Residency Subspecialty Shortlist - PGY2

One of the biggest appeals of internal medicine is that it is such a broad specialty. Even within adult medicine, you can choose to sub-specialize or remain a generalist. In Canada, internal medicine residents go through a second CaRMS process called the Medicine Subspecialty Match during PGY3. In Canada, there are 15 specialty fellowships to choose from.

Lately, I have been thinking a lot about what specialty I would like to do. To help with that decision, I have decided to make another shortlist of subspecialties I am considering. For those who are not familiar, I made similar shortlists during medical school - Year 1, Year 2 and Year 3 - which I found extremely helpful. Last year, I wrote a guide on how to choose a medical subspecialty. I found putting down my thoughts into words helped clarify what I liked and didn’t like about each specialty. It’s my hope that this shortlist will again help guide my career decisions. Since there are only 15 specialties, I will list them all with my current thoughts about each one.

Top 5

1. Respirology
   I really enjoyed my PGY1 respirology rotation and it was a subject I liked a lot during med school. It appeals to my undergrad physics background with its pressure and volume equations. I also find there’s a good balance of diagnosis and medical treatment. I have always had an interest in airway management even when I was on my anesthesia and thoracic surgery rotations. In resp, there’s a good combination of inpatient and outpatient servuce, young and old patients, and a mix of procedures such as bronchoscopy and thoracocentesis. I would say I’m 70% set on applying to this specialty and have arranged a few more respirology rotations for this year to re-affirm my choice.
2. Critical Care
   I was first exposed to critical care as a third year medical student and at the time I loved it. It was a key factor that made me apply to internal medicine. Caring for critical care patients was applying physiology concepts in real-time. I loved the comprehensive systems approach to patient care and the  team environment was amazing. ICU nurses are amongst the best to work with! The patients were complex and each required deep thinking to manage properly. There were lots of procedures to do and I found discussing goals of care with family members meaningful. However after doing ICU as a resident, it has come downon my rank list. I found that there were things I missed doing  - talking to patients, evidence-based physical exams, long term follow up. I’ll probably still apply to critical care for CaRMS but I will see what my subsequent ICU rotations are like.
3. Infectious Diseases (ID)
   What I like about ID is you get to see some really cool presentations of diseases. When you’re on consult service, you see patients on every service in the hospital. In the outpatient setting, you get to see a great breadth of cases from HIV patients to fevers in returning travelers. I worked several summers in a microbiology lab, so infectious diseases has always been something that interested me. However, what I don’t like so far is the I am smarter than you attitude of “why would you prescribe that antibiotic for that bug!” that gets perpetuated. Overall, ID is a really fascinating specialty that requires a broad base of general and specialist knowledge.
4. Gastroenterology
   I have put GI high on my list without having done a rotation in yet. I’m not sure if it will remain high on my list. What I do like about GI is there’s a variety of organ systems within GI itself. From esophagus to colorectal, there are a plethora of areas to focus on. However, when I’m on team medicine it seems the only reason I call the gastroenterologists are for bleeds and scopes. Maybe my thoughts will change once I finish my GI rotation. Of note, I think hepatology is a really neat subspecialty that is coming out with a lot of big breakthroughs will change things up.
5. General Medicine
   I enjoyed doing team medicine a lot as a PGY1 resident. You get to be the primary care team for patients, you get to coordinate their care with subspecialists, you take responsibility and I liked that. You also see a large variety of patients, whatever walks through the emergency room was fair game. This year I’ll be the senior resident on team medicine and I will have a different perspective on running a GIM team. One pitfall I do see with GIM is that in the foreseeable future GIM will equate to hospitalist medicine. Finding referrals for an outpatient practice may be challenging. Furthermore, I do think I would prefer to be an expert in one area than a generalist.

