To Cut or Not to Cut

Once, in high school, I made a speech about my desire to be a neurosurgeon. The only talking point of this presentation I remember now was a joke about how Jethro Bodine, the well-meaning but terminally ignorant nephew from "The Beverly Hillbillies," also wanted to be a neurosurgeon. In retrospect, much of what I knew about medicine back then was gleaned from popular entertainment - from Radar on "M*A*S*H" performing an emergency tracheotomy with a pocket knife and a ball point pen, to the Captain Trips plague wiping out most of humanity in Stephen King's, "The Stand."

Probably my first real introduction to the medical field was more educational in nature. My parents subscribed to "Reader's Digest," and in the early '70s it published a regular feature named "I am Joe's … ," with each new article focusing on a different part of the body. I read them all and the article from August 1972, entitled "I am Joe's Ear," must have stuck. Sometime not too long after that, when I was eight or nine years old, I found myself in the doctor's chair with plugged ears. He had me hold some water in my mouth while he occluded one of my nares with a tube, and he pressed the other nares closed with his finger. He asked me to swallow the water and, being a trusting soul, I complied. I was rewarded with a shocking "pop" as my ears were pressurized by the bulb he held in his other hand! I leapt in the chair, and then I made an intuitive leap from the "I am Joe's Ear" article to the present circumstances. I looked up at him and asked, "Was that my Eustachian tube?" He gave me a very funny look, as if I had spoken to him in tongues, and then rushed me and my mother out of the office.

Once the decision to go to medical school is made, it seems like everyone you know is asking, "So what kind of doctor are you going to be?"

"A good one!" was my standard reply, but I really wasn't sure. That's part of medical school, exposing ourselves to the different fields of medicine, taking tastes of the core rotations like internal medicine, general surgery, pediatrics, and OB/GYN. But amongst my friends in the trenches, it quickly boiled down to a decision demarcated between surgical or nonsurgical fields. Are you a cutter or a thinker?

I spent most of my third-year clinicals in an inner-city charity hospital, lots of trauma with the local "gun and knife club," lots of sick-sick medicine patients crashing in the wards. I delivered babies. I watched an extremely angry 16-year-old pregnant girl who said the magic words, "I want to kill myself," get locked in the secure-psych ward, proceed to escape from her restraints, and use the buckles of the restraints to break through the "unbreakable" window in the lockdown ward.

As the rotations turned through the year, a problem became apparent: I liked all the specialties a little, but nothing grabbed me. The internal medicine rotation was a nice mix of action and erudition. Call night was filled with patients in distress, inserting central lines, placing arterial lines, and marching to the lab to examine a urine sample for red cell casts. Dawn brought morning rounds, sitting at the roundtable and trading differential diagnoses like some ersatz poetry slam.

The surgery rotation was different, with an underlying pulse of urgency strung through the work. There was a refreshing directness to the perpetual calculus of deciding who needed an operation and there was the gratification of watching a successful case walk out the door. But for the medical student, ennui could set in. I became adept at napping and retracting a liver simultaneously. I became bored from not being able to see or participate in the action. During downtime, I would wander between rooms in the OR looking for interesting cases. Once I discovered a radical neck dissection unfolding in the otolaryngology suite, and I watched as the cervical nerve rootlets were cut, one-by-one. Not very elegant!

Ultimately, the time for match list submission approached, with the surgical devil clamping one ear, and the medical angel dictating into the other. Weighing my options, I finally decided that a year of medicine would be more useful than a year of surgery, no matter what I ultimately decided to pursue. So I matched in internal medicine at Wilford Hall USAF Medical Center.

It didn't take long to discover that internal medicine may not have been a long-term viable option for me. The intellectual pursuit of diagnostic dilemmas soon collapsed under the weight of that fifth clinic patient with chronic hypertension, poorly controlled diabetes, and a bad pork rinds habit. I caught myself taking my ophthalmoscope apart during grand rounds to figure out how it worked. I knew my internal medicine days were numbered when, during a particularly frustrating day in clinic, my hands lurched and I looked down to find the yoke of my stethoscope split into two pieces! My most memorable patient was a young, healthy female (already a standout amongst the retirees) who just wanted a routine checkup. During the checkup, I found a grapefruit-sized mass near her ovaries, and sent her directly to the GYN clinic. They called to confirm my find, but I secretly missed the chance to remove the mass myself.

I had a three-year commitment with the Air Force, and it couldn't be as an internist, so my backup plan was becoming a flight surgeon. People would ask, "Do you perform surgery in the air?" But flight medicine is a branch of occupational medicine treating pilots and the air crew, with special training in understanding the dangers that flying planes poses to the human body. Surgeon is sort of an honorary title for a battle-ready doctor.

As I treated more and more pilots, their problems primarily dealt with motion sickness, sinus blocks, and hearing loss. My thoughts went more to things ear, nose, and throat. This specialty had never really crossed my radar in school, but it seemed an interesting field of medicine with a variety of different types of surgery: ear surgery differs from sinus surgery, which differs from head and neck surgery. This made boredom with the field a less likely fate.

And of course, my pilots came in with all varieties of ear barotraumas - tympanic perforations, hemotympani, serous otitis - each reacquainting me with my old friend, the Eustachian tube.

So I started hanging out with the lone otolaryngologist on the base, and I got an idea what the day-to-day life of an ENT is like. And with that much exposure, I entered the match and found a medical home for myself. Now, sometimes as I stand over a tracheotomy case, I can't help thinking about Radar O'Reilly kneeling on a roadside, cutting a soldier's neck with a pocketknife under Hawkeye's feverish direction. And as I do a neck dissection, a small part of me still cringes as the bovie cuts through one of those cervical rootlets, like I cringed watching that neck dissection during medical school many years ago. But that decision I made to take a chance on otolaryngology was one of the best and most rewarding of my life.

John Jarboe is an otolaryngologist and voice specialist in Atlanta, Ga. He enjoys golfing, writing, and baking cookies with his two beautiful daughters, and sneaking an occasional Friday night margarita with his wife.

This article originally appeared online, September 2011, on PhysiciansPractice.com.