Matching and Specialty Selection

This is likely to be a multi-part posting but I thought that I needed to start to address this topic at some point. Speciality choice can be quite difficult for many medical students because some schools never quite spend much time on how to choose a speciality. This choice can be a source of life-long misery or it can become like a marriage with deep and passionate love in the early years only to be replaced with a wonderful familiarity that is both surprising and satisfying at the same time.

The wrong way to choose a speciality is based on what you will believe will be potential income. While it’s generally true that surgical specialties are better paying than primary care specialities, this is not always the case especially if you find that you just don’t enjoy surgery and surgical procedures after a while. Anesthesia has become very popular in the sense that people feel that this speciality pays well and had less hours than surgery but a description of Anesthesia as “hours of boredom punctuated with seconds of sheer terror” can be pretty accurate at times. Many people find that this aspect of anesthesia far outweighs any monetary rewards.

Another wrong way to choose a specialty is by how wonderful your medical school experience was in that particular rotation. While you may have loved your residents and interns, you may have not loved the patients that you were treating. This can make for a miserable residency experience and an even more miserable practice experience.

As you rotate through your required third-year clerkships, you may want to pay close attention to the types of patient that each speciality treats. Do you enjoy a long-term relationship with your patient and handling of chronic problems? If this is the case, then family medicine and internal medicine may be of interest to you. Do you enjoy treating only female patients? This brings to mind OB-Gyn but you may find yourself drawn to internal medicine with a track in women’s health.

Do you enjoy procedures? You may want to investigate the procedure-heavy specialties such as anesthesia, radiology, orthopedic surgery, ophthalmology and invasive cardiology. You might also place any of the surgical specialties in this category. Finally, do you enjoy the outpatient treatment of patients? This might lead you to emergency medicine as EM spend most of their practice time dealing with outpatient issues with a bit of trauma thrown in. Dermatology is also a specialty that has far more outpatient care than inpatient care. Psychiatry can also go into that category.

Pathology tends to appeal to individuals who love to study tissues and medical problems. Pathologists do not treat inpatients and pathologists perform few procedures other than those pathologists who subspecialize in tissue banking and transfusion medicine. If study and evaluation of tissues and medical problems are appealing to you, look into pathology.

Another way NOT to choose a speciality is by what your classmates have to say about a particular specialty. Don’t be drawn into the “the smartest people in medical school go into derm so derm is the best specialty”. This might not be the case for you if you don’t enjoy the scope of practice of the dermatologist. While dermatology is a competitive specialty, you may not enjoy much about this speciality other than the look on your classmates faces when you announce that you want to pursue Derm.

The telly shows such as “House”, “ER” and “Scrubs” have also tended to glamorize certain specialties. Do keep in mind that telly watching is for entertainment purposes. There is little reality to any of these shows no matter how compelling the characters and patient situations. These shows are written by people who are generally not in medicine with input for practitioners. These shows are written with entertainment factor built into them. Most of actual medical practice is not entertaining.

As you study through medical school years one and two, you are creating the foundation upon which you will enter your third year. It is during that third year that you will be exposed to different specialties and their patients. It’s good to keep an open mind during third year. Do not feel pressured to decide upon anything if you don’t have an idea of what type of specialty might be of interest.

I can tell you from experience, that I generally liked every rotation that I encountered during third year. Basically, I enjoy the practice of medicine and patient interaction. I saw plenty of very interesting pathology and patients on OB-Gyn but I didn’t particularly find this specialty appealing other than how I could learn to differentiate pelvic problems from abdominal problems in the course of seeing patients.

I loved my Psychiatry rotation and found the expertise of my preceptor far greater than any clinician that I have dealt with to date. I developed a very strong appreciation and high degree of respect for that multitude of psychiatrists out there that just do a good job taking care of their patients. While psychiatry was not for me, it was an awesome rotation that brought a depth of understanding as to how many medical and surgical problems might present with psychiatric symptoms.

As you go through first and second year, take the time to join one of two specialty exploration/interest groups at your medical school. By joining these groups, you ca expose yourself to residents and attendings that can assist with your exploration of their specialty. It is participation in these types of specialty interest groups that can allow you to keep your focus when you feel that you just can’t look at another histology slide or review another article for biochemistry.

Also keep in mind that certain specialties do require a high level of academic achievement in medical school. I have often spoken to medical students who have struggled with a course or two in medical school who feel like doors have closed for them because they won’t be competitive for a dermatology residency. My first inclination when I speak to theses folks is to find out if they actually understand the scope and practice of dermatology. If they do have this understanding, are there other less-competitive specialties that will satisfy many of their need? In the vast majority of cases, the answer is yes.

Finally, as a close to this little essay which is like a part one of this issue, if you know that you are not particularly competitive for a speciality that you feel you can’t live without, spend some quality time with the program director/department chairman of that specialty at your school. Try to figure out if you have some options that can increase your competitiveness for said specialty such as research. There might even be a possibility of finding a program or two in that specialty that might be in a less desirable location and therefor less competitive.

