A young relative of mine recently asked me my thoughts about medicine as a career. It’s a relatively common question in my mail bag, and a tough one to answer, especially when asked by strangers. Career choices are very personal, so I don’t like to give advice as much as let people know what they can expect from a career in medicine. Here’s one of the latest letters to show up in my inbox (edited by me for anonymity, etc.).
I’m a third year medical student at the end of my clerkships now, and I’ve found that I pretty well like everything. I did my pediatrics rotation early and absolutely loved it, but I also really liked women’s health and it turns out that adult medicine is also pretty good. I used to think that I want to be a super expert on one system or group of diseases, but I also like the relationships you can have with people in a primary care setting, and I find the epidemiology of preventive medicine interesting.
With this conundrum brewing as I near the point of applying to a residency, I’ve started to think about family medicine. Could you please tell me your opinion on family medicine as a career? Do you think family practitioners provide high quality care? Or do you think that people should generally go to pediatricians, internists, and OB/gyns? I realize that this is very highly doctor dependent.
Brutal honesty is appreciated. Thanks, and have a good weekend.
Medical training is so prolonged, and practice so specialized, that medical students often have to choose a specialty before they’ve had the change to really explore potential careers. This particular student is a third-year, meaning that he is done with his basic science coursework and is rotating through various clinical specialties. As is not uncommon, this student has found that developing longitudinal relationships with patients can be both rewarding and interesting. From the perspective of more than ten years out of medical school, it sounds like he is interested in primary care of one sort or another.
Primary care is provided by pediatricians, internists, family medicine specialists, and to a certain extent OB/Gyns. Each of these requires a residency after medical school, typically three to four years, depending on the specialty. It is not uncommon for a medical resident to start an internal medicine residency and decide to sub-specialize in something like cardiology or gastroenterology.
But assuming you’ve got your heart set on primary care or OB/Gyn, there are significant differences between these specialties. One of the more important differences is compensation. There are numerous surveys available, and compensation is dependent on geography, hours worked, malpractice costs, and other factors. Another important factor that students often don’t think about is lifestyle and hours worked. Some specialties lend themselves to part-time work better than others.
From a practical standpoint, each of these specialties approaches things differently. Internal medicine covers the prevention and treatment of adult diseases. Pediatrics, childhood health. Pediatricians often see more patients in a day, and for less money, but tend to enjoy their work. Their patients are not just the child, but the parents as well. Pediatricians will often deal with difficult problems such as child abuse (for which they are mandated reporters), eating disorders, and the problems of adolescence.
There are a number of combined internal medicine/pediatrics residencies, most of which are four year programs, a year longer than either alone. That’s starting to sound a bit like family medicine, but family medicine has a different focus.
Specialists in family medicine usually have more training in minor, in-office procedures than other primary care specialties. They are also trained in basic obstetrics and gynecology, but the extent to which they practice these varies based on local medical culture and custom. The perception, which may or may not correspond to reality, is that family docs in non-rural areas don’t do a lot of obstetrics.
Obstetrics and gynecology is a difficult and rewarding specialty. When things go well, there’s a baby at the end. When things don’t go well, there is sometimes a dead baby and a dead woman. The day-to-day practice of gynecology can vary from being very surgically-oriented to being primarily office-based.
And now it’s time to piss people off. The writer asked for brutal honesty. I have nothing useful to say about income and debt, but I can give you some very personal opinions.
If you like working with kids and their parents, pediatrics is great. If parents generally seem like a pain in the ass and you perceive them as “in the way”, you should consider another specialty. If for some reason you don’t like working with the elderly, you need to know that internists usually treat a lot of older folks. OB/Gyn is great if you like working hard, like working with your hands, and don’t get freaked out by high-risk procedures.
Family medicine has often suffered from being the picked-on kid at the playground. If you like small in-office surgeries, and especially if you plan on working in an area with a shortage of physicians, such as a rural area, family medicine can be great. But in most urban and suburban areas, family docs don’t use much of their obstetrics training—or at least that is the perception of other doctors. Family docs are self-contained, and do great work, but unless you are interested in providing the full range of care offered by family docs, I can’t think of a compelling reason to specialize in family medicine.
One other possible drawback is that residents who graduate from a family medicine program will have a harder time getting into most sup-specialty programs. Family med residencies are designed to train primary care docs, not cardiologists. If you, as a medical student, suspect you may wish to sub-specialize in nephrology, cardiology, etc., family medicine probably isn’t for you. Other primary care specialties allow a greater depth of practice, so in my opinion family medicine is at its best when practiced by doctors interested in the full breath of patients and problems. Like any decision, choosing a specialty opens some doors and closes others. Family medicine opens a door on complete, longitudinal continuity of care, an amazing thing to practice and an amazing gift to offer. But it does create certain limitations as well.
Of course, internal medicine is the pinnacle of medical thinking and practice, or so we internists tend to think. As much as I love internal medicine, though, it’s limitations are many. If you like procedures, want to work with kids, or want to get rich without a lot of work, internal medicine is definitely out. Internal medicine requires not only a tolerance for, but a desire to treat diseases that patients may, to a large extent, have brought on themselves. If you are the sort who gets mad at a smoker for continuing to smoke, you’re not going to like internal medicine.
Choosing a medical specialty is not easy, especially since you have to choose so early in your career. Just remember: you’re going to be doing this for a very long time. Make sure that above all else, you pick something you think you will enjoy. That makes it a helluva lot easier to get up in the morning and answer a page in the middle of the night.