"When you're choosing a specialty, you're deciding an old man's life with a young man's mind. Think about what you want for the future, not what's cool today. - unknown orthopedic surgery attending
Recently, I found a post in evernote titled “What I want to be when I grow up” written 11/11/2013. I’ve mentioned before that I wanted to to go to Emory and become a dermatologist since freshman year of undergrad, but there were other options that almost swayed me from both of those decisions (how I chose a medical school coming at a later date).
Choosing a specialty is a huge decision. Unlike most other professional fields, changing medical fields as a physician is a huge ordeal that requires additional years of scut level training. It’s not impossible, but like most things - it’s easier just to get it right the first time.
In this article, I’ll discuss factors to consider when choosing a specialty and then I’ll show you the contents of my “What I want to be when I grow up” note and encourage you to make your own. This article is based on the American system, but I hope that it will be useful for everyone. PS: I'm really enjoying learning about how the medical school process works in different countries. Thanks for your emails on the Australian and UK systems Florah and Louise!
Factors to consider:
[ 1 ] Intellectual curiosity
When you choose to practice medicine, you make a commitment to life-longer learning; this is your duty to your patients. For this reason, it’s essential to go into a field you find interesting! Cardiology has many of the functional features I loved about dermatology (see below), but I could not make myself excited about lipid profiles or statins. With that point, every specialty has one or two really cool procedures, but you should ideally find the most mundane things the specialty does interesting because that will be your “bread and butter.” Chest pain is not interesting to me, but I can talk to you about acne all day, everyday. On my medicine rotations, I was always blown away by the medical students who knew all the recent NEJM studies. When were they reading this stuff? They were reading it on Friday nights when I was reading about acne. That’s why we’ll both be more successful in our chosen fields than if we tried to do something else. Be true to your own mind. Don’t let what other people think is important determine your life. Most people find the topic of dermatology to be the absolute worst. To me, that’s just job security.
What topics do you find yourself reading about out of pure curiosity? In my opinion, this is the most important factor of them all.
[ 2 ] Skill set
Be honest with yourself. What are you good at?
If you're not a "people person," maybe you shouldn't go into a predominately clinic setting. With that said, just because you hate one clinic setting does not mean you do not like clinic at all. Clinic is a completely different experience depending on the patient population, your attending, your role, and the topic. I didn't care for primary care clinic, ophthalmology clinic, or breast clinic but ENT, derm, melanoma, and gynecology clinic were my favorite rotations of medical school.
If you're clumsy with your hands, maybe you shouldn't go into a surgical or procedural specialty. If you're a third or fourth year, realize that your skill set will increase with residency, but if you're significantly less coordinated that a normal human being, do some soul searching on this; residency and the match might be very difficult for you. If you're a first year and you're interested in a surgical or procedural specialty (this includes dermatology, anesthesiology, and emergency medicine) I suggests you pick up a hobby that requires good hand-eye coordination - such as video gaming, knitting, or cooking.
I was explicitly asked "are you good with your hands?" during interview season.
[ 3 ] Lifestyle
It pains me a little to write this section because I genuinely think dermatology is so freaking cool, and I can’t imagine myself doing anything else. It was really frustrating having to compete with people who were doing dermatology solely because of desired lifestyle and their aptitude for standardized tests, but it is not my place to judge, especially since I have come to realize lifestyle is also important to me.
For whatever reason, the idea of lifestyle gets a bad rap in medicine - as you can tell by the previous sentence, I've been brainwashed myself. There’s the idea that if you’re a doctor, that is your primary identify and the most important thing in your life. Don't drink this tea.
Don’t let anyone make you feel bad for wanting a life outside of medicine. At the same time, don’t let anyone make you feel bad for not caring about a life outside of medicine. We all want different things and that’s okay.
What’s important is that you’re honest with yourself. As a dermatology resident, I will have more time outside of the hospital than my surgery counterparts. I will be able to attend more weddings, more funerals, more trips to the dog park, etc. However, I will never acutely save anyone's life and I will never guide another infant into this world. This summer, the UAB orthopedic, trauma, and vascular surgery teams saved my seventeen year old cousins life when he was at the brink of exsanguination. Now, he's going on college interviews. I am so grateful to all of my friends who are becoming surgeons.
As more women become physicians and more men fight for the privilege to be present in their family's lives, every field becomes more lifestyle friendly. Obstetrics, for example, used to be notoriously awful for both attending and resident, but now it's common for attendings to share call and obstetric responsibility with their group members. The same is true of internal medicine now that hospital and ambulatory responsibilities are mostly split. The residency training for both of these careers are still incredibly tough though.
