MD choosing specialties in IM vs Surgery

[jop9095]

Hi guys,

I am currently a MS3 at a mid-low tier med school in Midwest with very limited and low tier home residency program (less than 1% match into our home program each year) We are currently half way through our rotation and I have done family, surgery, ortho elective, and finishing up Psych.

I personally had a lot of inner conflicts about what I am interested in doing. I grew up in a surgeon household in a different country (China) and was living under the influence of surgeon's life for 18 years before I came to US for college on my own. My father is a general surgeon but also manages GI patients at his hospitals (IBD, ICU, Infection disease).

Growing up in such household does gave a me a limited perspective on medicine as everything is surrounded by surgery. Although one of my uncle is a cardiologist and one my aunt is in EM, my Dad always had this "self feeling" that surgery is the best. Despite all these, I have always been keeping an open mind before and during medical school. I am still currently on a F1 student visa and often joke with my friend if the government want me to be in rural Montana to practice I will go. However, since the surgery rotation, I really had a lot of self doubt about what I want to do in the future. I want my future career to be a balance of critical thinking and procedure, with teaching and research sprinkled on top.

For surgery rotation

I like helping out with procedure, but just doing retractions and standing around is boring as hell. Especially those robotics one we are literally not doing anything...... I feel like the biggest punishment for surgery rotation is the limited opportunity to do anything

Although I was able to manage and enjoy a 6 week rotation during COVID, I know deep down if this was the original 8 weeks rotation+ weekend calls I would probably crash towards the end.

Although it was fun seeing different pathologies each day, waking up at 4am everyday is dreadful. I had to pull myself up every morning. No one should wake up that early unless you are selling breakfast.

We had a wonderful group of ortho residents but the general surgery residents are miserable to work with. You could tell the ortho people are genially happy and the general surgery people hate to work there. The attendings are also not that happy in general surgery. One attending had to be on call for a full month (he had notes as late as 2 am or 3am). It seems like the hours did not got better after residency. A good number of attendings yell at med students and residents for no good reasons. This is in a community-academic trauma center hospital.

I have heard of all the sayings such as if you can imagine anything outside surgery don't do surgery etc. After the rotation I could definitely tell why this is the case. For my overall impression, I think I am more of a detailed orientated person and enjoys the smaller parts of life. During ortho I like the spine cases but did not really enjoy their bread and butter cases of joint replacements, it was too messy and violent to participate. I am also surprised by how a limited scope of general surgery has become in the US. It seems like everything here have their boundaries and you can only practice a limited number of pathologies. I also don't like how little critical thinking diagnosis is playing in general surgery as our goal is just get them to the OR. Often times GI and IR have to come in to cancel our procedures due to various problems. Everything is just so specialized now, both in surgery and IM.

About my stats, I am an international student in a US medical school, Step1 260+, preclinical honors, decent number of volunteer and leadership activities, decent number of papers (10+) but scattered in many different fields (general surgery, wound, burn, GI, ortho) since I don't have a particular interest. Most of the conferences and research are done prior to med school (i did a master program and worked for 2 years). Had 3 conference presentation in med school life so far.

I think the biggest question I have in my mind is about the IM life. Unfortunately due to COVID my IM rotation won't happen till March and I kind of need to understand what to expect with IM? I am particularly interested in Cardio, GI and Pulm. What are my chances for these given their competitiveness? I want to know if it is possible to endure the 3 years of IM before getting into these fellowships? Also what about life in IM compared to surgery? Thanks a ton!

With regard to the surgical specialties (urology, ENT, Opth) we kind of limited options due to lack of connections and home programs. I tried reaching out to opth research but has been painfully slow and I am not confident if I can produce a valuable research project before submitting applications. Also I need a visa for residency and opth definitely has much less spots and programs than IM and general surgery

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[Banco]

I think you yourself will have to get some IM exposure to really be able to decide that. Same goes for the surgical subspecialties. But think of it this way, if you don't like general surgery, it's good that you've found this out relatively early.

What I can say is that with your step 1 and research experience, you are not limited at all...especially not for IM. Your visa considerations are something you will have to take into account though and I cannot advise there.

 

[jop9095]

I think you yourself will have to get some IM exposure to really be able to decide that. Same goes for the surgical subspecialties. But think of it this way, if you don't like general surgery, it's good that you've found this out relatively early.

What I can say is that with your step 1 and research experience, you are not limited at all...especially not for IM. Your visa considerations are something you will have to take into account though and I cannot advise there.

