Specialties that balance clinic and procedures?

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I was wondering which specialties have a good balance between doing procedures and clinic (working with patients).

Are there any that are evenly mixed?

Urology and ENT come to mind

GI/cards, ophtho.

OB/Gyn.

Some of the internal medicine subspecialties (eg GI) also come to mind.

Some of the surgical subspecialties could qualify--I once worked with an orthopedic surgeon who only operated 3 mornings a week and spent the rest of his time in clinic. He said that he could make more in the office than in the OR, especially with the number of clinic procedures (mainly joint injections) he did.

The moral of this story is unless you're doing an OR heavy specialty like gen surg, ortho, neurosurg, plastics you can find a balance in various specialties

You also need to think about what type of clinic time you enjoy. Ortho clinic, for example, is a lot less "medical" than urology or ENT clinic, because their patients are usually pretty well-differentiated.

OB/GYNs are practically PCPs for a lot of their patients, on top of all the procedures they perform.

Originally Posted by KinasePro

You also need to think about what type of clinic time you enjoy. Ortho clinic, for example, is a lot less "medical" than urology or ENT clinic, because their patients are usually pretty well-differentiated.

OB/GYNs are practically PCPs for a lot of their patients, on top of all the procedures they perform.

I definitely prefer medical / complex problem solving + patient interaction for clinic.

So it sounds like Interventional Cardiology may be a good choice? I don't know if I'm super competitive to be getting into the surgical subspecialties. Does general surgery have a fair mix?

Originally Posted by Cole Trickle

I definitely prefer medical / complex problem solving + patient interaction for clinic.

So it sounds like Interventional Cardiology may be a good choice? I don't know if I'm super competitive to be getting into the surgical subspecialties. Does general surgery have a fair mix?

1. Re: patients and problem solving: Complex problem solving is not the sole domain of the internist. Plenty of surgical problems are very complex, and it turns out you are operating on, you know, patients.
2. There is a large chasm between surgical specialties and medical specialties. Even in clinic-heavy specialties like ENT/urology, the"medical" part of the specialty isn't like internal medicine.

In regards to balance, you can make your own practice have whatever balance you want. As a general surgery resident, you'll be doing a ton of operating with minimal clinic, but post-training, it's feasible to have a practice where you're seeing GI patients, doing endoscopies/colonoscopies, and only in the OR 1.5 days/week. That being said, no one goes into a surgical field if they don't like to operate.

How far along in your training are you?

Originally Posted by VisionaryTics

1. Re: patients and problem solving: Complex problem solving is not the sole domain of the internist. Plenty of surgical problems are very complex, and it turns out you are operating on, you know, patients.
2. There is a large chasm between surgical specialties and medical specialties. Even in clinic-heavy specialties like ENT/urology, the"medical" part of the specialty isn't like internal medicine.

In regards to balance, you can make your own practice have whatever balance you want. As a general surgery resident, you'll be doing a ton of operating with minimal clinic, but post-training, it's feasible to have a practice where you're seeing GI patients, doing endoscopies/colonoscopies, and only in the OR 1.5 days/week. That being said, no one goes into a surgical field if they don't like to operate.

How far along in your training are you?

Just finished M1. How competitive is cardiology or interventional cardiology? Honestly, I like the surgical specialties but I don't know if I'm good enough on paper. I think I would enjoy operating but not ONLY operating.

Originally Posted by Cole Trickle

Just finished M1. How competitive is cardiology or interventional cardiology? Honestly, I like the surgical specialties but I don't know if I'm good enough on paper. I think I would enjoy operating but not ONLY operating.

Neither are surgical specialties. They are medical subspecialties that require fellowship training after an internal medicine residency. You apply to fellowships as a resident, and medical school grades don't matter much at that point (but getting into a good residency helps, especially for competitive fellowships like cardiology).

Also, you're an M1. You just finished the least significant part of your medical career. You could probably still match neurodermatologic radiology at Harvard at this point regardless of how you did as an M1.

I recommend trying to get some clinical exposure as an M2 in a few different areas. I know that my ideas of what I wanted out of my career changed when I saw what different specialties were actually like, and I know they'll continue to change M3 year.

Originally Posted by Cole Trickle

Just finished M1. How competitive is cardiology or interventional cardiology? Honestly, I like the surgical specialties but I don't know if I'm good enough on paper. I think I would enjoy operating but not ONLY operating.

