Choosing a specialty, at a loss

[GotToGetThatGPAUp]

Another one of these threads

I'm between my MS3 and MS4 years doing an MPH (It was paid for by my school, and in hindsight realize it's not really worth it but here I am), and just turned 30 last week and it has had me be introspective.

First, my stats:

• "Low-tier" MD
• Step 2: 265
• Pubs: 1 second author publication, ~ 4 posters/abstracts
• Awards: Academic Excellence (top 10% of the class), Outstanding Service (goes to ~9% of the class for community outreach), very likely AOA
• Leadership/ECs: Very involved in teaching/education with my school and beyond, started and ran a very successful clinic in an extremely underserved area during M1-M2, a bunch of other stuff

Sometimes I get caught up in the idea of competitive lifestyle specialties because I have a chance at them

What I'm looking for is a specialty where I can am dealing with a diverse selection of pathologies, and really need to sit down and think on how to both diagnose and treat said conditions. I would also want a decent mix of "act now" emergency scenarios, I work best under pressure and am very much the textbook definition of ADHD (this is not a personality descriptor but an actual diagnosis that has been upheld several times throughout my life).

I love working with my hands, and was initially drawn to the OR, but perhaps because I've only seen it as a med student and couldn't appreciate the nuance I'd start daydreaming and get antsy real quick in the OR (find the planes, restore proper anatomy, yada yada). I still love the OR as an idea, but it's not for me and I can satisfy the needs it does meet through hobbies.

I'm really interested in multi-system pathology, and that has gotten me deeply interested in critical care as well as heme onc. I also really love teaching, and believe I'd do whatever I do in an academic environment.

Lifestyle used to not be too important to me, but as I hit 30 I realized I havent had many opportunities to do much in my life. I've never traveled, I've never really just got to live. As such, I would like a specialty that gives me the opportunity to have chunks of time down, whether it be vacationing for 2-3 week blocks, or having a week-long block off every month, something where I can engage in hobbies and travel and be the part of me that isn't a physician.

I used to also be Peds >> IM, but the outlook of peds subspecialties and the income has made me begrudgingly cross this off.

When thinking about specialty choices, if youre able to help me come up with one what would you say my chances are at a "top 20" program in said specialty? This isn't absolutely important to me but I am curious.

Thanks

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[Captain_Falcon]

Anesthesia. If you don’t love the OR aspect can do a critical care fellowship. Could also just do IM -> CC fellowship too

 

[GotToGetThatGPAUp]

Anesthesia. If you don’t love the OR aspect can do a critical care fellowship. Could also just do IM -> CC fellowship too

Any difference between the two pathways I should choose one over the other? My gut tells me academic positions probably prefer IM -> Pulm/CC though I'd have no data to say if that's true or not.

 

[VA Hopeful Dr]

Any difference between the two pathways I should choose one over the other? My gut tells me academic positions probably prefer IM -> Pulm/CC though I'd have no data to say if that's true or not.

Going IM first you do pulm/cc which gives you a fallback (pulm) for when you burn out on the CC part.

 

[GotToGetThatGPAUp]

Going IM first you do pulm/cc which gives you a fallback (pulm) for when you burn out on the CC part.

I've heard this, but my only thing is I'd have to start pulm from the jump out of fellowship no? Because I can't go all in on crit care after fellowship and then 10+ years later decide to start at a pulm clinic, what with skill atrophy and the like correct?

I'm not necessarily against this (I'm quite neutral right now as I have no idea how I'd feel about pulm clinic at this time)

 

[DrStephenStrange]

I may be biased. But what about Neuro then Neuro CC or Neuro IR. They go well with alot of the things you mentioned above.

 

[srirachamayonnaise]

Heme/onc is multi-organ (so to speak) and a mixture of acute (coagulopathy) and chronic (CML and the like). Deep fields with lots of new things being discovered. Lifestyle isn't too bad given most of your follow-ups can be done remotely.

 

[mrbreakfast]

What I'm looking for is a specialty where I can am dealing with a diverse selection of pathologies, and really need to sit down and think on how to both diagnose and treat said conditions. I would also want a decent mix of "act now" emergency scenarios, I work best under pressure and am very much the textbook definition of ADHD (this is not a personality descriptor but an actual diagnosis that has been upheld several times throughout my life).

