Another Specialty Choices Thread

[ThrowawayScalpel]

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[hunterjumper14]

The only thing I would throw out there for neurosurgery is that you should try to round with the team a few times in the NeuroICU/SICU/PICU/etc to make sure you like managing patients with profound traumatic brain and spinal cord injuries. There are a lot of cases where Nsurg is working closely with the trauma and acute care surgeons to manage some really complicated and (in my opinion) sad cases. Often times neurosurgery is very involved early on, even if there is not a surgical intervention. Some people love this aspect, some people hate it! It's just something to think about.

 

[Anicetus]

We live in a time where it is more about your stats and success than interests for getting most of these specialties. Come back in 1.5 years with the same question.

 

[Entadus]

Now is not the time to narrow down your specialty choice. Now is the time to work hard to keep doors open. It is good that you are considering (haven't ruled out) competitive specialties like ENT and plastics since it will serve as motivation to excel in the first 2 years.

My suggestion is work as hard as you can without going too crazy. Keep your head down and remember it's a marathon, not a sprint. Try and start working on research at least by summer, or during 2nd semester if you've proven you can handle your classes.

 

[ACSurgeon]

Hi everyone,

I'm an MS1 who wants to get some opinions and advice on specialties and what I should start looking into. I know a lot of people suggest waiting until your third year to pick a specialty, but a lot of the specialties I'm considering require early research and I want to have some sense of idea of where I'm going before I try to get a research position. I've been reading through a lot of these types of threads on SDN for the past few weeks, including the ones currently on the first page and the ones in the residency-specific forums, but I figured I would start my own to get more targeted advice.

A bit about me:

I'm a first year medical student at a top ranked (research) medical school in the US. I'm interested in surgery. I've had exposure to multiple specialties (medical, surgical, and other) and will include relevant experiences later in this post. The two specialties I am most interested in are neurosurgery and general surgery. I would like to get people's opinions on how these two compare to each other and to other surgical specialties. Lifestyle considerations aren't a huge concern for me. I want to go into academic medicine and a bonus (but not a necessity) is possibility of doing international humanitarian aid work.

Neurosurgery:
Where to begin - I love the brain. I love brain anatomy. Nothing gets me more excited than learning about the brain, especially brain anatomy, brain pathology, and seeing what we can do to intervene in critical situations where someone's brain has been affected. I've shadowed in a variety of neurosurgical subspecialties and I've really enjoyed my time in the OR. I love the work hard, then work harder attitude so prevalent in neurosurgery. I know it's a rough life, but so far, it's the thing that has gotten me the most excited. The biggest downside I see to neurosurgery is that if I do it, I absolutely do not want to be at a community program. With neurosurgery, I'd want to be at a huge academic referral center with the most complex cases or I feel like it wouldn't be worth it. Also, not much opportunity for international work.

General Surgery:
So much variety yet still with the possibility of superspecialization. My main experience with GS is with surgical oncology, which I thought was very interesting, though I've also had some exposure to cardiothoracic and colorectal. There are very few GS fellowships that do not interest me. I think that GS would offer me initially more flexibility and more time to make a decision as to which realm of surgery I want to go into. I like that it's a mostly operative specialty. The biggest thing that turns me off to GS is that without subspecializing, you aren't really an "expert" in any particular area (though this can be solved with a fellowship). I would also be more open to community practice in GS if it turns out I can't cut it in academics than I would in NS. Also, good international opportunities.

Now,

with that in mind, here are the other surgical subspecialties that I'm at least somewhat interested in and what I like/don't like about them.

Orthopedic Surgery:
I'm just not that interested in the musculoskeletal system. I've heard that Ortho is basically GS but more interesting in terms of lifestyle/culture/etc, but I like visceral anatomy more than bone anatomy. A lot of people really seem to like this specialty, but I haven't really been able to understand why beyond the fact that the outcomes are good, cases are supposedly interesting (if you like bones), pay is good, and lifestyle is controllable when you get through residency. I have no experience shadowing an orthopedic surgeon.

ENT:
I really am not a fan of ear, nose, or throat anatomy, which is probably the biggest reason I'm not super excited about ENT. I've worked with an ENT in clinic, but have not gotten into the OR with one before, so maybe I'm biased, but the clinic visits were all very standard and boring, lots of scoping, nothing that really hooked me. Again, haven't been in the OR, so maybe that will change my mind, but based on the anatomy, I don't think it would be that interesting. The one thing I think might be super cool would be ENT surgical oncology, but I feel like very few people go into this because the case volume is just not there outside of major centers. I've heard the appeal of ENT is a mix of medical/surgical management, controllable lifestyle, good pay, not super long residency.

