How to Use This Book
THE BOOK IS DIVIDED INTO FIVE MAIN SECTIONS. PART 1 HAS material discussing the challenges facing you as you choose a specialty and offers practical guidelines and worksheets to aid in decision making.
Part 2 gives comprehensive information on the specialties and subspecialties for which there is board certification approved by the American Board of Medical Specialties (ABMS). Each chapter gives factual information about the specialty and draws a composite picture of its practitioners. The composite is based on a questionnaire completed by physicians from a variety of geographic locations, types of practice settings, and professional backgrounds. An effort has been made to have representation from both male and female physicians in each field more or less in proportion to the actual numbers in that specialty, and to have contributors who are board certified in their specialty. There is a wide spectrum of ages, ranging from 29 to 75. The questions asked were suggested by medical students as pertinent in helping them to compare themselves with the practitioners of various specialties. To help you get the full benefit from this book, let's review the format of the chapters in Part 2.
At the beginning of each of the "specialties" chapters "Fast Facts" gives statistical information on residency/fellowship training and practice data as well as what program directors value highly in an applicant. The information for this and other sections of the book is compiled from the following major sources:
National Resident Matching Program 2011 Match Data
Results of the 2010 NRMP Program Director Survey, May 2010
Charting Outcomes in the Match, 4th edition. Prepared by the National Resident Matching Program and the Association of American Medical Colleges, August 2011.
The 2011 Medical Education issue of the Journal of the American Medical Association
2010 American Board of Medical Specialties Guide to Medical Specialties
Physician Characteristics and Distribution in the US 2011 Edition, American Medical Association
Information on what residency directors look for in applicants is from two major sources: Results from the 2010 Program Directors Survey, a National Resident Matching Program (NRMP) research report and a national survey of residency directors. 1
General Information. Each chapter begins with a general description of the specialty, which may include historical data, information about the scope of activity, and commonly held beliefs about the specialty.
Residency Information. This section gives information about residency program requirements and the numbers of positions available.
American Board of Medical Specialties Certification. Twenty-one primary and three conjoint examining and certifying boards issue certificates attesting to an individual's qualifications to practice a particular specialty. The primary objective of specialty boards is to assure the quality of medical education and care; the certificate issued is not to be confused with a medical degree, license, or legal document.
The first specialty board, for ophthalmology, was organized in 1916. The most recent, for medical genetics, was approved in 1993. Subspecialists in surgery have formed their own specialty boards, whereas medical subspecialists are awarded certificates by the American Board of Internal Medicine (ABIM). Each specialty has different requirements for residency training and admission to the examination for certification. These requirements are included here since this is now the norm for physicians and you should be aware of the requirements for ABMS certification to help you make informed long-range decisions. More and more, physicians are finding that in legal and financial terms the effort to achieve ABMS certification is worthwhile. If medical liability issues arise, a physician's position is strengthened by being certified. Also, managed care organizations have excluded physicians without ABMS credentials.2
Supply and Projections. Though you should not base your specialty choice decision solely on the basis of projections of physician supply, you should be familiar with this topic. The major sources of data for this section of the chapters are studies on the physician workforce in the United States. Some of the studies were undertaken by individual specialty societies and others were done by individual researchers and recruiting companies and offer data on more than one specialty. The major sources of information on the entire profession of medicine are the Council on Graduate Medical Education report in 2005, 3 and the research reported by Cooper et al. in 2002 and 2009. 4,5
Past and present supply and activity statistics are from the individual specialty boards, the American Medical Association's publication Physician Characteristics and Distribution in the United States 2011 edition, 6 and referenced articles from the medical literature.
Economic Status and Types of Practice. Three income studies and data from a published article are the major source of data in this section of each chapter—the Medical Group Management Association (MGMA) Physician Compensation and Production Survey, 2011 report based on 2010 data; The Medscape Physician Compensation Report 2011; and the Merritt, Hawkins & Associates 2011 review of Physician Recruitment Incentives 7,8,9,10 Keep in mind that economic reimbursement systems in medicine change, and that the high-paying tertiary care specialties may not always be so financially rewarding because of increased competition, the cyclical emphasis on ambulatory care settings, and the federal government's restructuring of Medicare fees through the Resource Based Relative Value Scale (RBRVS).
Information on types of practice was drawn from answers to the questionnaires, as well as from representatives of specialty societies. Here also, change is predicted as many see more physicians choosing to work part-time and a variety of practice settings and styles.
Further Information. The name, address, telephone number, and internet address of the major specialty society are cited, as well as helpful resources for medical students pertinent to the specialty.
