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Help me choose a specialty

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Dolphind0c

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About me:
  • Non-trad student in mid30’s from CA. Rising m4 at “low-tier” MD school in Midwest, coming from professional career in the arts with great stories to tell about my past.
  • Average clinicals, mix of HP/H. Probably will not get AOA.
  • Pass step 1 first attempt. Step 2 in June. I’m a good test taker, scored 96th %tile on MCAT, so I’m anticipating a solid, but not phenomenal score.
  • 4 pubs, a couple more in various stages of completion, should be 6-7 by ERAS. Half are 1st author. Mix of review papers, case reports, and chart review outcomes based projects in a variety of specialty fields. Nothing in a top-tier journal.
  • Some interesting and productive self-directed leadership during med school but minimal volunteering.
What’s important to me in a career/specialty:

1. Autonomy. I hate rules, I hate HR, I hate academics, and don’t particularly enjoy breathing the stale air of hospitals. I want to be the one who decides what goes on the answering machine and what art is hanging on the walls. This probably means a future in a private group mainly outpatient practice.

2. Strong chance at returning to SoCal for residency. Location is extremely important to me for the next 3-5 years for personal reasons I won’t go into.

3. Longitudinal patient relationships with some mostly in-office procedures.

4. Ability to take time off to pursue my other interests. Wether this means 3-4 days of work per week or the freedom to take 12-15 weeks of time off per year.

5. Realistically be able to earn 300-500k a year with the above constraints.


Right now I’m between FM, IM, neuro, and psych.

FM: probably at the top because of flexibility, better outpatient training and more opportunity to do procedures. Although I am concerned about being overworked and underpaid. I think DPC is great but not sure how conducive that is to taking time off. I don’t like OB but do like peds, so would tailor my practice away from pregnant patients.

IM: I enjoyed my IM rotation but feel that I better fit in with the FM culture. Rounding for hours is torture, but IM does leave the most options for me for fellowship if I wanted, while still giving me opportunity to either do mostly outpatient clinic or a mix of that with hospitalist to maximize my time off. Additional plus would be avoiding OB, but no peds training.

Neuro: I also loved neuro, loved the physical exam and the puzzles to be solved, and see it being conducive to outpatient private/group practice. Plus great long term relationships. I don’t mind managing chronic non-curable illness. But don’t know how common it is to work 3-4 days. The neurologists I met on my rotation worked a ton.

Psych: I had a great time in my psych rotation and everyone tells me I “look and act like a psychiatrist” (not sure if that is a dig, haha), but I don’t really buy into the brand of psychiatry. I love talking to patients and geeking out about psychopharmacology but at least from what I saw, the medicines don’t work very well and I would miss the rest of what I learned in med school and feeling like a “real” doctor. Also I think dealing with the psych patient population would drive me nuts after a couple of years. That being said of all 3, psych probably has the most autonomy and best work/life balance. If I did it, I would probably want to get the training to do a good amount of talk therapy and not just medication management.

Am I missing something here? As far as ability to be flexible with work hours, plenty of outpatient time, and the ability to earn decent money, optho and ENT are probably on the top of most peoples lists. I enjoyed being in the OR during my surgical rotation, but didn’t really have a true hunger to operate. Also I doubt I have a good shot at matching in a big city on west coast coming from a low-tier Midwest school without a home optho or ENT program. I already crossed anesthesia off the list as well, it seemed incredibly boring from the couple of times I shadowed, and from what I observed during surgery.

Appreciate your thoughts and recommendations.

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You can do FM, outpatient neuro, and outpatient psych 3-4 days/week, but I think hitting 300-500k doing that part-time seems unlikely without a well-established private practice or rural location. Someone correct me if I'm wrong. Psych definitely has the flexibility but you would give up procedures if that's a deal breaker.
 
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Glad you out neuro on your list, as I was reading your OP I thought neuromuscular specialist. Gives you chance to go private practice, can do EMGs, occasional botox, etc in addition to long term relationships in outpatient setting. The kicker is - you won’t make 350k plus in any of these fields if you only work 3 days a week and only 40 weeks a year. For that you’d need Derm type volume and you won’t get that in neurology given the lengthy exams and history
 
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Whatever you choose - don't choose anesthesia. #gunner_move_2023 ;)
 
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But don’t know how common it is to work 3-4 days. The neurologists I met on my rotation worked a ton.
Standard neuro clinic week is 4 days. Plenty of people work 3. Keep in mind when people say "work X number of days" they're talking about when they actually see patients. You'll soon learn about the clinic inbox...

