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TEN FACTORS TO CONSIDER IN SPECIALTY SELECTION
No matter how each medical student goes about picking a specialty, everyone takes into account a long list of variables. An analysis of the 1993 graduating medical school class found that the following factors were the most influential in choosing a specialty:
• The type of patient problems encountered.
• The opportunity to make a difference in people’s lives and to help others.
• The intellectual content of the specialty.2
Further down on the list, some students look closely at malpractice insurance costs, or worry about overcrowding in a given field, and others seek specialties that offer the opportunity to pursue research. One of the most unifying variables, ranking at the top of the list, is a good personality match between student and specialty (see Chapter 4). The relative weight of any of these factors, of course, varies for each student.
When it comes down to the final decision, young physicians often choose their specialty based on less noble factors than the ones the study cites. Today’s debt-ridden medical student—who experiences firsthand the economic and legal domination of medicine—ascribes more value to practical variables. This chapter examines some of these less idealistic factors, such as quality of life, income potential, and job opportunities. Although they are less influential, each factor may still make a student think twice about committing to one specialty or another. When contemplating a possible specialty, keep the following 10 variables in mind, determine their order of importance, and apply them to each field you are considering.
GENERALIST, SPECIALIST, OR NONE OF THE ABOVE
The 20 medical and surgical disciplines can be further subdivided into 3 major specialty groups: generalist, specialist, or supportive. Before committing to a specialty, future physicians first need to decide what type of doctor they would like to become.
The generalist specialties are those in which physicians practice primary care medicine. Classically, these have always included family practice, internal medicine, and pediatrics. For many, psychiatrists and obstetrician–gynecologists also fall within this category. All generalists have broad medical knowledge, encompassing a variety of common (and often chronic) problems in their community. An integral part of their patients’ lives, they provide long-term continuous care in a single setting, referring their patients to specialists only when necessary. Preventive medicine—a major part of their job—can catch early signs of disease and keep patients from ending up in the emergency room with serious problems. As the first doctor to see a patient, a generalist must have greater tolerance for the unknown, especially when dealing with signs and symptoms that may not fall into a neat diagnosis. Generalists also have to cope with the pressure to know just about everything. Swamped with dozens of medical journals, they need to read daily to keep up with the latest advances in their fields.
Although pediatrics, for instance, is still considered a specialty, a true specialist, by definition, cares for a specific region of the body or a narrowly defined area of medicine. Ophthalmologists, cardiologists, urologists, and neurologists—just to name a few—all fit this description. As practitioners of secondary or tertiary care medicine, specialists prefer action-oriented patient interactions. Within their narrow scope of practice, they perform many technical procedures, like cataract surgery or cardiac catheterization. As consultants, nearly all practice on the basis of patient referrals from primary care physicians. After solving the clinical problem at hand (e.g., left hip replacement), specialists usually schedule infrequent follow-ups, leading to less long-term involvement in their patients’ lives. Most practice in the clinic and the hospital. Many are affiliated with large medical centers.
Several specialties are neither medical nor surgical—they function independently as the supportive disciplines of medicine. Radiology, physical medicine and rehabilitation, pathology, anesthesiology, radiation oncology, emergency medicine, and nuclear medicine fall within this category. They are all hospital-based specialties. Although not front-line doctors, these physicians still play a crucial role in patient care. Without them, patients would not make it through surgery alive, receive accurate diagnoses from imaging and biopsy studies, or receive the correct doses of radiation therapy to treat their cancer. Because of their anonymous roles and minimal patient contact, these behind-the-scenes doctors tend not to get the recognition they deserve from their patients. Without external rewards, they instead have to derive their professional satisfaction from within.
INTELLECTUAL CONTENT AND CLINICAL ISSUES
Radiologists cannot operate on a patient’s heart, dermatologists cannot administer general anesthesia, and neurosurgeons should not be delivering babies. Because the subject matter and type of patient care differ quite a bit across the specialties, every doctor practices a distinctive brand of medicine. Take ophthalmology and rehabilitation medicine, for instance. Lying on the opposite ends of the specialty content/patient care spectrum, these two fields almost seem like completely different professions!
At the most fundamental level, with all other factors aside, medical students should love the intellectual content of their specialty. Students with a genuine interest in the underlying clinical material and basic science of a certain discipline will find themselves voraciously reading its textbooks and journals, wanting to know more about the specialty’s diagnostic challenges. To gauge the appeal of the clinical problems found in a specialty, read the current literature for 1 week. If you love clinical pharmacology and physiology, then perhaps a career in anesthesiology is your destiny. If studying anatomy brings up bad memories from your first year of medical school, then stay away from surgical specialties, radiology, and pathology. Above all, you should never have to force yourself to love an area of medicine.
