"I fell into this and absolutely love it."

T.A. is a dermatologic laser surgeon and is on the medical faculties of two leading universities..

My father is a very practical guy. He thought nursing would be useful for me throughout my life. Nobody in my family is in medicine in any way, shape or form, but I was always strong in math and science. My father would only support my education if nursing was what I pursued.

In the first couple of years of college I knew I was taking a lot of the same requirements as pre-med students. I was doing exceptionally well and I ended up fulfilling my pre-med requirements at the same time as I got my nursing degree. So even while I was in nursing school I knew I was going on to medical school.

When I entered the clinical part of my training as a nursing student, in my third and fourth years, it was clear that I wanted more control of what was happening with the patient. Ultimately I wanted to be responsible for giving the orders so that I could directly influence patient care. I worked full-time as a nurse in the cardiac ICU for one year after graduation. As an ICU nurse you have a little more autonomy. Many times you can't wait for a physician's input.

I had deferred my admission to medical school for a year so I could use my nursing background. In addition, I needed time to regroup. I got the most out of that year by getting involved with advanced technologies using intra-aortic balloon pumps and pacemakers and learning more about congenital heart diseases. Any time there were any procedures to be performed, even if they were a resident's responsibility, I ended up finagling my way into assisting or even doing them myself. I therefore, acquired quite a few skills that I would not have acquired if I had been a regular floor nurse.

I'll never forget interviewing at the University of Virginia medical School, which was my "backup" school because my parents lived in Virginia. When the dean interviewed me, he asked, "What's a nice pretty nurse like you want to go into medical school for?" I thought the question was really inappropriate and withdrew my application. I majored in chemistry. Obviously my grades were good. I was like any other pre-med student; it was just that my first major was nursing and I happened to have had extra clinical experience. I wanted to do as well as I could and disprove the theory that if you are a half decent looking woman you could not also be bright.

I was the only nurse in my medical school class. There was a nurse in the class ahead of me and she, too, had been an intensive care unit nurse, but had been practicing for a little longer than myself. There seemed to be one nurse in each class. Those of us who have gone back have done extremely well and also have chosen professions which enable us to have a life. Specialties like open heart surgery and neurosurgery attract a lot of medical students because of the machismo and glamor associated with them. Former nurses could see from the other side that it wasn't that way and be more realistic about what would give us satisfaction as individuals.

A large amount of stress in medical school is related to the patient interaction, and being able to formulate a plan for a patient. While most of my classmates were struggling with their interview skills and physical exam techniques, I was already comfortable with mine, so I could concentrate on what the differential diagnosis was.

Even in the basic sciences many of the questions on exams had a clinical overtone, so that when you were learning glycolysis and glucogenesis in biochemistry, questions would be related to diabetic ketoacidosis, etc. I had seen patients affected with these diseases, and I knew when I was preparing for my exams what type of things would be stressed. This was all new and threatening to some of my colleagues, because they couldn't see where this was all heading. Having the clinical background enabled me to incorporate the basic science a little bit better, and it stuck with me more. It wasn't just a big black hole.

A lot of situations you're thrust into as an intern you may only have done once or twice during the whole course of your medical school training. Skills-wise, whether it was drawing blood or starting an IV, these were simple for me. In fact when I was going through medical school I used to draw blood for the morning blood draws in a hospital. I could concentrate more on the fact that somebody is really sick, rather than on my lack of skills in that area.

Because I had been a nurse in the open heart intensive care unit, I had spent the first two and a half years of medical school thinking I was going to be a cardiothoracic surgeon. The further I went along the more realistic I became about what that entailed and what I wanted to do with my life. The specialty no longer had the charm that it perhaps had for people who were exposed to it for the first time.

A lot of medical students go through this macho thing where the more hours you put in, the better you are. I had gone beyond that. So I started looking at alternatives and ended up going through all the surgical specialties trying to figure out exactly what I wanted to do. At Duke we did all the sciences in the first year, and we did all the clinical rotations the second year. The third year was a research year that was supposed to be basic science again. In my third year I had worked in the surgical laboratory, in urology, because I had decided pediatric urology was the way to go.

My fourth year I was still thinking, "I want to do surgery but I don't know in which specialty." Through plastic surgery, I became interested in dermatologic surgery. I wanted a field that was more surgically-oriented, but in a nine-to-five schedule, for more flexibility with the rest of my life. Pursuing dermatology would require a year of internal medicine rather than surgery; I had to cancel all my surgical internship applications and put in internal medicine applications instead. During my internship year was when I interviewed for dermatology residencies.

When I was doing my dermatology training I had thought I was going to follow it with a fellowship in dermatologic surgery. I had a patient who had come to me from New York City (at that time I was in New Haven) who had a devastating birthmark. I didn't know how to treat it because all the treatments we had to date left significant scarring. Our best advice was to use cosmetic camouflage.

But I remembered something that had been published about a new laser which did not scar, and this woman was very persistent about me finding the original publication. She called me every day until I finally did recall the article. The more I read about the new laser surgery, the more interested I became in it. I found out that there was a laser surgery fellowship offered in Boston. In lieu of my third year of training at Yale, I was able to complete a dermatologic laser surgery fellowship in Boston.

When I started the fellowship, I knew nothing about lasers except what I had read, because nobody at Yale was practicing laser surgery. In fact they poked a lot of fun at me, saying, "What do you think this is, Star Wars medicine?" I answered, "I really doubt the people up at Harvard are wasting their time doing something that doesn't work." The worst scenario was that I would spend a year in Boston learning lasers and end up doing another dermatologic surgery fellowship after that.