Rather than pick a specialty based on the salary and benefits, I'd recommend picking a specialty based on your interests and what you truly want for from your work, regardless of the pay or hours. Because you're asking for a part-time job at a full-time job salary, and that's not specialty-specific.

Since you mentioned neuro, I'll note that I agree with @Captain_Falcon in that you're basically describing a neuromuscular-focused practice, with the caveat that a job that pays $350-400K is not going to be 3 days a week, not 40 weeks a year, and not located in California.
 
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It sounds like FM is a good fit for you. Autonomy, longitudinal care, opportunity for in-office procedures, schedule flexibility, and able to see both adult and peds patients. Med-peds would be an option that avoids OB if you're ok with 4 year residency

As an IM resident, would not recommend using "rounding length," as a reason to avoid IM. Most IM jobs are in the outpatient setting, either as a PCP or subspeciailst (after fellowship), which makes rounds a moot point. Even if you're a hospitalist, you dictate your own rounding pace
 
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Seems more like a contest between FM and neuro to me.

Neuro seems like you enjoy the content more, FM the flexibility more. Do you actually enjoy the content and day-to-day of FM?
 
Thank you for your thoughts everyone!

Seems more like a contest between FM and neuro to me.

Neuro seems like you enjoy the content more, FM the flexibility more. Do you actually enjoy the content and day-to-day of FM?

I think my exposure to FM was skewed by my rotation experience. I was at an isolated rural private clinic with 5 doctors, no mid-levels, and we saw interesting stuff everyday. The relationships the docs had with their patients was incredible - they were truly part of the family. However, if living and practicing in a specialist-saturated urban area like SoCal meant it were just 10-15 minute diabetes, HTN, depression, and URI visits all day every day I don’t think I would enjoy it as much. But I’m hopeful that you can probably make FM out to be what you want. Perhaps it’s because I’m on the left side of the Dunning-Kruger curve, but when I was on outpatient neuro taking care of Parkinson and epilepsy patients, I kept on thinking that a competent family doc who took some time to learn further could handle 90% of the outpatient neuro stuff I saw.
 
Thank you for your thoughts everyone!



I think my exposure to FM was skewed by my rotation experience. I was at an isolated rural private clinic with 5 doctors, no mid-levels, and we saw interesting stuff everyday. The relationships the docs had with their patients was incredible - they were truly part of the family. However, if living and practicing in a specialist-saturated urban area like SoCal meant it were just 10-15 minute diabetes, HTN, depression, and URI visits all day every day I don’t think I would enjoy it as much. But I’m hopeful that you can probably make FM out to be what you want. Perhaps it’s because I’m on the left side of the Dunning-Kruger curve, but when I was on outpatient neuro taking care of Parkinson and epilepsy patients, I kept on thinking that a competent family doc who took some time to learn further could handle 90% of the outpatient neuro stuff I saw.

Your experience is not the norm. The bolded is much closer to reality. Also, once you dive into the management of Parkinson's and Epilepsy, often times patients that are being seen in those clinics are patients that your general neurologist may have referred becuase they aren't comfortable enough managing things that go beyond 1st or 2nd line treatment. This is way too much to expect your run of the mill Family Medicine provider to handle - especially for Parkinson's patients where the subtleties on the exam would go unnoticed routinely by the PCP
 
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Thank you for your thoughts everyone!



I think my exposure to FM was skewed by my rotation experience. I was at an isolated rural private clinic with 5 doctors, no mid-levels, and we saw interesting stuff everyday. The relationships the docs had with their patients was incredible - they were truly part of the family. However, if living and practicing in a specialist-saturated urban area like SoCal meant it were just 10-15 minute diabetes, HTN, depression, and URI visits all day every day I don’t think I would enjoy it as much. But I’m hopeful that you can probably make FM out to be what you want. Perhaps it’s because I’m on the left side of the Dunning-Kruger curve, but when I was on outpatient neuro taking care of Parkinson and epilepsy patients, I kept on thinking that a competent family doc who took some time to learn further could handle 90% of the outpatient neuro stuff I saw.
I would say that, whatever specialty you choose, you need to be OK with whatever the bread and butter is for that specialty. Every specialty has cool cases that get you excited, but somewhere between 50-90% of your day is going to be bread and butter. You have to decide for yourself which specialty's bread and butter is tolerable enough to make it worth getting the cool cases.
 
