3rd year with a specialty dilemma

[Confusion Abound]

Dilemma: I have to submit my fourth year schedule in the next month. I'm interested in several surgical fields but I can't decide what I want to do. I'm having trouble deciding between the surgical specialties. I spent the first 3 years barreling head first into ENT, and now that I've completed my surgery rotations, I'm wondering if I may fit in better elsewhere.

Any advice or suggestions welcomed!

What I'd like from a specialty:
-interested in healthy patients with problems that affect QoL
-primary interest in craniofacial plastics.
-I will likely need to train in a large coastal city. My fiancé has to work too.
-I would prefer more predictable hours, meaning more scheduled cases and less emergencies, although long hours do not scare me. I'm trying not too put too much stock in lifestyle, so Lifestyle is lower on my list of priorities; I'd rather find something I love to do than something with a lot of time off.
-I'm pretty laid back. I joke a lot, which probably gets me into trouble sometimes. I'd like a laid back atmosphere with good senses of humor. Obviously this is likely more program than specialty dependent.

What I don't want:
-I HATE cancer. I don't like the surgeries and the margins, tumor boards, surveillance, guidelines, the egos, etc. it's depressing, and not what I want to be the focus of my practice.
-not particularly interested in cosmetics. DEFINITELY do not want a solely cosmetic or even majority cosmetic practice. I find the patients to be difficult and tiring, and most certainly do not want to deal with these people every day for the rest of my career.

I'm trying to avoid taking salary into account. Most surgical specialties do well, and so much is in flux right now with the ACA it seems silly to base career choices on salary numbers that will likely be totally different in the next decade.

260+, HP in IM and surgery , research in ENT

ENT
Pros:
-presumably better training in the head and neck region. Rhinoplasty can be functional due to significant endoscopic training during residency vs. cosmetic for plastics trained folks alone
-big QoL benefits to patients
-pts generally healthy, with the obvious exception of H&N pts
-good mix of clinic. Longitudinal relationships with patients, ability to offer non operative management
-OTO departments usually good money makers for hospitals. Get their fair share of new toys and gadgets.
-highly technical. Surgeries can be very meticulous with attention to detail
-wide variety of fellowships. Main interest is in plastics, but also rhinology and otology.
-5 year residency with most fellowships only 1 year long
-I have significant research in the department, with potential letters from both my home program and another well respected program director
-more spots and more programs, theoretically better chance of matching
Cons:
-tracheostomys are disgusting. Of all the various body fluids and exciting smells in medicine, nothing has phased me except bronchial secretions and saliva. I'm wondering if I can be comfortable with trach care and laryngology. Snot and cerumen, on the other hand, don't really bother me.
-I feel fairly weak in neurology and neuroscience. ENT often overlaps with neurosurg
-LOTS of cancer. head and neck is a significant part of many residency programs. Big whacks = good for training but not what I want to do long term
-academic practices almost necessitate fellowship training and pigeonholing into one specific subspecialty. Academic practice loses the variety that makes the field appealing.
-ENT clinic is pretty boring
-more uptight atmosphere, at least at my home program

Plastics:
Pros:
-focus entirely on plastics. No cancer surgeries, except the reconstruction.
-wider variety of surgeries offered. Hand, face, body, etc.
-highly technical, lots of attention to detail
-wide variety of fellowships
-generally healthier patients
Cons:
-no home department. No research and no prospective letter writers. I feel that I'm incredibly behind the ball, and won't be able to get any exposure until 4th year aways.
-fewer programs, higher chance of not matching. Will not likely match in a coastal city
-training is more cosmetics focused instead of functional, as in ENT.
- 6 years for integrated plus an additional year for craniofacial. If unmatched, 5+3+1
-difficult to run a reconstructive-heavy practice. Will likely have to take on substantial cosmetic patients
-QoL benefits to patients are cosmetic, not functional