A Composite Picture. The composite of each specialty was drawn from the answers to the questionnaires. "Respondent" refers to a physician who gave that specific answer to the question. By not attributing comments to specific individuals, some degree of anonymity has been preserved; this was my agreement with the contributors. The questionnaire used as a basis for these chapters is printed in the Appendix.
Why Choose This Specialty? The composite picture under this heading derives from answers to numbers 1, 2, 11, and 12 of the questionnaire: when the choice was made, what was attractive about the specialty, what other specialties had you considered and why were they not chosen, and what specialty was and is not attractive? It would be helpful to compare yourself carefully to the responses to this last question. It is often easier to identify the specialties you do not like than to determine one favorite, and, in this question, both sides of the issue are addressed. Look for specific similarities of interests between you and the respondents in each specialty.
What Do You Like Most About This Specialty? The responses will give a clue as to what you will find enjoyable about the work of this specialty. Evaluate the satisfactions you need from your work activity in relation to those described by the respondents. Is patient contact important? Do you feel energized in the operating room? Do you look forward to—or dread—the responsibility of being in charge? Do you like to be presented with new challenges or would you prefer having a fairly well-defined set of answers to problems presented?
One source of career satisfaction data is from a 2002 article 11 reporting data from the Community Tracking Survey of 12,474 physicians (response rate 65 percent) from the late 1990s. There are two satisfaction variables: very satisfied and dissatisfied. The mean for all specialties combined was 42.3 percent for "very satisfied" and 17.6 percent for "dissatisfied." The statistically significant results on specialties are the following:
Even though more than 70 percent of US physicians reported being satisfied or very satisfied with their medical careers, nearly 1 in 5 are dissatisfied. The highest percentage of "very satisfied" are over age 65 and, to a lesser degree, young physicians. No differences were found between men and women. Specific information on specialties reported is presented in the individual specialty chapters.
What Do You Like Least About This Specialty? Here the responses will give you clues as to what your frustrations will be if you choose this specialty. Some complaints, such as "paperwork" and "bureaucracy," are common to almost every specialty, but they seem to be more bothersome to those physicians who value personal independence highly. Other aspects, such as "no continuity of care" or "office routine," must also be evaluated in terms of your own temperament. Respondents generally stated that they found negative aspects of their specialty to be minor inconveniences. To you, they may be major frustrations.
What Is Your Typical Daily Schedule? Some specialties have a less typical daily schedule than others. First, you should ask yourself if you like a typical daily schedule. How much of a schedule is tolerable? Or intolerable? The responses provide information about the time commitment made, the type of activities performed, and how much is expected professionally during evenings and weekends. Although it is true that you can work as much or as little as you like in any specialty (radiologists can go to the hospital and read x-rays all night if they really want to), some fields will require a less structured time commitment than others. The surgeon cannot be sure that an operation will be finished at a predetermined time; the emergency room physician knows when a shift will end. You need to have some reasonable expectations as to how much time you are willing to spend in the practice of medicine and match that with the typical daily schedule in each specialty.
What Abilities and Talents Are Important in This Specialty? No matter how motivated you are to work in a specific specialty area, you may not have the talents and abilities required for success in that field. In some cases you may be able to develop the talent or ability, such as learning good management and listening skills in preparation for a career in physical medicine and rehabilitation, but you may not be able to acquire manual dexterity or good eye-hand coordination needed to perform surgery, or the physical requirement of normal color vision which is a prerequisite for ophthalmology. Included in the responses are areas of training that are related to personal interests and skills, such as "a strong scientific orientation with interest in anatomy and histology" for pathology or "piloting aircraft" for aerospace medicine.
What Personality Traits Best Characterize This Specialty? This question is closely related to the previous one. The key word in assessing yourself in relationship to this question is temperament. Anyone can practice almost any specialty in medicine, aside from some physical limitations. In some specialties, however, you will feel more comfortable than in others, and it will be easier for you to do the required work. Your own individual personality (or temperament) will be the key factor. In addition to the responses of the physician contributors, I have drawn upon Mary H. McCaulley's "Application of the Myers-Briggs Type Indicator to Medicine and Other Health Professions" as a resource.12
What Advice Would You Give to Medical Students Interested in This Specialty? Because so many respondents said they would advise a student to "take a clerkship in the field," "talk to physicians in the specialty," or in similar ways get first-hand experience of the specialty considered, this advice can apply to all specialties. Each chapter includes advice specific to the specialty under consideration.