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You can make good money in FP but not working 3 days per week.

You can take that much time off if your partners are supportive. The amount of control you want in a practice isn't well suited to a group practice generally speaking.
 
Have you looked into PM&R?

One of our locals physiatrists works 3 days/week. Does injections, botox, EMGs (plus usual outpt MSK stuff, general neurorehab follow up, etc.). Then goes surfing or whatever. It's her practice. She rents out her clinic to a sports doc a day or two per week. Probably doesn't make what you're asking for, but should be on par if not better than FM/IM.

Note that will be harder and harder to make ends meet as a practice owner as time goes one. Consistently all the medicare rules/requirements/reimbursement are to the detriment of physician-owned practices, so most of the physician owned practices where I live in the Central Coast had been bought out by the larger hospital groups, or are owned by higher-earning specialties (urology, gen surg), or just run by a classic "I'm in charge until I die" type of doc. Psych is really the only specialty where it's not only very feasible, but very very easy to hang your own shingle.
 
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Have you looked into PM&R?

One of our locals physiatrists works 3 days/week. Does injections, botox, EMGs (plus usual outpt MSK stuff, general neurorehab follow up, etc.). Then goes surfing or whatever. It's her practice. She rents out her clinic to a sports doc a day or two per week. Probably doesn't make what you're asking for, but should be on par if not better than FM/IM.

Note that will be harder and harder to make ends meet as a practice owner as time goes one. Consistently all the medicare rules/requirements/reimbursement are to the detriment of physician-owned practices, so most of the physician owned practices where I live in the Central Coast had been bought out by the larger hospital groups, or are owned by higher-earning specialties (urology, gen surg), or just run by a classic "I'm in charge until I die" type of doc. Psych is really the only specialty where it's not only very feasible, but very very easy to hang your own shingle.
I haven't really looked into it. We had no exposure in the first 3 years. I'm not sure if its too late to discover it now that I am about to start the 4th year and have my schedule already set. Thanks for the ideas though.
 
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Why is psych easier to do that?
My impression is that because cash-only is very prevalent, and there's no overhead other than nice chairs and a scented candle or two.
 
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Why is psych easier to do that?
As stated above, there's hardly any overhead. Malpractice + a room to rent/office supplies and biller fees. Though now many are doing remote work, so you don't even need that--could use your dining room table with a decent background.

Most solo psychiatrists do their own scheduling/answering calls/etc. So they have no staff. Few physicians in other specialties can get by without any office staff, though I've heard of some FM docs who will rent a room in someone else's clinic, room their own patients, do their own vitals, immunizations, etc., and are one-man/woman shows as well. Not sure what their income was--probably lower, as the few docs I knew doing that wanted a slower/simpler pace of things.
 
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Want an idea out of left field? Arts background, run the show, outpatient, longitudinal care with some procedures, work in Southern California?

Do FM and some side aesthetics courses and start a medical spa, maybe do a little concierge PCP work through it. The risk is high, but it’s a high paying cash business where you set your hours.

It’s a business model I wouldn’t touch with a 10 foot pole, but it might be a fun idea for you to think about.
 
Probably FM and can learn to do cosmetic procedure or buy in to an aesthetics clinic and you should be good. I think DPC is also a good option for any of the above (even though neuro and psych aren’t primary care they certainly lend themselves to concierge practices)
 
About me:
  • Non-trad student in mid30’s from CA. Rising m4 at “low-tier” MD school in Midwest, coming from professional career in the arts with great stories to tell about my past.
  • Average clinicals, mix of HP/H. Probably will not get AOA.
  • Pass step 1 first attempt. Step 2 in June. I’m a good test taker, scored 96th %tile on MCAT, so I’m anticipating a solid, but not phenomenal score.
  • 4 pubs, a couple more in various stages of completion, should be 6-7 by ERAS. Half are 1st author. Mix of review papers, case reports, and chart review outcomes based projects in a variety of specialty fields. Nothing in a top-tier journal.
  • Some interesting and productive self-directed leadership during med school but minimal volunteering.
What’s important to me in a career/specialty:

1. Autonomy. I hate rules, I hate HR, I hate academics, and don’t particularly enjoy breathing the stale air of hospitals. I want to be the one who decides what goes on the answering machine and what art is hanging on the walls. This probably means a future in a private group mainly outpatient practice.

