Choosing a Specialty

[freddytn]

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Here's a question out there for the masses. How are you choosing your medical specialty for your residencies? Is it related to your research or is it just a field that satisifies your clinical medical curiosity? Or are you choosing a residency that will allow you to jump into your career at an earlier stage?

 

[Fermata]

$$$$

 

[b&ierstiefel]

So I'm choosing pathology. And I chose it for the various reasons you state in your question.

1) Relation to research - pathology has a very intimate relationship with research. Another field that is intimately related to research is internal medicine. Choosing between the two was easy. I liked pathology. I hated IM.
2) Satisfies medical curiosity - this was very important. Pathology is the study of disease. And you learn lots and lots about a huge variety of diseases (even the really rare ones).
3) Jumping into research quickly - this was important in a practical sense. Internal medicine allows you to short-track (short 2 year residency). Pathology doesn't allow short-tracking (if you do AP or CP only, it's 3 years) however it can be negotiated at some of the research-oriented institutions. For instance, there is the UCSF Molecular Medicine Training program. It allows you to short-track residency (IM, path, or peds) and complete it in 2 years which is followed by a 3 year, fully-funded, postdoc fellowship (sounds a lot like MD/PhD programs all over again doesn't it?). Along those lines, I certainly wouldn't wanna do a 7 year residency (i.e., General Surgery) or a long residency that approaches or even exceeds 7 years!

Ultimately, my career goal is to do 90% basic science research and 10% clinical duties. You hear a lot of people saying they wanna do 50-50. That's fine if you can pull it off. I'm just not one of those people.

 

[BDavis]

So I'm choosing pathology. And I chose it for the various reasons you state in your question.

Pathology is also attractive in that you don't do an internship and start right off in pathology.

 

[b&ierstiefel]

Pathology is also attractive in that you don't do an internship and start right off in pathology.

Shh! Keep that on the down low. 🙂

No more Q4 for me...EVER!

 

[BDavis]

Shh! Keep that on the down low. 🙂

No more Q4 for me...EVER!

I think I would enjoy pathology except for part where I stare into a microscope for extended periods of time. After 2 hours of immunofluorescence on a confocal or H+E stains on a light microscope I always feel like I am going to barf. The feeling of nausea is even more pronounced when you look through those multihead scopes while someone flies through the slide.

 

[tr]

I think I would enjoy pathology except for part where I stare into a microscope for extended periods of time. After 2 hours of immunofluorescence on a confocal or H+E stains on a light microscope I always feel like I am going to barf. The feeling of nausea is even more pronounced when you look through those multihead scopes while someone flies through the slide.

I've actually come to enjoy the microscope. Never thought I would say that; but by now it's got positive associations. It represents the reward (in data units) for all your hard work making the slides. 🙂

On the other hand, I don't think I could take the postmortems. I never want to touch a cadaver again.

 

[b&ierstiefel]

I think I would enjoy pathology except for part where I stare into a microscope for extended periods of time. After 2 hours of immunofluorescence on a confocal or H+E stains on a light microscope I always feel like I am going to barf. The feeling of nausea is even more pronounced when you look through those multihead scopes while someone flies through the slide.

That cracks me up man. I'm the same way actually. It's like some kind of motion sickness...especially during signouts when the attending just moves the slide all over the place within a span of 5 seconds and you're still trying to get a sense of orientation

Confocal gives nice images but yeah, you spend lots of time at the scope. The nice thing about confocal though is that it takes several minutes for data acquisition (longer if you're getting high resolution data) so you can just sit back. Lemme tell ya, pop in some Pink Floyd while using the confocal...you got your own little laser show in your little confocal room (well not really).

On the other hand, I don't think I could take the postmortems. I never want to touch a cadaver again.

I'm the same way. I don't hate doing autopsies, but it isn't my favorite aspect of anatomic pathology either. Let's face it, postmortems smell, real bad. But doing rectal exams or stool disimpactions in a paralyzed elderly patient sucks too. In each field, there's some things you like more and some things you like less. It's all about which way the balance shifts. Clearly, I would pick a program where you do autopsies 3-4 months out of the first year over a place where they make you do autopsies 6 months out of the first year.