Urology:
Pros:
-dick jokes galore. Many LoL's to be had.
-more relaxed atmosphere, not uptight
-big QoL benefit
-minimally invasive procedures. I LOVED laparoscopy and robotics on my gen surgery rotation
-good mix of clinic and surgery. Lots of medical therapies and in-office interventions
Cons:
-prostate cancer is bread and butter
-patients are often pretty ill
-the kidneys are black boxes of mystery. Nephrology is my Achilles heel
-I really don't know much or have much exposure to the specialty

Ortho:
Pros:
-great benefit to patients. Huge QoL improvement
-patients generally healthy
-huge money maker for hospitals. Lots of new and fancy equipment, facilities, etc.
Cons:
-minimal longitudinal care.
-no medical therapies. Feel more like a carpenter than a doctor
-lots of trauma and call
-lots of physics/mechanics

Gen surgery
Pros:
-lots of fellowships available, would likely pursue plastics or hand
-many programs, good probability of matching in a desirable location
-minimally invasive surgery is really cool. I loved laparoscopy on my rotation
Cons:
-sick patients, many emergencies, crap lifestyle for mediocre pay as far as surgeons go
-can be considered the "low man" on the totem pole. Last in line for new toys, get shafted with scheduling cases, etc.
-5 years of training to ultimately pursue an unrelated fellowship
-I'm not sure I'd be happy as a general surgeon. Intense personalities.

Procedural derm/Mohs
Pros:
-interesting intersection of many basic sciences: ID, rheum, immunology, path, etc.
-many quick procedures, advancement flaps, etc.
-big QoL benefit to patients
-visually oriented
-lifestyle is nice, although I'd like this to not be a deciding factor
Cons:
-not real surgeons, don't really feel like real doctors either
-most "cool" cases with ultimately get referred to ENT or plastics
-stigma of "laziness" or "in it for the lifestyle"
-heavy cosmetics

I know I'm not interested in neurosurg or ophtho. I'm also not interested in "procedural" specialties such as IR or anesthesia. I really do enjoy the OR, I just can't decide where I fit in.

Basically: would it be unwise to pursue ENT knowing that my end-goal would be plastics? Is it wise to pursue ENT knowing I dislike trach care and laryngology despite strong interest in rhinology, otology, and plastics? Based on my goals, would plastics be a more approrpiate route? Will HP in IM and surgery hold back my application significantly?

Sorry for the wall o' text.

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[vhawk]

If you only dislike half of a certain specialty, thats certainly not a dealbreaker or reason to rule that out. There is at LEAST half of general surgery I dislike (breast, trauma, to some extent vascular) and I ****ing LOVE general surgery and it was without doubt the best choice for me.

 

[Mad Jack]

It sounds like you don't really like any field of surgery. Good luck with that.

 

[Winged Scapula]

There's such a plethora of misconceptions in your description of the various fields that I don't know where to start, so I won't. You're a medical student so you're allowed to misperceive other fields (heck attendings do it as well).

But you need to separate lifestyle and practice obligations during residency from your career. The former is a short time limited span and the left is presumably many decades. You may have to do tracheostomies during residency but once you're in practice you never have to do another one if you don't like. The same goes for many of your cons with the above specialties.

And while you may prefer a large coastal city, I can assure you that there are many large cities between the coast where your fiancé could find a job (presuming he's not a fisherman or running Ocean trip expeditions).

 

[Confusion Abound]

@Winged Scapula My fiance works for a large company with offices primarily in coastal cities, except Chicago and Dallas. She'd prefer to stay with that company since she has a supervisor position and is paid very well for relative to her field. She would move to the central US if we had to, but we're trying to avoid it if at all possible since she'll likely take a pay cut and I'll be making ~$50,000 with $400,000 in loans.

I understand that residency and practice are different, and I can avoid aspects of specialties I do not like as an attending. I wanted opinions on whether hating a part of a specialty that's pretty integral would be a deal-breaker. It doesn't seem to be?

