End of M3 - need to narrow things down

[mrbreakfast]

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A few months back I posted something similar and got a bunch of helpful responses, so I figured I'd repost for a bit more advice as I still am fairly undecided. We basically have to pick most of our M4 electives within the next few weeks, and I'm stressing over narrowing things down, as right now I'm signed up for a bunch of electives all across the board and am worried about being in the same position in September.

What I would like: something I'm interested in (duh), relatively controllable hours, some procedures, at least some patient interaction. Am open to inpatient + outpatient mix, but undecided.
What I don't want: lots of rounding - I can tolerate some, but not hours of it - lots of call, pure med management, but also not lots of pay - I'd probably be happy in the $200ks, ideally mid-upper 200s.
I'd ideally like to be in the 40-50 hour range for work (or less), as I have many interests outside of medicine, and am willing to sacrifice pay for them, potentially significantly once loans are paid off. That's average - I'm happy to work more as long as I have time off.

I'm currently signed up for 8 weeks of EM (half my electives, just for SLOEs), 4 of radiology, and 4 of PM&R, and can shadow some. The rest is dumb required rotations.

I have good board scores, good grades/evals, lots of research, etc, so that is not an issue for anything. If it matters, I am somewhat interested in academic medicine, and would be interested in doing some research as a physician.

With that in mind:

1) Neurology:
Pros:
-enjoyed pathophysiology a lot
-liked the "cerebral" nature, like feeling like a diagnostician, relying on observational skills/physical exam/"weird" symptoms.
- inherently very good at neurology, if that matters. Actually liked studying it.
- More emphasis on fewer patients, which I like. Haven't liked watching/waiting and trending labs, etc, on a long list.
-Enjoyed most of outpatient, enjoyed impatient more than other rotations.
-Think I might like neuro ICU too. 7 on/14 off with an outpatient practice during the off sounds decent.
-Some aspect of emergent care, which I would want (i.e., I would want some, but not all, emergent care - e.g. I think I might like some stroke/SAH/etc)
- did very well on this rotation and should be able to get letters w/o issue
- good home program
Cons:
-I find dementia depressing (dumb, I know) and while I'm OK with end-of-life discussions, I generally didn't like the feeling of not being able to do anything for some inpatients (despite liking aspects of neuro ICU).
-Don't want to do pure med management. A lot of neuro seemed to be this
-Don't like table rounding -> bedside rounding for hours
-Salary is low? Not sure on this
-seems like a lot of call, at least in residency

2) Child neuro
Pros:
-no stroke, no dementia, fewer patients with destroyed brains, etc. More treatable? I'd be OK with movement disorders, epilepsy, concussion, etc. So, potentially more enjoyable than adult neurology.
-I like kids/adolescents. Liked peds rotation more than IM.
-can probably get a solid peds letter. Also, can probably get a letter from the one peds neurologist at my institution
Cons:
- Biggest hold-up is this is practically non-existent in my home institution. Would have had close to zero experience in this, and likely won't have much prior to applying. Might have to dual apply. Not sure how I can get more exposure outside of aways, at which point I will have already applied....
-haven't experienced this yet, but people say parents can be exhausting for peds in general
-long training (5 years + up to 2 years of fellowship) for low pay? Also, peds years might suck and I kind of want to start my life...

3) PM&R
Pros:
- Neuro + ortho/MSK (which I also like) without having to live in the OR.
- potentially lots of procedures!
- I think I would like pain management
- seems very controllable with good lifestyle/salary control
- can work in multiple settings, e.g. VA, etc
- as I understand it, little call
- good home program
Cons:
- inpatient rehab doesn't really appeal to me
- neither does general medical management. I understand the emphasis on functionality and that appeals to me, but I don't want to do a ton of social work
- think I might miss the CNS stuff, the movement disorders, etc. I understand there's still some diagnostic aspects, but don't want to only see back pain, etc
- chronic pain management might not be that great. I honestly don't know. Think I would rather focus on neuro/MSK rehab than disability, etc, and not sure on the balance
- outside of shadowing, will have little experience prior to 2-3 weeks before applying....