Going to second neurology, specifically neurohospitalist. You get a variety of extremely complex/rare presentations intermixed with constant chaos - stroke alerts, seizures, cerebral edema, etc. You spend plenty of time running around and seeing patients in the ED - you have time to do this because you have no primary patients. See plenty of multisystem pathology (cardiac and hematological for stroke, renal/hepatic for toxic encephalopathy, etc) and will spend a lot of time in various ICUs. Not a lot of procedures, but you do use your hands to diagnose your patients - neuro exam is a powerful tool once you learn it. Oh, and you don't need to do a fellowship; and if you decide to, they're all one or two years.

Neurology isn't for everyone, but if you haven't had the chance yet in medical school, tag along with the neuro consult attending for a day or two and see what it's like.

 

[GotToGetThatGPAUp]

Heme/onc is multi-organ (so to speak) and a mixture of acute (coagulopathy) and chronic (CML and the like). Deep fields with lots of new things being discovered. Lifestyle isn't too bad given most of your follow-ups can be done remotely.

Going to second neurology, specifically neurohospitalist. You get a variety of extremely complex/rare presentations intermixed with constant chaos - stroke alerts, seizures, cerebral edema, etc. You spend plenty of time running around and seeing patients in the ED - you have time to do this because you have no primary patients. See plenty of multisystem pathology (cardiac and hematological for stroke, renal/hepatic for toxic encephalopathy, etc) and will spend a lot of time in various ICUs. Not a lot of procedures, but you do use your hands to diagnose your patients - neuro exam is a powerful tool once you learn it. Oh, and you don't need to do a fellowship; and if you decide to, they're all one or two years.

Neurology isn't for everyone, but if you haven't had the chance yet in medical school, tag along with the neuro consult attending for a day or two and see what it's like.

thanks folks, I may need to find a chance to do that as we didn't really get any neuro exposure (besides what was essentially a teeny bit of shadowing in the neuro ICU)

 

[VA Hopeful Dr]

I've heard this, but my only thing is I'd have to start pulm from the jump out of fellowship no? Because I can't go all in on crit care after fellowship and then 10+ years later decide to start at a pulm clinic, what with skill atrophy and the like correct?

I'm not necessarily against this (I'm quite neutral right now as I have no idea how I'd feel about pulm clinic at this time)

CC is 2 years, pulm/cc is 3 years combined.

 

[GotToGetThatGPAUp]

CC is 2 years, pulm/cc is 3 years combined.

I'm aware, my question is you mentioned going Pulm/CC because you can start putting more work into pulm clinic and less into the ICU as you burn out, but that requires you going into pulm clinic from the jump as I imagine you're not going to just start clinic work 10 years after fellowship and I'm not even sure if I want to do any clinic work.

 

[VA Hopeful Dr]

I'm aware, my question is you mentioned going Pulm/CC because you can start putting more work into pulm clinic and less into the ICU as you burn out, but that requires you going into pulm clinic from the jump as I imagine you're not going to just start clinic work 10 years after fellowship and I'm not even sure if I want to do any clinic work.

Ah, my mistake then.

I'm a simple FP so I can't claim to know the ins and puts of how this can work.

 

[Dr G Oogle]

Pulm/cc also can do sleep medicine I believe which can be quite lucrative.

Neuro IR is still predominantly done by rads and neurosurgery, not sure how landscape has changed for accepting neurology applicants but I’m sure it’s better.

 

[Mad Jack]

Any difference between the two pathways I should choose one over the other? My gut tells me academic positions probably prefer IM -> Pulm/CC though I'd have no data to say if that's true or not.

I can only speak to the big academic place I worked years ago. Pulm/CC is usually first choice for MICU, surg/CC for SICU, and neuro/CC for NICU. Anesthesia/CC tends to be able to pick up SICU spots more easily than MICU, as surgeons would rather be doing surgery than weaning vents. Never saw an anesthesia/CC in MICU or cardiac ICU (which tended to be staffed by the surgical service with backup from pulm/CC), and NICU was kind of it's own thing.

