Choosing a Medical Specialty II—the view from above

MarkH is going through the process of deciding what to what to do when he grows up. This is a much more difficult and important decision than many may realize. In order to understand the gravity of this process, I’ll have to refresh your memories a bit regarding medical education.

In the U.S., to apply for medical school, you must have completed a (usually) 4-year bachelor’s degree from a university. During the final year, you take what amounts to an entrance exam (the MCAT), and send out preliminary applications (often with fees). If the schools like your preliminary applications, they will send you secondary applications which are more lengthy and involve more fees. If they like your secondary application, you will be invited for interviews. For those of you who may not be familiar with U.S. geography, this place is big—really big. When I went on my interviews, I typically crossed two or three time zones. I took the red-eye out of SFO for Washington National, leaving around 11 p.m. and arriving around 7 a.m. The process is time-consuming and expensive.

After finishing the interview process, you may or may not receive invitations to matriculate. If you don’t get an offer, and you still want to become a doctor, you must repeat the entire process the next year. It is, needless to say, unwise to go through this process unless you’re pretty sure you’ll be happy with your decision to go to medical school.

I’ve always been happy with my decision—except when I haven’t been. I remember one night driving home from the anatomy lab a little after midnight, looking at the Chicago skyline, wondering what it would be like to have a normal job and to go out partying in the evening instead of digging through pickled viscera. Usually, these feelings washed through me after a good night’s sleep. During third and forth year of med school, a good night’s sleep can be hard to find, so I frequently reminded myself that gut-wrenching regret is usually temporary.

For some people, that regret is not temporary, and the lucky ones suck it up, leave medicine, and find a career they actually enjoy. The ones who fail to make that hard decision are easy to spot because of the air of misery that surrounds them.

During the third year of medical school, usually before you’ve finished sampling all of the core medical specialties, you have to start the application process for residency. This involves another round of applications, interviews, etc. If you’re thinking about internal medicine, you are interviewing for a three year residency spot. If you’re looking at surgery, it’s generally a five to seven year program. These commitments are long, so once again, you’d better choose wisely.

So how does one actually choose a medical specialty? Hopefully, during your clinical rotations, you’ve developed strong opinions about what you do and do not enjoy. MarkH posted some stereotypical but not unrealistic personality questions that may point folks in one direction or another. Certain specialties do attract certain personality types. But the more you know, the better your decision will be. If you’re looking to get rich quick, medicine isn’t for you—nothing about medical education is quick. Some specialties are certainly more lucrative than others, though. Very few primary care docs (internists, pediatricians, family docs) strike it rich. Compensation for doctors is biased toward doing rather than more intellectual endeavors. For instance, if I put a diabetic patient on an ACE-inhibitor, examine their feet, and make sure they go to the ophthalmologist, my care is likely to save their kidneys, feet, and eyesight. For this type of visit, and can expect to make about 70 bucks. If I simply clean the wax out of the patient’s ears, I can make around 100 bucks instead. Preventing illness doesn’t pay nearly as well as sticking a knife or a needle into someone. Because of the cost of medical education and the compensation structure, only about two percent of American medical school grads are picking a primary care specialty.

Decisions on specialties are, I suspect, made for economic reasons, but also for other good reasons. A student may have had a particularly influential mentor in surgery, for example, or may have just loved the thought process and patient interactions of internal medicine. But however the decision is made, it’s another breakpoint. Choosing to go to and finish medical school is big. Choosing a medical specialty and finishing the training is bigger. It’s a damned good thing I was happy with my choice—some of my friends were not, and the smart ones were willing to move on to another field or another career altogether.

My first day of internship, I showed up in my tie and new white coat, feeling appropriately nervous, but also ready. A very haggard-looking intern enveloped by a chair outside the ward, looked up at me and said, “PAL, eh? Well, you’re post-call [as if I couldn’t tell by how crappy he looked] so let me go over the new ones with you. Mr…aw, never mind. Here, take my cards. I’m going to bed.” I took them, entered the ward, and a nurse marched up to me, grabbed my name tag, and said, “Hmm, Dr. Pal. Well, “Dr.”, Mr. Z. isn’t looking too good. You’d better start there, and now.”

I walked into a room to find an elderly man lying in a bed with the usual assortment of tubes dripping fluid in one place, and collecting it out of another. Except his breathing wasn’t normal. He would breathe rapidly, then more and more slowly and deeply, and then stop.

And then finally he would start again, at first slowly and deeply, then more quickly and more shallow, then more slowly, until he would stop again, in a pattern known as Cheyne-Stokes respiration. This was a change from earlier that morning, and we got to work trying to figure out what had changed.

I loved it. I took to medical school and residency like a fish to water (most of the time), and I was usually good at it. Now, that’s not what I expect from all of my students and residents—some will like it better than others. But I hope that they are all able to make good decisions based on their talents, their financial needs, and most important, what they enjoy. With the amount of time devoted to training and to the career that follows, you’d better choose well, or you are going to be a very unhappy person.