Making a good match depends on the “discovery and comparison of information about three distinct domains: one’s self, the others practicing in a specialty, and the content of that specialty.”1 When it comes to the third domain, nearly all students rely heavily in the end on their gut feelings. After much deliberation, you will become aware of feeling at home in certain fields of medicine. Those who like immediate interventions, technical skills, and urgent problems find themselves drawn to surgical specialties or medical subspecialties. Students who prefer lots of interpersonal contact, a diverse patient population, and preventive medicine usually select a primary care specialty.
AMOUNT OF PATIENT CONTACT
All physicians-in-training choose careers in medicine, perhaps the noblest of all professions, because they want to help people—to take care of sick patients, cure disease, and make a difference in people’s lives. Yet until medical students finally spend hours with patients in the hospital while on clinical rotations, they really have no idea what this experience is like. Most love talking with patients, forming relationships with them, and examining them for signs of disease. Others, however, find that interacting with sick people is less appealing than they had imagined. They do not like performing physical examinations, for example, or dealing with gushes of body fluids or the smell of infected wounds.
No matter what your colleagues might say, wanting a specialty with more (or less) patient contact has no bearing on how good a physician you will be. There is a place for everyone in medicine—even for those who decide to work behind the scenes. Radiologists and pathologists, who have basically no contact with patients, are equally as righteous doctors as internists, who interact with and examine patients in every single encounter. Every specialist or subspecialist has an important role in patient care; some just have more face time with patients than others.
You should decide how much patient contact you want in your career and rule out specialties that may not meet your needs. If long-term relationships and continuity of care are important, consider areas like internal medicine and family practice. If you like getting down and dirty, think about careers in emergency medicine, obstetrics–gynecology, and surgery. In some specialties, like urology and orthopedic surgery, doctors only have to perform focused physicals (instead of examining everything). Cleaner specialties—those with lots of patient interaction but not much physical contact—include psychiatry, ophthalmology, and radiation oncology. In fields like emergency medicine and anesthesiology, contact with the patient is typically short and to the point.
TYPE OF PATIENTS ENCOUNTERED
Every physician—including pathologists working in the laboratory—interacts with patients in some way. (One cannot practice any form of medicine without patients!) Many aspiring doctors forget to factor the different types of patients into their specialty decision. Take a closer look at the typical patient in the specialty you are considering. Ask yourself whether or not you could thrive both emotionally and professionally in that type of doctor–patient relationship. Emergency medicine physicians, for instance, are always dealing with many angry patients with nonemergent complaints who have been kept waiting for hours on end. Pediatricians have to interact with demanding, concerned parents in addition to sick infants and children. Oncologists (medical, surgical, and radiation) have patients with mortal diseases that typically lead to poor outcomes despite aggressive treatment. Although these examples seem like stereotypes, the maxim that all doctors are not equal also holds true for their patients.
Medical students often wonder about the risk of facing a malpractice suit within their chosen specialty. Some patients are more litigious than others. Obstetricians, for instance, manage a group of patients who could slap them with a malpractice suit for any minor defect in their baby. A recent study took a closer look at specialty-specific malpractice risk.3 Specialties with the highest probability of facing a malpractice claim include neurological, cardiothoracic, general, and orthopedic surgery; those with the lowest include family medicine, pediatrics, and psychiatry. However, no correlation between lawsuit risk and indemnity payment size was found. The average plaintiff payout for low-risk specialties like pediatricians and pathologists was actually much greater than those of high-risk specialists like neurosurgeons and obstetricians. Regardless of specialty, medical students should be aware that nearly all physicians face at least one malpractice suit by the end of the careers. The cumulative career risk is quite high, unfortunately.
PRESTIGE, STATUS, AND SOCIAL EXPECTATIONS
The selection of a specialty should be your own choice. Think about the areas of medicine in which you are the happiest and forget about how others (family, friends, and colleagues) might view your chosen specialty. Always remember that every type of doctor has an important role in the big picture of medicine, and the idea that one specialty garners more respect and prestige than another is really just a matter of personal opinion. Because all medical students have excelled academically their entire lives, those who subscribe to these beliefs find it hard at this point to stop being the best. For them, a career in family practice or psychiatry may not carry as much social status as being a world-renowned neurosurgeon or earning a position in ophthalmology, an ultracompetitive specialty. Yet as a soon-to-be-physician, it is no longer necessary to prove yourself. By putting aside external influences such as social prestige and others’ expectations, you will likely choose the right specialty and end up a much happier doctor.