 

[Gfunk6]

Here's a question out there for the masses. How are you choosing your medical specialty for your residencies? Is it related to your research or is it just a field that satisifies your clinical medical curiosity? Or are you choosing a residency that will allow you to jump into your career at an earlier stage?

In general I think you are better off going into a speciality related to your research. This will give you a tremendous leg-up over other applicants. Of course, there is always the possiblity that you become interested in something entirely new during your 3rd year.

Personally I'm going into Rad Onc (most likely) or Med Onc (less likely). These fields are related to my research and are well suited for academic medicine.

 

[Dr. Chiquita]

I was just wondering, are post-doc years in bench research required for MD/PhD peeps before they jump into residency?

One more question, I hear if you want to get into a tough residency like cardiology, GI, etc. You have to first do IM residency, then get a fellowship in those fields. As a MudPhud who did research, let's say on how the voltage-gated channels work in heart cells, can you somehow short-track the IM residency and cardiology fellowship in combination? Also, are there programs out there that will guarantee you a fellowship position from the beginning when you are applying for residency?

Any words of wisdom from current MD/PhD students will be appreciated. Thanks a ton in advance. 😀

 

[b&ierstiefel]

I was just wondering, are post-doc years in bench research required for MD/PhD peeps before they jump into residency?

Postdoc is certainly not required before residency. The far majority of people will do residency right after medical school. If one does a postdoc after med school, it can be hard to do a residency and get back into the swing of the clinical realm. So postdoc right after med school is not a requirement, nor is it something that is even commonly done.

One more question, I hear if you want to get into a tough residency like cardiology, GI, etc. You have to first do IM residency, then get a fellowship in those fields. As a MudPhud who did research, let's say on how the voltage-gated channels work in heart cells, can you somehow short-track the IM residency and cardiology fellowship in combination? Also, are there programs out there that will guarantee you a fellowship position from the beginning when you are applying for residency?

Any words of wisdom from current MD/PhD students will be appreciated. Thanks a ton in advance. 😀

If you wanted to go into cardiology, you are right. First you must do 3 years of IM residency and then complete a fellowship afterwards. These short-track residencies you speak of frequently attract MD/PhD folks. I know that residency can be shortened from 3 to 2 years. The third year gets tacked onto fellowship, which is done in combination with the residency. My understanding is that fellowships are not typically short-tracked and one has to do a full fellowship anyway (which makes sense because that's what you're going into right?).

As for your final question, I think that the short-track residency programs have joint fellowships but I'm not entirely sure. I thought about all of the issues that you raise when I was momentarily thinking of going into IM back in the day. However, when I decided against doing a IM residency, I kinda stopped thinking about it. Hopefully others can chime in here and help you out (and correct me if I am mistaken in some of my points).

 

[Dr. Chiquita]

Thanks, AndyMilonakis. Great to hear that I can have my options open on the post-doc in bench research.

Anybody who knows about the short-track residency programs with joint fellowships in cardiology, GI, etc, I would love to hear more.

 

[BDavis]

Thanks, AndyMilonakis. Great to hear that I can have my options open on the post-doc in bench research.

Anybody who knows about the short-track residency programs with joint fellowships in cardiology, GI, etc, I would love to hear more.

Here are some short-track residency programs that seem to like MSTP graduates. This list is not all inclusive.

http://medicine.ucsf.edu/molmed/

http://www.mgh.harvard.edu/medicine/medicine_res_careerpath_research.htm

http://meded.im.wustl.edu/application/MentorsInMedicine.html

http://medicine.stanford.edu/education/scip.html

 

[FunnyBones]

Two related categories of reasons that freddytn left have to do with opportunity and relative intellectual freedom (at a cost of course...):

4) Abundance of "virgin" topics ready, no begging, to be explored
5) Dearth of clinician-scientists, I mean, you can fit their names on one sheet of paper

Let me get on my soap box here and say that if our forefathers investigated only subjects that were already fruitful, made sense, were already "hot," and created easy career paths, we would not be where we are today. There are fields dying for clinician-scientist, fields where you can really make an impact, where you are desired (although not always suppoted...and there's the challenge) and where the exciting topics are being worked on by only a few or tens of people rather than hundreds.

