was already growing dissatisfied in my junior anaesthetics role, could I really put on a brave face and pretend I was all-in just in case I grew to love it? I felt conflicted about quitting at the start line, how would I feel once the race had already started?
It’s no secret that medicine views “quitters” with disdain. We’ve all heard about trainees 'washing out' of the program, usually spoken in hushed tones behind closed doors. Changing paths is viewed in a very negative light. Rampant speculation throws up a myriad of explanations – “they couldn’t cut it,” mental health issues, lack of commitment, other competing life priorities. Very seldom do we consider they decided they were not happy on the path they had chosen.
In my case, the ‘try before you buy’ approach was fraught with danger.
My ‘reasons to stay’ were already motivated by emotionally detrimental sentiments of sunk costs and saving face. Changing my mind as a resident was nothing compared to the potential humiliation of quitting one year in.
I began to examine the motivation behind my wanting to quit. Truthfully, I was anxious about stepping up to registrar and of sitting the daunting primary exam, let alone failing out of the program. But mostly, I was anxious that the growing discontent I had towards the job would consume me. I was worried that I would succeed on this path where I did not fit, that I would sink into joyless cacophony, then settle down into the next three-ish decades of a career that I had grown to find unfulfilling. That I would feel trapped in an inherently stressful profession (one with a disproportionately high risk of suicide and substance abuse) and see no way out.
Understanding the factors that kept me in the rat race was liberating. I realised that my reasons to stay were in fact an aversion to the act of “quitting” rather than a true passion or affinity for the specialty. I re-examined what it is I loved about being a doctor – the way the job satisfied my inquisitive nature, the on-the-fly problem solving that challenged me to be better every day, getting to meet new people and help them in their time of need. I had lost sight of these things in the pursuit of what I was convinced was my dream.
Deciding at the eleventh hour, I opted to apply for an unaccredited ED training position — a year to try on a different hat and see if it fits. It ticks the boxes of what I wanted: hands-on clinical work, a good work-life balance, supportive seniors and opportunities to grow.
Unlike my last career choice, I am trying to remain pragmatic. The difficulty of backtracking to anaesthetics if I rediscover my former passion weighs on my mind. I realise I may have squandered the career momentum I had — my perfect-on-paper Cinderella story of a doctor destined to be an anaesthetist since he emerged from the primordial soup of med school, supplanted by one of indecision and wavering commitment to the cause. No doubt the speciality colleges prefer the former — they don't put positions on hold for prodigal sons returning from their search for greener pastures.
2021 may well end up being a year I live to regret — the spanner in the works that forced me to take the long way round into anaesthetics. But I would much rather take the long way, knowing it is the path I want to be on, than take the shortcut and be forever looking over my shoulder, wondering about the path not taken, and feeling it is too late to turn back.
I have the luxury of time on my side. I am younger than the average JMO, I have no dependents or financial commitments to any colleges. My sunk costs pale in comparison to many of my colleagues. But sunk costs grow over time, and the influence they exert on our decision making becomes more profound. No matter your circumstances, exploring and unpacking doubts about your career path EARLY allows you to minimise the impact of the sunk cost fallacy on your decision. And if it takes a year off the beaten track to discover where your passion lies, that is a small price to pay to make the decision that is right for you, and to know you want to make it.
So here’s my advice for people on the fence:
- Talk to people at all levels about what they like and dislike about the specialty and lifestyle. Ask yourself: Does this fit with who I am and what I want?
- Be aware of the sunk cost fallacy when making decisions to stay or go
- Change your mindset – imagine you have already made the decision to change path and see how it makes you feel. This will help determine if it is the decision you want to make.
- Be honest with your seniors who have supported you. I worried about disappointing my mentors with my decision, when in fact they were happy I had made the right decision for me.
- Don’t burn bridges: Thank mentors for their help and the experience you have gained. Don’t be TOO honest about why you changed your mind, “I don’t think I am suited to this specialty,” is good enough.
- Try to have your existential career crisis early in the year so you have decided before annual medical recruitment rolls around.
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