4) Radiology
Pros:
- like imaging
- ability to do procedures
- lots of diagnostic puzzles
- $$$
- probably a better fit personality-wise than neuro in terms of getting along with colleagues, if that matters at all
- all the specialty quizzes have this somewhere near the top for me, which is why I'm looking into
Cons:
- little/no patient interaction. I don't count poking a patient with a needle as patient interaction
- not super interested in anatomy in general. I like certain aspects of anatomy, but I'm not an anatomy "person"
- not sure I want to stare at a computer all day
- call

5) EM
Pros:
- Seeing EM consults has been the highlight of most of my rotations
- Emergent/trauma aspect - I'm good at/enjoy aspects of physiology, and the rapid management of such is interesting
- I think generally I would prefer a few long days to many short days. I have many interests outside of medicine (see neuro ICU)
- procedures, albeit less interesting ones
- not boring/no rounding
- from my perspective, good pay
- no call!
- short residency
Cons:
- pill seekers/routine boring stuff? I haven't experienced this yet but am told it's part of the game
- overall, less interested in the pathophysiology, outside of trauma
- super stressful? I do OK on-the-spot, but I wouldn't say I'm awesome at it
- messing up circadian rhythms seems intimidating to me. My main concern with call is that I already don't sleep well/don't do well on chronic sleep deprivation and am worried changing shift schedules might be tough, especially later in life
- would not consider home program


My issue (or, my school's issue) is I haven't formally rotated in 4 out of 5 of the above fields yet, and have limited time to experience them. I feel like I need to narrow down beforehand. E.g. eliminating EM and focusing on the overlap between neuro and PM&R would make things simpler, but I am apprehensive about pulling the trigger and dropping my EM away rotation (and thus eliminating EM) without experiencing it. I'm not really considering other fields - the only thing I have left is FM, and anesthesiology looks super boring to me.

Would love any insight from anyone who had to make similar decisions. Also would like some insight into residencies; I know that's a minor part of one's career, but I would like to get married/have a family/life/whatever during residency and want to avoid being miserable like a number of residents I've met.

I know this is super long, but would appreciate some help.

 

[spacegun]

What I would like: something I'm interested in (duh), relatively controllable hours, some procedures, at least some patient interaction. Am open to inpatient + outpatient mix, but undecided. What I don't want: lots of rounding - I can tolerate some, but not hours of it - lots of call, pure med management, but also not lots of pay - I'd probably be happy in the $200ks, ideally mid-upper 200s. I'd ideally like to be in the 40-50 hour range for work (or less), as I have many interests outside of medicine, and am willing to sacrifice pay for them, potentially significantly once loans are paid off. That's average - I'm happy to work more as long as I have time off.

It sounds like family medicine would be a good fit for you. You can make $250+ working 40-50 hours, you can have controllable hours, it has minor procedures, and obviously there's patient interaction, and also can have an inpatient and outpatient mix. Call is limited too, depending on your practice. You can choose to focus on certain patient populations or pathologies if you want too. It's one specialty where you can still be your own boss so you're not beholden to big corporations or hospital systems, at least not as much as other specialties like anesthesiology. You can make your own hours (as long as your partners are fine) and don't have to work nights, weekends, and holidays like in EM unless you want to. You will always have a job literally almost anywhere in the world you want to go to. You can be an academic if you want to, but it's a pay cut like every specialty.

 

[LuciusVorenus]

I would eliminate PM&R. It SOUNDS interesting but I did some of it and it's honestly SO boring. You just watch demented old people learn to walk again...or they don't and stay upstairs from your SAR forever. I wouldn't say it's like neuro+ortho, I think it's more Geriatrics+All the parts of neuro you mention not liking.

Also consider some of the subspecialties. What about doing just stroke or structural neuro. IR? Neuro IR?