My bias is surgical so I urge all of you to consider surgical fields that are poorly represented by md-phds (esp ortho, plastics, ent, ob/gyn, urology and to a lesser extent g surg, ophtho, and neurosurg). You may not like it but too many mudphuds rule it out immediately. The training is not any longer than cards or gi. In fact, to get a spot in an academic cards department you need residency, fellowship and sometimes extra time as a post-doc or instructor before you get an ass prof position. There's a lot more to medical science than diagnosing a disease on a slide, much of which you can directly affect with your own hands. Enuf said.

FunnyBones, MD, PhD
Former future pediatric oncologist, now future orthopod

Where I'm coming from:
Undergrad at Stanford studying genetic recomb and neuronal tnf regulation
Research at UCSF studying malaria
MD-PhD at UPenn studying p53 repression, heterotopic ossification, mudphds
Ortho res at UPenn studying research policy, recruitment, spine deformity/pain, fracture management, novel approach to isolating disease genes...

 

[b&ierstiefel]

There are fields dying for clinician-scientist, fields where you can really make an impact, where you are desired (although not always suppoted...and there's the challenge) and where the exciting topics are being worked on by only a few or tens of people rather than hundreds.

My bias is surgical so I urge all of you to consider surgical fields that are poorly represented by md-phds (esp ortho, plastics, ent, ob/gyn, urology and to a lesser extent g surg, ophtho, and neurosurg). You may not like it but too many mudphuds rule it out immediately.

I think this statement has a lot of merit. At Michigan, we have quite a few MD/PhD folks who are doing their residency in gen surg or surgical subspecialties. And they are doing it because they are truly in love with those fields. However, I believe this is a very important point. They love what they're doing. Please people, do not choose a field just because the field needs you. You need to serve yourselves. You need to pursue training in a field that interests you. I agree that surgical fields are fertile research grounds now. But do surgery if you like surgery. Do surgery research, if you like surgery related research.

The training is not any longer than cards or gi. In fact, to get a spot in an academic cards department you need residency, fellowship and sometimes extra time as a post-doc or instructor before you get an ass prof position. There's a lot more to medical science than diagnosing a disease on a slide, much of which you can directly affect with your own hands. Enuf said.

The time difference between various clinical tracks with the end point being getting your first ass prof position is not monumental in the grand scheme of things. We're not talking tens of years, we're just talking just a few years. So again, do what makes you happy. The time issue is only part of the equation. And, in response to the last statement, I agree. Medicine is not only about diagnosis but is about diagnosis, treatment, and management. Medicine is a team proposition where, in order to carry out all three missions, fields must work and complement each other. Each field, in isolation, cannot be 100% effective.

 

[FunnyBones]

AndyMil,

I may have been a little unclear on a few points:

1. Should you have interest and "passion" for what you're doing? (And I use you in the general sense here.) Absolutely. But there is so many factors that determine interest. The philosophy of a field, future directions, interesting zebras, daily drudge, practice environment, colleagues, compensation, legal climate, EASE of research, direction of research, topics of research, LACK of research, INTELLECTUAL FREEDOM, complexity of simplicity of biology, availability of mentors, mentors YOU happen to interact with--ALL these things factor in. As a premed or early medical student, you see only a smidgen of these things. Sure, that's okay too. No one said you have to think about all of these things early. That's too complicated. You'll still find a field you like. I'm trying to stir things up a little; to get you to think about some of these other things that may stimulate you to consider fields that students tend to RULE OUT based on preconceptions. Think you love peds because kids are perky, cute, get better, have a whole life ahead, because they need advocates and haven't ruined their bodies etc. Well, those same kids with those same characteristics also get MRIs, facial reconstructions, hypospadia reversals and scoliosis reductions.

