A Proposed Approach for Speciality Selection

[medschoolappl]

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I wanted to share my approach to picking my medical speciality. There are a lot of humorous flow charts and algorithms that suggest an approach to picking a medical speciality; however, we would all agree it is a serious issue and I was frustrated that I didn't receive a lot of guidance.

Often when I would ask doctors how they chose their speciality they would say that it was a gut feeling or that they met a particular mentor who influenced them and they sought to emulate his professional life. I found this unsatisfying.

My approach is not algorithmic per se. Rather, it approaches it bottom-up: start with your values and then try to find a specialty that best reflects them. This recognizes, of course, that there are trade-offs at every step and there is a lot of diversity within particular specialities.

Here's what I propose:

1) Disease Process, Systems, Anatomy:

Sample questions to ask:

What disease processes do I like (oncologic, autoimmune, infectious, etc)?

Do I want a wide mix of disease processes or narrow?

What physiologic systems did I like learning about most? Do I want to deal with many systems or a few?

Was there particular anatomy that I enjoyed learning about?

2) Population

Do I want to deal with high acuity disease, lower acuity disease, or mixed acuity?

Patient demographics (age, gender, disease burden, etc)

3) Skill mix

Do I want my job to be more knowledge based or based on technical application?

4) Professional lifestyle

How intense can I accept my residency being?

How much can I accept standing in day?

How much call am I willing to accept?

Am I willing to work non-traditional hours?

Is it important to me to be wealthy in absolute terms or do I care more about pay/work ratio?

What kind of practice setting would I enjoy?

Do I want to be purely clinical or are there other things I want to do in my professional life?

Example:

Cardiology:

1) Single system, many disease processes, restricted anatomy

2) Mixed acuity skews higher, mixed demographics skews older, higher disease burden

3) Varied skill mix at baseline, opportunities to sub-specialize more knowledge based or more technical.

4) Not particularly lifestyle oriented, high call burden, traditional hours, high compensation, moderate-low pay/work ratio.

Emergency Medicine.

1) Many disease processes, many systems, varied anatomy

2) Mixed acuity skews higher acuity, highly diverse patient demographics

3) Knowledge base is highly algorithmic, technically oriented

4) non-traditional hours, moderate compensation, moderate pay-work ratio.

Dermatology.

1) Many disease processes, single system, restricted anatomy

2) Low acuity, diverse patient demographics

3) Varied skill mix at baseline, opportunities to sub-specialize more knowledge based or more technical.

4) Highly lifestyle oriented, no call, traditional hours, high compensation, very high pay/work ratio

Hope you find this helpful. Let me know if you would add anything.

 

[bashwell]

I wanted to share my approach to picking my medical speciality. There are a lot of humorous flow charts and algorithms that suggest an approach to picking a medical speciality; however, we would all agree it is a serious issue and I was frustrated that I didn't receive a lot of guidance.

Often when I would ask doctors how they chose their speciality they would say that it was a gut feeling or that they met a particular mentor who influenced them and they sought to emulate his professional life. I found this unsatisfying.

My approach is not algorithmic per se. Rather, it approaches it bottom-up: start with your values and then try to find a specialty that best reflects them. This recognizes, of course, that there are trade-offs at every step and there is a lot of diversity within particular specialities.

Here's what I propose:

1) Disease Process, Systems, Anatomy:

Sample questions to ask:

What disease processes do I like (oncologic, autoimmune, infectious, etc)?

Do I want a wide mix of disease processes or narrow?

What physiologic systems did I like learning about most? Do I want to deal with many systems or a few?

Was there particular anatomy that I enjoyed learning about?

2) Population

Do I want to deal with high acuity disease, lower acuity disease, or mixed acuity?

Patient demographics (age, gender, disease burden, etc)

3) Skill mix

Do I want my job to be more knowledge based or based on technical application?

4) Professional lifestyle

How intense can I accept my residency being?

How much can I accept standing in day?

How much call am I willing to accept?

Am I willing to work non-traditional hours?

Is it important to me to be wealthy in absolute terms or do I care more about pay/work ratio?

What kind of practice setting would I enjoy?

Do I want to be purely clinical or are there other things I want to do in my professional life?

Example:

Cardiology:

1) Single system, many disease processes, restricted anatomy

2) Mixed acuity skews higher, mixed demographics skews older, higher disease burden

3) Varied skill mix at baseline, opportunities to sub-specialize more knowledge based or more technical.

4) Not particularly lifestyle oriented, high call burden, traditional hours, high compensation, moderate-low pay/work ratio.

Emergency Medicine.

1) Many disease processes, many systems, varied anatomy

2) Mixed acuity skews higher acuity, highly diverse patient demographics

3) Knowledge base is highly algorithmic, technically oriented

4) non-traditional hours, moderate compensation, moderate pay-work ratio.

Dermatology.

