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What Do You Wish You'd Thought About When Selecting Your Specialty?


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I know we don't have many residents and attendings on here, but I'd be appreciative if those who do visit could respond.

 

What factors did you prioritize when selecting your specialty? Looking back, do you feel you should have placed more importance on some things rather than others? Were there things you didn't consider at all before you decided on one field but wish you had?

 

Just trying to get a feel for what I really need to be focusing on and researching when it comes to deciding on my eventual specialty.

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I prioritized the type of work (i.e. what is the worst thing about the specialty and would it bother me in the long term; what do I find most meaningful and would not be satisfied without). So far so good. Best of luck with your decision; given how reflective your posts are, I doubt you will overlook any factors of true importance to you.

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1) They keep a lot of things hidden from you as a med student which can make figuring it all out damn near impossible. As a student you don't see a lot of the politics or how things actually operate day to day. Most people try to present their specialties in a positive light, either because they want to attract good people to change it, or they are trying to convince themselves they made the right choice. It is rare that you get told the "real story". On a peds NICU elective I did, I had a great preceptor who told me straight not to get into this specialty. It is changing to mostly NPs and it is very hard dealing with parents and dying kids for an entire career. There is lots of controversy in the specialty around who should be resuscitated and there is a lot of factions and infighting between staff. Might be at just that location but he said it is pretty pervasive. 

 

2) Actual commitment. Prior to residency my way of thinking was that 5 years was only a small part of my life and that the hard work would be worth the pay off. I didn't really care how hard the residency was and given how hard I have worked to get through undergrad and med, what was 5 more years? Living it is a totally different thing. 1 month in and I am already exhausted and looking for ways out (hopefully it passes). Surgical residencies aren't just slightly harder than others, they are monumentally more difficult. Just write off those 5 years in a very literal sense. Having kids and a partner makes this exceptionally difficult. Everything is a trade. Time with them, looking stupid on half day, studying for POS, studying for home service, spending time with kids, sleep. It is no wonder why people bail on surgical specialties and I admit I was naive to think I was above it and could just push through.

 

3) I didn't pick medicine specifically because I didn't want to CaRMS twice. I have lots of friends who went that way and have not got the subspecialties they wanted. Going through CaRMS once is crappy enough, you don't know if you are going to get program you want or in the place that you want, now go through that again. I really like critical care, but there is no guarantee I could get there as it is very competitive. The alternative could be doing general medicine which to me is almost as bad, if not worse, than family med (for me). Going into medicine you really have to be prepared to accept any of the subspecialties.

 

4) Jobs. There are entire threads on this page about if you should consider the job market when picking a specialty. The fact is things change rapidly in this country. It is a total crap shoot about where you could end up working and that is a reality our generation just has to accept. When it comes to jobs what i would warn is that if you want to be at a teaching hospital in a major city you are almost certainly going to need a) a masters B) PhD c) fellowship d) all 3. Add that on to a surgical residency and some of us just don't have enough time before the grave to get all that done. There is a major difference between academic and community medicine and in med school we only really get exposed to he academic side. 

 

5) Baggage and portability. Where you can work is a big deal for some people and your ability to move is highly dependent on specialty. Most surgical specialties take up roots after getting a job and maybe only move once over the course of their career if at all. Fam docs on the other hand seem to change practices like some people change underwear and can traverse the country multiple times in a career. I ran into an old family doc of mine just yesterday on the ward. She is now doing hospitalist and is on her 5th job in the 10 year time I have known her. the more specialized you are the fewer places you can work at. If you are CV surgeon there is like 10 cities in Canada you can find a job for eg. In such a small world politics is everything and if you don't like where you are there really isn't much room to move.

 

6) Patients. Surgeons see their patients for consult, surgery, and then maybe a couple times for follow up. Ob's will see a patient for 9 months. Fam docs and internists can be with the same people for life and emerge docs as little as 5 minutes (although there are a lot of frequent fliers). I guess it depends on how close you want to be with your patients and how much of a people person you are. Pathologists and radiologists rarely see their patients (when they are alive anyway). Just something to think about.

 

There is lots more but that is a start.

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Isn't a lack of autonomy something common to all hospital-based specialties? 

 

not like with pathology. most other hospital specialties still bill FFS and if they see patients can operate clinics. pathologys right to operate their own labs disappeared in the 80s and their billings struck from the fee schedule so what we have now is a deluge of salaried employee positions. and salaried employee = non-autonomous drone.

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not like with pathology. most other hospital specialties still bill FFS and if they see patients can operate clinics. pathologys right to operate their own labs disappeared in the 80s and their billings struck from the fee schedule so what we have now is a deluge of salaried employee positions. and salaried employee = non-autonomous drone.

How would you go about finding more about autonomy, lifestyle, etc for a speciality? Would it be appropriate to ask a doctor that you are observing these types of questions?

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How would you go about finding more about autonomy, lifestyle, etc for a speciality? Would it be appropriate to ask a doctor that you are observing these types of questions?

Depends on the personality of the doctor, some of them are more laid back and are willing to talk to students about these things. The best way is during those interest group talks and you can submit the question anonymously so you don't feel guilty about asking lifestyle questions.

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How would you go about finding more about autonomy, lifestyle, etc for a speciality? Would it be appropriate to ask a doctor that you are observing these types of questions?

