5
FINDING THE PERFECT SPECIALTY
This chapter addresses the potential opportunities for students to go about researching medical specialties. Use the different resources and options available to immerse yourself fully in a specific area of medicine. By interacting with other clinicians, you will find out whether that specialty makes good use of your interests, preferences, talents, and values. The list may seem daunting, but every student has 4 years in which to take advantage of the many sources of information. These are the only means by which doctors-to-be can figure out answers to many questions: What types of patients do you prefer? Can you handle diagnostic ambiguity or do you require absolute certainty? What kind of lifestyle do you want? Do you need to be an expert in your field? By pursuing as many of these options as possible, medical students will better determine their needs and preferences regarding each important variable in specialty selection.
This discussion is particularly beneficial for first- and second-year (preclinical) medical students. Compared to their upperclass peers, these medical students’ exposure to patients, doctors, and the hospital is extremely limited. Instead, they are immersed in the rigorous demands of studying anatomy, pathology, microbiology, and other basic sciences. Although preclinical students gain little practical knowledge or clinical exposure, they have ample opportunity outside the classroom and laboratory to explore different specialties.
Yet, first- and second-year medical students, just like juniors and seniors, also agonize greatly about what type of doctor to become. Most of them mistakenly believe that there really is no way to start learning about the different specialties until they start clinical rotations in the hospital. This is a misconception. By actively engaging in each of the following opportunities, all medical students—whether first year or fourth year—will help alleviate some of their apprehension about specialty choice as the time to make the decision approaches.
BASIC SCIENCE (PRECLINICAL) COURSES
The first 2 years of medical school consist of courses designed to provide a solid foundation in the scientific basis of medicine. You spend long days in the classroom and laboratory, memorizing anatomic terms, studying biochemical pathways, and reading about bugs, drugs, and diseases. During these years, students rarely step foot inside the hospital (except to learn how to take patient histories and conduct physical examinations under resident supervision).
Without direct clinical experience and exposure, is it possible to figure out which specialty may be right for you? Yes. Believe it or not, the basic science courses also give insight into areas of medicine that may be a possible match for you. Every specialty represents a clinical discipline that draws upon a particular group of basic sciences as its scientific foundation. Some of the broader fields of medicine—like emergency medicine, family practice, and internal medicine—make use of nearly all of the basic sciences in the diagnosis and treatment of disease. Other specialties focus on one or two fundamental sciences within their clinical spectrum. For instance, if you thoroughly enjoyed the course in neuroscience and neuroanatomy in the first year of medical school, there are many ways to study the diseases of the brain as a clinician. You could become a neurologist, neurosurgeon, psychiatrist, or physical medicine/rehabilitation specialist. If you absolutely thrived on the study of gross anatomy, then specialties like diagnostic radiology and surgery are perfect for you. Take a closer look at Table 5–1.
By the end of the second year of medical school, you will have a much better idea of which basic sciences thrill you—and which ones bore you to death. During the clinical years, pay close attention to how each specialty makes use of the basic sciences. This will reinforce whether or not that field of medicine is right for you.
SUBJECTS AND SPECIALTIES
“CAREERS IN MEDICINE”
To help medical students choose their specialty, the Association of American Medical Colleges (AAMC) offers a web-based self-evaluation program titled “Careers in Medicine” (formerly known as “MedCareers”). This excellent career planning tool allows medical students to assess their skills, interests, talents, and personality characteristics. Starting right from the beginning of medical school, you can access it at www.aamc.org/careersinmedicine. Students will get the most out of this program if they use it repeatedly (ideally once or twice per year) as they refine their decision. After all, each educational experience during medical school can shape your ideas about which specialty is the perfect one. For this reason, Careers in Medicine is a superb way to create an honest and interactive self-assessment.
The actual program consists of four components: (1) personal career assessment—figuring out your values, interests, and long-term career aspirations; (2) career exploration—collecting information and learning about the different medical specialties and career options; (3) decision making—applying the results of your personal assessment with the information gathered about career options to select a single specialty; and (4) implementation—explaining how to go through the residency application, interview, and matching process. In essence, the entire system is an interactive questionnaire full of easy-to-use tools.