2. Team work and treatment. Again, I agree with you but I think you misunderstood me. I was trying to balance your excitement in your post about path--satisfying medical curiosity by studying disease--and making a counter point that in other fields you can study AND treat. Team work is obviously important. Ortho tumor guys would be lost without path, med onc and rad onc. You think cancer research is the bomb. You can do cancer research from g surg, ent, ob/gyn, ophtho, rads, ortho, uro. Rb was characterized using mathematical models and then finding a genetic defect that worked with that model studying a rare familial eye tumor--go ophtho. All those anti-angiogenesis therapies...a pediatric surgeon named Judah Folkman pioneered that. You think diabetes is debilatating and needs a cure? An orthopod named Frederick Banting discovered insulin (and the got the ol Nobel) and transplant surgeons are doing trials to get your body to accept allo beta cells to make endogenously regulated insulin. Like using scopes? Try out some retinal surgery or a microvascular anastamosis in a 4 year old's finger or minimally invasive spine surgery--all done with scopes. Like pretty pictures (for all you path people)? How about functional mri. (Rads is underrepresented by MD-PhDs as well. Come on folks, seize the opportunity here! Rads/imaging is the newest division of the NIH--that means growth--and the current head of the NIH is a radiologist.) And I can go on...but won't...have to go read about total knee arthroplasty and work on a paper analyzing career intersts of mdphd students...

FunnyBones

 

[freddytn]

Actually here at the University of Illinois at Urbana-Champaign, surprisingly large majority of our graduates have gone on to Radiology and Diagnostic Radiology for their residencies. At least a much bigger trend then any other specialties I have been able to track down. Then again our program gives us the freedom to pursue our PhD in just about anything which may attract some of those who are already inclined towards engineering, physics, and chemistry (i.e. some of our top programs).

 

[Dj neema]

There probably is a reason why surgery does not have many MD/PhD (relatively) residents and that can be explained by several things. I learned from many people I interviewed with last year that surgery at this point in time does not require basic science type of research. Secondly, the surgical field has a large amount of hierarchy and solidarity. Take a recent winner of the Lasker award for his sonication technique on lens replacement. It took several years for the process to actually be accepted. Now his technique is employed in the vast majority of lens replacement surgeries.

But, other fields are not immune to acceptance of heretical views. Take H. pylori in ulcers. I suppose that was laughed at by both surgeons AND internal medicine physicians as well.

But getting down to it, I find IM to be a very flexible and advantageous process. That, and you wouldn't be learning any special skills that you'd throw away to do research. It's not like radiology or surgery. In the eyes of many surgeons, it would be a waste of time and money to train someone in a surgical subspecialty and then have that person not practice surgery.

Finally, if you walk into this whole process convinced that specialty X is the only thing for you, then why even bother with a PhD? It would be to your advantage to just skip the PhD and go straight to residency plus an extended fellowship if you really feel it. I mean come on. An MD/PhD program takes 6-8 years on the average. In that time frame, the research in your specialty could very well dry up. Science is always changing. IMO, doing a PhD in field X, and then expecting to do a residency, a fellowship, and then pick up where your PhD left off is ludicrous. You'd be lucky if the pathway, syndrome, or disease is even yesterday's news.

One thing the field of medicine needs though: Innovators in the field of radiology. I mean come on. With the advances in computer processing as well as conductors, you'd think we'd be able to do simple panoramic technology? And pathology is just begging for better molecular probes than what we currently have. Where are my physicists?

 

[Gfunk6]

There probably is a reason why surgery does not have many MD/PhD (relatively) residents and that can be explained by several things. I learned from many people I interviewed with last year that surgery at this point in time does not require basic science type of research.

At our Department of Surgery (and I suspect at others nationwide) there is a small cadre of PhDs who are dedicated to basic science research. In this way, surgeons can practice and teach full-time and contribute with research of immediate clinical relevance and the scientists can focus on basic issues.

The only surgery field which seems amenable to MD/PhDs is Neurosurgery, which seems to have a rather high percentage.

But getting down to it, I find IM to be a very flexible and advantageous process. That, and you wouldn't be learning any special skills that you'd throw away to do research. It's not like radiology or surgery. In the eyes of many surgeons, it would be a waste of time and money to train someone in a surgical subspecialty and then have that person not practice surgery.

A good point and this is why, historically, that MD/PhD graduates have gravitated towards IM, Neurology or Peds. A research-intensive career in IM could allow for 1-2 months/year of dedicated time in clinical care (with maybe a half day/week in an outpatient continuity clinic) and the remainder of the year running a basic research lab. This scenario is clearly not feasible for a surgeon.

