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Choosing a Medical Specialty Round Two

Choosing a medical specialty (ervega)

Choosing a Medical Specialty in Internal Medicine

One good (and bad) thing about choosing a residency in internal medicine is that you have choices. Just like in medical school, I often get asked about what kind of a doctor I would like to be in the future. Preceptors want to know whether I would be a good fit for their specialty. Is my personality is that of a cardiologist gunner or a laidback rheumatologist. Am I a generalist or am I a super specialized specialist?

Internal Medicine Subspecialties

With 15 subspecialties within Internal Medicine in Canada, there’s almost as many choices for fellowships as there were for residency. In some ways it’s better because I have already narrowed my interests. I have decided I like treating adult patients. I have already decided that I like doing something medical and not surgical. I have a keen interest in most of these specialties, especially the systems centred ones like Cardio, Resp, GI, Nephro and ICU.

For those who are about to go through the upcoming residency match, picking a specialty can be a daunting task. I had several friends who did not know their specialty choice even during their interviews. A few even changed their minds hours before the deadline.

I’ve written briefly before about choosing a medical specialty. I’ll be using a similar strategy during residency to find a sub-specialty I will enjoy doing in the future.

Factors to Consider When Choosing a Specialty

In my opinion, the first step in choosing a medical specialty is to decide on the type of patient care you want to do. Do you want to be working on the front lines, being the most responsible physician for your patients or would you rather be behind the scenes helping the medical teams in specific roles. Supportive roles includes pathologists, microbiologists, radiologists. In internal med,

A key distinction to figure out early on is whether or not you want to do something surgical or medical. How much time would you want to spend doing procedures and operations? Even within internal med, there are some procedure heavy specialties like gastroenterology that differ greatly from something more diagnostic based like endocrinology.

The patient population you work is the next key thing you should think about. Do you want to care for mainly women like in OBSGYN, seniors in geriatrics, kids in pediatrics or a mix in family practice. Even with internal medicine, some specialties will tend to see older age groups like geriatrics and cardiology.

There are many variables within your patient population to think about too such as acuity. Do you want to care for acutely sick patients like those found in the ICU or would you rather prefer helping patients manage their chronic illnesses like in rheumatology. This will also dictate what type of setting (big hospitals, community hospitals, clinics) you can practice out of in the future.

Choosing a field you find intellectually stimulating is important in keeping you dedicated to your career. If you have always found the electrolyte balances of the kidneys fascinating, nephrology will be a good match. Luckily, I have found that almost all specialties have topics that are very interesting. It then becomes much more important to find a specialty that has bread and butter cases that interest you. If even the routine presentations excite you then that is a field you should strongly consider.

Things to Ignore When Deciding on a Specialty

Everyone will have a different opinion on what matters when choosing a specialty, but here are a few things I think should have less weight.

There’s always talk from recently graduated residents to think about Job Prospects. In my opinion, which might be naive, it’s hard to predict what the job market will be like five years from now when you graduate. For medical students, it’s even harder to project that far in the future. Furthermore, most medical graduates will find a job as long as they are open to opportunities. If you’re flexible with your career, finding a job shouldn’t be a worry. It’s a lot harder when you become fixated on just one location or niche. Looking around, I’ve never seen starving doctors.

Similarly, you shouldn’t be influenced too much by Peer Pressure.  Ultimately, you are responsible for the choices you make. Just because your friend thinks plastic surgery is an attractive specialty it doesn’t mean it’s the right one for you. There are some hidden gems that people end up really enjoying including PMR, pathology, palliative medicine and rural medicine.

Another thing that is less important than you would think is potential income. There’s such a large variation even amongst the same specialty. There are family doctors who make enough to get by and then there the ones who will bill seven figures. Making money in medicine is reflected more in how much you are willing to work than it is the specialty you choose to do.

Where Does Lifestyle Factor In?