Also keep in mind that academics is a skewed view of what most of medicine actually looks like. If you have the time, reach out to someone in private practice to get a good view of all of your options. Although, I will say, the doctors at my private hospital appear to work way more clinical hours than my attendings in academics.
Final note - one of my colleagues was advised that "If you can see yourself being equally happy in two fields, chose the one with the better lifestyle."
[ 4 ] Length of training
A popular piece of advice people give is to “look at the attending’s lifestyle - not the resident’s - because that will be your life.” I agree and disagree with this depending on how long your residency training will be and at what point you’re at in your life. Residency occurs during most people’s late 20s/early 30s - this is a very important time of life where most people are starting families, making lifelong investments, etc. If those things are important to you, you should think long and hard about a 7+ year residency.
image source: scutmonkey comics
[ 5 ] Expected salary
This is another thing that medicine demonizes, but don't lose sight of the fact that you are choosing your career. If you expect to live a certain lifestyle, you should be able to afford it. If you have a significant amount of loans, you will need to earn more money than a classmate who doesn’t have any loans to maintain the same lifestyle. Most of my friends who went into pediatrics don’t care about money. That’s important because they won’t make a lot of it (relatively speaking), but they won’t be resentful to their career or their patients because they knew what they were getting themselves into.
The other side of the coin is medical reimbursements are volatile and will most definitely change during our lifetime. A primary care attending once told me that when he was a resident, the smartest people went into primary care because specialties didn’t make any money at that time. bahahaha. Oh how things have changed. So, keep expected salary in mind, but this should be a small consideration. Also, keep in mind that salaries can be very variable depending on your patient population and your "niche." Skin cancer and cosmetics are two of the highest paying areas of dermatology, but I'm not particularly interested in either. I want to work with inpatient dermatology, skin or color, and patients with systemic rashes.
[ 6 ] Colleagues/Environment
This one is somewhat tricky. Usually certain personality types are attracted to certain specialties, but programs tend to have clusters of certain personalities. So, just because everyone in your dermatology program is mean (are there mean dermatologists?) does not mean that is true everywhere. I wouldn’t let this factor too much into your decision. It’s very unlikely that you can't find a group of people that you like who practice your same specialty; you just might have to do some searching. “Eventually soul mates meet, for they have the same hiding place” applies to more than romantic lovers. Away rotations are a good way to get a better glimpse into this.
image source: scutmonkey comics
[ 7 ] Competitiveness
I hate that this is a factor, but it very much is. Have an honest conversation with someone about your chances of matching into your desired specialty. We’ve reached a point where every specialty is continually becoming more and more competitive. There are a few options when applying to a competitive specialty - 1) apply to that specialty with a backup plan if you don’t match 2) apply to that specialty and a less competitive specialty at the same time 3) take time off before applying to boost up your application and then do option 1 or 2. If you have your heart set on something that you're maybe not competitive enough to do, realize that there are probably less competitive alternatives. All hope is not loss. For example, instead of orthopedic surgery, you could do an internal medicine or family medicine residency then do a sports medicine fellowship. Charting Outcomes in the Match is a great resource that makes everyone wet their pants. It's published every two years. I've linked to the most recent 2014 data.
Keep in mind that grades are not the only way to be competitive. There are multiple components of your application including clerkship grades, step I & II scores, AOA status, research experience, and letters of recommendation. Each of these items hold different weight in different specialties. Letters of recommendation matter a lot in small fields because all of the applicants are so spectacular. It just makes sense to take someone that your respected coworker vouched for.
My clerkship grades were above average, but not perfect, and in the words of my mentor, my step I score was "fine, but won't blow anyone away" (my step II score was in the blow away range). I think the strongest aspect of my application lied in the fact that Emory is a highly regarded dermatology program and the chair and vice chair of the department put onto paper how highly they regarded me. Don't get me wrong, I worked my butt off for a dermatology spot. I have JAAD publications from the first year of medical school to just this month. I worked with everyone in the department either in clinic or on research. The faculty in the department watched me grow up from a little first year that didn't know anything to a confident and competent fourth year. That consistent and productive interest and energy, in my opinion, was my most competitive feature. (Disclaimer: I don't actually know why programs ranked me.)
Related articles: Find your competitive advantage with our personal SWOT analysis and the 5 people to have in your inner circle for success
One question I got on instagram while making this post is the question of exposure:
How do you decide on a field that you've had very little exposure to?