However, as mentioned by others, there is an increase in MD/PhD grads going into Dermatology, Diagnostic Radiology, Radiation Oncology, Anesthesiology, etc. In competitive fields the PhD will give you (at least hypothetically) a significant edge. I am curious to see if these graduates will be able to procure the protected research-time that IM MD/PhD attendings do.

 

[BDavis]

However, as mentioned by others, there is an increase in MD/PhD grads going into Dermatology, Diagnostic Radiology, Radiation Oncology, Anesthesiology, etc.

Many of our MSTP graduates are gravitating to the above mentioned fields, but interestingly for other reasons than research opportunities such as lifestyle. It will be interesting to see if they will continue research or stay in academics altogether.

 

[ears]

Many of our MSTP graduates are gravitating to the above mentioned fields, but interestingly for other reasons than research opportunities such as lifestyle. It will be interesting to see if they will continue research or stay in academics altogether.

Interesting that you should make that association; I've noticed the same thing. And one possible interpretation is that MD/PhDs, because they're competitive residency candidates, can get the attractive fields right now (which tend to be the so-called "lifestyle" fields).

An alternative interpretation: these fields offer attractive lifestyles because they offer flexibility in the kinds of careers that can be pursued. That is, a radiologist or a pathologist can make time during their week to pursue research projects that isn't as easy for a general surgeon to make. This leads to both "lifestyle" and the potential for a research career.

Just a thought; obviously, it's difficult to figure out how anyone has made this high-stakes decision.

 

[BDavis]

An alternative interpretation: these fields offer attractive lifestyles because they offer flexibility in the kinds of careers that can be pursued. That is, a radiologist or a pathologist can make time during their week to pursue research projects that isn't as easy for a general surgeon to make. This leads to both "lifestyle" and the potential for a research career.

I agree-"a good lifestyle" doesn't always imply less work hours and a high salary. In terms of residencies, pathology is close to the #1 choice for our MSTP students (or equal to neurology), followed by ophtho=neurosurgery> rad onc, derm,rads. I think internal medicine is becoming less and less popular for our graduates. Not too many general surgeons, OB/GYN (I think 1 for the whole history of our program) or anesthesiologists.

 

[mytirf]

I would love to know about statistics (solid data) with regards to resisdencies that MD/PhDs pick coming out of medical school. Does anyone know of any such information?

 

[tr]

I would love to know about statistics (solid data) with regards to residencies that MD/PhDs pick coming out of medical school. Does anyone know of any such information?

Sure, a few schools did a study on it. There's a link to their results on intransit.us. Hang on a second, I'll find it...

www.intransit.us/outcomedata.pdf

Also of interest:

http://www.nigms.nih.gov/news/reports/mstpstudy/mstpstudy.html

 

[Doctor&Geek]

I would love to know about statistics (solid data) with regards to resisdencies that MD/PhDs pick coming out of medical school. Does anyone know of any such information?

Here's all of the available match information I could find for 2004 MD/PhD graduates:

http://www.dpo.uab.edu/~paik/match.html

Hope you find it useful.

 

[Neuronix]

Here's all of the available match information I could find for 2004 MD/PhD graduates:

http://www.dpo.uab.edu/~paik/match.html

Hope you find it useful.

👍

 

[coldchemist]

At our Department of Surgery (and I suspect at others nationwide) there is a small cadre of PhDs who are dedicated to basic science research. In this way, surgeons can practice and teach full-time and contribute with research of immediate clinical relevance and the scientists can focus on basic issues.

The only surgery field which seems amenable to MD/PhDs is Neurosurgery, which seems to have a rather high percentage.

I have several different fantasy careers. One of them is to get my PhD in a lab affiliated with the Dept. of Surgery that works on the basic science of traumatic and burn injury healing and repair, then do a residency in surgery and continue on with a fellowship in trauma/critical care. I've also thought about doing radiology and then going into mood disorder research. They've got a great program at NIH where they do MRI studies on people with a variety of mental illnesses and look for genetic markers. Of course, I have no idea what I would get my PhD in if I went that route (I really don't want to do genetics unless its in tandem with something cool like MRI or CT).

 

[tr]

They've got a great program at NIH where they do MRI studies on people with a variety of mental illnesses and look for genetic markers.

Hey, that sounds cool! I'm curious to know more. Do you have a link to that program, or any other identifying info?