A post about choosing a medical specialty would not be complete if I did not mention lifestyle. In general, the current generation of doctors pay more attention to work life balance and career lifestyle.  We are not as likely to work the same hours as our teachers and predecessors. Although there will always be some unchangeable culture such as surgeons rounding early, cardiologists being paged about heart attacks at night, obstetricians having unpredictable schedules,  more and more careers are oriented around lifestyle.

However, having talked to many different preceptors, I’ve realized that your career’s lifestyle is what you make of it. I’ve worked with general internists that work over 12 hours a day, 6 days a week. They even run clinics in between their call schedules. In contrast, I spend some time with another internist who spent 3 months in a year doing something he loved – golfing.

A physician specialty lifestyle is what you make of it. I’ve talked to trauma surgeons who only take call and have opted out of elective surgeries so they can spend more time at home with their kids. I met with a psychiatrist who makes a general surgeon look lazy with the amount of patients he sees. You get a lot of autonomy as a staff physician and it’s really up to you to design your job the way you want it.

Putting It All Together

Choosing a speciality is a big task but it doesn’t have to be a difficult one. A little planning and self reflection from time to time goes a long way.

For everyone who is deciding on a residency program, or a specialty choice like myself, I would encourage you to do some reflection at the end of each of your rotations. Write down what you liked about it and what you disliked. Get some perspective from your preceptor on what they think about their specialty.

Sometimes the best way to answer a question is to keep asking questions. Ask the most basic questions. I remember I was quite undifferentiated during medical school. But I kept asking questions that would help narrow down my choices.  I would break down choices into extremes. Would I rather see a 9 year old kid with diabetes or a 90 year old man with diabetes? Could I treat only women, only men, or do I like treating both? Ask enough and sometimes the answer becomes quite obvious.

Keep looking, keep asking questions, keep an open mind. Answers are revealed to those who seek them out.

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  1. Nice post. I would add the following comments:
    1) If you get along well with the attending physicians and residents that you work with, that is a good sign. These will one day be your peers and if your personality doesn’t mesh with those already practicing in that field, that should be a red flag.
    2) On a more vague and general note, ask yourself which days during your clinical exposure passed most quickly. Was it days holding a retractor in the OR, was it days triaging in the ED, was it time spent with your team on the medical wards? In the end, abstractions about what type of patients we wish to see and what type of interactions we imagine we might enjoy are inextricably influenced by our own prejudices (and the prejudices of peers). Sometimes, the visceral attraction that we feel to an aspect of medical practice is more powerful than our ability to reason through such a weighty decision. Make sure that your choice is sustainable in the long term, but go with your gut.

  2. MCAT
    MCAT July 24, 2012

    nice post. family doctors can bill 7 figures? don’t they have a cap?

    • medaholic
      medaholic July 24, 2012

      Yeah, those family docs are rare but there are some that exist. They tend to work like dogs though, but there’s no cap as long as they’re fee for service. To my understanding, they probably get audited frequently.

      • MCAT
        MCAT July 24, 2012

        Thanks for the reply. If there is no cap then what is the rationale for physicians not accepting new patients?

        • medaholic
          medaholic July 25, 2012

          Most people can only work up to a certain point. Once your clinic is full of patients, if you decide to take on more patients than you can handle, the quality of your care might decrease. Most people also want to work within reasonable amounts. You could see 100 patients a day, but you should expect to be working a lot more than the guy who sees 30 patients a day.

  3. Aliyo
    Aliyo July 24, 2012

    Your process of decision making is awesome because it makes so much sense. It’s so easy to get overwhelmed by having so many factors to influence one’s decision, but critically analyzing every factor in regards to how it fits it with your core values makes the process less stressful. Even though I am not going to be studying allopathic medicine, I find a lot of your posts to be so helpful because of your approaches. Thanks for posting, and good luck with your final decision, you will be happy with it 🙂

  4. […] the first step. I’ve written about my thought process in choosing a specialty before (Part 1, Part 2), it’s a topic I frequently talk about on this blog, and there are a lot of good resources […]

  5. smileengine
    smileengine January 4, 2014

    Thanks very much
    It’s such a great advice for those who are confused including me!

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