 

Try talk to fellows or graduating residents, see what kind of job/offer they've seen, and that give you a pretty current look at the market. I find a lot of attending only has vague ideas about the job market, although program directors usually has a good idea how their past residents/fellows did (but then again keep in mind PD are biased in favour of their own program).

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It's not at all inappropriate to ask any doctor what a typical day is like for them. It's a very standard question for someone exploring specialties. As for autonomy, you can ask what is challenging about the career, do you feel you have the resources and support to provide quality care, are you able to implement changes, etc. This goes a bit deeper than most students shadowing would, but is likely to come across as insightful more than not. If there is anything that you are concerned about asking, you can say that someone else shared such a viewpoint with you, and you were wondering if it fit with the experience of the person you are observing.

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Dont mind me asking, what is a typical day for a pathologist? why is there little autonomy?

 

salaried. if you are salaried you technically have no autonomy. the control over the business - hiring, firing, what you pay your workers, how your work operates - is all controlled by the hospital.

if volumes increase you dont get paid more like every other physician does because youre salaried.

if someone quits and youre doing their work on top of your own you dont get paid more like every other physician does because youre salaried.

the hospital can cut corners to save money and will risk patient care to do so, if you stick your neck out you lose your job.

if one of your workers is incompetent you have no say in what happens to them.

the work "turn around time" is measured to whip pathologists into pushing through all the volume.

cancer care ontario forces pathologists to do data entry for them and if the pathologist doesnt comply, even for cases where doing a report is not warranted, he is publicly shamed on their website.

since hospitals want good employees theyre apt to hire pathologists with questionable qualifications because they know they will stay quiet. comply or be unemployed.

youre told when to come in and when to leave. they will monitor your parking pass entry and exit.

its like being a resident forever.

 

its an important specialty but its being treated like dirt.

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that sucks, I really hope there's some way you can switch out of it 

It seems like you believe autonomy is very important when choosing a specialty, if you are undecided between a hospital-based specialty vs a community clinic based specialty, it's better to choose the clinic one b/c it's more autonomous?

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I think another thing to think about when selecting your specialty is to think about what population you prefer to work with.

 

I enjoyed inpatient medicine and inpatient pediatrics pretty similarly. I applied to both and interviewed for both during CARMs. However, now as an internal medicine resident, I'm realizing how much I enjoyed working with young people and their families and I miss it sorely. I feel that I placed too much value on the salary discrepancy between internal and pediatrics and ranked the former higher and now regret it. All physicians make enough money. If the fields you are considering are similar in terms of the lifestyle and career prospects, then go with your gut and think about what patients you want to see every day.

 

For me, I wish I could trade in the AECOPDs for the cranky babies with bronchiolitis...

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Just wanted to thank everyone for their perspectives. People tend to give a lot of fluffy advice to med students ("do what you love! The rest will follow!") which doesn't necessarily line up to reality, particularly for a non-trad like myself, so it is helpful getting direct answers to this sort of question.

 

My primary interest leads me to a specialty that has a reputation for a terrible lifestyle and a horrible residency, whereas I'm also interested in family, and so I lean a lot towards family because of the lifestyle, but I also really, really enjoy working with a particular population and have found I actually enjoy procedural stuff more than I thought I would so I'm really hung up on deciding. This gives me a lot of food for thought.

 

Thank you all. I hope we'll hear even more from residents and staff.

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  • 3 weeks later...

I followed my gut in the spur of the moment away from a planned chill life as a small town family doc doing some ER into a surgical sub-speciality with an exhausting residency and terrible job prospects.  My wife was thrilled..

 

I regretted it at times during residency, especially when friends were done training and out in practice as FM docs.  But residency was also pretty great at times.  Job satisfaction is important, and for me, doing surgery was and is very satisfying.  Three years out of residency things have worked out better than I could have imagined, moving from a good first job in a location most people only dream of living, to an amazing second job in a busy academic center that is almost as nice. 

 

In retrospect I am so happy that I followed my gut. 

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  • 2 weeks later...

Birdy, from reading your blog you're stuck between OB and family, which is where I was at the end of my core clerkship.

 

Ultimately I decided on FM because I love the continuity and relationship I can build with my patients of all ages and situations. I also found I could not stand gyne OR...

 

To satisfy my love for OB I am planning to incorporate low risk obstetrics in my practice. Bonus, I get to see that baby grow up and maybe even deliver their babies in the future.

 

To satisfy my love for women's health I'm hoping to incorporate things like contraception, Paps, sexual health, IUD insertions. This is easy being a female GP. Who knows maybe in time create a women's clinic in my community where GPs who are less experienced in women's health can refer.

 

I also love procedures and there's opportunity to do some (albeit simple) in family medicine. Excisions, lac repairs, ingrown toenails, whatever skills you are comfortable doing in office. If you work in a smaller or rural community you could even do your own casting, or work in the ER for more of those procedures.

 

As someone already mentioned, one could make FM into whatever one wants, which is a huge plus for me. In time I can change my practice into sports med, or geriatric focused, or do hospitalist etc.

 

I'm halfway through FM residency and I love it, though it's a bit daunting to be staff in less than 12 months :)

 

Good luck!

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