Plastics:
Cool toys, cool procedures, interesting cases. Reconstructive surgery is interesting and life-changing. However, I don't find purely cosmetic surgery that appealing or fulfilling. I don't have too much exposure with plastics, so I'm not totally sure of what the general day-to-day is like for a plastic surgeon. Additionally, if I have the credentials to go into plastics, I feel like I would just go into NS, though plastics does give great opportunities for international work.

Not really interested in, but haven't ruled out:

Urology:
I'm going to admit, the only reason I'm interested at all in urology is because they get to do robotic surgery, and I'm a sucker for cool technology. People say they go into urology because it pays well, has a good medical/surgical mix, good hours, and interesting cases.

Ophthalmology:
There was one point where I was interested in Ophtho, but I'm not really anymore. Office visits seem too much like my ENT experiences. Anatomy isn't super interesting to me. However, possibility for international work.

So that's it. Does anyone have any advice for what I should do next, or want to clear up any of my misconceptions (of which I am sure there are many)? I know that I should reach out to attendings here and start shadowing in different specialties, but I'm wondering if people have their own experiences with any of these specialties that they would like to share.

Thank you!

I stopped reading after neurosurgery and general surgery. With that said:

- Your stats might help you make that decision. If your step score and clinical grades are not stellar, none of the surgical specialties will be an option. General surgery might still be an option with "average" scores. Below average and you'll struggle to match anything surgical.

- Neurosurgery: outcomes can be very poor. Spine has good outcomes, but as one neurosurgeon describes: you're never the same once the air hits your brain. You can do a perfect crani and the patient can still have profound deficits. If this doesn't bother you, then proceed. I will mention that neurosurgery has excellent international opportunities. If nothing else, you can go around the world placing VP shunts in kids.

- General surgery: lot's of diversity which means there's likely something for everyone. You are the best trained physician, and know more medicine than any of the other surgical specialties.

 

[Donald Juan]

You're most interested in GS and Neurosurg, which is good because they are the least competitive of your list. If you want academics and need research just start doing it with whoever you find interesting without feeling like it absolutely has to be in the specialty you will ultimately do.

 

[tiedyeddog]

Only pick neurosurgery if you can't imagine being happy doing anything else. You have to be OK with poor outcomes. As lazymed talked about, you might do a perfect glioma resection but that likely won't change the outcome for the patient. You might also do a textbook trauma crani and the patient will still need a trach/peg tube and will be forever limited to a long-term facility. Also, when we have complications they can be extremely terrible. A small meningioma resection might have a small amount of bleeding post-op, but a small amount of bleeding within the fixed confines of the skull can mean death or permanent dysfunction. Even our elective spine complications can be gut wrenching, it can be easy to contuse the cord during a two level degenerative spine case that causes permanent weakness.

There is a growing ability to do international work in neurosurgery. There are currently a couple big named people at academic centers doing outpatient cranis for tumor resection in third world countries with surprisingly good outcomes. Same with AComm aneurysm clipping. Plus, LP and VP shunts can easily be done same day.

As others have said, your step 1 scores will help determine some of these options for you. I would advise doing some kind of research, it will help regardless of the field you end up going into.

 

[byaaaaaaah23]

@tiedyeddog Is it really that irrelevant which field your research is in? Don't most specialties expect that you will have done research in their field before you apply? For most fields it sounds like you have to take a year off to do specialty-specific research to be competitive, but I would really love to hear that's not true.

 

[tiedyeddog]

@tiedyeddog Is it really that irrelevant which field your research is in? Don't most specialties expect that you will have done research in their field before you apply? For most fields it sounds like you have to take a year off to do specialty-specific research to be competitive, but I would really love to hear that's not true.

Doing research within the field you are applying will help you but doing it in another field is not a deal breaker by any means. Most people who match in neurosurgery have not taken a year off, I'd say under 10 percent.

 

[WinslowPringle]

Neurosurgery: Where to begin - I love the brain. I love brain anatomy. Nothing gets me more excited than learning about the brain, especially brain anatomy, brain pathology, and seeing what we can do to intervene in critical situations where someone's brain has been affected. I've shadowed in a variety of neurosurgical subspecialties and I've really enjoyed my time in the OR. I love the work hard, then work harder attitude so prevalent in neurosurgery. I know it's a rough life, but so far, it's the thing that has gotten me the most excited. The biggest downside I see to neurosurgery is that if I do it, I absolutely do not want to be at a community program...Also, not much opportunity for international work.