 

[Mad Jack]

Going to second neurology, specifically neurohospitalist. You get a variety of extremely complex/rare presentations intermixed with constant chaos - stroke alerts, seizures, cerebral edema, etc. You spend plenty of time running around and seeing patients in the ED - you have time to do this because you have no primary patients. See plenty of multisystem pathology (cardiac and hematological for stroke, renal/hepatic for toxic encephalopathy, etc) and will spend a lot of time in various ICUs. Not a lot of procedures, but you do use your hands to diagnose your patients - neuro exam is a powerful tool once you learn it. Oh, and you don't need to do a fellowship; and if you decide to, they're all one or two years.

Neurology isn't for everyone, but if you haven't had the chance yet in medical school, tag along with the neuro consult attending for a day or two and see what it's like.

I feel like neurology is basically the anti-ADHD specialty. It has this strong focus on particulars that doesn't tend to favor the ADHD brain, but that's just my personal experience. I've never known someone with ADHD that loved it, but that's just my N=whatever

 

[Tenk]

Call or no call?
Nights/holidays/weekends or bankers hours?
Hospital or clinic?

These questions are far more important in terms of career and longevity than anything else. Think long and hard about these and it will eliminate probably >50% of choices depending on your answers.

 

[operaman]

Seconding anesthesia as a good option and would add things like derm and Ophtho. Sure there’s some OR in the latter but on balance is less than most other surgical fields.

ENT as well is a nice balance and our OR (outside the academic big head and neck cancer surgeries) tend to be shorter and outpatient. I’ve got the adhd brain too and find the variety in my week very helpful. I operate 1-1.5 days a week, then 3 days of clinic where some of those are actually awake in office procedures. I like that I never do the same thing 2 days in a row. The residency is very OR heavy because that’s such a key part of your learning, but the actual practice tends to be more clinic heavy and OR tends to be lots of short cases that all go home and do well.

 

[GotToGetThatGPAUp]

Call or no call?
Nights/holidays/weekends or bankers hours?
Hospital or clinic?

These questions are far more important in terms of career and longevity than anything else. Think long and hard about these and it will eliminate probably >50% of choices depending on your answers.

1. I'm fine with the occasional call. Overall much prefer long shift work hours with more blocked-off time. I worked a schedule similar to 7-on/7-off before med school and really enjoyed it. I like being on when I'm on, off when I'm off. Plus blocked time off allows my hobbies to be a bigger part of my life rather than just something I do after work.
When I'm on I like to be moving. I'd take a 12 hr busy day over a 6hr do-nothing day, I find myself far more exhausted after the latter.

2. I love the hospital at night tbh, but seeing how the switch between night and day shifts has affected people around me I would rather not as a career and even if I was a pure nocturnist the studies still haven't been promising and some things I like to do have to be done during the day anyways. As for weekends and holidays I'm fine with missing them, I actually prefer having weekdays off over weekends stuff is less crowded heh

3. Hospital >> Clinic, at least that's how I feel at this stage

 

[GotToGetThatGPAUp]

Seconding anesthesia as a good option and would add things like derm and Ophtho. Sure there’s some OR in the latter but on balance is less than most other surgical fields.

ENT as well is a nice balance and our OR (outside the academic big head and neck cancer surgeries) tend to be shorter and outpatient. I’ve got the adhd brain too and find the variety in my week very helpful. I operate 1-1.5 days a week, then 3 days of clinic where some of those are actually awake in office procedures. I like that I never do the same thing 2 days in a row. The residency is very OR heavy because that’s such a key part of your learning, but the actual practice tends to be more clinic heavy and OR tends to be lots of short cases that all go home and do well.

ENT is something I wish I had gotten some exposure to earlier. I don't think I'll be going that route personally, but how is residency competitiveness, especially for someone with minimal research and 0 ENT research?