 

[libertyyne]

I would eliminate PM&R. It SOUNDS interesting but I did some of it and it's honestly SO boring. You just watch demented old people learn to walk again...or they don't and stay upstairs from your SAR forever. I wouldn't say it's like neuro+ortho, I think it's more Geriatrics+All the parts of neuro you mention not liking.

Also consider some of the subspecialties. What about doing just stroke or structural neuro. IR? Neuro IR?

I dont think the hours are good for neuro IR , the call schedule for for those folks is insane.

 

[LuciusVorenus]

I dont think the hours are good for neuro IR , the call schedule for for those folks is insane.

True. I've also heard the job market is pretty bad too.

 

[LuciusVorenus]

It sounds like family medicine would be a good fit for you. You can make $250+ working 40-50 hours, you can have controllable hours, it has minor procedures, and obviously there's patient interaction, and also can have an inpatient and outpatient mix. Call is limited too, depending on your practice. You can choose to focus on certain patient populations or pathologies if you want too. It's one specialty where you can still be your own boss so you're not beholden to big corporations or hospital systems, at least not as much as other specialties like anesthesiology. You can make your own hours (as long as your partners are fine) and don't have to work nights, weekends, and holidays like in EM unless you want to. You will always have a job literally almost anywhere in the world you want to go to. You can be an academic if you want to, but it's a pay cut like every specialty.

Being a hospitalist wouldn't be horrible either. 7 on 7 off can be pretty good. Unfortunately, it would involve a good bit of rounding. Still wouldn't be as bad as ICU rounds though!

 

[libertyyne]

True. I've also heard the job market is pretty bad too.

yeah,I spoke to one and she explicitly said that there are many unregulated fellowships pumping out grads and that the market will be completely saturated by the time I am done with training.

 

[operaman]

Everything in your post screams EM. I can't believe you're even toying with the idea of the other things on your list. I mean, you like neuro but don't want medical management, rounding, or seeing sad demented old patients?! Your cons for most everything above are the defining bread and butter of each field.

I think EM is the best fit with what you're looking for. It seems to hit all the high points while the cons are much more manageable. Yes drug seekers and non-emergent care are the bane of ED docs everywhere, there's no denying it. They also see every other specialist out there -- plenty of pain seekers seeing neuro folks trying to some kind of radiculopathy diagnosis to simultaneously game the disability system and get some narcotics. There is no specific pathophys for ED -- it sees everything. Your home program issues are no big deal - it's a short residency and you probably won't end up being an attending there anyhow. All in, you hit the points most EM guys seem to harp on: fast pace, no rounding, no call, time for activities outside medicine, patient interaction but not too much of it.

Other things I'd consider - anesthesia. No rounding, minimal call, good lifestyle, patients who are 100% compliant with taking every med you push through their IV. You'd have some fellowship options for some light procedural work.

Internal medicine fellowships - Lots of variety here, but being a straight internist would hit a lot of your desired points, especially if you did a mostly outpatient practice. Great procedural options in cards, gi, pulm if you want to go that way.

 

[spacegun]

I don’t think EM or anesthesia would be a good fit for OP. EM because you have to work nights and weekends and holidays and OP sounds like he or she wants something more controllable than that.

And anesthesia because you aren’t in charge of when you finish cases, that’s more up to the surgeon, and you can stay late and miss family events if the surgeon goes long, cases get added on, or if the surgeon wants to do a weekend case. And at the majority of places now you have to manage or “medically direct” CRNA’s at ratios of 2:1 to 4:1 or maybe more, and you don’t always get to do your own procedures anymore, and you might get into trouble if they the CRNA’s get into trouble legally. OP sounds more like they want to be their own boss and make the decisions, and have more controllable hours than anesthesia would have.

IM fellowships some of them could be good though.

