Choosing a speciality

[M3478]

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I am a rising M4 at a USMD school. Honored all rotations, but I haven’t taken Step 2 yet. Have research in a surgical subspecialty but after my surgery rotation, I realized I’m not as interested in pursuing that field. Now really confused and have to set up my 4th year schedule soon.

Things I like:
-Talking to people
-Being at least a little specialized
-The option to be fully outpatient
-OBGYN (actually loved OBGYN clinic, liked gyn surgery, but can not see myself doing L&D often and worried about pursuing OBGYN only if I can see myself in a gyn heavy practice, especially with those fellowship being very competitive)
-Breast clinic/ Breast surgery (really cannot get passed the fact that I would have to complete general surgery residency to get there)
-Inpatient pediatrics/IM/FM were good
-Outpatient IM/FM were okay (not the most exciting but can still see myself happy doing either of these. Do not mind the paperwork, etc)

Things I do not like:
- Inconsistent/unpredictable hours after residency
- Probably pathology/diagnostic radiology/anything without direct patient interactions

 

[GoSpursGo]

If you're not dead set on a specific specialty, and you liked IM inpatient, then IM followed by a subspecialty seems like a decent option for you.

I will say that eliminating a fellowship field just because you wouldn't love your residency, while valid, is somewhat limiting. Residency is going to be rough no matter what you do, so would think and prioritize your endgame.

 

[purpledoc1]

My vote is for IM or peds

 

[operaman]

Anesthesia is certainly a well trod path after surgery - can do OR based, critical care, and things like interventional pain with more outpatient options if you’d like. Not sure which surgical sub you were after, but they’re not all the same. Ophtho can be very chill and outpatient heavy. ENT is much the same if you want it to be. I actually make a lot more money in clinic than I do in the OR so could easily do 100% outpatient if I wanted, but then I’d probably go nuts. My guess is you were ortho bound and they are definitely very OR heavy.

Not sure what exactly turned you off from surgery but Gen Surg is quite different from the subs, and tertiary care anything quite different from community practices. If you just hated the OR then definitely want to find something else, but if it was more about hours and unpredictability, maybe worth considering. I average under 40 hours a week (range 36-42h according to my tracker on my phone) and it’s fairly predictable too unless I’m on call. Plenty of docs with even cushier setups than me too.

Psych would also hit most of your requirements. Ditto IM and specialties.

 

[M3478]

Anesthesia is certainly a well trod path after surgery - can do OR based, critical care, and things like interventional pain with more outpatient options if you’d like. Not sure which surgical sub you were after, but they’re not all the same. Ophtho can be very chill and outpatient heavy. ENT is much the same if you want it to be. I actually make a lot more money in clinic than I do in the OR so could easily do 100% outpatient if I wanted, but then I’d probably go nuts. My guess is you were ortho bound and they are definitely very OR heavy.

Not sure what exactly turned you off from surgery but Gen Surg is quite different from the subs, and tertiary care anything quite different from community practices. If you just hated the OR then definitely want to find something else, but if it was more about hours and unpredictability, maybe worth considering. I average under 40 hours a week (range 36-42h according to my tracker on my phone) and it’s fairly predictable too unless I’m on call. Plenty of docs with even cushier setups than me too.

Psych would also hit most of your requirements. Ditto IM and specialties.

I was actually planning on ophtho. Realized I don’t like working with microscopes, physics, or super quick interactions… Not sure if I am making a mistake giving it up for those reasons, but also ignoring those things and trying to go for it does not feel right.

 

[purpledoc1]

I was actually planning on ophtho. Realized I don’t like working with microscopes, physics, or super quick interactions… Not sure if I am making a mistake giving it up for those reasons, but also ignoring those things and trying to go for it does not feel right.

What made you realize that you don't like physics?

 

[M3478]

What made you realize that you don't like physics?

I have actually never liked physics (undergrad, MCAT), but I honestly had not thought about how much physics was in ophtho before this year.

 

[eyeeye_captain]

I was actually planning on ophtho. Realized I don’t like working with microscopes, physics, or super quick interactions… Not sure if I am making a mistake giving it up for those reasons, but also ignoring those things and trying to go for it does not feel right.

Microscopes are unavoidable. What’s the hang up there?

Physics is only applicable to board exams - it’s generally not clinically relevant since machines do most of your calculations.