1) Many disease processes, single system, restricted anatomy

2) Low acuity, diverse patient demographics

3) Varied skill mix at baseline, opportunities to sub-specialize more knowledge based or more technical.

4) Highly lifestyle oriented, no call, traditional hours, high compensation, very high pay/work ratio

Hope you find this helpful. Let me know if you would add anything.

Well done -- all helpful questions to ask! 🙂

Just some minor constructive criticisms if I may:

-I wouldn't number the questions 1, 2, 3, and 4 if the numbering is meant to proceed in order (i.e., first 1, then 2, then 3, then 4). Instead I'd say you can ask the questions in any order you like. It's person-dependent. For example, some people might value patient population more than disease process, so they might prioritize patient population above disease process.

-Regarding #3, I don't think I'd ask, "Do I want my job to be more knowledge based or based on technical application?" as much as simply between doing more procedures or less procedures. I think all specialties are "more knowledge based" and "based on technical application" in a general way.

-It might be worth distinguishing between the kinds of procedures a specialty does. Surgeons are obviously very procedural, but even surgical procedures differ, however we can at least say surgical specialties are very different from medical specialties. That said anesthesia and critical care for example have a lot of procedures too. Derm has some procedures as well but obviously derm procedures (even Mohs) is not going to be like general surgery or neurosurgery's standard procedures. In any case, my point is just that some people might like procedures but not like surgical procedures but be okay with critical care for example. While some people might not want to do any procedures at all.

-Perhaps you could also include geography under #4 because a lot of the answers may vary depending on place or region you end up living in.

-One issue is how uncertain the future is for many if not most specialties (e.g., in terms of expected compensation, in terms of working in an employed position such as for a hospital or VA or in a private group). So it's hard to say one specialty will definitely have a high compensation while another will have a low one. You can probably evaluate specialties relative to each other (e.g., adult cardiology is likely to pay more than general pediatrics or pediatric cardiology).

Just some very minor criticisms, but overall I think this is helpful! 🙂

 

[medschoolappl]

Well done -- all helpful questions to ask! 🙂

Just some minor constructive criticisms if I may:

-I wouldn't number the questions 1, 2, 3, and 4 if the numbering is meant to proceed in order (i.e., first 1, then 2, then 3, then 4). Instead I'd say you can ask the questions in any order you like. It's person-dependent. For example, some people might value patient population more than disease process, so they might prioritize patient population above disease process.

-Regarding #3, I don't think I'd ask, "Do I want my job to be more knowledge based or based on technical application?" as much as simply between doing more procedures or less procedures. I think all specialties are "more knowledge based" and "based on technical application" in a general way.

-It might be worth distinguishing between the kinds of procedures a specialty does. Surgeons are obviously very procedural, but even surgical procedures differ, however we can at least say surgical specialties are very different from medical specialties. That said anesthesia and critical care for example have a lot of procedures too. Derm has some procedures as well but obviously derm procedures (even Mohs) is not going to be like general surgery or neurosurgery's standard procedures. In any case, my point is just that some people might like procedures but not like surgical procedures but be okay with critical care for example. While some people might not want to do any procedures at all.

-Perhaps you could also include geography under #4 because a lot of the answers may vary depending on place or region you end up living in.

-One issue is how uncertain the future is for many if not most specialties (e.g., in terms of expected compensation, in terms of working in an employed position such as for a hospital or VA or in a private group). So it's hard to say one specialty will definitely have a high compensation while another will have a low one. You can probably evaluate specialties relative to each other (e.g., adult cardiology is likely to pay more than general pediatrics or pediatric cardiology).

Just some very minor criticisms, but overall I think this is helpful! 🙂

This is excellent. Thanks for your feedback!

 

[acutepox]

This is super helpful, thanks for thinking through this. How do you control for differing opinions on these metrics? I've heard people disagree on how much "diagnostic/knowledge" based EM is, for example.

 

[medschoolappl]

This is super helpful, thanks for thinking through this. How do you control for differing opinions on these metrics? I've heard people disagree on how much "diagnostic/knowledge" based EM is, for example.

I would recommend getting a lot of different opinions from physicians in a variety of practice settings at different levels of training. I did 3 derm rotations for example 1) at my home institution a large academic medical center 2) another large academic medical center on the west coast with a poorer more urban population and 3) a community program in my home state with a faculty practice read private group practice at the center of training.

 

[Goro]

I find it interesting that none of your criteria has "working with patients". Your demographics appears to be a bin for the diseases you find interesting.

They're not cases...they're patients.

I wanted to share my approach to picking my medical speciality. There are a lot of humorous flow charts and algorithms that suggest an approach to picking a medical speciality; however, we would all agree it is a serious issue and I was frustrated that I didn't receive a lot of guidance.

Often when I would ask doctors how they chose their speciality they would say that it was a gut feeling or that they met a particular mentor who influenced them and they sought to emulate his professional life. I found this unsatisfying.