 

[deleted610572]

I would eliminate PM&R. It SOUNDS interesting but I did some of it and it's honestly SO boring. You just watch demented old people learn to walk again...or they don't and stay upstairs from your SAR forever. I wouldn't say it's like neuro+ortho, I think it's more Geriatrics+All the parts of neuro you mention not liking.

Also consider some of the subspecialties. What about doing just stroke or structural neuro. IR? Neuro IR?

Not if he goes on to interventional pain. Can make 300+ at 40-50 hours. And it was no dementia, all outpatient. Sure you weed out pain seekers but besides that it’s not bad

 

[IslandStyle808]

I would eliminate PM&R. It SOUNDS interesting but I did some of it and it's honestly SO boring. You just watch demented old people learn to walk again...or they don't and stay upstairs from your SAR forever. I wouldn't say it's like neuro+ortho, I think it's more Geriatrics+All the parts of neuro you mention not liking.

Also consider some of the subspecialties. What about doing just stroke or structural neuro. IR? Neuro IR?

Except that isn't the only thing PM&R does, its one of many things. It depends on the practice structure you want.

 

[IslandStyle808]

Not if he goes on to interventional pain. Can make 300+ at 40-50 hours. And it was no dementia, all outpatient. Sure you weed out pain seekers but besides that it’s not bad

Had one PM&R docs tell me, they can make as much as people doing ortho or more if they did similar hours.

 

[bananafish94]

I'm only an M2 and have no insight to offer whatsoever, but as an objective observer reading what you just wrote it seems to me like neurology is definitely your favorite.

 

[siliso]

Rheum? Derm? Neuro?

 

[PTPoeny]

Have you considered Peds pm&r? Seems like it combines some of your interests and avoids some of the things you want to avoid.

 

[mrbreakfast]

Thanks all.

Have you considered Peds pm&r? Seems like it combines some of your interests and avoids some of the things you want to avoid.

Not really. I'll look into it but know nothing about it, and a quick google makes it look like a de facto 6 year residency...haven't seen too much about it on SDN.

Internal medicine fellowships

Other than perhaps surgery, IM was my least favorite rotation. I've pretty much ruled it out, and I consider the prospect of an intern year in IM as a negative for the residencies which require it. You're right in that I might like the practice/lifestyle in general, but generally speaking the IM pathologies don't really interest me.

I dont think the hours are good for neuro IR , the call schedule for for those folks is insane.

Pretty much ruled it out too as someone who doesn't want a ton of call. At my institution neuro IR is Q2 call.

It sounds like family medicine would be a good fit for you.

Haven't had FM rotation yet actually, but outpatient general IM was awful. Managing DM/COPD and telling people to stop smoking and eat better was rough. I know there's more to FM than that, but still...

plenty of pain seekers seeing neuro folks trying to some kind of radiculopathy diagnosis to simultaneously game the disability system and get some narcotics.

Yea, saw some of that in headache clinic. It was frustrating, but I've seen this kind of thing on literally every rotation (including peds).

 

[YoungDoc25]

Rads + mammo or Peds fellowship for cool/meaningful procedures and a decent amount of patient interaction.

PICU (unless gen Peds isn’t doable)
+1 for anesthesia + pain (or CC)

 

[spacegun]

Some are saying anesthesia or PM&R, then pain. But there's no guarantee OP will match into pain from anesthesia or PM&R. Pain is competitive even from anesthesia. And if anyone has ever seen pain patients, they are not exactly easy patients to see! OP might end up not wanting to deal with pain patients or for other issues in pain even something trivial like wearing a lead apron all day for interventional pain procedures. I think OP should decide if he or she likes the base specialty (e.g. anesthesia, PM&R) first, before deciding on pain. Choosing pain at this stage is premature in my opinion.

 

[RinShanKaiHo]

Very interesting discussion! Thank you guys.
Wonder how neuro ICU works? How much pay usually it generates for one week on two weeks off? Is it likely to stay in academia and do research for the rest of the time?

Sent from my SM-G960U1 using Tapatalk

 

[siliso]

Check the job market on neuro icu in your desired area. It’s a bit of a niche, not that it’s impossible.