What Are the Future Challenges to This Specialty? In addition to published material about the future of each specialty in terms of personnel, income, and practice styles, it would be interesting for you to read what practicing physicians see as the future trends in their specialties. It is important to measure your expectations of a career field in relation to these responses.
Job Values of This Specialty. In a pretest, physicians listed their job values; their top choices are listed below. Each respondent was asked to choose four of the following job values that are most important to him or her:
_____ Creativity
_____ Good income
_____ Variety
_____ Security
_____ Independence
_____ Decision making
_____ Working with my hands
_____ Prestige
_____ Working with my mind
_____ Achievement
_____ Taking care of people
_____ Working with people
_____ Feedback from others
_____ Sufficient time off
At this time, check off your top four choices from this list, or complete this quiz online at http://www.sdn.net. As you read through each chapter you will be able to compare your job values with those of the respondents in each specialty.
It is also important to know which job values were not chosen by any of the respondents because this may give you a clue as to what you should not expect from the specialty. For example, no one in aerospace medicine chose "good income," "working with my hands," "taking care of people," or "feedback from others" as a job value; in dermatology, no one chose "prestige."
Summary Profile of This Specialty. For each specialty ten tendencies are cited. These have been derived from the short-answer statements in number 14 of the questionnaire (see the Appendix) as well as from information on the questionnaires. You will be asked to compare yourself with the tendencies listed on a numerical scale to provide a score at the end of each specialty chapter. The higher your score, the more similar you are to the respondents in that specialty; the lower your score, the less similar you are. You may record your individual chapter scores in the Appendix. When you finish Part 2 some specialties should seem to offer opportunities satisfying to you—and these should be investigated further.
Part 3 discusses emerging areas of specialty interest. This section has been written in response to student requests for information about medical fields that are certified by more than one primary board (such as geriatrics and critical care) or that may be practiced with training in any of a variety of specialties (such as administrative medicine). The key question from students was, "How do I prepare myself to offer special expertise in these areas either in a full-time practice or as an adjunct to one of the traditional specialties?" Suggestions for other areas that might be included in future editions are welcome.
The discussion of these emerging areas of specialty interest follows a format similar to that used in Part 2, that is, it offers information about the specialties and the physicians who practice in these fields. Information about training pathways for their practice focus and advice for students interested in pursuing similar interests are included.
Part 4 focuses on practice options and outlines clinical and non-clinical pathways you can follow. The goal is to learn how to integrate your preferences of where and how you live and your interests outside medicine with your specialty choice. To this end I have responded to students' requests for information on international medicine, wilderness medicine, research opportunities, and hospitalists' careers, as well as adding a plethora of other pathways you can follow.
Part 5, After You Have Chosen a Specialty, is comprised of six chapters. There is information on the NRMP, the military programs, the couples match, shared residencies, and independent matching programs, as well as what happens if you do not match. A chapter discusses changing specialties during or after residency. Resources for these chapters include medical students, residents, and the annual Directory of Graduate Medical Education Programs published by the American Medical Association.
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Green M, Jones P, Thomas JX. Selection criteria for residency: results of a national program directors' survey. Acad Med 2009; 84(3):362-367.
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Wallace AP. HMOs and physicians without board certification. Letter to the Editor. NEngl J Med 1993; 328(20):1501-1502.
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Council on Graduate Medical Education. Physician Workforce Policy Guidelines for the U.S. for 2000 - 2020. Rockville, MD: U.S. Department of Health and Human Services; 2005.
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Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physicians shortage. Health Affairs 2002; 21(1): 140-154.
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Cooper RA, Getzen TE, Johns M.M.E. Physicians and Their Practice Under Health Care Reform, A Report to the President and the Congress prepared on behalf of The Physicians Foundation, September 9, 2009.
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Physician Characteristics and Distribution in the US, American Medical Association, 2011.
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Physician Compensation Report 2011 Medscape. Accessed June 16, 2011 at www.medscape.com
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MGMA Physician Compensation and Production Survey: 2011 Report based on 2010 data. Englewood, CO.
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2011 Annual Review of Physician Recruitment Incentives, Merritt, Hawkins & Associates, Irving, TX, 20
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Leigh JP, Tancredi D, Jerant A, Kravitz RL. Physician wages across specialties. Arch Intern Med 2010; 170 (19): 1728-1734.
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Leigh JP, Kravitz RL, Schembri M, Samuels SJ, Mobley S. Physician career satisfaction across specialties. Arch Intern Med 2002; 162:1577-1584.
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McCaulley MH. Application of the Myers-Briggs Type Indicator to Medicine and Other Health Professions, Monograph I. Gainesville, FL: Center for Applications of Psychological Type, 1978.