Thanks for the post. Funny thing is I always grow up thinking I am going into general surgery. It is not until this rotation when I see how miserable our residents and even attendings are that I realize sth. is not right......

My friends and mentors all suggested specialty surgeries but the competitiveness is too much to risk for it. Even with good grades I honestly don't know how to secure a research and a strong letter in 10 months. Also we are currently very limited on electives.. Frieda showed maybe 20 optho program I can apply and they are all very top programs

IM is a safer net to jump into and the top programs have much more seats in the top program. Although it is stressful to go through another round of fellowship match, specialization is common in almost all medical fields.

My Dad is also supportive of me going the IM route but I can tell he is sort of upset that I am not into general surgery...

 

[Banco]

Thanks for the post. Funny thing is I always grow up thinking I am going into general surgery. It is not until this rotation when I see how miserable our residents and even attendings are that I realize sth. is not right......

My friends and mentors all suggested specialty surgeries but the competitiveness is too much to risk for it. Even with good grades I honestly don't know how to secure a research and a strong letter in 10 months. Also we are currently very limited on electives.. Frieda showed maybe 20 optho program I can apply and they are all very top programs

IM is a safer net to jump into and the top programs have much more seats in the top program. Although it is stressful to go through another round of fellowship match, specialization is common in almost all medical fields.

My Dad is also supportive of me going the IM route but I can tell he is sort of upset that I am not into general surgery...

I would definitely speak to some advisors and I wouldn't rule out other surgery specialties just because of competitiveness. You already have a lot of research and an extremely high step 1. Keep that in mind.

 

[jop9095]

I would definitely speak to some advisors and I wouldn't rule out other surgery specialties just because of competitiveness. You already have a lot of research and an extremely high step 1. Keep that in mind.

Thank you. Surprisingly my ophthalmology PI just replied my email and had a zoom call with me after weeks of no response. Maybe it is still possible with optha after all?

 

[Dr.K124]

Thank you. Surprisingly my ophthalmology PI just replied my email and had a zoom call with me after weeks of no response. Maybe it is still possible with optha after all?

As an Ophthalmology attending, I can tell you I regret nothing choosing this field. Definitely look into it, and if you love it, shoot your shot.

Not if you keep forgetting the first h though (although you got it right once!)

 

[Dr G Oogle]

Not all GS residents are miserable. There are excellent community programs and probs some academic ones that are “Cush”, 60-80 hours per week, lots of OR time. GS jobs are in demand and pay a lot. I work with many that often deal with complex medical issues and do surgery, probably not as complex as an ICU patient with multi system organ failure. The general rule of thumb is if you can find the interesting in the mundane and can deal with the 💩 of the field with a smile on your face that’s the field for you.

As people above said your academic record has pretty much laid every door open for you.

 

[DarkHorizon]

As an ortho attending, can’t imagine doing anything else. I feel PTSD just thinking about all the rounding from my medicine rotation. So thankful for my hospitalist colleagues, but I’d be miserable in medicine. Highly recommend ortho if you like the field and don’t mind working hard.

 

[jop9095]

As an ortho attending, can’t imagine doing anything else. I feel PTSD just thinking about all the rounding from my medicine rotation. So thankful for my hospitalist colleagues, but I’d be miserable in medicine. Highly recommend ortho if you like the field and don’t mind working hard.

I agree. Working with ortho residents and attendings are the highlights of my surgery rotation. They really love life and what they are doing.

However, I have to admit that I am kind of concerned about the radiation dosage from ortho. I had done fracture cases when the attending directly placed his hand under the C-arm projector for hours..... I cannot imagine doing that in the future. Same goes to cardiology catheterization and GI ERCP

 

[7331poas]

I think if you do surgery it has to be an integrated route. I could not imagine slodging through a gen surg residency just so you get the "privilege" of doing cardiac surgery.

 

[jop9095]

I think if you do surgery it has to be an integrated route. I could not imagine slodging through a gen surg residency just so you get the "privilege" of doing cardiac surgery.

that's my concerns for IM as well. Not sure if I can actually enjoy the 3 year thought it is shorter than surgery's 5 year

 

[jop9095]

Not all GS residents are miserable. There are excellent community programs and probs some academic ones that are “Cush”, 60-80 hours per week, lots of OR time. GS jobs are in demand and pay a lot. I work with many that often deal with complex medical issues and do surgery, probably not as complex as an ICU patient with multi system organ failure. The general rule of thumb is if you can find the interesting in the mundane and can deal with the 💩 of the field with a smile on your face that’s the field for you.

