Choosing a Medical Specialty II---the view from above

MarkH is going through the process of deciding what to what to do when he grows up. This is a much more difficult and important decision than many may realize. In order to understand the gravity of this process, I'll have to refresh your memories a bit regarding medical education.

In the U.S., to apply for medical school, you must have completed a (usually) 4-year bachelor's degree from a university. During the final year, you take what amounts to an entrance exam (the MCAT), and send out preliminary applications (often with fees). If the schools like your preliminary applications, they will send you secondary applications which are more lengthy and involve more fees. If they like your secondary application, you will be invited for interviews. For those of you who may not be familiar with U.S. geography, this place is big---really big. When I went on my interviews, I typically crossed two or three time zones. I took the red-eye out of SFO for Washington National, leaving around 11 p.m. and arriving around 7 a.m. The process is time-consuming and expensive.

After finishing the interview process, you may or may not receive invitations to matriculate. If you don't get an offer, and you still want to become a doctor, you must repeat the entire process the next year. It is, needless to say, unwise to go through this process unless you're pretty sure you'll be happy with your decision to go to medical school.

I've always been happy with my decision---except when I haven't been. I remember one night driving home from the anatomy lab a little after midnight, looking at the Chicago skyline, wondering what it would be like to have a normal job and to go out partying in the evening instead of digging through pickled viscera. Usually, these feelings washed through me after a good night's sleep. During third and forth year of med school, a good night's sleep can be hard to find, so I frequently reminded myself that gut-wrenching regret is usually temporary.

For some people, that regret is not temporary, and the lucky ones suck it up, leave medicine, and find a career they actually enjoy. The ones who fail to make that hard decision are easy to spot because of the air of misery that surrounds them.

During the third year of medical school, usually before you've finished sampling all of the core medical specialties, you have to start the application process for residency. This involves another round of applications, interviews, etc. If you're thinking about internal medicine, you are interviewing for a three year residency spot. If you're looking at surgery, it's generally a five to seven year program. These commitments are long, so once again, you'd better choose wisely.

So how does one actually choose a medical specialty? Hopefully, during your clinical rotations, you've developed strong opinions about what you do and do not enjoy. MarkH posted some stereotypical but not unrealistic personality questions that may point folks in one direction or another. Certain specialties do attract certain personality types. But the more you know, the better your decision will be. If you're looking to get rich quick, medicine isn't for you---nothing about medical education is quick. Some specialties are certainly more lucrative than others, though. Very few primary care docs (internists, pediatricians, family docs) strike it rich. Compensation for doctors is biased toward doing rather than more intellectual endeavors. For instance, if I put a diabetic patient on an ACE-inhibitor, examine their feet, and make sure they go to the ophthalmologist, my care is likely to save their kidneys, feet, and eyesight. For this type of visit, and can expect to make about 70 bucks. If I simply clean the wax out of the patient's ears, I can make around 100 bucks instead. Preventing illness doesn't pay nearly as well as sticking a knife or a needle into someone. Because of the cost of medical education and the compensation structure, only about two percent of American medical school grads are picking a primary care specialty.

Decisions on specialties are, I suspect, made for economic reasons, but also for other good reasons. A student may have had a particularly influential mentor in surgery, for example, or may have just loved the thought process and patient interactions of internal medicine. But however the decision is made, it's another breakpoint. Choosing to go to and finish medical school is big. Choosing a medical specialty and finishing the training is bigger. It's a damned good thing I was happy with my choice---some of my friends were not, and the smart ones were willing to move on to another field or another career altogether.

My first day of internship, I showed up in my tie and new white coat, feeling appropriately nervous, but also ready. A very haggard-looking intern enveloped by a chair outside the ward, looked up at me and said, "PAL, eh? Well, you're post-call [as if I couldn't tell by how crappy he looked] so let me go over the new ones with you., never mind. Here, take my cards. I'm going to bed." I took them, entered the ward, and a nurse marched up to me, grabbed my name tag, and said, "Hmm, Dr. Pal. Well, "Dr.", Mr. Z. isn't looking too good. You'd better start there, and now."

I walked into a room to find an elderly man lying in a bed with the usual assortment of tubes dripping fluid in one place, and collecting it out of another. Except his breathing wasn't normal. He would breathe rapidly, then more and more slowly and deeply, and then stop.

And then finally he would start again, at first slowly and deeply, then more quickly and more shallow, then more slowly, until he would stop again, in a pattern known as Cheyne-Stokes respiration. This was a change from earlier that morning, and we got to work trying to figure out what had changed.

I loved it. I took to medical school and residency like a fish to water (most of the time), and I was usually good at it. Now, that's not what I expect from all of my students and residents---some will like it better than others. But I hope that they are all able to make good decisions based on their talents, their financial needs, and most important, what they enjoy. With the amount of time devoted to training and to the career that follows, you'd better choose well, or you are going to be a very unhappy person.


