From Destiny to Specialty
Recently, I wrote a blog post for Medscape on weighing the various benefits and drawbacks of certain job opportunities in my field of neurology. In the spirit of Star Wars, I now offer a “prequel” essay intended to help medical students choose a specialty in the first place. For me, deciding to go to medical school was easy. I was one of those kids who always wanted to be a doctor. But choosing a specialty? It wasn’t until the middle of my internal medicine residency that neurology captivated my attention.
Like me, you probably picked medicine as a career because you knew it was your destiny. At least one of the following descriptors applied: You liked the idea of helping people, learning about human beings, or gaining some understanding of life’s mysteries. Of course, you wanted a career where you could enjoy your work and pay the bills, but law school was a distant second. A small voice inside you insisted that mastering organic chemistry was worth the trouble. No sooner were you accepted to medical school than someone asked which specialty you would choose. It’s kind of like asking newlyweds how many children they want the day after the wedding.
Some might quickly respond, “Two: a boy and a girl.” But most newly married couples have yet to finalize their family planning. Medical school is a challenge, and you’ve just begun. You are probably more focused on learning anatomy, histology, pharmacology, and physiology, as well as moving into a new apartment, than selecting your specialty.
Too Many Doors
A medical education opens the door to countless fascinating careers. Every area of medicine is available to you, from pediatrics to geriatrics, orthopedics to plastic surgery. Within these disciplines, your role could be clinician, researcher, teacher, or some combination thereof. But stepping through one door means shutting all the others. Although the first 2 years of medical school include more clinical work than they did in my day, you may still need more exposure to the various specialties and subspecialties before you find your niche. Don’t be intimidated by classmates already jockeying for competitive residency positions. Remember, you will become a physician (few medical students drop out; admissions committees select for success). One of my classmates knew she wanted to be a dermatologist before school even started. When she was a young girl, a large birthmark on her leg required frequent visits to a dermatology clinic. Her successful treatment inspired her to help patients with similar problems.
However, barring such an exceptional personal experience, most medical students don’t know which direction to take on the first day. If you ask your mentors to guide you, be prepared for lots of bad advice. Most physicians are convinced that their specialty is the best, and it validates their choice to tell you so. No doubt Tom Brady would encourage you to become a football player, whereas Steph Curry would push you towards a hoop. But you are different from them, so take any advice (including mine) with a grain of NaCl. Some residents tell me they chose a specialty because of the influence of a particularly engaging teacher. One loved her pediatrics rotation because the preceptor was so compassionate and enthusiastic. Although it is important to have good role models, they can exert undue influence. For example, when you are finally in practice as a pediatrician, it will be just you facing hordes of screaming children and demanding parents, day after day. Your exemplary role model will be nowhere in sight. Just saying…
Deciding Factors (aka, the Boring Stuff)
It’s what is in your heart that really matters. Nonetheless, pragmatic concerns, such as lifestyle, geographic location, and compensation count. I would be remiss to omit these.
One of my residents chose radiology because of its well-defined hours. He loved his after-work activities and wanted a manageable schedule. Cardiovascular surgery or interventional vascular neurology would not offer the same liberty. Before he even began his radiology residency, he had picked the city he wanted to live in and the radiology group he hoped to join. He and his wife were starting a family, and he planned to spend a lot of time with his children. Lifestyle was clearly the most important criterion in deciding his specialty.
Another consideration is whether you envision yourself practicing in a big city or out in the country. If you love the idea of living on a horse farm in Kentucky, don’t become a pediatric endocrinologist. Such a rarified subspecialist can only survive in a big city, and will most likely end up at an academic center. If you want the freedom to practice anywhere, then primary care, including family medicine, internal medicine, obstetrics/gynecology, pediatrics, and emergency medicine are practical choices.
There is also the matter of income. The current compensation system preferentially rewards volume and procedures. Working harder and longer (mostly longer) results in a higher income, but the absolute number of dollars varies a great deal between specialties. For example, a neurologist may earn less after struggling through a 1-hour dementia consultation than a dermatologist makes in 10 minutes armed with a liquid nitrogen canister. If you have a large student debt or a lifestyle that demands only the best, keep your compensation requirements in mind when selecting a specialty. Bear in mind, the compensation system may change by the time you start practice, so please consider what you really want to do as well.
Pay attention to this one. While in medical school, I loved my general surgery rotation so much that I did a 1-month subinternship. The surgical residents were passionate about their work; their only complaint was that the every-other-night call schedule deprived them of half the cases. Nothing delighted our surgery attending more than rushing to the hospital in the middle of the night for a ruptured aortic aneurysm or other life-threatening emergency (just ask his two ex-wives). Although I’m not a morning person, 6 AM rounds were a blast. One resident examined the sleeping patient’s incision, another checked the labs, while a third charted the note. My medical student contribution was to assess the presence or absence of flatulence in the past 24 hours. By 7 AM, we were in the operating room for the first case.
A chance to cut was a chance to cure. The energy of those days was intoxicating. What could be better? Well, it could have been better if I had more manual dexterity. Learning to tie those knots was arduous. I’m pretty good at building and fixing things, but I don’t have a “gift.” Not all of the surgical residents did either, and I felt bad for the ones that didn’t. Cases could be long and tedious, and the talented residents finished more quickly, with better results. Surgical decision-making was important too, but the craft required gifted hands. It seemed I had more of a talent for keen observation and thoughtful analysis—more the Sherlock Holmes type. Consequently, I chose neurology rather than manual labor. Definitely the right move. When in doubt, go with your gifts.
Some students love children and want to do pediatrics in order to help them. Some love children but can’t bear to see sick kids. Some students prefer things clean and neat and like to wear suits; they make great ophthalmologists. Others love to get their hands dirty; they thrive in the emergency department. Some students like to listen—a critical quality for psychiatrists. Others have little patience for people; the pathology lab works for them. Students with a lust for tangible results tend to select surgical specialties. Pay attention to your temperament. You were born that way and can’t change it. Take advantage of it.
Burnout affects more than 50% of physicians. You don’t want to be one of them. There are lots of reasons for burnout and some strategies to avoid it. Physicians who find meaning in their work are less likely to experience burnout. Burnout is less common in those who see medicine as a “calling.”
Conclusions Take a wide range of clinical rotations. Notice the ones you truly enjoy. As a physician, you have the potential to practice your chosen profession to a ripe old age. You may be able to afford to retire early, but with luck you won’t want to. Choose wisely. May the force be with you!