 

[Dr. Bruce Banner]

A few months back I posted something similar and got a bunch of helpful responses, so I figured I'd repost for a bit more advice as I still am fairly undecided. We basically have to pick most of our M4 electives within the next few weeks, and I'm stressing over narrowing things down, as right now I'm signed up for a bunch of electives all across the board and am worried about being in the same position in September.

What I would like: something I'm interested in (duh), relatively controllable hours, some procedures, at least some patient interaction. Am open to inpatient + outpatient mix, but undecided.
What I don't want: lots of rounding - I can tolerate some, but not hours of it - lots of call, pure med management, but also not lots of pay - I'd probably be happy in the $200ks, ideally mid-upper 200s.
I'd ideally like to be in the 40-50 hour range for work (or less), as I have many interests outside of medicine, and am willing to sacrifice pay for them, potentially significantly once loans are paid off. That's average - I'm happy to work more as long as I have time off.

I'm currently signed up for 8 weeks of EM (half my electives, just for SLOEs), 4 of radiology, and 4 of PM&R, and can shadow some. The rest is dumb required rotations.

I have good board scores, good grades/evals, lots of research, etc, so that is not an issue for anything. If it matters, I am somewhat interested in academic medicine, and would be interested in doing some research as a physician.

With that in mind:

1) Neurology:
Pros:
-enjoyed pathophysiology a lot
-liked the "cerebral" nature, like feeling like a diagnostician, relying on observational skills/physical exam/"weird" symptoms.
- inherently very good at neurology, if that matters. Actually liked studying it.
- More emphasis on fewer patients, which I like. Haven't liked watching/waiting and trending labs, etc, on a long list.
-Enjoyed most of outpatient, enjoyed impatient more than other rotations.
-Think I might like neuro ICU too. 7 on/14 off with an outpatient practice during the off sounds decent.
-Some aspect of emergent care, which I would want (i.e., I would want some, but not all, emergent care - e.g. I think I might like some stroke/SAH/etc)
- did very well on this rotation and should be able to get letters w/o issue
- good home program
Cons:
-I find dementia depressing (dumb, I know) and while I'm OK with end-of-life discussions, I generally didn't like the feeling of not being able to do anything for some inpatients (despite liking aspects of neuro ICU).
-Don't want to do pure med management. A lot of neuro seemed to be this
-Don't like table rounding -> bedside rounding for hours
-Salary is low? Not sure on this
-seems like a lot of call, at least in residency

2) Child neuro
Pros:
-no stroke, no dementia, fewer patients with destroyed brains, etc. More treatable? I'd be OK with movement disorders, epilepsy, concussion, etc. So, potentially more enjoyable than adult neurology.
-I like kids/adolescents. Liked peds rotation more than IM.
-can probably get a solid peds letter. Also, can probably get a letter from the one peds neurologist at my institution
Cons:
- Biggest hold-up is this is practically non-existent in my home institution. Would have had close to zero experience in this, and likely won't have much prior to applying. Might have to dual apply. Not sure how I can get more exposure outside of aways, at which point I will have already applied....
-haven't experienced this yet, but people say parents can be exhausting for peds in general
-long training (5 years + up to 2 years of fellowship) for low pay? Also, peds years might suck and I kind of want to start my life...

3) PM&R
Pros:
- Neuro + ortho/MSK (which I also like) without having to live in the OR.
- potentially lots of procedures!
- I think I would like pain management
- seems very controllable with good lifestyle/salary control
- can work in multiple settings, e.g. VA, etc
- as I understand it, little call
- good home program
Cons:
- inpatient rehab doesn't really appeal to me
- neither does general medical management. I understand the emphasis on functionality and that appeals to me, but I don't want to do a ton of social work
- think I might miss the CNS stuff, the movement disorders, etc. I understand there's still some diagnostic aspects, but don't want to only see back pain, etc
- chronic pain management might not be that great. I honestly don't know. Think I would rather focus on neuro/MSK rehab than disability, etc, and not sure on the balance
- outside of shadowing, will have little experience prior to 2-3 weeks before applying....

