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.

What do you want from a career in medicine?

I am often asked why I decided to pursue a career in medicine; starting at a later age and with many demands both mentally and physically. Quite simply, I knew that I would enjoy those mental and physical demands because I love working with my patients to identify and help solve their health problems. When a patient walks into your clinic, office or you encounter them in the hospital, the most amazing relationship develops that you will ever experience. A person walks into your life and puts their health and trust into your hands. This trust means that you give your best knowledge in terms of figuring out their needs and meeting them.Too many people will confuse what they see on the telly (House, Dr. Kildare, Gray’s Anatomy,Ben Casey, Scrubs, ER) with what is the actual reality of being a physician. There is little “glamor” in this job but there is loads of personal satisfaction in winning those hundreds of little “victories” that you will win over the course of a day. There is also the knowledge that if the health care system continues along the road that it has taken, you are going to make less money for every day that you work in the practice of medicine. The question that you need to ask is “am I willing to work this hard for this career?” If you can answer this in the affirmative no matter what the future holds, then likely you will have a satisfying career in medicine.

In no other career are you asked to be out of the work force for essentially 8 years just to be able to enter a job where you will be making less than minimum wage with an average educational debt of more than $150K. In no other career is your income totally dependent on the policies and regulations of private industry, government regulatory agencies, Congress and state governments. You have no control over what reimbursement will be for your services (those reimbursements have been cut every year in the name of holding down costs) while your costs of maintaining your practice have continued to increase dramatically. 

Primary care (Internal Medicine, Family Medicine, Pediatrics and OB-GYN) have seen their ranks shrink in popularity among graduates of American medical schools for a number of reasons not the least of which is the extremely high costs of medical education, rising interest rates on loans and decreased pay. Those people who are yet to enter medical school and those who are yet to graduate face even more challenges in terms of just being able to make a living (purchase a house, pay off educational loans, open a practice). If you are not yet in medicine/medical school, you are likely (unless you enter the armed forces) not going to be able to afford to enter primary care because of past educational expenses. Along with that, add the fact that if you are not a very strong performer in medical school, you won’t be eligible for residency in one of the “money” specialties and thus, you will be scrambling to make a living even if you are able to get into medical school.

The American Medical Association has been extremely slow to organize and speak for the needs of the young physician. Most of the people (and I am thankful for their efforts) that are able to lobby, have been established physicians in specialties such as opthalmology who can afford to take a day away from practice because their loans are paid off and their homes are purchased and their children have their college education paid for. They have little in common with the newly minted physician who has a young family, a 10-year-old car from residency and a $2,000 a month loan payment in addition to rent (mortgage if they are lucky)and office overhead expenses.  I remember my cousin, who is a neurosurgeon state back in the early 1990s that she had to make a minimum of $10,000 per week in order to keep her office door open.  I am sure that number has increased (increased malpractice costs and office costs) while her payments have been decreasing. In the face of this, why would anyone want to enter this career? How would anyone afford to enter this career?

The answer to these questions are not easy but they are expensive both in time and energy. The truth of the matter is that you had better know as much about the day-to-day practice of medicine before you enter your pre-med curriculum because by the time you have finished your first two years of medical school, you have racked up too much debt to be able to do anything else. Little is taught about practice management/investment/finance either in medical school or residency. Medical school  prepares you for residency and residency prepares you for practice.

Some people want residency programs to include more about practice management, marketing and finance but along came the 80-hour work week restrictions and thus, most residency programs are still scrambling to make sure that they can include all of the experiences that residents need to learn just to practice let alone add to what they need. The business of medicine is very complicated and growing more complicated daily with policy changes at both the federal and state level. It takes many hours to keep up and keep yourself informed.

This gets back to what do you want from a career in medicine? Financial/job security isn’t out there anymore. Definitely respect and admiration are not out there anymore. Hard work, long hours of study and personal and financial sacrifice are definitely out there and ahead. i caution anyone to look long and hard at this career because it’s not easy and there is no relief on the horizon.  Be very, very sure that you have a realistic idea of what day-to-day life is like for physicians who are coming out today and not what you see on the telly. None of those shows are remotely close.

Working on your application to…

I am in the “thick” of application to fellowship and I thought I would write a few notes on the process. The application process is quite similiar be it for medical school, residency, fellowship or whatever else. Though I am done with the actual applications and interviews, I will reflect on the process.

Once you have decided that you are going to apply for something, you need to take a look at the criteria that will be used for evaluation of your application. For medical school, this means your undergraduate grade point average, your score on all sections of the Medical College Admissions Test, your extra curricular activities, your letters of recommendation and your personal statement. For residency, the players change to your grades in medical school and your scores on USMLE/COMLEX exams (Steps 1 & 2) and for fellowship, your evaluations during residency and scores on in-training exams.