I was also curious, although it's probably more appropriate for the ghost-town ENT forum, if my motivations and what I want in a specialty make sense for pursuing ENT. It seems to match up with what I ultimately want in a specialty, but maybe I'm missing something?

And I understand most of my impressions of the various specialties are based on anecdotes and stereotypes and extremely limited personal experience. Any enlightenment would be appreciated.

 

[joker2400]

@Winged Scapula My fiance works for a large company with offices primarily in coastal cities, except Chicago and Dallas. She'd prefer to stay with that company since she has a supervisor position and is paid very well for relative to her field. She would move to the central US if we had to, but we're trying to avoid it if at all possible since she'll likely take a pay cut and I'll be making ~$50,000 with $400,000 in loans.

I understand that residency and practice are different, and I can avoid aspects of specialties I do not like as an attending. I wanted opinions on whether hating a part of a specialty that's pretty integral would be a deal-breaker. It doesn't seem to be?

I was also curious, although it's probably more appropriate for the ghost-town ENT forum, if my motivations and what I want in a specialty make sense for pursuing ENT. It seems to match up with what I ultimately want in a specialty, but maybe I'm missing something?

And I understand most of my impressions of the various specialties are based on anecdotes and stereotypes and extremely limited personal experience. Any enlightenment would be appreciated.

The middle of the country is generally cheaper COL than the coasts so the pay cut may not be as big of a deal as you think.

 

[VisionaryTics]

@Winged Scapula I was also curious, although it's probably more appropriate for the ghost-town ENT forum, if my motivations and what I want in a specialty make sense for pursuing ENT. It seems to match up with what I ultimately want in a specialty, but maybe I'm missing something?

We generally will respond to stuff posted on oto forum, it's just not a bustling center of daily conversation.

I think your reasons for pursuing ENT are legit and match up with most people's reasons for going into the field. I do think the "ENTs are better at functional aspects of rhinoplasty and reconstruction" stuff is a little bit overblown (but many ENTs will puff up their chests and say the opposite).

Most people do not do heavy-duty H&N outside of residency. 95% of graduates will not do laryngectomies and maxillectomies and stuff like that. Thyroids, parotids, limited oral cavity stuff, sure. But nothing requiring a free flap or salvage cases or stuff like that. That being said, ENT residency is dominated by H&N because they are really the only patient group that tends to have long inpatient stays.

WRT trachs, you'll probably get over it pretty quick, and even if you're doing mostly facial plastics, you'll probably still pick up some trach consults on call as an attending. No big deal.

One thing that separates ENT from the other surgical fields (except perhaps uro), is that ENT is a lot of clinic. FPRS guys probably have the highest percentage of new office patients that end up getting an operation, but many subfields in ENT are 3.5-4 days of clinic per week on average, especially rhinology and otology. You have to accept that if you think you want to do ENT for the rest of your life.

 

[filter07]

Vascular surgery = no cancer, other than the random carotid body tumor.
No tumor board, no neoadjuvant, no adjuvant, no randomly changing guidelines every month, no blobs and no berry picking.
Mostly sick patients but usually stable-sick. With a lot of the practice being endo, lifestyle isn't too bad. There are emergencies to be sure, but nowhere near as much as general surgery, unless you are at a major referral center known for taking all the misery.
Also, no cancer.

 

[TallScrubs]

You can take 'nephrology' out as one of the cons of doing urology. If you know obstructive nephropathy, and how to consult nephro I assure you that you know enough.

Also, the patients may be 'pretty ill' but its far more common they are ill from other co-morbidities.

 

[Confusion Abound]

I guess the main question would be: is it a poor decision to pursue ENT with a strong eye towards plastics and with a general lack of interest in bread and butter ENT?