My approach is not algorithmic per se. Rather, it approaches it bottom-up: start with your values and then try to find a specialty that best reflects them. This recognizes, of course, that there are trade-offs at every step and there is a lot of diversity within particular specialities.

Here's what I propose:

1) Disease Process, Systems, Anatomy:

Sample questions to ask:

What disease processes do I like (oncologic, autoimmune, infectious, etc)?

Do I want a wide mix of disease processes or narrow?

What physiologic systems did I like learning about most? Do I want to deal with many systems or a few?

Was there particular anatomy that I enjoyed learning about?

2) Population

Do I want to deal with high acuity disease, lower acuity disease, or mixed acuity?

Patient demographics (age, gender, disease burden, etc)

3) Skill mix

Do I want my job to be more knowledge based or based on technical application?

4) Professional lifestyle

How intense can I accept my residency being?

How much can I accept standing in day?

How much call am I willing to accept?

Am I willing to work non-traditional hours?

Is it important to me to be wealthy in absolute terms or do I care more about pay/work ratio?

What kind of practice setting would I enjoy?

Do I want to be purely clinical or are there other things I want to do in my professional life?

Example:

Cardiology:

1) Single system, many disease processes, restricted anatomy

2) Mixed acuity skews higher, mixed demographics skews older, higher disease burden

3) Varied skill mix at baseline, opportunities to sub-specialize more knowledge based or more technical.

4) Not particularly lifestyle oriented, high call burden, traditional hours, high compensation, moderate-low pay/work ratio.

Emergency Medicine.

1) Many disease processes, many systems, varied anatomy

2) Mixed acuity skews higher acuity, highly diverse patient demographics

3) Knowledge base is highly algorithmic, technically oriented

4) non-traditional hours, moderate compensation, moderate pay-work ratio.

Dermatology.

1) Many disease processes, single system, restricted anatomy

2) Low acuity, diverse patient demographics

3) Varied skill mix at baseline, opportunities to sub-specialize more knowledge based or more technical.

4) Highly lifestyle oriented, no call, traditional hours, high compensation, very high pay/work ratio

Hope you find this helpful. Let me know if you would add anything.

 

[neusu]

More realistically: look at your Step 1 Score. Look at charting outcomes mean Step 1 score by specialty. Look at average salary for each field. Narrow to highest salaries where your Step 1 > mean Step 1 for that field. Look at # hours worked, rank in order of hours worked from least to most.

 

[medschoolappl]

I find it interesting that none of your criteria has "working with patients". Your demographics appears to be a bin for the diseases you find interesting.

They're not cases...they're patients.

I'm not sure of the utility of making a tired cliche like "they're not cases..they're patients". Obviously, we chose to go to medical school to treat disease and make people well. Given that there are a tremendous number of ways to do that, I tried to apply some rigor to the decision making. An Ob-gyn, geriatrician, neonatologist, and radiation oncologist are dealing with very different types of patients. That is what I mean by demographics.

If you are making the point that some providers, like radiologists, might not want a lot of direct patient contact, then I agree that is a very important consideration. More patient interaction or less.

 

[aalamruad]

More realistically: look at your Step 1 Score. Look at charting outcomes mean Step 1 score by specialty. Look at average salary for each field. Narrow to highest salaries where your Step 1 > mean Step 1 for that field. Look at # hours worked, rank in order of hours worked from least to most.

Is anyone else fed up with these lifestyle threads?

Medicine is a calling for most of us. Much of the reason we are entrusted with the privilege to care for others is that we sacrifice for it. They can count on us. This notion that "well I just want banker's hours, not much to do during those hours, no call, and a lot of money," gives the entire field a bad image.

If you want to play doctor, but not have the responsibilities that come with it, there are other pathways to clinical medicine.

You simply can not expect to have your cake, and eat it too.

😕

 

[neusu]

😕

Not saying I support it, simply that is the trend!

 

[Goro]

I'm not sure of the utility of making a tired cliche like "they're not cases..they're patients". Obviously, we chose to go to medical school to treat disease and make people well. Given that there are a tremendous number of ways to do that, I tried to apply some rigor to the decision making. An Ob-gyn, geriatrician, neonatologist, and radiation oncologist are dealing with very different types of patients. That is what I mean by demographics.

If you are making the point that some providers, like radiologists, might not want a lot of direct patient contact, then I agree that is a very important consideration. More patient interaction or less.

Do you want to work on patients, or with them? I didn't get any sense of which one you preferred.

 

[BigRedBeta]

Reasonable approach - your key elements are important, but I'd change the order for actually narrowing down specialties. I say this mainly for getting rid of large numbers of options more rapidly.

I generally tell students to go down the following path: Operating Room or not, kids or not, single organ system or more general.

Things like lifestyle are important, but really hard to predict. There are a ton of different practice models out there and for even the most rigorous of specialties, there are cush jobs out there that can be found. Likewise, cush specialists can be worked to death if the circumstances are correct. Further, most people if they find the right professional satisfaction will readily sacrifice hours worked.