I see over 60 retina patients a day, know many of them extremely well, and have never been accused of being rushed. You won’t have super quick interactions early in your career because you’ll be slow. When you get up to speed and have a panel of patients you know, then you know where your time goes. Who wants to get out the door, who’s chatty, who’s the really tough case. You learn how to put your time together. Granted I have people I’ll see monthly until either of us retire, but it’s easy (at least for me) to have strong relationships with 5 or so minute visits. Pretty easy to chat during an exam or procedure.

 

[operaman]

I was actually planning on ophtho. Realized I don’t like working with microscopes, physics, or super quick interactions… Not sure if I am making a mistake giving it up for those reasons, but also ignoring those things and trying to go for it does not feel right.

Yeah not sure how much actual physics would play a role in practice. I feel like we had a lot of that basic stuff on boards but in practice it’s more about having an intuitive understanding of the system so you can troubleshoot it effectively. The physics for me is mostly fluid dynamics, but I’m not working out equations, just thinking through clinical problems.

The quick interactions are entirely up to the doc. when I started practice I was probably more like 20-30 minutes per patient. Now I’m 7-10m per encounter and I get everything accomplished I need and see twice as many patients in the same timeframe and still have patient satisfaction scores in the 97th percentile nationally. You can make interactions anything you want.

Microscope a bit tougher. I’ve known of people with eye conditions that made it hard to use the scope. I’m not sure what those are, but I’ve known of people changing fields as a result in rare cases. That aside, it’s definitely a learned skill and it’s a bit weird in the beginning. Learning to focus and balance and get the view is tricky at first. I’ve got a PA who just started with me and is learning the micro and I’m remembering how hard it is in the beginning. It’s also night and day different between the surgeon view and the side port because you lose the depth perception. I was probably a pgy3 before I felt good about the scope and was efficient with it. Now I can’t imagine practicing without it.

It does sound like Ophtho fits everything you’re looking for otherwise. I would caution against letting early technical struggles define your path. Everyone sucks at this stuff in the beginning; it’s not something we’re born knowing how to do. My buddy who got teased as an intern for his nasal endoscopy skills went to a top Rhinology and skull base fellowship and is a very successful Rhinologist. My first attempt at a phonosurgical micro flap was terrible - I could barely keep the instruments still much less perform the surgery. Now I’m a Laryngologist and do those all the time.

 

[Dr. Robb Bassett]

I really appreciate how clearly you're thinking this through. A lot of students don’t slow down long enough to ask these questions until they’re already halfway down the wrong road. You’re in a strong position, even if it feels uncertain right now.

From what you’ve shared, it sounds like you're someone who:

• Cares deeply about real, ongoing patient interaction
• Wants a career that's a bit specialized, but still flexible
• Leans toward outpatient work with a more predictable lifestyle
• Can appreciate thoughtful, lower-acuity medicine without needing constant “excitement”

Here are a few things to reflect on:

OBGYN — Loved the clinic, unsure about the full scope

The fact that you enjoyed the clinic and GYN surg is more than a lot of people can say. But your reservations about L&D are valid—and pretty common among students I’ve worked with in both clinical and coaching roles.

Here’s a question worth asking:
If L&D were a permanent part of your job, how would that sit with you five years in?
Unless you match into a specific subspecialty, OB coverage is hard to avoid—and it's not something easily “tolerated” long-term.

Women’s health–focused training in FM or IM might be worth exploring. I’ve seen students build deeply fulfilling outpatient practices centered around women's health, contraception, breast health, and adolescent care—without needing to go through OB call or surg residency.

Breast Surgery — Is the tradeoff worth it?

If the end point excites you but the path gives you pause, that’s important to listen to. I’ve seen it often—students drawn to breast surg for its meaning and population, but totally misaligned with the general surgery culture and training model.

This question might help tease that apart:
Is it the surgical doing you love—or the patient population and continuity of care?

If it’s the latter, there are meaningful paths through primary care specialties. In my own experience working in addiction med and women’s health clinics, I’ve seen IM and FM-trained physicians play central roles in breast health and survivorship care.



IM/FM/Med-Peds — Not flashy, but flexible and high-impact

The fact that you can “still see yourself happy” in IM or FM is actually a quiet green light. You don’t need to feel electrified by a field for it to be a good fit—you need to feel like you could do it well, sustainably, and with meaning.

Given that you liked both inpatient and outpatient IM and Peds, I’d suggest looking into Med-Peds. It keeps your options wide open and gives you space to figure out whether you want to go more specialized later—or stay broad and outpatient-focused.

In many of the settings I’ve practiced in, I’ve seen generalists leading meaningful clinical and public health work—especially when they’ve carved out a niche.