The route I took was a surprise to me, and I ended up doing something I truly loved. As it turned out, my training coincided with remarkable growth in the field. Now I am practicing dermatologic laser surgery, whereas nine years ago I would have said, "Are you kidding? What is that?"

As a medical student I used to ask physicians, "How did you decide what you were going to do?" Some people said their fathers were surgeons, so they were surgeons. Other people said, "I kind of fell into it." You'd think, "That's so unglamorous." But they were experts in that area. Well, I fell into this and absolutely love it. And I'm glad I took the route I did.

Doctors use medicine as an excuse for not getting on with the rest of their lives. I know a woman who's a plastic surgeon here in town who has this big chip on her shoulder about how hard she worked to get there. She's never been married, and she's very resentful.It's really a shame. So many people are extremely unhappy. I often hear surgeons or internists say if they had it to do again they wouldn't go into medicine.

I don't hear many dermatologists saying that. I don't hear many ophthalmologists saying that. The subspecialists, who have had time to live a bit not only while going through training but subsequent to training, end up liking what they do. Those are hard programs to get into, but they are a little more humane. At least you can go home every night. You're not in the hospital on call.

I know I would do it all again, but I chose my path very carefully. I weighed all the options. I knew I didn't want to have a chip on my shoulder about going through some surgical training program for ten years, being raked over the coals, and being forty before I was out there in practice reaping the benefits.

That's not to say I haven't made sacrifices along the way, even with the nine to five schedule. But if I had picked another career outside of medicine, or had stuck with nursing, my life would probably be very different personally than it is now. I've been pleased in the way my life has come full circle. Of course, in another ten years I could get burned out of this and go on to something else. I have a lot of other interests, but my choice of my medical career has enabled me to look at other things I enjoy--art and architecture, for instance. I've been able to combine the best of all worlds. I have a nice clinical practice, maintain my academic ties, and I've written four books. So my life has come full circle for me. I couldn't be more happy.

I don't know whether I'm like other nurses who go back to medical school. I was a pre-med rat from the beginning, because I knew earlier that was the direction I wanted to take. I was extremely competitive in medical school. It was important to me to be the best. That doesn't have much to do with my nursing background. It's an individual thing. Basically you go to the best schools or training programs that you can.

My background as a nurse has made me appreciate where nurses come from and how integral they are in patient care. The myth is perpetuated that physicians are a step above nurses. I've never felt--as I think so many doctors do--that nurses are there to order around. But doctors are still writing the orders and nurses are still carrying them out. The best nurses are the ones who are happy carrying out those orders, who don't look at it as a threat to them or their intelligence. That's not to say that nurses are less intelligent. By no means. The best ones certainly do have different personalities than physicians. The ones who have personalities more like physicians don't get along with them because of competition.

When I went through nursing school, I was at a very good university and all the young women with me in nursing school were bright, but they were not of the same caliber as those women who were planning to go into medical school, academically speaking. Nursing enabled a lot of my classmates to pursue a very good profession. Some of them have left the field of nursing altogether. Several have gone to law school and are successful attorneys. A couple of us went to medical school.

Whether nurses or physicians, there are good ones and bad ones. A good nurse is invaluable. I appreciate them and I know how hard a job it is to be a good nurse. Unfortunately, good nurses are few and far between. The best ones are the ones who truly love nursing as an art and healing profession. They're not trying to prove anything other than that they are nurses taking care of patients, and they like that. The hardest thing for nurses is not getting burned out in the area in which they're working. Obviously the solution of switching to another type of nursing situation wouldn't be bad, but I wonder if just leaving altogether for a bit and then coming back later is also not a bad solution.

My biggest complaint about many nurses is that they're lazy. They don't take their careers very seriously. They seem to not like what they're doing; they're just pulling their shifts. Others are angry that they don't have autonomy, so working with them is difficult. They challenge every order that is written.

I thoroughly enjoyed my nursing experience because I knew it was going to be short-lived. I used it as a tool to get as much from that year as possible. Even curing the first two years of medical school I split a full-time nursing position with another nurse who had gone back to health administration school. I enjoyed it because I was able to maintain my skills and some patient contact.

Most nurse/doctors have had closer experiences not only with patients, but also with patients' families, who suffer when they see a loved one in the ICU. As a nurse, you're there all the time. You see what these people in the ICU go through--it's a miserable existence. We know how few of them walk out of the hospital and carry on well. Many times they're in the ICU for months and months. They have their good days and bad days, and then ultimately most of them die.

This is a great drain not only financially to the whole system, but most importantly emotionally. It's emotional not only for the health care providers but for the parents of children and for loved ones. It's awful. Nurses all say: If we get to this point, we do not want to go through this, even if there is a 1% chance that we could pull through and have a normal functioning life. We know that the odds are not in favor of that occurring and it's not worth it.

As a nurse you have witnessed the whole process of death and dying many times in the ICU--dealing not only with a dying patient but also dealing very closely with the family. Physicians are removed from that. They deliver the bad news to the family, but it's the nurse who does all the support work, holding the hands for the hours afterwards that it takes for everybody to say good-bye. The doctor comes and gives bad news, and leaves. Physicians are looking at the problem or the disease and thinking there's always a chance of survival. They don't look at the situations in the same humane way as most nurses who have been closer to the events and the people involved in them.

In general female physicians, whether or not they were nurses, tend to be more empathetic towards their patients. I do know men who are very compassionate, empathetic, etc., but women as a group tend to look at more variables--the impact of illness on the family, for instance. Women are better at integrating many factors. I hear this all the time from patients of mine, and I'm not even involved in death and dying situations. But spending the extra time with patients, holding their hands--a lot of men, even the younger ones, do not take the time to do that.