2. Strong chance at returning to SoCal for residency. Location is extremely important to me for the next 3-5 years for personal reasons I won’t go into.

3. Longitudinal patient relationships with some mostly in-office procedures.

4. Ability to take time off to pursue my other interests. Wether this means 3-4 days of work per week or the freedom to take 12-15 weeks of time off per year.

5. Realistically be able to earn 300-500k a year with the above constraints.


Right now I’m between FM, IM, neuro, and psych.

FM: probably at the top because of flexibility, better outpatient training and more opportunity to do procedures. Although I am concerned about being overworked and underpaid. I think DPC is great but not sure how conducive that is to taking time off. I don’t like OB but do like peds, so would tailor my practice away from pregnant patients.

IM: I enjoyed my IM rotation but feel that I better fit in with the FM culture. Rounding for hours is torture, but IM does leave the most options for me for fellowship if I wanted, while still giving me opportunity to either do mostly outpatient clinic or a mix of that with hospitalist to maximize my time off. Additional plus would be avoiding OB, but no peds training.

Neuro: I also loved neuro, loved the physical exam and the puzzles to be solved, and see it being conducive to outpatient private/group practice. Plus great long term relationships. I don’t mind managing chronic non-curable illness. But don’t know how common it is to work 3-4 days. The neurologists I met on my rotation worked a ton.

Psych: I had a great time in my psych rotation and everyone tells me I “look and act like a psychiatrist” (not sure if that is a dig, haha), but I don’t really buy into the brand of psychiatry. I love talking to patients and geeking out about psychopharmacology but at least from what I saw, the medicines don’t work very well and I would miss the rest of what I learned in med school and feeling like a “real” doctor. Also I think dealing with the psych patient population would drive me nuts after a couple of years. That being said of all 3, psych probably has the most autonomy and best work/life balance. If I did it, I would probably want to get the training to do a good amount of talk therapy and not just medication management.

Am I missing something here? As far as ability to be flexible with work hours, plenty of outpatient time, and the ability to earn decent money, optho and ENT are probably on the top of most peoples lists. I enjoyed being in the OR during my surgical rotation, but didn’t really have a true hunger to operate. Also I doubt I have a good shot at matching in a big city on west coast coming from a low-tier Midwest school without a home optho or ENT program. I already crossed anesthesia off the list as well, it seemed incredibly boring from the couple of times I shadowed, and from what I observed during surgery.

Appreciate your thoughts and recommendations.
Your transparency is appreciated, but you're living in a fantasy land here because anything that would fit your criteria would not pay well. In others words even the most competitive applicants can only choose 2: A) autonomy, B) lifestyle, and C) pay...unless you're willing to train for more years so your RVU or Hourly Salary would be so high you could earn the 300-500K with less work, which I would imagine is less feasible at this your stage of life. Alternatively, you could do something like FM and get creative with your business model on things like aesthetics for cash. It may not work out but if it does you'll like it.
 
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Based off your 5 desires, it's FM vs neuro. Do you care more about doing random, somewhat lame after the 10th time procedures and being a generalist? Or would you rather be super specialized, probably not do procedures, and make more money in Nuero? I'd do neuro. IM is for the hospitals, sounds like you don't love psych.
 
Your transparency is appreciated, but you're living in a fantasy land here because anything that would fit your criteria would not pay well. In others words even the most competitive applicants can only choose 2: A) autonomy, B) lifestyle, and C) pay...unless you're willing to train for more years so your RVU or Hourly Salary would be so high you could earn the 300-500K with less work, which I would imagine is less feasible at this your stage of life. Alternatively, you could do something like FM and get creative with your business model on things like aesthetics for cash. It may not work out but if it does you'll like it.
What are good specialties for A and B?
 
Lots of psych in our area have 2 or 3 small gigs and do very well. Hard to reach them anytime, but have an inpatient, outpatient, and specialty gig
Addiction, jail,adolescent, etc..Almost impossible to reach after hours.
 
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