As people above said your academic record has pretty much laid every door open for you.

thanks for the encouragement. What are some of the S*** you have to deal with in surgery?

 

[7331poas]

that's my concerns for IM as well. Not sure if I can actually enjoy the 3 year thought it is shorter than surgery's 5 year

I think the plus for IM is that no matter what you will have to do at least 1 year of IM regardless (rads, derm, etc). So you will only be spending 2 years in IM versus 4 years in gen surg.

 

[Prehealth1011]

that's my concerns for IM as well. Not sure if I can actually enjoy the 3 year thought it is shorter than surgery's 5 year

Doesn't GS usually require fellowships now if you wanna be employed? That would push it to 7 years.

 

[slowthai]

Doesn't GS usually require fellowships now if you wanna be employed? That would push it to 7 years.

Nope, GS doesn't require fellowships for employment at all. And most fellowships are 1 year. Depending on the program you went to (5 vs 7 year residency), residency + fellowship could take 6-8 years. If you're doing something like PRS, it could take 8-10 years total.

 

[AnatomyGrey12]

Doesn't GS usually require fellowships now if you wanna be employed? That would push it to 7 years.

No. True general surgeons are in high demand.

 

[Dr G Oogle]

thanks for the encouragement. What are some of the S*** you have to deal with in surgery?

Well I’m in urogyn so it’s less 💩 and more 💧 but some of the stuff that’s relatively annoying is having to come in to labor and deliver to fix perineal lacerations and bladder injuries during csections mostly because they usually happen at inconvenient hours, chronic pain patients, being on call for both general gyn and urology, being consulted for any one with urinary rententon in the middle of the night when a Foley catheter and a morning text will suffice. That being said at worst I find the above to be minor inconvenience and a more than fair trade off for the real joys of my job.

i can’t really speak to GS or other specialties,but basically the above is what you should shoot for.

 

[OnePunchBiopsy]

I think if you do surgery it has to be an integrated route. I could not imagine slodging through a gen surg residency just so you get the "privilege" of doing cardiac surgery.

Cardiothoracic and vascular are the two fields where I would actually recommend going through a general surgery residency then doing a fellowship.

If you’re interested in academics, programs are starting to turn down people for jobs who trained integrated Cardiothoracic. Not sure how things are in the community side of things.

 

[slowthai]

Cardiothoracic and vascular are the two fields where I would actually recommend going through a general surgery residency then doing a fellowship.

If you’re interested in academics, programs are starting to turn down people for jobs who trained integrated Cardiothoracic. Not sure how things are in the community side of things.

Wow, that's crazy. Why do you think this is happening?

 

[7331poas]

Cardiothoracic and vascular are the two fields where I would actually recommend going through a general surgery residency then doing a fellowship.

If you’re interested in academics, programs are starting to turn down people for jobs who trained integrated Cardiothoracic. Not sure how things are in the community side of things.

if that is true then that is a good reason to do gen surg. but only if.

 

[Redpancreas]

You seem to have good perspective. Apply to surgical subspecialties. It will be tough, then apply to IM as a back up. Good luck!

 

[OnePunchBiopsy]

Wow, that's crazy. Why do you think this is happening?

Because older attendings who trained fellowship format are hiring young graduates out of integrated programs and are not impressed.

In addition to the heart and lungs, CT Surg does a lot of things related esophagus, neck and the trachea. It’s not uncommon for thoracic surgeons to be the primary consultants doing esophagectomies and re-do Nissen patients that no one will touch.

 

[Lawpy]

Because older attendings who trained fellowship format are hiring young graduates out of integrated programs and are not impressed.

In addition to the heart and lungs, CT Surg does a lot of things related esophagus, neck and the trachea. It’s not uncommon for thoracic surgeons to be the primary consultants doing esophagectomies and re-do Nissen patients that no one will touch.

Is integrated pathway going to be phased out then?

 

[OnePunchBiopsy]

Is integrated pathway going to be phased out then?

Not phased out as of yet, but not expanding. The chairman at my program said that at a recent national meeting the powers at be declined expanding the integrated model among existing and new programs. Doesn’t mean they are going away, just that there is hesitation at the national level.

 

[Matthew9Thirtyfive]

I know it’s already been said but not all GS residents and attendings are miserable. The ones I’ve met at my home program are not at all.