You need to look carefully at what you bring to the application process. You cannot change your grades so if you are an undergraduate and reading this, you need to get the highest grades that you can possibly achieve. Do whatever it takes and make thorough mastery of your undergraduate subject matter (along with your pre-med coursework) your major priority. Contrary to popular belief, great letters of recommendation or wonderful extracurricular activities will not erase a poor undergraduate performance (nor will obtaining a graduate degree). You have one shot with your coursework so make the most of every opportunity to show your excellence.

As I have written elsewhere, you need to thoroughly prepare for and take the Medical College Admissions Test. This test should be taken after complete knowledge and preparation using the same manner of questioning as on the actual exam. Do not believe that you can take this exam once for practice and then once for “real”. Nothing sounds an application “death-blow” like more than one mediocre MCAT attempts (or several attempts unreported). This is not an exam for “practice” but a measure of your suitablity for medical school. Whether you believe this test is valid or not, it’s a stepping stone that is quite important.

Once you reach your sophomore year, you should have a good idea of where you stand in terms of preparation for medical school. If you have taken the pre-medical courses in sequence, you should be done at this point. You should start writing your personal statement too. The reason for this is that when you request a letter of recommendation from your pre-med science professors, you should include a copy of both your CV (curriculum vitae) and personal statement. These two documents allow your letter writer to get an idea of you and your outside of class achievements. You should also include a deadline and waiver of inspection of the letter. For most undergraduates, these letters should be sent to your pre-medical advisory committee/office where they will be stored in your folder. (If you have not made contact with this office, you need to do so as soon as you know that you want to attend medical school).

During your junior year, you should be solidifying your knowledge in your undergraduate major and preparing for completing your AMCAS/ACOMAS application. This usually involves obtaining unofficial transcripts from every institution that you have taken courses at since secondary school without exception. Even if you took a typing course at a local community college, you need to request and obtain a transcript because that course needs to be listed on your application.

Choose your medical schools in early fall of your junior year and make sure that you have taken 0r are scheduled to take the required coursework to make application. Some schools require courses like genetics, biochemistry or calculus in addition to the traditional pre-med courses. A consult of the MSAR (Medical School Admissions Requirements) should keep you informed on these additional requirements.

In terms of a choice of what major is best for you, choose the undergraduate major that interests you most. It is a huge chore to attempt “engineering” because you “heard” that it was more impressive to members of a medical school admissions committee. Nothing is more unimpressive than a mediocre undergraduate performance in a major that doesn’t interest you. I often say to myself, if I had it to do over, and I knew that I would be going straight to medical school, I would have majored in American Studies, minored in Spanish and took my pre-med courses.

These thoughts are only fleeting because I attended college with the notion of preparing myself for a career in scientific research (not medicine). My undergraduate majors of Analytical Chemistry and Biology with minors in Physics and Math were my preparation for graduate school. I also loved and was quite passionate about those subjects. I enjoyed hours of working on problems in applied differential equations class and higher algebra/advanced calculus. If these courses are not for you, head into something that DOES excite you. After all, you are spending thousands in tuition dollars so you might as well get your money’s worth.

I also cannot emphasize the importance of exploring the nature of your fellow human beings. College is a great time to gain exposure to a diversity of ethnicities and ideas. Immerse yourself in another culture by spending a semester or two abroad or studying the art, language and music of another culture. These experiences are easy to find on the campuses of universities and are a great source of stress-relief. There are literally millions of ideas out there to explore and enjoy even if the experience makes you a bit uncomfortable. Your life will be richer for the experience.

Application for residency closely parallels application for medical school except the deadlines are more unforgiving. In the allopathic system, the ERAS (electronic residency application service) deadlines have to be exceeded or you miss out on interview opportunities. You have to be thinking about your choice of residency shortly after you complete first year.

The reason why I give the end of first year as a deadline, is that you can use your summer between your first and second year as a means of exploring some of the specialties. Do not choose a specialty because you believe it will be prestigous or pay loads of money. Dermatology is often sought after as a prestigous and highly paying specialty but I would be a miserable dermatologist. I enjoy my colleagues who pursued this specialty but it was not for me. (See my posts on why I chose surgery).

Don’t choose a specialty because you believe it will be in demand. Demand in terms of specialty comes in cycles and by the time you are applying for residency, the demand could be poor. I remember when I started medical school, the demand for anesthesiologists and anesthesia residency was pretty poor. Now, this specialty is fairly sought-after and in a couple of years, the field will be saturated. (Anesthesia is not a rapid turn-over specialty).

Choose a specialty because you love it and you can’t imagine doing anything else. Sounds just like the reasons that you choose to apply to and attend medical school.