Don’t listen to anyone except yourself when it comes to your needs in terms of the practice of medicine. In the end, it doesn’t matter what you classmates say about the specialty that interests you. It’s how you feel about what you are interested in practicing and your suitability for said specialty. It’s also about your attentiveness to your academics/boards too.

If you had a slow first year, try to have a strong second year. If you had a weak second year, then try to have a very strong third year. In short, you can decide at any point, that you are going to upgrade your work ethic and performance.

As Match Day Approaches…

The residency interviews are over and you have submitted your Rank List to the NRMP. If you have been fortunate as I was, you have been guided along this process by more senior medical students and/or a good faculty advisor. In any event, at this point in the process, that is less than a week to the point where you find out if you have matched or not, you are nervous but excited; depressed but hopeful; and a couple of hundred other emotions that fit the situation of having your immediate future in the hands of a computer.

During your third year of medical school, as you moved through your clinical rotations, you should have been collecting your letters of recommendation from your clinical preceptors. At my medical school, these letters were sent to the Dean of Students for inclusion in your file and made available for you to designate when you filled out your ERAS application. (ERAS is Electronic Residency Application Service). It was up to you to ask for the letters and up to you to make sure that the letters were in your file by the appropriate deadlines.

I had the added advantage of making sure that my personal statement, CV and letters were done very early. I had to apply for one of my away-rotations which had an early deadline. This rotation application needed the exact same content as my residency application so I was done long before I needed to be done. My application for this away rotation netted me a full-scholarship to cover travel costs and housing costs at my rotation location. During third year, investigate some possible away rotations that have scholarships attached. This does cut down on expenses during travel season.

As Match Day approaches, there is a tendancy to listen to all kinds of rumors that abound. Some people will try to say that you need 15 interviews in order to insure a match. If you are a marginal applicant to a competitive speciality, you might need 50 and still not match. If you are limited by geography and have a solid relationship established with a program, you actually only need one interview especially if you are a strong candidate for that program.

If you do not match, the Monday before Match Day, you will receive an e-mail that lets you know that you did not match. If you find that you are the recipient of this e-mail, you should contact your Dean’s office immediately and find out what services are going to be availble for you during the Scramble.

The Scramble allows unmatched applicants to apply to any unfilled positions in any programs across the United States. In order to receive the list, you have to be unmatched, and in order to make sure that you application is ready to be faxed or e-mailed to programs with openings, you need to have all of your materials. You can print out a copy of your ERAS CV but you will need copies of your Dean’s Letter and LORs which you should be able to get at your Dean’s office. In addition, you need to have copies of your USMLE score reports and you need a copy of your personal statement.

A great advantage of being in your Deans office is that there are usually plenty of phone lines and fax machines available for you. If a program has an opening, they usually notify Dean’s offices and your Dean can speak directly to a program director on your behalf. In any event, scramble from your Dean’s office if at all possible. You can also find plenty of great classmates to help you man the fax machine and speak to program directors for you. (I helped a couple of classmates scramble and thus I learned loads about the process). Another advantage of being in the Deans office is that the Dean gets the unfilled list 30 minutes before it is available to the unmatched candidates. This gives you a 30-minute head start on getting your materials loaded in the fax machine and ready to go at nooon.

If you matched, you have to wait another three days to find out where you have matched. This can be more unnerving than finding finding out that you didn’t match. On Match Day, many people have so much emotion pent up that they end up crying or depressed. I can tell you that as soon as you find out where you are going, you need to start looking for a place to live unless you have interviewed at places in the same location as your medical school and know that you don’t have to move.

My medical school held a Long White Coat Ceremony on Match Day. On that day, we all received letters that told us where we would be going. At noon, we could open those letters and thus, we waited until everyone had letter in hand. We also received a Long White Coat with our names and the specialty that we had matched into. For some folks, they didn’t know the specialty so they ended up with a nice long white coat that had their name and M.D. In any event, it was a great ceremony. We all open champagne and celebrated for the rest of the day. The first and second year students got the afternoon off so that they could participate in out fun too. I must say, that every year, I always enjoyed Match Day but I enjoyed it more when I was the “Matchee”.

Match Day is a time of high emotions and expectations. It’s far more charged than graduation day. On graduation day, everyone is just happy to have the whole situation over and done with. On Match Day, the anticipation is very high and we really do not know what to expect. The whole Match algorithm makes little sense and it is difficult to know why you ended up in the position that you ended up in. It’s great to get your top choice but ask anyone who has scrambled and they will tell you that it is good to get any match at all. If you planned on going into a competitive specialty and found that you did not match, it can be pretty unsettling to end up in a preliminary position in a town or city that you did not plan to move to with the prospect of going back into the Match next year.

I have to say that going into the Match for fellowship is much better than residency. If I don’t match into a fellowship, then I know for sure that I at least will be able to practice my specialty. It’s a small victory but it’s a victory.