Fourth-Year Elective Ideas

This is a great moment to “test-drive” what your future could look like. Some elective ideas that align well with your interests:

• Adolescent Med
• Women’s Health in FM or IM settings
• Breast clinic electives outside of surg (oncology, survivorship)
• Med-Peds sub-I
• Rheum, Endo, or Palliative (lower acuity, outpatient, thoughtful care)

One last thing to consider:
If you could design your ideal “Tuesday in clinic” 10 years from now—what kind of patients are you seeing? What problems are you helping with? How do you feel when you walk out the door at the end of the day?

Sometimes that vision gives more clarity than any algorithm or flowchart.

Happy to bounce around more thoughts if it’s helpful. You're asking the right questions—just keep going.

 

[M3478]

I really appreciate how clearly you're thinking this through. A lot of students don’t slow down long enough to ask these questions until they’re already halfway down the wrong road. You’re in a strong position, even if it feels uncertain right now.

From what you’ve shared, it sounds like you're someone who:

• Cares deeply about real, ongoing patient interaction
• Wants a career that's a bit specialized, but still flexible
• Leans toward outpatient work with a more predictable lifestyle
• Can appreciate thoughtful, lower-acuity medicine without needing constant “excitement”

Here are a few things to reflect on:

OBGYN — Loved the clinic, unsure about the full scope

The fact that you enjoyed the clinic and GYN surg is more than a lot of people can say. But your reservations about L&D are valid—and pretty common among students I’ve worked with in both clinical and coaching roles.

Here’s a question worth asking:
If L&D were a permanent part of your job, how would that sit with you five years in?
Unless you match into a specific subspecialty, OB coverage is hard to avoid—and it's not something easily “tolerated” long-term.

Women’s health–focused training in FM or IM might be worth exploring. I’ve seen students build deeply fulfilling outpatient practices centered around women's health, contraception, breast health, and adolescent care—without needing to go through OB call or surg residency.

Breast Surgery — Is the tradeoff worth it?

If the end point excites you but the path gives you pause, that’s important to listen to. I’ve seen it often—students drawn to breast surg for its meaning and population, but totally misaligned with the general surgery culture and training model.

This question might help tease that apart:
Is it the surgical doing you love—or the patient population and continuity of care?

If it’s the latter, there are meaningful paths through primary care specialties. In my own experience working in addiction med and women’s health clinics, I’ve seen IM and FM-trained physicians play central roles in breast health and survivorship care.



IM/FM/Med-Peds — Not flashy, but flexible and high-impact

The fact that you can “still see yourself happy” in IM or FM is actually a quiet green light. You don’t need to feel electrified by a field for it to be a good fit—you need to feel like you could do it well, sustainably, and with meaning.

Given that you liked both inpatient and outpatient IM and Peds, I’d suggest looking into Med-Peds. It keeps your options wide open and gives you space to figure out whether you want to go more specialized later—or stay broad and outpatient-focused.

In many of the settings I’ve practiced in, I’ve seen generalists leading meaningful clinical and public health work—especially when they’ve carved out a niche.



Fourth-Year Elective Ideas

This is a great moment to “test-drive” what your future could look like. Some elective ideas that align well with your interests:

• Adolescent Med
• Women’s Health in FM or IM settings
• Breast clinic electives outside of surg (oncology, survivorship)
• Med-Peds sub-I
• Rheum, Endo, or Palliative (lower acuity, outpatient, thoughtful care)

One last thing to consider:
If you could design your ideal “Tuesday in clinic” 10 years from now—what kind of patients are you seeing? What problems are you helping with? How do you feel when you walk out the door at the end of the day?

Sometimes that vision gives more clarity than any algorithm or flowchart.

Happy to bounce around more thoughts if it’s helpful. You're asking the right questions—just keep going.

Thank you so much for the thoughtful response. This decision has been incredibly difficult for me and these responses are very validating. I do think I am now leaning towards IM and doing something like general IM clinic, clinic with a women's health focus, or outpatient specialities like allergy/immunology or one of the others you mentioned. I have definitely ruled out the breast surgery after general surgery path; I do think I was more drawn to the clinic and patient population than the actual surgeries. I do still worry often that I would miss the excitement or impact of something like OBGYN, especially the impact I think I could have on my specific community, but I also worry that excitement would wear off and I would be left with a lifestyle I knew I did not want.

Generally, an ideal clinic day for me would be relatively calm, treating more concrete/focused conditions, and feeling like I did something to help people at the end of the day (even if chronic management, does not have to be immediate).

 

[Dr. Robb Bassett]

I love the way you are thinking about this now!

 

[Captain_Falcon]

Consider Neurology