As you complete the different structured steps in the Careers in Medicine workshop, the AAMC recommends reassessing and reviewing previously answered questions. In fact, the system allows the user to store and update his or her personal profile and answers to different aspects of the program at any time. Using its decision-making tools, students can approach their choice in a systematic manner. To log in to the system and begin the program, medical students must obtain an access code from the appropriate AAMC liaison at their medical school.
CLINICAL ROTATIONS
Nearly all medical students base their choice of specialty on their third- and fourth-year clinical experiences. These are the years during which students complete their required clerkships, elective rotations, and subinternships in different medical and surgical specialties. Most schools require a set of core rotations in the basic areas of medicine in which all students must gain solid knowledge: internal medicine, pediatrics, surgery, obstetrics–gynecology, psychiatry, family practice, and neurology. The rotations last anywhere from 2 weeks to 3 months. During the surgery and internal medicine clerkships, you will have an opportunity to spend time in some of the relevant subspecialties, like cardiology, orthopedic surgery, and neurosurgery.
Unlike the basic science courses, clinical rotations allow students to gain first-hand experiences and inside looks into a medical specialty. As full members of teams in each department, medical students have the important responsibility of knowing in detail every single aspect of their assigned patients’ medical care, such as their test results and medications. As a subintern, a fourth-year medical student receives even more responsibility by functioning at the level of a first-year resident (or intern) in that specialty. These are the only times in medical school when you will immerse yourself in what specialists do on a daily basis—the kinds of problems they face, the tests they order, the procedures they perform, and the kinds of patients they treat.
During each clinical rotation, take the time to talk in depth with your attending physicians and residents. Find out what made them choose their specialty. As you meet new physicians, ask them a lot of tough probing questions like, “Would you pick your field again if you had the option?” “What do you dislike about your specialty?” Write everything—especially your own impressions and thoughts about these experiences—down in a journal that you can refer to once the third year is over and it is time to choose a specialty. Hospital rotations are your only opportunity to gain a real-world perspective about the many different areas of medicine. Medical students, therefore, should use their limited elective time wisely to explore a specialty if they feel their previous exposure to it was inadequate.
Although clinical rotations are the best way to learn about the options available for every medical student, they are certainly not perfect. Take this time to review the section in Chapter 1 that discusses the limited value of the clinical clerkship in specialty selection.
GLAXO PATHWAY EVALUATION PROGRAM
Similar to Careers in Medicine, the Glaxo Pathway Evaluation Program (cosponsored by Duke University and GlaxoSmithKline, a major pharmaceutical company) is designed to help medical students undergo the specialty selection process. This innovative career planning program—endorsed by both the American Medical Student Association (AMSA) and the US Department of Health and Human Services—is an important part of medical education. The program consists of an interactive workshop, self-assessment exercises, and CD-ROM resources (like specialty surveys and profiles). Diligently taking part in each component allows students to carefully evaluate their many options and to make a better-informed decision about their future career direction. Medical students who are completely clueless about what specialty to choose (or who are deciding between multiple specialties) find this program particularly helpful. It can give them an excellent start on the whole decision-making process.
The main component of the Glaxo Pathway Evaluation Program is a 3½-hour workshop for third-year medical students. The program facilitator is a faculty member from your medical school. The program consists of a series of discussions, lectures, and interactive exercises, with an emphasis on informed, educated decision making. You will also interact with your peers while participating in both small and large discussion groups. Topics include factors in your decision such as the skills and talents a specialty requires, the type of patient population, lifestyle issues, and so on. You will learn much about yourself and the specialty in which you are best suited.
Not everyone can participate in the Glaxo Pathway Evaluation Program. Your medical school has to set it up for you; therefore, get a group of students together and petition your Dean of Students Office to bring the program to campus. To obtain more information about the program, call 1-800-444-PATH or talk with any faculty advisor at your medical school.
GRAND ROUNDS
Throughout all 4 years of medical school, attending grand rounds is yet another way to check out what different specialties are like. Every department holds these hour-long meetings, typically once per week. They bring in a very prominent physician who gives a lecture about the latest advances in medical science related to his or her subject. Food is often served. Do not be bashful about showing up to listen to the talk. Everyone in the medical center is invited, and almost every member of that department—faculty, residents, staff—makes a concerted effort to attend.