I will say, my ENT always seemed like a happy fella

 

[operaman]

ENT is something I wish I had gotten some exposure to earlier. I don't think I'll be going that route personally, but how is residency competitiveness, especially for someone with minimal research and 0 ENT research

I will say, my ENT always seemed like a happy fella

Yeah it’s definitely competitive. You’ve got a pretty solid app as far as numbers go but you would need some research and dept connections to feel good about matching. Would likely mean a research year unless you can jump on some projects now. I have seen people decide ent in January and have 4-5 pubs by the fall so it’s doable. Just not easy.

Would likely have the same challenge with derm and Ophtho. But depending on what you want, may be worth it.

I think with some research and strong letters you could have a shot at competitive programs. You’re clearly a top student at your school.

 

[mrbreakfast]

thanks folks, I may need to find a chance to do that as we didn't really get any neuro exposure (besides what was essentially a teeny bit of shadowing in the neuro ICU)

Every academic hospital has a neurology consult service, even if medical students don't traditionally rotate with it (and even if there's no neurology clerkship). You can probably just email someone.

Neuro ICU is its own thing and, depending on where you practice, can have a relatively narrow scope of what it sees on a day-to-day basis. It generally self-selects as a specialty.

 

[deleted1095841]

My $0.02: IR, IM hospitalist, Pulm CC, EM

 

[holdthemayo]

Anesthesia. If you don’t love the OR aspect can do a critical care fellowship. Could also just do IM -> CC fellowship too

I'll echo this.

You are basically describing anesthesia in what you want from a specialty.

 

[ACSurgeon]

Emergency medicine
Critical care
Combination of EM/cc

The above will give you chunks of time off and also suits some of your preferences of high pressure work.

You mention academia and teaching. Many community hospitals have residents and fellows… my experience was the academic jobs paid about 2/3 or less of the private job and required a lot more time for clinical duties, research and teaching. If you find a large community hospital with a residency in your specialty you can teach and still earn a more fair wage.

 

[ACSurgeon]

I'll echo this.

You are basically describing anesthesia in what you want from a specialty.

I don’t know that anesthesia makes it easy to take a week off every month. There’s a lot of call levels and it doesn’t seem like they have that much flexibility with taking big chunks of time off unless the few weeks of vacation per year…

 

[holdthemayo]

I don’t know that anesthesia makes it easy to take a week off every month. There’s a lot of call levels and it doesn’t seem like they have that much flexibility with taking big chunks of time off unless the few weeks of vacation per year…

Several of my coresidents signed contracts with 10-12 weeks vacation.

Others signed 4 day a week no call no weekend jobs.

Our job market is so strong right now, there is a lot of flexibility in schedules. That doesn’t mean it will still be that way in 10 years, but right now jobs with only “a few weeks a year” off are not the norm. Anyone working those hours is making bank if they do.

 

[OraclePL]

Everything about your post screams critical care.

Not sure about anesthesiology, but as someone with a little ADD myself, I always found it hard to focus during those rotations. 95% boredom, 5% terror. I’m sure anesthesiologists will disagree with that crude characterization of the field, but that was just my impression.

Derm and ophtho are OK options, but I don’t think he will get the immediate impact on emergency cases you’re looking for. And it’s a lot of clinic at high volume.

CC gives you the complex multi organ system pathology. Those are the most complex notes I’ve ever seen. you get the adrenaline rush and make a big difference. Many CC physicians also work like hospitalists where they have a chunk of time off. Most of the ones I know who were pulm trained do a pulmonology clinic, like one week for every three weeks of critical care or something like that. No field is perfect but it really seems like a great fit for you.

 

[MateoGM416]

Everything about your post screams critical care.

Not sure about anesthesiology, but as someone with a little ADD myself, I always found it hard to focus during those rotations. 95% boredom, 5% terror. I’m sure anesthesiologists will disagree with that crude characterization of the field, but that was just my impression.

Dermatop those are OK options, but I don’t think he will get the immediate impact on emergency cases you’re looking for. And it’s a lot of clinic at high volume.

CC gives you the complex multi organ system pathology. Those are the most complex notes I’ve ever seen. you get the adrenaline rush and make a big difference. Many CC physicians also work like hospitalists where they have a chunk of time off. Most of the ones I know who were pulm trained do a pulmonology clinic, like one week for every three weeks of critical care or something like that. No field is perfect but it really seems like a great fit for you.