You don't! This is why it's so important to take advantage of your time as an M1 and M2 to shadow different physicians. Dermatology, ophthalmology, ENT, orthopedics, radiation oncology, urology, and emergency medicine are fields that people are notorious for changing into at the last minute (read TeawithMD's story here), or switching to during residency, or completing a second residency for, or just missing out on all together. Take the time before rotations start to read about different specialties and then get exposure to fields that peak your interest. Ask residents in fields you are interested in what else they considered (I'm working on a list for the blog too). Of course, the shadowing experience you get as an M1/M2 won't be enough to decide on a specialty, but it will be enough to peak your interest in doing an elective early on.
If you're a third year and already into rotations, try hard to make time to get exposure to these fields. Definitely talk to residents about their experiences so far, why they chose that specialty, and what they're planning to do after residency. Always talk to residents. You can also use our career profile series as a resource. I ask all of the residents how they made their specialty decision.
The AAMC careers in medicine is also a useful resource.
Okay, with all that said - here are the contents of that evernote document i mentioned earlier:
I encourage you to make three lists:
- Things that are important to you (your values)
- Topics that interest you (what do you want to know more about). These topics don't have to be obviously related to medicine. This will allow you to imagine different career paths in different specialties
- The specialties you're deciding between with a quick word vomit about how you feel about each specialty.
Related articles: I wrote this post before Yentil wrote "From dreams to objectives: Identifying your vision, mission and values," but it's amazing how similar the approaches are!
When I made this list I'd completed all of the rotations except for cardiology, dermatology, and allergy.
Things that are important to me (in no particular order):
- strong doctor-patient relationship; long-term relationships
- feeling like I have accomplished something at the end of the day
- I have to use my hands
- variety in day to day work
- lifestyle / salary
- i want to make people feel beautiful. i want to help people fall madly in love with themselves.
Topics that interest me (in no particular order):
- the philosophy of beauty - what does it mean to be beautiful? how the perception of beauty changes over time, between cultures, and between individuals within the same culture
- immunology - autoimmunity, gut microbiome
- nutrition - how what we eat affects us physiologically
- women's health
good mix of quick procedures/chronic medical conditions, happy, friendly patients, RASHES ARE AWESOME, large quality of life impact, I get to use my hands and my mind; very competitive.. (because it’s awesome)
- women’s gynecology clinic has good balance between procedures/routine follow-up, happy, healthy patients, I would love to support women through specific issues, but hate the political air that surrounds the field, also, i hate obstetrics, surgeries are fun and quick
- Is there a greater betrayal than to be betrayed by one’s mind??? It would be an honor to help people through difficult times. I find the concept of how we perceive ourselves vs how society perceives us very interesting. Really interested in the budding research into how autoimmunity and inflammation affects (causes?) psychiatric conditions. Such a good feeling to discharge a patient that came in psychotic or depressed at the VA, but horrible feeling working at mental health hospital for lower socioeconomic patients; they have no social support, that makes me very sad and frustrated, I had a couple of patients threaten me or become infatuated with me during my rotation. I don’t think I would like that for the rest of my life.. plus, psychiatrist aren’t the best at interpersonal relationships themselves. also, i need to use my hands.
- I could really see myself as an eating disorder specialist or a physician who specializes in medical care of psychiatric patients. hmm...
- umm dr. love the cardiologist that fixes broken hearts??? SOLD! I like the idea of a clinic based practice and I could read echos 1-2 half days a week for a break from clinic. Oh you have chest pain after you walked a mile for the first time in 8 years? okay.. here’s a statin. I'm absolutely not interested in gunning for another 3 years to get a cardiology spot.
Allergy and immunology
- atopic kids are my favorite patients! This is a niche I am most definitely comfortable with. After all, all of my research is in chronic pruritus, most of which has an allergy component. I would have to do a medicine residency though because peds is out of the question.. Also, i like the allergic component of different diseases, but I also like non-allergy related aspects of dermatology - acne, hyper pigmentation, hair loss, etc. However, derm doesn’t deal with asthma and food allergies which I also find interesting. I’m particularly interested in the new budding idea of “sensitivities” vs complete allergies. I wonder if I could do an allergy fellowship after dermatology?
Without going into my personal statement, I chose dermatology because of the fact that I find the pathology really interesting and the day to day practical aspects enjoyable. My small group, to this day, insists that I should be an ob/gyn. haha.
Okay, that was a lot. I hope it was helpful. Leave your questions below in the comments section and I'll get to them ASAP! Sign up below to receive updates whenever a new post is published!