 

[Dr. Retractor]

I'm a gen surg intern and it's freaking awesome. Seeing how attendings and chiefs can handle the craziest situations in and out of the OR with supreme calm because of how well they are trained and how confident they are in their abilities is a huge motivator. The great thing about gen surg is you can do fellowships in super cush, chill subspecialties like endocrine or breast and those attendings have great lifestyles because their surgeries are quick and patients almost always do well. Of course 5 years of general surgery training is tough no matter where you go, so you have to really want to do surgery, but you come out very well trained and ready to handle anything that gets thrown at you. Your description of what you like in surgery makes me think of hand surgery, which you can do out of ortho or general surgery. If you're choosing between ortho and general surgery you have a good shot at both with your CV. Take this part with a huge grain of salt because every institution is different but the difference between the two in my experience is that ortho does ortho surgery and that's it. All the medicine stuff beyond the most basic is taken care of by IM docs. Whereas gen surg usually manages all but the most complex medical issues themselves.

 

[deleted980918]

I was in your shoes. My father was a neurosurgeon and mom a medicine specialist in another country. I went to a mid tier med school and worked hard to have the scores/research (250+ steps) to choose, I was deciding between integrated vascular and IM. I eventually chose IM and I’m now a card fellow at my top choice probably going to apply to IC. The main reason I went the IM route is that from my observation, most of surgeons tend to peak their surgical skills in their 50s then things go downhill and it was kind of sad to see older surgeons getting pushed away by their younger colleagues. In cardiology, there are so many things u can do, u can be a cath machine when you are young then gradually transition to general card as u age. And honestly IM residency isn’t as bad as you think. Everyone exaggerate their misery. Esp coming from a decent med school, with your steps u can probably match at a upper mid tier if not a top tier IM spot which will virtually guarantee (95%+) u a competitive fellowship spot.

 

[jop9095]

I was in your shoes. My father was a neurosurgeon and mom a medicine specialist in another country. I went to a mid tier med school and worked hard to have the scores/research (250+ steps) to choose, I was deciding between integrated vascular and IM. I eventually chose IM and I’m now a card fellow at my top choice probably going to apply to IC. The main reason I went the IM route is that from my observation, most of surgeons tend to peak their surgical skills in their 50s then things go downhill and it was kind of sad to see older surgeons getting pushed away by their younger colleagues. In cardiology, there are so many things u can do, u can be a cath machine when you are young then gradually transition to general card as u age. And honestly IM residency isn’t as bad as you think. Everyone exaggerate their misery. Esp coming from a decent med school, with your steps u can probably match at a upper mid tier if not a top tier IM spot which will virtually guarantee (95%+) u a competitive fellowship spot.

sorry it took too long to reply got caught up in rotations. I really enjoyed the cardio portion of my preclinicals and actually seriously considered cardiology during my M1 summer years. The only issue, and I would say probably the biggest issue I have towards cardiology is the radiation. That hospital I worked with during the summer, man the pathology are so interesting, the procedures are fascinating.................But the whole cath lab looks like sth from a nuclear power plant...

Do you plan a going to the interventional route or non interventional? I know there are 1 particular route the Electrophysiologist don't need lead protections and deal with amazing procedures too. Is it possible just do EP in the future? Not sure if the job market requires you do stents at the same time?

 

[jop9095]

I'm a gen surg intern and it's freaking awesome. Seeing how attendings and chiefs can handle the craziest situations in and out of the OR with supreme calm because of how well they are trained and how confident they are in their abilities is a huge motivator. The great thing about gen surg is you can do fellowships in super cush, chill subspecialties like endocrine or breast and those attendings have great lifestyles because their surgeries are quick and patients almost always do well. Of course 5 years of general surgery training is tough no matter where you go, so you have to really want to do surgery, but you come out very well trained and ready to handle anything that gets thrown at you. Your description of what you like in surgery makes me think of hand surgery, which you can do out of ortho or general surgery. If you're choosing between ortho and general surgery you have a good shot at both with your CV. Take this part with a huge grain of salt because every institution is different but the difference between the two in my experience is that ortho does ortho surgery and that's it. All the medicine stuff beyond the most basic is taken care of by IM docs. Whereas gen surg usually manages all but the most complex medical issues themselves.

greatly appreciate the input. Although growing up with my dad is slowly pushing me away from this field...

Here is the funny story. My Dad works as a surgeon in China. Most of his colleagues don't send their kids to medicine, but those who did, all went to ophthalmology.

I agree this is hospital and residency dependent. Unfortunately the hospital I did my rotation in definitely turned me away from the gen surg field. Wishing you the best in your residency!