By going to grand rounds, medical students (particularly first and second years) will begin to expose themselves to new fields of medicine. It is a chance to hear about interesting cases, follow the thought processes of different specialists, and observe the interactions among faculty members and resident physicians. These talks are a great way to learn about a specialty by hearing about the newest research and other updates in the field. Although some topics may be technically overwhelming, grand rounds can give you an excellent sense of a discipline’s clinical subject matter. If you find yourself nodding off, maybe that specialty is not the right one. If you find yourself excited and keenly interested in the discussion, perhaps that field should move to the top of your list.
INTERNET RESOURCES
Through the World Wide Web, medical students can obtain a wealth of information on any topic in medicine—especially the important issues related to any medical specialty under consideration. Want to know what the job market is like for anesthesiologists? Check out www.gaswork.com. What are today’s practicing radiologists talking about? Check their discussion forums and chat groups on www.auntminnie.com. Wondering about the state of burnout among emergency medicine physicians? Then take a look at studies published in the online version of Academic Emergency Medicine. To find the specific piece of information you are looking for, simply run a keyword search on one of the many Internet search engines, like the popular www.google.com.
One of the best starting points for gathering information about a particular medical specialty is its national professional association. For example, the American College of Surgery is the main entity for surgeons; their colleagues in anesthesiology belong to the American Society of Anesthesiologists. The websites of these organizations contain a wide variety of medical, professional, educational, and patient-related information. You could spend hours reading the articles and newsletters posted on these pages. It is an excellent way to learn about the latest issues and debates within that specialty. In addition, becoming a student member of these societies entitles you to a subscription to their monthly journals as well as invitations to national meetings. A complete list of the national specialty associations and their respective websites (as well as other highly recommended Internet resources) can be found at the end of this book.
MEDICAL JOURNALS
Each medical school has its own library that is stocked with nearly every single medical journal that exists. In your spare time, take a look at some of them. You are probably thinking, “What spare time?” From cramming for biochemistry examinations to preparing presentations for morning pediatrics rounds, the intense workload of medical school leaves little time for outside reading. However, reading the journals of different medical specialties can provide a nice flavor of the subject matter in that field—but on the same level that a practicing specialist would read. Instead of reading that surgery review/outline book, flip open The American Journal of Surgery. Do not be concerned about understanding every single word or unfamiliar topic. The point of this endeavor is to get an overall sense of the current research in each of the many specialties. These issues, in general, will have a different focus than the topics that students read about in their texts or outline books.
To help you choose a specialty, there are several noteworthy publications within every library’s collection. Several times per year, the Journal of the American Medical Association (JAMA) publishes a series of articles of particular relevance to medical students and residents in its “msJAMA” section. Previous topics have included specialty selection, the match process, and women in medicine. The AMSA publishes a monthly magazine called The New Physician, which typically has features on choosing a specialty. Many faculty members read Academic Medicine, a well-respected publication that has featured many articles and studies about residency, medical school, specialty selection, and the match. These journals and others can provide illuminating information that most medical students might not otherwise come across.
MEETINGS: NATIONAL AND LOCAL
Attending national and local meetings is another excellent opportunity for medical students (especially first and second years) to meet physicians in various specialties. These conferences generally consist of lectures, discussions, poster presentations, and social events. Every national specialty association holds an annual, multiday meeting in a major US city—possibly one in which you currently attend medical school. For instance, every December, the meeting of the Radiological Society of North America draws radiologists and radiation oncologists from all over the country to Chicago. Interested in a career in internal medicine? Try to make it to the annual meeting of the American College of Physicians. Some meetings occur locally, such as the annual get together of the Massachusetts Society of Anesthesiologists. Others are even more specific, like the National Conference of Family Practice Residents and Medical Students, sponsored by the American Academy of Family Physicians. Although some events may require an entrance fee, medical students are generally welcomed at each of them. By going to these meetings, you will see the specialty from a different perspective—similar to that of a private practitioner attending their annual continuing medical education conferences. Specialties hold their national meetings in different locations each year and so you will have to look them up on their respective websites.
MENTORS AND COLLEAGUES
It goes without saying that the physicians and future doctors-to-be with whom you interact on a daily basis are some of the best sources of information and advice. All medical students should make good use of any formal (and informal) career advising at their institution. Cultivate relationships with faculty members in various specialties and ask them questions about their areas of interest. Explore various specialty areas by establishing relationships with at least two mentors who will take a professional interest in you. Sharing in their professional, community, and family lives will provide great insight into what being a physician is like in their particular specialty of medicine. Of course, do not forget about your fellow upperclass students. They are also invaluable sources of inside information and personal experiences. Seek out these informal advisors and ask them a lot of questions about their specialty interests.