Dude, don't even worry about this now. Everyone changes their mind anyway. It's tough to say something like "I think I would enjoy X" when you haven't done more than maybe a few weeks of shadowing. That's what third year's about.

Also, don't worry about "not being good enough on paper" - there has been absolutely nothing you've done so far in med school short of dating the dean's daughter, getting a DUI or flunking most of your classes that will change anything. If you look at the NRMP data, you can see that pre-clinical grades mean almost nothing beyond how they effect your class rank. I know it's tough to hear, because that's all you can control right now, but do your best to just be calm. Your step 1, third year rotations, step 2 and rec letters will mean a lot more than if you got a C in biochem.

Lastly, cardiology is a fellowship, not a residency. If you end up going into something like this, then you match into it after residency, in which case, what you did in residency is more important than med school.

Enjoy your M1 summer.

Originally Posted by Cole Trickle

Just finished M1. How competitive is cardiology or interventional cardiology? Honestly, I like the surgical specialties but I don't know if I'm good enough on paper. I think I would enjoy operating but not ONLY operating.

I'd like to point out that even for the most OR heavy physician that is never going to be the only thing that you go. (if there were such as thing there are plenty of people that would love to hear about it) Patients don't just pop by the OR for a procedure. Clinic (and the ER) is how you get those people in there.

depends on what you mean by "procedures"? if you mean outright surgery, then the best fields with a nice mix of clinic and surgical procedures are def. urology and ENT. one point that i think is important to note is that yes although every surgical field requires having a clinic so that you find patients that need surgery, you gotta realize that i think of "clinic" as being a place where you can actually treat conditions. for instance, in urology and ENT, their clinics have a bunch of patients that eventually need to go to the OR for surgery but they also have many patients that can get medical treatments for a variety of conditions. so i think of them as truly have a mix of clinic and surgery. on the other hand, for example, take neurosurgery...sure there are nsg clinics but they don't have much that they can offer in terms of treatment in the office for the conditions they see. just a distinction that pple may miss sometimes which i think is important as in urology/ENT, one can easily tailor their practice away from big-time surgeries and have more of a office-based practice if one wants to. that is not really as easy an option in other surgical fields like neurosurgery, CT surgery, ortho, etc. that's why i think uro/ENT are true mixes of clinic and surgery b/c you can do either in each and do just fine and be super busy.

but if you don't want to do surgery and rather do procedures and have clinic, i'd consider GI or cardiology. they're much more medical though b/c each really only has 1 or 2 procedures that they do mostly and htat's it.

For those interested, here's a thread from the surgery forums discussing mix of clinic and OR:

http://forums.studentdoctor.net/showthread.php?t=915057

This very question was something I've thought about and researched for myself.

For surgery specialties, the best mix would be ENT, Ophthalmology, Ob/Gyn and Urology. Special honors go to Vascular Surgery (Phlebology clinic), Hand Surgery and Breast Surgery.

For nonsurgical procedural specialties, we have Cardiology, Gastroenterology, Pulmonology, Dermatology, Physiatry and Anesthesiology (Interventional Pain clinic). Special honors for Hem/Onc and Neuro-interventional Radiology.

Originally Posted by Poetic Silence

This very question was something I've thought about and researched for myself.

For surgery specialties, the best mix would be ENT, Ophthalmology, Ob/Gyn and Urology. Special honors go to Vascular Surgery (Phlebology clinic), Hand Surgery and Breast Surgery.

For nonsurgical procedural specialties, we have Cardiology, Gastroenterology, Pulmonology, Dermatology, Physiatry and Anesthesiology (Interventional Pain clinic). Special honors for Hem/Onc and Neuro-interventional Radiology.

Good post, thanks.

Every surgeon I know hates clinic. I have yet to meet one who was excited for clinic.

Originally Posted by link2swim06

Every surgeon I know hates clinic. I have yet to meet one who was excited for clinic.

Many surgeons just hire mid-levels to take care of clinic duties... It's less common in uro and ENT, but a lot of ortho, CT, gen surg, etc would rather be in the OR 4-5 days a week and let the NPs/PAs take care of clinic.