LIFESTYLE CONSIDERATIONS
Medicine has always been a demanding profession. After working long hours in the hospital or clinic, physicians end up taking calls in the middle of the night to deliver a baby, remove an appendix, or admit a patient. Tired of delayed gratification and ungodly schedules, many of today’s doctors-in-training want careers that leave room for other interests or allow more time for their families. Compared to previous generations of physicians, the millennial medical student seeks a much better balance between life and work. They desire less night call, fewer hours spent in the hospital, and more control over their work schedules. Many are even willing to give up income and professional aspirations to have better personal lives and more free time. The current focus is now shifting to specialties with more controllable lifestyles and higher incomes relative to the length of training.
What accounts for the higher priority of quality-of-life issues in a medical career? The dean at one prestigious medical school believes that the change mirrors a general shift in societal values and professional goals. “Residency program directors were brought up to honor the Christian work ethic. Delayed gratification and unremitting toil were the rules of the day, and residency programs were built on that model. But young people coming through now want to spend more time with their families,” she commented.4
Perhaps this change reflects the composition of the current generation of medical students. Today nearly half of all graduating doctors are women, most of whom want flexible careers with time to raise children and maintain a normal family life. Additionally, the average age of entering medical students has increased. Many older students left behind careers in business and technology, where they could have earned more money with much less stress. For them, “medicine, once aspired to as both a noble profession and a guarantee of financial security, strikes many current students as simply a stressful and poorly paid job.”4 Instead of focusing solely on good patient care, today’s physician has to cope with more insurance paperwork, lower reimbursements, overnight phone calls from patients, loss of autonomy due to managed care, and the ever-growing threat of malpractice litigation. Certain areas of medicine, particularly the primary care specialties, have more of these problems than others. Medical students, therefore, are turning to specialties that afford better lifestyles and minimal hassles.
As medical students began to reject fields with more grueling lifestyles (like internal medicine and obstetrics–gynecology), one workaholic specialty particularly suffered: general surgery. In the past, only the most elite students—those within the upper tier of their class—went into surgery. A highly competitive specialty for decades, general surgery is the gateway to high-status careers in vascular, cardiothoracic, oncologic, and plastic surgery, among others. But the current generation of students seems less concerned with prestige. The poor quality of life and years of personal sacrifice are discouraging many top medical students from surgical careers. These shrewd students “do their cost–benefit analysis and surgery is the loser.”5 General surgery began to hurt for qualified students. In 1981, 12.1% of all US seniors went into general surgery; by 2005, the numbers were predicted to decline to just 4.8%, with only 76.6% of available positions filled by American medical graduates.6 Fortunately, surgery programs have accommodated these lifestyle concerns. No longer are the best and brightest US seniors committing to other specialties. In the 2017 Match, 99.6% of all available positions in general surgery (categorical) were filled—and with the majority by US senior medical students. General surgery is back to being quite competitive once again.
So which are the so-called lifestyle specialties that the most academically successful students are selecting? They include radiology, dermatology, emergency medicine, anesthesiology, pathology, ophthalmology, physical medicine and rehabilitation, and neurology (among others), all of which allow you to control the number of hours you devote to your practice. You could potentially have a career with adequate family and leisure time, less stress, a more regular schedule, and an income commensurate to the workload. Although any specialty can offer job satisfaction, today’s medical student believes that only certain specialties allow enough time for family and recreational activities (instead of an overly taxing workload). The evidence is in the numbers: by 2002, the fill rate of programs in anesthesiology and physical medicine and rehabilitation increased by 7% and 13%, respectively.7 The 2017 NRMP Match shows that high fill rates in these “lifestyle specialties” continue today.
LENGTH OF RESIDENCY TRAINING
Keep in mind that certain specialties require more years of residency training than others. In general, the shortest programs (3 years) are fields of primary care—internal medicine, pediatrics, family practice, and certain emergency medicine programs. Surgical specialties require much longer training, anywhere from 5 to 8 years. Within this spectrum, 4 to 5 years of residency training are necessary for careers in anesthesiology, pathology, dermatology, and radiology, for example. If you want to become a subspecialist, plan on adding even more years of training in a fellowship. Cardiologists, for instance, spend a total of 6 years learning the discipline before entering practice (a 3-year internal medicine residency plus a 3-year fellowship). Some doctors even “super-subspecialize,” such as the cardiologist who undertakes an additional fellowship year to master echocardiography. You could potentially be a physician-in-training forever!