-There is some international work opportunity. And if it doesn't meet what you want, why not be the forerunner?
-Why would you absolutely not want to do community? Community can mean a pretty wide variety of places from 10,000 to 500,000 (or more); as the local neurosurgeon, you'd get some of the first glimpses at some very complex cases that you could do or not depending on your skills and local infrastructure (which can greatly vary).
-As mentioned, get some more experience esp on the floor/clinic. See if you can deal with the outcomes, the migraine and chronic back pain patients.

General Surgery: So much variety yet still with the possibility of superspecialization. My main experience with GS is with surgical oncology, which I thought was very interesting, though I've also had some exposure to cardiothoracic and colorectal. There are very few GS fellowships that do not interest me. I think that GS would offer me initially more flexibility and more time to make a decision as to which realm of surgery I want to go into. I like that it's a mostly operative specialty. The biggest thing that turns me off to GS is that without subspecializing, you aren't really an "expert" in any particular area (though this can be solved with a fellowship). I would also be more open to community practice in GS if it turns out I can't cut it in academics than I would in NS. Also, good international opportunities.

-Also, GS does also absolutely include the work hard, then harder mentality.
-Lots of medical management, lots of comorbidities
-Depending on subspecialty, opportunities for consistently pretty good outcomes
-Options for robotic surgery (and endovascular, and SILS, and other cool stuff...)
-Pay is better than some gloomy rumors published in dark corners of the net...

Orthopedic Surgery:
I'm just not that interested in the musculoskeletal system. I've heard that Ortho is basically GS but more interesting in terms of lifestyle/culture/etc, but I like visceral anatomy more than bone anatomy...

-Ortho is not basically GS. Ortho does no med management. Ortho does little suturing beyond non-plastics skin closures.
-Ortho is not more interesting in terms of lifestyle/culture (unless you are a stereotypical lifting jock person)
-Ortho may be another path to spine if that's what you are interested in.

ENT: I really am not a fan of ear, nose, or throat anatomy, which is probably the biggest reason I'm not super excited about ENT. I've worked with an ENT in clinic, but have not gotten into the OR with one before, so maybe I'm biased, but the clinic visits were all very standard and boring, lots of scoping, nothing that really hooked me. Again, haven't been in the OR, so maybe that will change my mind, but based on the anatomy, I don't think it would be that interesting. The one thing I think might be super cool would be ENT surgical oncology, but I feel like very few people go into this because the case volume is just not there outside of major centers. I've heard the appeal of ENT is a mix of medical/surgical management, controllable lifestyle, good pay, not super long residency.

-Lots of clinic
-Some residencies are 7 years long
-What do you mean by medical management? There are lots of opportunities of non-operative management that include medicines, but not 'medical' management in the same sense as I think of like 'internal medical' management with heavy management of comorbidities (if the difference makes sense)

Plastics: Cool toys, cool procedures, interesting cases. Reconstructive surgery is interesting and life-changing. However, I don't find purely cosmetic surgery that appealing or fulfilling. Additionally, if I have the credentials to go into plastics, I feel like I would just go into NS, though plastics does give great opportunities for international work.

-The credentials needed for plastics are different than those needed for NS. Personalities (in general) are very different.
-Can get here (currently) through GS, but who knows what that will be like by the time you're ready
-Would you be happy with community practice with this or only academic?

Urology: I'm going to admit, the only reason I'm interested at all in urology is because they get to do robotic surgery, and I'm a sucker for cool technology. People say they go into urology because it pays well, has a good medical/surgical mix, good hours, and interesting cases.

-Lots of stones
-Lots of prostates that people debate taking out vs watching vs other management and outcomes can be devastating for patients
-Lots of peen jokes
-Some renal cancers
-Not the only specialty that does robotics
-Typically cool people

Ophthalmology: There was one point where I was interested in Ophtho, but I'm not really anymore. Office visits seem too much like my ENT experiences. Anatomy isn't super interesting to me. However, possibility for international work.

-Lots of decently established opportunities for international work; several of my friends heavily interested in international work, in fact, picked optho just for that. Can make a real difference with good outcomes in good amount of time with little follow-up with cataract surgery.
-Lots of clinic. Lots.