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Good luck to Mark on the decision and application process! I was and am very happy with OB/GYN, the combination of some primary care with surgery and being able to share one of life's most life-changing events for families was the best one I ever made, besides marrying my husband!

I absolutely loved residency! I wish I didn't have to take a break from practicing, but in our rural area there were no other options for me. Someday...

PalMD, I love the article, it brings back memories! We did the married match, that was a bit more complicated to coordinate. I just wondered if you could correct "Cheyne-Stokes" for me, my OCD for spelling, former secretary and all ;0)

Thanks for the memories!

This sounds very familiar. The problem with medical school begins in the first year. Most of the two preclinical years have little to do with practicing medicine. Those trained in some basic science in the last several years of college realize very quickly that medicine has little to do with science or curiosity about science and/or health. It is more like elementary school for doctorsjust like you learned reading, writing and rythmatic to prepare you for middle school, and high school to learn trig, algebra and calculus. What you learn during those first two years is nomenclature, and linguisiticsmuch like any vocation which has specific terms. Lawyers learn how to speak lawyerese, computer scientists learn geekology. These first two years expand your vocabulary, which few other people can or will understand.

The second two years expose medical students to some clinical work, which they will perform only if the intern and resident are overwhelmed with their duties. If the clinical material is scarce it will be monopolized by the intern/resident. Actually the medical student rotation may bear little resemblance to the actual clinical work that a mature physician will do in his practice. Ordinary medical stuff is usually lacking in a university or tertiary medical center where formal training takes place.

So what actually occurs is that the medical student must make a choice of what he will do with very little chance to experience a specialty or general practice prior to having to select a specialty or match for postgraduate training. In addition to this major shortcoming, the free standing postgraduate year of what used to be called internship is now called pgy 0, or 1, whatever the term is these days. This is also another reason why PCP, or primary care providers are so rare. (this used to be called general practice or family practice for you really young guys.) Many young doctors used to take an internship, then go out and practice general medicine for a few years to get a real taste of what they like or dont like about each brand of medicine. Yes, Johnny it is possible to do this, and quite safely if apprenticed with an older physician. I did it in the U.S. Navy aboard a floating naval ship in the middle of a war. I was able to do so because of my strong general medicine training in med school and INTERNSHIP. This is because the internship required and demanded competency in general medical,pediatric, surgical and OB/GYN.( I and my classmates delivered over 100 babies during our senior year of med school. Those who had OB in their third year also did the same.) After the navy experience I chose to do general medicine and even became medical director of an emergency department. It was 6 years before I specialized, some by choice and others by necessity.

Early on I was not sure what I liked or disliked. The clinical part of medicine bears little if any relationship to the science of what you study in the first two years of medical school. You may love endocrinology, or cardiac physiology, but find the clinical aspects of gyn, proctology, or cardiac resuscitation, or surgery revolting. You may like ENT but the thought of treating nosebleeds at 2AM a turn off. The bread and butter of medicine has little to do with what you see or do at University Tertiary Medical School.
And you are being trained by a guy with one more year of training than you have experienced. Not only that, but he or she will be ranking you, in many cases. Those professors who run the department are off giving lectures, writing speeches, or patting some other professor from eithr your institution or another one, on the back.

Being on call every other night, or dealing with very sick patients has little resemblance in internship to practicing general medicine, pediatrics, or other specialties. The journey through med school and internship may be more a journey of avoidance rather than seeking fulfillment.

Sometimes doctors near or at the end of their formal training are uncomfortable entering the real world. Some chose to go on because of this and subspecialize, some even do multiple fellowships, in neurology, ophthalmology, oculoplastic surgery or other areas.

Some even decide to avoid real medicine by becoming academicians. (which is another whole story on dysfunctional adult behavior)

When you reach the pinnacle of success in your own practice and look outward at your colleagues you will find clusters of physicians in a group who trained at one particular institution or anotherthe Harvard guys, the Yale guys, the UCLA guysall self selected into their own tier. My experience is that they are neither smarter or dumber that the rest. Only the patients think that is really important. I often times would have to bail them out or show them some ordinary thing that they never saw at the IVORY tower university. Perhaps they saw 100 cases of Sarcoid or Wegeners granulomatosis, but never managed an Alzheimer patient, or chronic congestive heart failure,nor managed a new diabetic that was not in severe ketoacidosis

So all you say is spot on, except you left out a lot more.

That was quite an insightful post by 'Anonymous'. Thanks.

"For instance, if I put a diabetic patient on an ACE-inhibitor, examine their feet, and make sure they go to the ophthalmologist, my care is likely to save their kidneys, feet, and eyesight. For this type of visit, and can expect to make about 70 bucks. If I simply clean the wax out of the patient's ears, I can make around 100 bucks instead. Preventing illness doesn't pay nearly as well as sticking a knife or a needle into someone."

Are the policymakers doing anything about this illogical pay-structure?