This variable should only have limited influence on your choice of specialty. Yet some medical students are more concerned than others about the number of years residency training requires. Tired of delayed gratification, these students are quite anxious to finish training, practice medicine unsupervised, and start earning a real salary. Older, nontraditional students—especially those with children—often fall into this group. Others simply want to finish training so that they can devote time to outside interests. In any case, never forget that the arduous, low-paying years of residency and/or fellowship are only temporary. Medical students should not select a less-preferred specialty just because the residency training is shorter. Otherwise you may spend a lifetime as a rather dissatisfied physician. Is it really worth it?
DIFFICULTY OF OBTAINING A RESIDENCY POSITION IN THAT SPECIALTY
Over the past 10 years, several new medical schools opened, current class sizes increased, and larger cohort of graduates sought nearly the same number of residency positions. Correspondingly, the increasing competitiveness of many fields of medicine has become a daunting obstacle. Because entrance into certain specialty programs is much more difficult than others (see Chapter 11), medical students must be well aware of their chances. Unfortunately, just because your heart is set on becoming a plastic surgeon or an ophthalmologist does not necessarily mean it will be possible for everyone. For many specialties, there are far more applicants than available positions. Medical students should be careful about basing their decisions on predictions such as, “I can only match into pediatrics,” or “I’m not going to bother with radiation oncology because I know I won’t get into it.”
Before contemplating any specialty of choice, take an honest assessment of your academic competitiveness. Compare the difficulty of obtaining a training position in that specialty with your chances of matching into it. Medical students interested in highly competitive specialties need a great deal of flexibility when making these choices. You might need a backup specialty (second or third choice option) if the field you want is slightly beyond your academic reach. By factoring in this variable, future physicians will match with the most appropriate specialty.
Unfortunately, scores on Step I of the United States Medical Licensing Exam (USMLE) play a very important role in the direction of medical careers. This difficult examination of the basic sciences is typically taken after the second year of medical school. In 2011, the minimum passing score for Step I was 188.8 All students who pass the exam begin a multistep pathway to becoming licensed physicians; however, those with the highest scores have more specialty options from which to choose. This discrepancy has defeated the primary purpose of the exams—to provide a shared pass/fail evaluation system for individual medical licensing authorities.
But faced with large numbers of highly competitive applicants, certain specialty programs have little choice but to screen candidates for interviews based upon their USMLE Step I scores. Many medical schools have “honors–pass–fail” grading systems, which means that the USMLE provides the only standardized objective measure by which to compare students. In a survey of national program directors on their selection criteria, across all specialties, directors ranked the USMLE Step I score as second in importance (after grades in required clinical clerkships).9 Step I scores carried more weight than Step II scores (ranked fifth). Similar to the emphasis on MCAT scores for medical school admissions, it is not surprising that so much weight is given to a single examination performance. The Electronic Residency Application Service (ERAS) will automatically submit USMLE score transcripts to applicants’ chosen residency programs.
Published results from the National Resident Matching Program in 2017 confirm the very important role of the USMLE Step I score.10 These results are summarized in Table 3–1. In general, the average Step I score correlates with specialty competitiveness. You can see how lower board scores will make it much more difficult for medical students to obtain entrance into the more competitive specialties. In a recent letter to the most preeminent journal within academic medicine, one senior dean believes that “it is a travesty that student affairs deans are annually forced to explain to perfectly capable, sometimes truly outstanding, medical students that their career dreams of being in ‘X’ specialty are categorically eliminated simply because their USMLE Step I scores were insufficiently high.”11 As a residency program director, I agree with this assertion. I would argue that the results from the USMLE correlate weakly with clinical success in residency and performance on that specialty’s board certification exam. Unfortunately, without other evaluation tools, this practice is likely to continue for the near future. Students who are displeased with their Step I scores should focus on achieving outstanding clerkship grades, collecting superb letters of recommendation, and studying for a high Step II score (see Chapter 11).