4) Radiology
Pros:
- like imaging
- ability to do procedures
- lots of diagnostic puzzles
- $$$
- probably a better fit personality-wise than neuro in terms of getting along with colleagues, if that matters at all
- all the specialty quizzes have this somewhere near the top for me, which is why I'm looking into
Cons:
- little/no patient interaction. I don't count poking a patient with a needle as patient interaction
- not super interested in anatomy in general. I like certain aspects of anatomy, but I'm not an anatomy "person"
- not sure I want to stare at a computer all day
- call

5) EM
Pros:
- Seeing EM consults has been the highlight of most of my rotations
- Emergent/trauma aspect - I'm good at/enjoy aspects of physiology, and the rapid management of such is interesting
- I think generally I would prefer a few long days to many short days. I have many interests outside of medicine (see neuro ICU)
- procedures, albeit less interesting ones
- not boring/no rounding
- from my perspective, good pay
- no call!
- short residency
Cons:
- pill seekers/routine boring stuff? I haven't experienced this yet but am told it's part of the game
- overall, less interested in the pathophysiology, outside of trauma
- super stressful? I do OK on-the-spot, but I wouldn't say I'm awesome at it
- messing up circadian rhythms seems intimidating to me. My main concern with call is that I already don't sleep well/don't do well on chronic sleep deprivation and am worried changing shift schedules might be tough, especially later in life
- would not consider home program


My issue (or, my school's issue) is I haven't formally rotated in 4 out of 5 of the above fields yet, and have limited time to experience them. I feel like I need to narrow down beforehand. E.g. eliminating EM and focusing on the overlap between neuro and PM&R would make things simpler, but I am apprehensive about pulling the trigger and dropping my EM away rotation (and thus eliminating EM) without experiencing it. I'm not really considering other fields - the only thing I have left is FM, and anesthesiology looks super boring to me.

Would love any insight from anyone who had to make similar decisions. Also would like some insight into residencies; I know that's a minor part of one's career, but I would like to get married/have a family/life/whatever during residency and want to avoid being miserable like a number of residents I've met.

I know this is super long, but would appreciate some help.

I'm on the same boat as you, so take my words with a grain of salt. I LOVE neuro, I repeat, LOVE. I believe it has a very bright future, and everyone talks about now you can manage a lot of problems but still can't cure anything (but it's not like IM can either, internist just MANAGE problems like neurologists MANAGE problems; and EM just stabilize, they don't really CURE anything). It's kinda true, but great technology is coming... but they've been saying that for a while. And it WILL come, but it'll take 10 - 20 years. Another thing is like you said, just because we love neuro doesn't mean we will necessarily enjoy taking consults to every single altered mental status patient in the hospital... and this problem is only going to be worse as there is an increasing neurologist shortage and increasing elderly population, which means more cases of altered mental status that nobody else in the hospital can apparently manage except for a neurologist. So if we become neurologists, we better be prepared for BUSY call days in the years to come... *shivers*

Child neurology is cool, if you like genetics. After publishing couple of papers in child neuro, I realized it's not for me. Also a child neuro fellow told me if I really like neuro, consider PM&R. She said she would choose child neuro again, but she was completely burnt out, and she was telling me how happy her colleagues in PM&R are. But again, you need to love neuro and MSK to go into PM&R. It's a super cool field especially with the dawn of exoskeleton (at least it's cool to me).

It's difficult to decide. I'm still 50/50 between neuro and pm&r to be honest... but it's reassuring that I know I can become a great and competent doctor no matter which field I end up choosing.

 

[Redpancreas]

My logic is that if you don’t have something you’re absolutely set on, do EM/Anesthesia. Both are the best bang ($$$) for their buck (time). The only thing to consider is if you can handle that stress in the moment.