Choosing Your Specialty or Sub-Specialty

I just found out about your blog through Scrub Notes, where your topic “failure”was reposted. And I had more fun exploring the topics you’ve discussed especially about how you chose surgery. I am doing my post grad internship now and have (i think) ruled out surgery–but i keep on reading surgeon’s blogs! Would you have another topic about choosing your specialty?

I’ve had a lot of recent conversations with medical students and residents about how to choose a specialty (or subspecialty).  I have to admit, they have changed the way I think about this a little.   I’ve begun to realize that there are different forces at play, including some I used to discount.

The Philosophical View

Your work is to discover your work
And then with all your heart
To give yourself to it.

Buddha

In the ideal world, your speciality picks you.  (How to Choose Your Medical Specialty).  In a nutshell, I think if you are paying attention, you will be pulled towards the specialty that fits you best. If the pull towards a particular specialty is very strong, you really shouldn’t ignore it.  Some of the most miserable doctors I know picked their specialty based on income,“lifestyle” (more about that in a minute), or other “practical” issues…and then were miserable.

As I’ve thought about it more, and talked to more and more students and residents, it’s clear that the “pull” towards a specialty can be really strong… or not so strong.  So, how do you figure out what you should do if you don’t have a strong calling for a specific field of medicine?

Stellaris_Yin_Yang

I believe that most of us are either “surgical” or “medical” in the way we view our professional world.  It’s like the Yin-Yang symbol – the two halves that make up the whole.  There is no judgment here – patient care needs both medicine and surgery.  It’s not an either-or proposition, either –  just like the Yin-Yang symbol, there is some “medicine” in every good surgeon, and some “surgery” in every good internist or pediatrician.  So, the first step in deciding on your future career is to decide where you fit on the medical-surgical spectrum.  At one extreme, the most “surgical” specialties are general surgery, vascular surgery, cardiac surgery, and trauma surgery.  At the other end of the scale, the most “medical” specialties are general pediatrics and internal medicine, as well as many of the subspecialties in pediatrics and medicine (e.g. nephrology, rheumatology, etc).  There are surgical specialties that have more of a “medical” component (e.g. ophthalmology, ob-gyn) and medical specialties that have a significant “surgical” component (e.g. gastroenterology, invasive cardiology, interventional radiology). As you are exposed to specialties, think about where you fit on the “medical-surgical spectrum” and how wide your “bandwith” is i.e. is it a larger number of specialties that fit your personality and talents, or is it really a relative limited number of specialties?   It’s important, too, to realize that you will be exposed to only a small percentage of the 145 specialities in medicine.  Take time to learn about the specialties you haven’t heard about – one of them might be a perfect fit.

The second step in thinking about your future career is to decide if you want to work with adults, children or both.  If you have a strong pull towards (or against) working with children, it will narrow the specialties you are considering.  If you don’t feel strongly one way or another, keep an open mind as you go through pediatrics and family medicine.

If, at the end of this process, you find you have eliminated a few specialties but still have a list of possibilities, that’s ok.  You will end up choosing one and – it will be the right one.  All field of medicine are important and all of them allow you to impact the lives of other people.  As I’ve gotten more experience helping people through this process, I realize that there are some people that choose the work and then make it their passion (instead of the other way around).

What if you make the wrong choice?

There is nothing that is set in stone.  Despite your best effort to make a good choice, you may find that it’s just not a good fit.  There are plenty of examples of people who started in one field and realized that they had made the wrong choice.  This isn’t a personal failure!  The only failure would be staying in a field you really don’t like.  Yes, starting over will add some years.  But if it’s really clear that you should be in a different field, make the choice and move on.

The Practical Issues

As I’ve talked to more and more trainees, I’ve realized that practical issues are important to consider when you are choosing your specialty.  Practical issues cannot and should not be the only thing you consider though.  Please don’t talk yourself out of something you really love because you are worried about your talent for the field, money or lifestyle.

Your talents.  “I really want to be a heart surgeon, but how can I know if I have the hands to do it?”  Physical skill, in my opinion, is a bell shaped curve.  There probably are 5% of people on the right side of the curve who are truly gifted when it comes to technical skills (and, yes, 100% of surgeons think they are in that 5%)  Likewise, there are 5% of people on the left side of the curve who simply won’t be able to do it. These people will self select out of a career that requires technical skill – they just aren’t comfortable with working with their hands (and never have been). Everyone else can absolutely learn the technical skills needed in their specialty.  Physical talents may be the most obvious talent we think about, but there are other talents that play a role as well.  How well can you sit still?  How easy is it for you to listen to other people’s stories and feel empathy for them?  Are you more comfortable knowing a smaller amount about a lot of things, or being a real master of a smaller area? It’s a good idea to consciously think about your talents and ask people close to you to help you with this task.

Money. The average amount of debt a medical student incurs is currently $160,000 Loans for medical education can only be deferred for 4-5 years, which means if you choose a career that requires 7 years of training, you will be paying back your loans on a resident’s salary.  The math is scary – and our system is flawed.  One of the best explanations of this problem is a post by Benjamin Brown, MD called The Deceptive Income of Physicians.  If you have a family to support, I understand that choosing something that requires more years of training is problematic.  If you are in this category, your issue is going to be how much to let financial considerations affect your decision… without letting them totally drive the decision.

Lifestyle.  I was talking to a colleague in pediatrics the other day who told me a great story about when she was an intern.  She had been taking calls from families and had a family call around 5pm about their baby.  After talking to them, she decided the baby probably had croup, but it was not dangerous.  The next morning, in morning report, the chief resident asked her how the baby was when she called back.  When he found out she hadn’t called, he responded “If a family calls you about croup at 5pm and you don’t call back at 9 or 10 to find out how the baby is doing you haven’t done your job.”  Medicine – no matter what your specialty – is not “easy”.  Every field has issues that will keep you up at night and working at times you wished you didn’t have to work.  There are some that are worse than others, but don’t confuse “lifestyle” (i.e. the ability to have a balanced life and be happy) with an idea that your specialty will be “easy”.  

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