You will get lots of advice from lots of people along the way on your choice of specialty and while it’s important to listen to and factor in advice into your decision, ultimately this is YOUR decision. What worked (or didn’t work) for someone else might not apply to YOU. It’s necessary to put out that disclaimer because I encountered many physicians unhappy with their choice of career/specialty. It’s important to hear the bad as well as the good about specialties, but be wary of sour grapes masquerading as advice.
Another key point I want to express early is if you choose a specialty and don’t like it YOU CAN CHANGE IT, truly. Sure, it will set you back in your training, but 1-2 years will seem like nothing in a career spanning more than 30 years. And to spend your whole career doing something you don’t enjoy would be a shame, especially when you have so much to offer. I’ve met many residents who changed specialties after intern or PGY2 year.
Some general advice that you will hear from faculty, upperclassmen, physician advisors, etc. is to get exposure to as many specialties early as on as possible so you can be making an informed decision. Don’t wait until 4th year to get exposure to Anesthesia or Radiology. If it’s something you think you might be interested in, try hanging out with the anesthesiologist on a surgery you’re not scrubbed in on. Ask your attendings what they like and dislike about their specialties and if they’d pick the same specialty if they were making the choice today. As you do your core rotations pay attention to what you do and don’t like about that specialty. Imagine the best day on that rotation and then the worst day on that rotation. If the best day is still not interesting or bearable to you, it’s not the right field. What is the “bread and butter” of that specialty? If it’s not something you’re prepared to do for a large part of your career it’s probably not the right specialty.
Pay attention to where you feel you fit in best. Where do you feel most yourself? You’ll notice on your rotations that certain personality traits are common amongst doctors in certain specialties. Surgeons like DOING things. Mulling things over doesn’t appeal to them the way it does to IM docs. Try seeing if you have the same personality traits and preferences as the physicians you’re working with. Keep an open mind in 3rd and 4th year; you might like something you didn’t expect to and hate something you loved studying in your didactic years.
And now, six things to consider when choosing your specialty:
1. How much autonomy does this specialty offer?
Autonomy is defined as the freedom from external control or influence; independence. Most people feel better about their work when they have a fair degree of control over it. Healthcare reform and governmental mandates affect all specialties, however different specialties offer varying amounts of autonomy. On your rotations you might hear doctors venting about bureaucracy or health care reform. This is because they the lack the autonomy to make the decisions they want to offer the best care they can. Malcolm Gladwell wrote in his book Outliers: The Story of Success, “Those three things - autonomy, complexity, and a connection between effort and reward - are, most people will agree, the three qualities that work has to have if it is to be satisfying.”
Complexity being another ingredient in Malcolm’s recipe for job satisfaction is synonymous with interest/challenge. If you’ve gotten this far in your medical education, I hope that medicine is still interesting to you because it sure is going to be challenging. To be fully engaged in your work you should find it interesting and embrace the challenges that are presented to you. What are your burning questions? What puzzles do you most want to know the answers to? Let this guide you to your specialty.
3. Work/Life Balance
Older physicians will roll their eyes and call you a millennial if you mention work/life balance, but it’s an important element of your career. It should not, however, be placed above interest in importance. That is to say, that I don’t think you should choose a specialty you’re not jazzed about because it offers a good work/life balance. You’re going to be spending many many hours in residency and thereafter (even in a field with a good work/life balance) that’s going to make performing job duties difficult if it’s not something you enjoy or piques your interest.
Portability isn’t something that immediately jumps to the forefront of everyone’s mind, but you may want to consider it if your spouse’s job requires relocation or you want to relocate yourself later in your career. All physician jobs are portable to some extent (there is a national shortage after all), but some are more portable than others. Doctors in specialties that foster long-term relationships with patients (think cardiology, endocrinology, surgery, etc.) might have a harder time relocating. Many of their patients get referred to them and when you move your referrals don’t come with you. Emergency medicine and hospitalist internal medicine offers more in the way of portability and flexibility. If you have wanderlust, specialty portability may be something to factor in.
5. Future Pathways
For internal medicine future pathways via fellowships are fairly straightforward and well known (cardiology, endocrine, etc.). What might be less well known in the early stages of making your decision are the pathways requiring fellowships available in other fields for example sports management for family medicine or ICU for emergency medicine. Consider that you might really like EM, but are concerned with the burnout rate. While you can always stop working in the ED and switch to an Urgent Care Center that might not be what you want either. There is a fellowship in ICU training that EM trained physicians are eligible for. Perhaps the ICU would be more appealing if you want to stay based in the hospital (they generally work hospitalist schedules - on for 7 days off for 7 days).
Another not-so-openly discussed but important factor is salary. You will do just fine economically as a physician in any specialty you choose, but you will also have lots of debt because you went to medical school (and maybe some undergrad debt too). Try to imagine the kind of life you want to have when contemplating future salary potential. Do you want to live in an expensive area of the country (NYC, LA, SF) or are you moving to a rural area? Do you want lots of children (kids ain’t cheap!) or no kids? Will you have two incomes - is your spouse going to work too? But don’t let salary potential fool you into picking a specialty you don’t enjoy. Ask yourself, if the specialty I’m interested in paid 25-50% less would I still be interested in it? If the answer is no, expand your options.