Middle 5

1. Cardiology
   I think cardiology is really cool. From managing STEMIs, arrhythmias, coding patients to outpatient secondary prevention, I think every internist needs to know cardiology well. And although I like the day-to-day activities of a cardiologist - taking good histories, listening to heart murmurs, interpreting ECGs and echos and implementing solid evidence based treatments - I don’t think I will be pursuing it too seriously. After three months of cardiology as a medical student and resident, I don’t think I love cardiology enough. Becoming a cardiologist requires an extra long training and an adjustment in lifestyle compared to other specialties. Regardless, I’m still excited for my CCU rotation this year because I feel as if you can never have enough cardiology knowledge.
2. Geriatrics
   I genuinely like looking after elderly patients, it’s one of the big reasons I went into internal medicine. What I like about geriatrics is its holistic care. It’s medicine practiced the right way. Instead of looking after just medical disease, you look after psychological health, emotional well being and social supports. It’s a combination of internal medicine, family medicine and psychiatry. The downside is geriatrics can be draining for the same reasons that it can be rewarding. The lack of acuity is also something that I don’t find that appealing. And I feel like I will see geriatrics patients in any specialty I choose, so I don’t feel like I would be missing too much if I didn’t choose it.
3. Hematology
   This was a hidden gem for me and I didn’t expect to like hematology as much as I did when I rotated through it. The patient population is diverse and the diseases are quite interesting. From simple anemia workups to treating heme-malignancies, I found hematology a cool specialty. It’s also one of the few specialties that can practice bench to bedside care. Diagnoses made under the microscope can translate to clinical decision making and it was something I never really appreciated.
4. Nephrology
   Kidney doctors are true internists. They are detail oriented, comprehensive and care for some of the sickest patients. I learned a lot of key concepts during my nephrology rotation that I will use throughout my career. Unfortunately, I wasn’t too fond of dialysis and chronic kidney disease and unfortunately that is the bulk of a nephrologist’s work.
5. Rheumatology
   I don’t really know much about rheumatology other than (1) it’s an area of knowledge I need to work on and (2) it’s got a good lifestyle. I’m looking forward to my rheum rotation. I think I’ll learn a lot but I don’t expect it to move too much on my list.

Bottom 5

1. Endocrinology
   Sugars, sugars, sugars, hormones and more sugar. Endocrinology is synonymous with diabetes management. Occasionally there are other hormones affected. I’m ok with treating diabetic patients but I don’t think I could spend so much time on just one disease.
2. Medical Oncology
   Cancer treatment is one of the fastest evolving fields right. New treatments continue to come out and outcomes are getting better and better. Despite that, I still feel awful every time I break bad news about cancer. It’s heartbreaking. I think I would be really sad if everyone I looked after had cancer. Overall, I think it’s a really promising specialty with a good balance of new therapies, comfortable lifestyle and deep relationships with patients, but it’s not the specialty for me.
3. Immunology and Allergy
   Unclear about this one… I don’t know much about it… but I can’t see why I would choose it.
4. Clinical Pharmacology
   I was never really that interested in pharmacology. This might be a neat specialty to do an elective rotation in but I can’t imagine doing it as a career.
5. Occupational Medicine
   I often wonder why this specialty is under internal medicine. I question whether someone had to rotate through the cardiac care unit, intensive care unit and every other subspecialty to end up doing occupational health. I understand workplace ergonomics and hygiene are important but I wonder what it has to do with internal medicine. I feel as if public health or physiatry would be better entry programs.

Wrap Up

I’ll try to make a shortlist next year around this time just before I apply. I found writing this shortlist was useful not only for identifying specialties to consider but it helped me understand what I liked about each specialty. I hope it will give me some guidance during my subsequent rotations this year.

If you are having trouble deciding on what specialty you would like to do, I encourage you to make your own shortlist and write down your thoughts about each specialty.

(Photo credit -  Flickr Caese)

Related posts:

The Shortlist - Year One The Shortlist - Year Three The Shortlist - Year Two Deciding on a CaRMS Residency Rank List