I am so glad that I’m only a partially conflicted, semi-neurotic, intermittently confused middle-aged psychiatrist. It would be so much harder to be a young guy, just coming out of residency, trying to decide what to do and how and where to do it. The stress!

When I finished training, career paths were relatively easy to research, vet, and decide upon. You could go into private practice, in a group or solo, and many took that route right away. You could stay in academics (I did), choosing to mentor, teach, write, research or round with students, residents and fellows, thereby extending your own professional adolescence as long as you wanted or needed to. You could work for the VA, the state system, or a local mental health center. You could go for the prestige, the padded CV, the money, or the satisfaction that comes with helping those less fortunate. Or some combination of all the above.

The world is different now.

Some systems have the tech toys, the money, and the infrastructure to see hundreds of thousands of patients, documenting every move their patients and providers make. Some clinics, especially local mental health clinics, barely have two nickels to rub together after legislatures have cut spending back to 1980s levels. Some programs are using every advantage to reach out and include, while other systems are fighting to survive, writing policies that exclude based on severity of diagnosis, adjudicated need, or simply based on financial platform.

I have one foot in both worlds.

Some days I fight mental illness using T1 lines, high definition monitors, Polycom boxes and electronic medical records. Other days I count on traditional clinic appointments, handwritten prescriptions, and good old fashioned staffings to communicate. On the one hand I have twenty four hour cutting edge technical support. On the other I still use Windows XP on an old Dell laptop that would make an excellent boat anchor. I have computer and social media savvy patients who want to communicate using those platforms, and policies and procedures that chronicle a deathly fear of privacy violations and inappropriate provider-patient contact.

What is the young doctor to do?

When is it good to take care of yourself, making as much money as you can in order to pay back tens if not hundreds of thousands of dollars in student loans while paying the mortgage and feeding your kids? When is it okay to go for the gold? When is it more noble to do more with less, working in an inner city clinic that treats those with chronic illnesses, no insurance and no income? When is it okay to surround yourself with the latest greatest technology and love coming to work/play, versus writing handwritten notes in frayed brown charts with little colored stickers on their spines?

Can you do both?

Can you really be a doctor in the twenty first century and have it all?

Is it even your choice any more?

I’m leaving this one for the young ladies and gentlemen of my profession (and their long-suffering patients) to grapple with.

Let me know what you decide. Staffing is at nine on Tuesday morning. I’ll be waiting for you.

Greg Smith is a psychiatrist who blogs at gregsmithmd.