In 40-some years of summer weekends and vacations at the beach, I always avoid Labor Day weekend. It is not the traffic I fear, nor the fireworks I disdain. I loathe the melancholy of summer’s waning days: the brisk mornings, the lake’s white-capped waves, the hints of red on the Tupelo trees that are like a dirge. I prefer summer’s messy energy: the fine coating of sand in the back of the car, the unremitting cycle of packing and unpacking coolers, and the din of grown children, nieces, and nephews whose dinner conversation is boisterous enough to make my parents wince.

Like most pediatricians, I have a nearly limitless tolerance for chaos and unpredictability, if I can leave on a happy note. I eschew fall’s solitary calm, or any seasonal reminder of inevitable decline. My husband, now that we are not tethered to tennis tournaments or dance rehearsals, would spend every fall weekend watching the leaves change over his laptop in the silent dining room. He has an anesthesiologist’s ability to live in the moment, unencumbered by foreshadowing. Where he finds respite, I see emptiness.

A psychoanalyst would hypothesize childhood trauma has shaped my desire to exist amid happy pandemonium. A cognitive psychologist might wonder how to reframe my anxiety about my children’s adulthood or my parents’ aging. A behaviorist (and my husband) could prescribe a series of exposures to teach tolerance of this experience. Each approach has some validity, but none offers a complete explanation.

In college, one lecture changed my personal and professional thinking when I heard psychologist Jerome Kagan speak about his work on temperament. According to Kagan, there is a biological basis for the temperamental traits of introverts and extroverts. He offered the vivid example that asking an introverted child to run for office was equivalent to asking your spouse to grow a few inches. Perhaps, he suggested, you should encourage that child to be a physicist instead of a politician. Thirty years later, I remain amazed at how poorly Kagan’s work has filtered into our understanding of decision-making.

Sometimes physicians focus on superficial reasons for choosing a specialty: the procedures, schedule, or peers. We get sidetracked by taste (I find eyes revolting) and forget the importance of temperament to long-term satisfaction. Medicine is rife with jokes and memes in support of a surface interpretation of Kagan’s hypothesis: tinkerers become orthopedists, introverts become pathologists, and short attention-spanned folks enter emergency medicine.

These stereotypes miss the core issue, as I learned from someone on the other side of the fence. Several years ago, I played “Whose job is worse” with an oncologist friend. I posited that her job was worse: cancer. She shocked me with the claim that my job was worse, explaining that when she sees a patient, she knows they have cancer. When I see a patient, each one might have cancer, and I must discern who.

Therein lies the fundamental divide of medical temperament. The specialist has a high tolerance for repetition (hundreds of patients on the same leukemia protocol) but a low tolerance for uncertainty. The generalist has a low tolerance for repetition and a willingness to live with uncertainty. As physicians choose fellowship or general practice, we rarely consider this aspect of practice. Those of us content with our choices, often by happenstance, may recognize the truth of this assertion. Yet we fail to explicitly discuss this issue with trainees weighing their options or colleagues dissatisfied with their current work. We ought to acknowledge this foundational temperamental tendency and use it to steer career choices rather than risk the persistent stress of forcing physicians to practice through daily discomfort.

When new physicians begin their careers as generalists, it can be hard to separate constitutional intolerance of uncertainty with the normal (and beneficial) anxiety arising from awareness of the limits of one’s knowledge. Time will tell. Those who can, by dint of personality, make peace with the intrinsic uncertainty of a generalist will develop confidence in their abilities and acknowledge the limits of their omniscience. Those who cannot stand the not knowing will flee for a specialty or become the kind of generalist who orders a consult for everything. All of us could do a better job discussing this personality divide with young physicians who may see their own discomfort without understanding its source.

There are, of course, more obvious facets of temperament for which clinical experience serves as a sorting hat. If you cannot stand the screaming stickiness of pediatric wards, you will drift towards adult medicine. If memory loss in elderly patients induces tears, you will veer towards pediatrics or obstetrics. There is enough space, and need, in medicine to accommodate all flavors of physicians. Clinicians (and patients) will be happier if we follow temperament’s guide and listen when the sorting hat speaks.

I spent one fall weekend at the lake this year because our youngest child was visiting with college friends. Busy cooking, distracted by the laughter from the ping-pong table, I could almost pretend I was in the thick of summer. As I shrugged on a sweatshirt against the morning chill, I blinked back tears. Temperamentally, I am unchanged: eager to dive into hopeful beginnings but unsettled by quiet finales.

2025