Originally Posted by Cole Trickle

Just finished M1. How competitive is cardiology or interventional cardiology? Honestly, I like the surgical specialties but I don't know if I'm good enough on paper. I think I would enjoy operating but not ONLY operating.

I wouldn't worry too much about fellowships at this point. I would focus on getting good grades and learning. Then decide M3 year on surgery vs IM.

In regards to cardiology realize that most of this work is office based. Also the intv cards guys I am aware of don't even have clinic. They just work with a group and do the procedures for the group. The other docs follow the patient.

Originally Posted by KinasePro

Many surgeons just hire mid-levels to take care of clinic duties... It's less common in uro and ENT, but a lot of ortho, CT, gen surg, etc would rather be in the OR 4-5 days a week and let the NPs/PAs take care of clinic.

Eh maybe they could get away with that for simple post-op patients or those pts with very common complaints. But they still have to go in for new pts.




With regards to clinic vs procedures you have to understand what is involved with the clinic in each specialty. If you're goal is to see patients and treat various diseases in clinic medically then you really don't do that in surgery or any subspecialty because their job is to operate. Even in fields like GI you will mostly just be doing colonoscopies and endoscopies for procedures and clinic is solely focused on GI compliants that a general PCP cannot manage properly alone w/o some sort of f/u with a procedure. Same goes for fields like cards.

PM&R can give you the opportunity to do lots of procedures as well as see patients in clinic. I think the amount of balance between the two once you're done training is a matter of personal preference.

Originally Posted by Cole Trickle

So it sounds like Interventional Cardiology may be a good choice? I don't know if I'm super competitive to be getting into the surgical subspecialties. Does general surgery have a fair mix?

Don't forget that peds has all the same fellowships as IM, but getting a peds fellowship is significantly less competitive. Even peds cardiology which is the most competitive fellowship is easy compared to the adult match.

For perspective:
Peds cardiology in 2011 match had 157 applicants for 127 positions - 1.23 applicants per spot. 9 spots (7%) went unfilled.

Meanwhile adult cardiology had 1133 applicants for 779 spots - 1.45 applicants per spot. Only 17 spots (2%) went unfilled.


And the odds are in your favor if you are a US Grad - across all fields (since the NRMP doesn't break down individual specialties by applicant type), the unmatched rate for US Grads in peds was 7.7%, compared to 12.2% in the adult match.

Of course you have like taking care of kids...and sick kids at that, which is not appealing for a lot of people.

Originally Posted by SlickNickMD

The moral of this story is unless you're doing an OR heavy specialty like gen surg, ortho, neurosurg, plastics you can find a balance in various specialties

All surgical specialties have a mix of clinic and procedures. Clinic is absolutely necessary to the successful practice. Your elective cases come from clinic. Follow up patients are seen in clinic. Anyone that thinks they will go out and be in the OR full time 3-4 days is likely mistaken. The surgeon that can spend the vast majority of his time in the OR is a very lucky individual.

Originally Posted by BigRedBeta

Don't forget that peds has all the same fellowships as IM, but getting a peds fellowship is significantly less competitive. Even peds cardiology which is the most competitive fellowship is easy compared to the adult match.

For perspective:
Peds cardiology in 2011 match had 157 applicants for 127 positions - 1.23 applicants per spot. 9 spots (7%) went unfilled.

Meanwhile adult cardiology had 1133 applicants for 779 spots - 1.45 applicants per spot. Only 17 spots (2%) went unfilled.


And the odds are in your favor if you are a US Grad - across all fields (since the NRMP doesn't break down individual specialties by applicant type), the unmatched rate for US Grads in peds was 7.7%, compared to 12.2% in the adult match.

Of course you have like taking care of kids...and sick kids at that, which is not appealing for a lot of people.

.....and you generally lose money becoming a peds subspecialist.

I'm shocked only one person has mentioned derm so far. Derm allows you to do a lot of short procedures throughout the day: cut this off, laser that off, throw acid on this, freeze this off, inject this stuff there, etc

Dermatosurgery.

Originally Posted by LisaFrank

I'm shocked only one person has mentioned derm so far. Derm allows you to do a lot of short procedures throughout the day: cut this off, laser that off, throw acid on this, freeze this off, inject this stuff there, etc

Yup, one of the reasons I went into Derm. Keeps things interesting.