RESEARCH PROJECTS
Clinical and basic science research are fundamental components of the medical profession. Many aspiring physicians enter medical school with varying degrees of research experience from college or other positions prior to beginning their medical education. Once in medical school, a fair number of students engage in research projects outside of their classroom and clinical work requirements. There are two types of research you can pursue—in the basic sciences (e.g., microbiology, biochemistry) or clinical disciplines (e.g., radiology, surgery).
Engaging in clinical research is a wonderful way to learn about a specialty. You will immerse yourself in the department, interact with faculty members, and have a chance to see their clinical and nonclinical activities every day. Moreover, you can become familiar with the subject matter of that discipline. If you are undecided about a specialty, then seek out research projects that deal with topics that cross multiple specialties, like diabetes, asthma, or hypertension. For instance, many students conduct clinical research projects in the emergency department, where they get to talk to patients, take surveys, and see what emergency medicine specialists do down in the trenches. The early exposure to specialties through research projects may help you rule in or out particular ones. In the end, even if taking part in research does not help you select a specialty, it is still a valuable experience. You will learn how to critically interpret the scientific literature and ask probing questions—skills essential for all types of specialists.
On a specialty-related side note, getting involved with medical research has the potential to strengthen your application. A few residency programs will invite only those applicants who completed extensive research for an interview; therefore, consider your options carefully (see Chapter 11 for specifics). Residency selection committees like to see students with excellent achievement—and nothing looks better than a publication in a major medical journal. This is particularly true for the most competitive specialties, where anything that makes you stand apart from the crowd is helpful. In fact, some specialties—like radiation oncology—almost require students to have completed research projects. (Keep in mind, however, that it looks best to continue any research started during the summer following first year. One-time projects have less influence.)
Most medical students initiate the pursuit of research during the summer between the first and second years of medical school. By this point, they have become familiar with their university, its departments, and its faculty members. Many medical schools offer funding or generous stipends for their students to stay at their institution and conduct research within one of the departments. Some students leave for other medical centers. There are several sources of outside funding for medical students through a competitive application process. These include the National Institutes of Health, the Howard Hughes Medical Institute, and AMSA. See your Dean of Student Affairs Office for more information.
At the most prominent research universities, a small cadre of students participates in the “Medical Scientist Training Program” (MSTP), an ultra-competitive program in which students simultaneously pursue both MD and PhD degrees. Sponsored by grants from the National Institutes of Health, the MSTP aims to train the next generation of physician–scientists for careers in both biomedical research and clinical practice. What kind of specialties do these physician–scientists select? A survey of all MSTP graduates from 2004 through 2008 found that the top five specialties chosen were internal medicine (24.6%), pathology (10.3%), pediatrics (10%), diagnostic radiology (6.9%), and dermatology (5.9%).1 Clearly, MD/PhD graduates were much less likely to pursue training in the surgical specialties and subspecialties. Perhaps the five most commonly chosen areas have many strong physician–scientist role models who encourage careers in academic medicine.
SHADOWING RESIDENTS AND ATTENDING PHYSICIANS
First- and second-year medical students spend very little time in the hospital and clinics. Aside from learning how to take patient histories and perform physical examinations, you rarely interact with many specialists during these 2 years. For this reason, get a head start in checking out different areas of medicine by spending your free time shadowing physicians—either residents or attendings. Many hold weekend clinic hours in which you can tag along with them as they see patients. Most residents will not mind if you want to attend daily rounds in the hospital, too. Get some practical volunteer or work experience in the hospital or neighborhood clinic. Hang out in the emergency department, where the doctors will teach you how to suture wounds and perform other minor procedures. The time you spend with specialists in different areas of medicine may ultimately give you the necessary exposure to help make a final decision in the next year. Moreover, you will begin to get to know physicians who may write letters of recommendation in support of your residency applications.
SPECIALTY INTEREST GROUPS
During medical school (especially in the preclinical years), almost every student gets involved in many kinds of medically related extracurricular activities. There are lots of options from which to choose—giving tours to prospective applicants, teaching elementary school students about how the heart works, or coordinating the delivery of medical supplies to third-world countries. To help you to figure out what specialty might be the best match (before you head out on the wards in third year), consider taking part in a specialty interest group as one of your extracurricular activities.