LENGTH OF RESIDENCY TRAINING IN YEARS
FUTURE INCOME AND EARNING POTENTIAL
According to the Association of American Medical Colleges, the average educational debt of a recent medical school graduate was roughly $100,000. In fact, 21% carried loans of over $150,000. The issue of financial rewards, therefore, becomes very important during the senior year when it comes time to select a specialty. At this point, the amount of debt has reached its peak. After 4 years of paying exorbitant tuition, coupled with the prospect of many low-paying years of residency training, graduating physicians are very concerned about their future income potential. With massive amounts of debt, they often put their altruistic motives aside and focus instead on economic realities.
As a result, future reimbursement can be an influential factor in some students’ decisions to enter a given specialty. A recent survey of 843 medical students revealed that medical school debt and potential earnings influenced a majority (53%) on their choice of specialty.12 New physicians with huge amounts of indebtedness are shunning the primary care fields because of their low earning potential. Others want to pay off their loans right away, and therefore they lean toward specialties that shell out high starting salaries, like radiology, anesthesiology, and orthopedic surgery. But once loans are out of the picture, remember that you will practice in that specialty for the rest of your professional life. For that reason, financial remuneration should be only a less influential variable. No amount of income can make up for a lifetime of miserable days in the wrong specialty.
No matter the specialty of choice, all physicians will earn a comfortable salary. Table 3–2 ranks the average compensation per specialty according to a single survey. Keep in mind that compensation also varies depending on the geographic location (metropolitan vs. rural) and practice model (solo, group, managed care, hospital). As you can tell, the “doing” specialties generally receive a higher level of compensation than the “thinking” specialties. This discrepancy is partly due to the current Medicare physician payment schedule known as the resource-based relative value scale (RBRVS). In this system, reimbursement is calculated by the resource costs necessary to provide those services. With the shifting emphasis on outcomes in upcoming health care reform measures, it remains unclear how physician reimbursement may actually change.
JOB OPPORTUNITIES AND PREDICTIONS ABOUT THE SPECIALIST WORKFORCE
There is plenty of erroneous information out there about physician workforce projections and employment patterns. One day students hear rumors about pathologists having trouble finding jobs; the next week they read an article in the newspaper about significant shortages of cardiothoracic surgeons. Many of the published expert workforce studies have significant flaws in their methodology. Who, then, should everyone believe? Because it is impossible to predict the nature of the specialist job market, medical students should not base their specialty choice on any workforce projections. This ill-advised approach is full of inherent problems.
AVERAGE USMLE STEP I SCORES OF MATCHED US SENIOR ALLOPATHIC APPLICANTS BY SPECIALTY
The challenges anesthesiologists faced in the 1990s, when this specialty lost some of its allure, serve as a word of warning. In this case, medical students heeded the wrong advice of supposed experts, leading to drastic changes within the specialty. In response to national discussions about an oversupply of specialists, the American Society of Anesthesiologists commissioned an outside consulting group to evaluate the relative glut of new anesthesiologists and their future manpower needs. Patterned after other flawed studies, their report recommended decreasing the number of anesthesiologists entering the workforce. Private practices immediately reacted by dropping their starting salaries and hiring fewer partners. Discouraged by their advisors and by reports about the specialty’s economic future in newspapers like the Wall Street Journal,13 medical students responded by shunning anesthesiology.
MEDIAN COMPENSATION BY SPECIALTY
With fewer applicants, and underestimating the future need for anesthesiologists, residency programs drastically slashed the number of training positions. Today there is nearly an 11% shortage of anesthesiologists, a substantial deficit that will continue for years to come.14 Private practice groups are fighting over residents by offering incredibly lucrative salaries. Because of the aging population, greater involvement in the intensive care unit and pain clinic, and advancements in surgical technology, anesthesiology is rapidly returning to its competitive status (Table 3–3).
The recent changes within anesthesiology illustrate an important take-home point. In this case, the miscalculation of demand in an influential study, combined with declining incomes, left students fearful of selecting this field. It is hard to make career plans in an uncertain economic world. Even the supposed experts—who have been wrong many times before—cannot predict these kinds of changes, whether in the scope of practice of competing mid-level health providers or in the turf wars between specialists over shared procedures and tests. When choosing their dream specialty, students should pay little heed to its current or projected state of job opportunities. Shortages and surpluses can change rapidly by the end of residency training; therefore place this variable low on your list of influential factors. After all, have you ever heard of any unemployed, starving physicians?
REFERENCES
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8. The United States Medical Licensing Examination, http://www.usmle.org/transcripts. Accessed December 13, 2011.
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13. Anders G. Numb and number: Once a hot specialty, anesthesiology cools as insurers scale back. Wall Street J. 1995;17.
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