I was full steam ahead ENT until I did my rotation and realized I don't get excited by general bread/butter ENT. I don't find sinusitis or ear infections or tinnitus or vertigo intellectually stimulating. The science and pathology behind thyroid diseases don't rev my engine. I don't want to do H&N since it's all cancer, laryngology grosses me out, too much neuroscience in otology/neurotology. I like the procedures in rhinology, but I can't say that sinus pathology is remotely exciting from an intellectual standpoint. Skull base procedures carry a lot of morbidity, and feels more like neurosurgery than ENT. Allergy is intellectually complex, but I think allergy is generally a minor portion of an ENT practice. Plastics? Awesome. Septos, rhinos, flaps, post Mohs recon? Sign me up! But I wonder if a practice can thrive on plastics alone, especially in larger cities.

Is it wise to pursue ENT when a good portion of the specialty doesn't excite me? Is this normal? I get the impression that FPRS is an incredibly competitive fellowship, and will only get more competitive as time goes on.

 

[Winged Scapula]

I guess the main question would be: is it a poor decision to pursue ENT with a strong eye towards plastics and with a general lack of interest in bread and butter ENT?

I was full steam ahead ENT until I did my rotation and realized I don't get excited by general bread/butter ENT. I don't find sinusitis or ear infections or tinnitus or vertigo intellectually stimulating. The science and pathology behind thyroid diseases don't rev my engine. I don't want to do H&N since it's all cancer, laryngology grosses me out, too much neuroscience in otology/neurotology. I like the procedures in rhinology, but I can't say that sinus pathology is remotely exciting from an intellectual standpoint. Skull base procedures carry a lot of morbidity, and feels more like neurosurgery than ENT. Allergy is intellectually complex, but I think allergy is generally a minor portion of an ENT practice. Plastics? Awesome. Septos, rhinos, flaps, post Mohs recon? Sign me up! But I wonder if a practice can thrive on plastics alone, especially in larger cities.

Is it wise to pursue ENT when a good portion of the specialty doesn't excite me? Is this normal? I get the impression that FPRS is an incredibly competitive fellowship, and will only get more competitive as time goes on.

Sounds like you should apply for PRS.

 

[Pir8DeacDoc]

Agree with above, if you like almost nothing that we do, you should consider something else.

 

[Confusion Abound]

I'm not competitive for PRS. And even then, I think I have the same problem with plastics: I'm not interested in boobs or body work. I like wound care, but breast augs and recon don't particularly excite me.

I think I have to come to terms with the fact that there's likely no "perfect" specialty where I like every aspect of the field.

I hear the laryngology guys talk about how much they hate ear stuff, and how the H&N guys dislike rhinology, and how everybody hates vertigo and epistaxis.

 

[Confusion Abound]

No PRS home department, no PRS letters, no PRS research, and no real PRS exposure until 4th year aways. In the last five years, only one person has matched plastics from my school, although I don't know how many have applied.

 

[TallScrubs]

No PRS home department, no PRS letters, no PRS research, and no real PRS exposure until 4th year aways. In the last five years, only one person has matched plastics from my school, although I don't know how many have applied.

Who gives a **** about that? BE THE PERSON from your school who matches.

 

[Winged Scapula]

No PRS home department, no PRS letters, no PRS research, and no real PRS exposure until 4th year aways. In the last five years, only one person has matched plastics from my school, although I don't know how many have applied.

You're making excuses. None of those are insurmountable.

You're also stereotyping PRS. There's a lot more to it than "body work and boobs". If you want to do facial PRS and/or craniofacial, that's your route.

Now that I think about it, you're protesting too much. You've got a great Step 1 score, a soon to have US MD and the opportunity to choose your specialty. Stop finding things to hate about these fields and making excuses about why you can't match. Of course there's no "perfect" specialty; nothing in life is perfect:not your partner, not your friends, not your career.

On Monday go to your advisor and say you need PRS exposure and some letters before next September. Your schools goal is to get you to match and well. They should help you.