Is the job outlook good for CC?

 

[operaman]

Everything about your post screams critical care.

Not sure about anesthesiology, but as someone with a little ADD myself, I always found it hard to focus during those rotations. 95% boredom, 5% terror. I’m sure anesthesiologists will disagree with that crude characterization of the field, but that was just my impression.

Dermatop those are OK options, but I don’t think he will get the immediate impact on emergency cases you’re looking for. And it’s a lot of clinic at high volume.

CC gives you the complex multi organ system pathology. Those are the most complex notes I’ve ever seen. you get the adrenaline rush and make a big difference. Many CC physicians also work like hospitalists where they have a chunk of time off. Most of the ones I know who were pulm trained do a pulmonology clinic, like one week for every three weeks of critical care or something like that. No field is perfect but it really seems like a great fit for you.

Anesthesia to CC gives you a nice balance where you can still do OR if you get burned out on the CC side of things. Burnout is very high in CC and if you’re Pulm/cc trained, then your backup is mainly IM/Pulm clinic. Either way, worth strongly considering your plan if/when you tire of CC.

Also echo the comment above re finding a community hospital with residents. I stumbled into more of a quasi-academic position with all the pathology and fun cases of being the only tertiary referral academic center, but none of the academic baloney I hate. And pay is insanely good - I make substantially more than my chairmen from residency and fellowship do and I’m in my 2nd year attending.

I kinda stumbled into this due to Covid and hiring freezes and now I can’t imagine working anywhere else. Definitely worth a look at the hybrid community/teaching places when the time comes.

 

[OraclePL]

Anesthesia to CC gives you a nice balance where you can still do OR if you get burned out on the CC side of things. Burnout is very high in CC and if you’re Pulm/cc trained, then your backup is mainly IM/Pulm clinic. Either way, worth strongly considering your plan if/when you tire of CC.

Also echo the comment above re finding a community hospital with residents. I stumbled into more of a quasi-academic position with all the pathology and fun cases of being the only tertiary referral academic center, but none of the academic baloney I hate. And pay is insanely good - I make substantially more than my chairmen from residency and fellowship do and I’m in my 2nd year attending.

I kinda stumbled into this due to Covid and hiring freezes and now I can’t imagine working anywhere else. Definitely worth a look at the hybrid community/teaching places when the time comes.

This is an excellent point that goes too often overlooked. Positions within a specialty can vary significantly.

 

[OraclePL]

Is the job outlook good for CC?

I wouldn’t be able to speak to this, not my field.

 

[ACSurgeon]

I wouldn’t be able to speak to this, not my field.

Is the job outlook good for CC?

For now it is. But with new fellowships opening up and more NPs/PAs being trained to do critical care procedures, who knows what it will look like in 10-20 years. But COVID highlighted the importance of 24/7 critical care and even smaller hospitals in our system now are striving to staff as such.

 

[MateoGM416]

For now it is. But with new fellowships opening up and more NPs/PAs being trained to do critical care procedures, who knows what it will look like in 10-20 years. But COVID highlighted the importance of 24/7 critical care and even smaller hospitals in our system now are striving to staff as such.

I feel like you could say the same about midlevel encroachment for most specialties except surgery and the other competitive specialties, no?

 

[deleted1139416]

Going IM first you do pulm/cc which gives you a fallback (pulm) for when you burn out on the CC part.

Does ICU have a high rate of physicians quitting? And is this across all ICU-related specialties (NeuroCC, NICU, Trauma, etc)? Although not all hospitals have specialized ICU units.

 

[Niwrad]

Does ICU have a high rate of physicians quitting? And is this across all ICU-related specialties (NeuroCC, NICU, Trauma, etc)? Although not all hospitals have specialized ICU units.

Yes, there's a study in J of Crit Care Burnout Study 2021 . It says around 70% of healthcare professionals met criteria for burnout in Mainland China, and this is prior to the current covid breakout this year. Also antedotally, ICU burnout is very high. One of the contributing factors was increased years of experience, which intuitively would indicate burnout as increased experience improves skills and efficiency.