Surprised no one has brought up EM yet.

It depends what kind of "procedures" you mean. But I spend a ton of my time during my day intubating, starting lines, reducing fractures, doing LPs/paracenteses, lac repairs, conscious sedation, removing foreign bodies from corneas, and less commonly pericardiocentesis or crics.

Originally Posted by alwaysaangel

Surprised no one has brought up EM yet.

It depends what kind of "procedures" you mean. But I spend a ton of my time during my day intubating, starting lines, reducing fractures, doing LPs/paracenteses, lac repairs, conscious sedation, removing foreign bodies from corneas, and less commonly pericardiocentesis or crics.

Don't think you do any clinic though, which is what the OP is looking for.

Originally Posted by dude1344

Don't think you do any clinic though, which is what the OP is looking for.

What's the true definition of "clinic?" EPs see patients all day, everyday and have a good mix of procedures. Seventy-five percent will be outpatients, and 25% will be admits.

Originally Posted by alwaysaangel

Surprised no one has brought up EM yet.

It depends what kind of "procedures" you mean. But I spend a ton of my time during my day intubating, starting lines, reducing fractures, doing LPs/paracenteses, lac repairs, conscious sedation, removing foreign bodies from corneas, and less commonly pericardiocentesis or crics.

How common is that in EM? I realize there's going to be variability amongst different programs; I just mean, in general, do EM residents gain significant experience in the bolded procedures? And, if you don't mind answering, how "easy" is it to continue doing those types of procedures once you're an attending? I'm guessing practice politics plays a significant role in that.

Originally Posted by Kaushik

How common is that in EM? I realize there's going to be variability amongst different programs; I just mean, in general, do EM residents gain significant experience in the bolded procedures? And, if you don't mind answering, how "easy" is it to continue doing those types of procedures once you're an attending? I'm guessing practice politics plays a significant role in that.

Do ER docs get to do all those things listed - absolutely. Do they likely make up a "ton" of time on any given day? No. That was one of the main critiques of the show ER - that many of those things happened, but what was shown in the course of one "day" on the show was more typically spread over 10-14 days. But it's entirely reasonable that in a given month of shifts, a post-residency EM doc will do every single one of those things multiple times. In between there's going to be a lot of chest pain rule outs, lots of drug seekers, and plenty of people who show up for completely non-emergent things.

Originally Posted by Kaushik

How common is that in EM? I realize there's going to be variability amongst different programs; I just mean, in general, do EM residents gain significant experience in the bolded procedures? And, if you don't mind answering, how "easy" is it to continue doing those types of procedures once you're an attending? I'm guessing practice politics plays a significant role in that.

Location, even more so. Some traits to take into consideration:

Location of hospital

Size of hospital

Trauma certified (1, 2, 3 & 4)

Specialists on staff/call

Affiliation with a medical, nursing or other allied healthcare practitioner school or training program

Nurse unions/politics

Admin politics

Size of the district served

Medical resident and student participation

All these characteristics and more define your duty as an emergency physician at any given location.

Originally Posted by dude1344

Don't think you do any clinic though, which is what the OP is looking for.

I run clinic all day long :-/ unfortunately - I wish it were just the sick people.

How common is that in EM? I realize there's going to be variability amongst different programs; I just mean, in general, do EM residents gain significant experience in the bolded procedures? And, if you don't mind answering, how "easy" is it to continue doing those types of procedures once you're an attending? I'm guessing practice politics plays a significant role in that.

Do residents gain significant experience in those things? Yes. Most people in my program graduate with over a hundred intubations, several dozen lines, TONS of paracenteses (really not a super exciting procedure), several dozen reductions (the only reason its not more is we start punting to Ortho when we don't have time or don't want to do it), a couple of dozen LPs and a couple of dozen conscious sedation procedures.

Every graduate walks out being able to do those things very comfortably.

How easy is it to continue? Depends on where you work. If you end up an attending at an academic hospital with every subspecialty and residents in the ED you probably won't do a ton of procedures as an attending, if you're in an average community hospital you will probably do all those things regularly (every couple of weeks), if you were in a rural hospital with little back up you will do many of those things daily. There is a hospital in the desert that I think UCLA_Olive View residents rotate at that literally cracks a couple of chests every week because they get super sick patients and do all the procedures themselves.