Medical students often get together and form an interest group based on a particular specialty, such as the Emergency Medicine Interest Group or Pediatrics Interest Group. The purpose of these unique and valuable groups is to bring together medical students, residents, and faculty physicians who share the same interest in that specialty. As a member, you can set up time to shadow physicians, attend special lectures, get ideas and make contacts for research projects, meet with clinicians outside of the hospital in social situations, perform services for the local community, and much more. This educational resource provides time to ask questions to more experienced physicians. Because there is no pressure to perform well and obtain a good evaluation, specialty interest groups are excellent ways to learn informally about a specialty before hitting the wards as an upperclass medical student.
Some specialty interest groups have even established a national presence on the Internet. Future family practitioners, for example, can take advantage of one of the best ones—the Virtual Family Medicine Interest Group. Modeled after successful campus specialty groups, this website provides information and resources to help students explore the specialty of family practice and all of its related topics (like residency training and the match process). You can take a look for yourself at http://fmignet.aafap.org.
SUMMER BETWEEN MS-I AND MS-II
Unlike the best years of your life in college, medical school only provides a single summer vacation—between the first and second years. Most medical students agonize over what to do during this last free summer. They are not sure whether to work to make money, pursue research, read up before second year (!), hang out and relax, or do something that looks good on their resume—like vaccinating all the children of Africa. After all, students are generally worried about what those residency program selection committees might think about how exactly they spent their summer vacation.
Your goal during this summer should be to attach yourself to clinicians (while at the same time taking a rejuvenating break from all the lecture and laboratory work from the first year). In these formative years of training in medical school, future doctors should seek out any and all experiences and chances to build a solid foundation of the best physician that they can be. So take this summer break seriously and do something productive at least the majority of the time. Early clinical exposure during this summer will give you a jump-start to specialty decision making before the crucial third year. By pursuing a structured activity, you can start thinking and learning about different areas of medicine, particularly the ones you might not have time to rotate through during third year, like dermatology or ophthalmology.
There are a number of summer opportunities for career exploration, such as clinical externships, research programs, and community preceptorships. All of these paths can help you check out different medical specialties and start figuring out your preferences, likes, dislikes, and values when it comes to career options. Some medical students make informal arrangements to volunteer in community health clinics or shadow physicians (while also earning money through part-time jobs like waiting tables). For motivated students who do not mind another round of applications, there are formal programs that provide more structured clinical experience. Following are some examples:
• The National Health Service Corps, a federal agency, offers a month-long rotation (funded with a stipend) to expose students to the practice of rural medicine and primary care in underserved areas. You might be placed in Alaska, Nevada, North Dakota, West Virginia, or other exotic locales. This program (called Student/Resident Experiences and Rotations in Community Health [SEARCH]) allows preclinical students to get a taste of clinical medicine, practice taking patient histories, and get a head start on their physical examination skills.
• On a more local level, many states offer summer externship programs. For instance, the Illinois Academy of Family Practitioners has a program for rising second-year students in which they are paired with a family practitioner for a month-long one-on-one preceptorship.
• You can obtain funded externships directly from medical centers. For instance, Thomas Jefferson University Hospital in Philadelphia sponsors a 6-week experience in radiation oncology (The Simon Kramer Society Externship) for interested medical students.
• Want to get some clinical experience and learn how to speak Spanish? AMSA offers a summer program in many Latin American countries called SALUD—a Medical Spanish program abroad. Through classroom and practical clinical work, you learn about another country’s health care needs and become proficient in another language.
Although not every specialty has its own organized clinical summer program, many do exist and more are established every year. Either conduct searches in the Internet or contact your Dean of Student Affairs Office to find out more information on these externship programs. Above all, make every effort to use this summer to gain early exposure to different specialties without having to commit yourself to any of them. It will help you to begin prioritizing some of the many factors that go into deciding on a specialty (and on what you want out of your medical career in general). Even if your heart has always been set on orthopedic surgery, use this last summer to check out primary care or family practice. You never know what kind of meaningful clinical experience may end up changing your mind.
REFERENCE
1. Paik JC, Howard G, Lorenz RG. Postgraduate choices of graduates from medical scientist training programs, 2004–2008. JAMA. 2009;302(12):1271–1273.