How can I decide early between multiple competitive specialties? (ortho, ENT, ophtho)

[annasofttofu]

I’m an MS1, and I didn’t realize how medical specialty selection worked before only a few months ago. I didn’t realize how competitive some of them were and how you need to start doing research in that specialty specifically and applying to programs in that specialty really, really early.

I know people advise to start early with the most competitive specialty that you’re interested in so that you can change afterwards, but I’m interested in 3 really different and very competitive specialties so I feel like I can’t do that. This must be a very common situation for medical students though, so I figure someone out there has to know what could help.
Here’s a bit about me, in case it helps discussion and because I might not have considered every specialty:

- I’m an extremely family oriented person. I know I want a family, and I know they’ll be important to me. My parents are extremely important to me as well. I’m really close to them, I currently spend a lot of time with them, and I want to spend a lot of time with my future kids. In fact, the main reason I became interested in ortho was because my mother became physically disabled after working a manual labor job, and an orthopedic surgeon helped us out so much. As a result, I’m pretty scared of specialties without good work/life balance.

- I want a specialty with a lot of possibilities for math/technology/engineering research. I want to do research in developing new technologies or devices and ways to do things so that I don’t feel stagnant, and I was a software engineer for 5 years before going to medical school so I want to help out in my own special way. I’m also a 3D printing hobbyist and I also majored in math, so non-software engineering really interests me too. I think I’d like a career in academic medicine in my future.

- I love anatomy, and I don’t like molecular bio or biochem. Anatomy was literally my favorite class in my whole life, and I did really well in it naturally. Molecular bio and biochem have always been an uphill climb my entire life, and I never liked it. I think I’m leaning towards surgical specialties as a result, especially cause I also like the instant gratification and fixing things for real instead of just maintenance or dealing with unfixable problems by treating only the symptoms.

- I want patient interaction and a mix of clinic and procedures. I’m not that big a fan of just talking and not fixing the problem directly, but I also love talking to patients about who they are, what their goals are, and I love educating them.

- I’m a very visual person, and I love the idea of walking a patient through their own imaging or a feed from a scope.

- I’m a person of only average dexterity. I was never a musician, and I never sewed or crocheted or anything like that. I like the ortho gross surgeries for this reason.

Now a bit about my current thoughts on each specialty:

- Ortho: I love biomechanics, the anatomy, and how ortho combines math/physics and medicine. I have a personal connection because ortho helped out my mom so much, and I feel like I want to restore people’s qualities of life just like that. But I’m scared of the poor work/life balance in academic ortho, and I don’t vibe with ortho at my school very much. I’m an Asian woman who is extremely out of shape, unathletic, and doesn’t know any sports teams. When I spend time with ortho people at my school, I question my ability to fit in socially and feel socially on the periphery. I also don’t like how fast ortho clinic feels, because I want to have a decent amount of clinic and spend time with patients, not just operate all the time and blaze through clinic to fill up my OR days.

- ENT: I had an extraordinary shadowing experience where the attending walked patients through feeds of scopes down their nose to diagnose deviated septums, and where she walked me through a sleep apnea genioglossus stimulation surgery. The attendings I’ve met in ENT have been so nice and energetic, and I always feel such positive energy when around ENT people at my school. I also love the anatomy, especially the face because I was a hobbyist portrait painter. The potential for research and technology is massive and the variety is wonderful. But I’m not terribly passionate about ears, noses, or throats, I’m not terribly dexterous, and I’m a bit averse to unpleasant smells.

- Ophtho: Checks off all my boxes perfectly, where the potential for math, research, and engineering is huge, and I can work in academic medicine and still have time for a great family life. It’s also really visual and has a great mix of clinic and procedures. But I don’t feel that passionate about the eye, and I don’t want to forget all my anatomy and medicine. I’m also not sure if I’m dexterous enough for the microsurgery in ophtho.

I’m having a really hard time deciding, especially because ENT and ophtho are currently not accepting shadows at my school.

How can I decide? (I posted something similar on r/medicalschool and got advice about what I can do regardless of specialty, like excel on Step 2 or take a research year. but I want to know how I can choose between the 3 specialties.)

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[Rachapkis]

Excellent grades and high step scores are the key to gaining entry to competitive specialties. As an MS1, make sure that you're doing what you can to take care of these two critical concerns. With that in mind, pick the specialty that most appeals to you (realizing that it may change) and seek out research experiences and other opportunities in that area. If things change, seek out research experiences and opportunities in your new area of interest. Residency programs realize that you are in a formative stage, and will not exclude you if you've demonstrated excellence and interest along the way.

 

[eyeeye_captain]

As above, good grades and actually figuring out what you want are your first steps. From an ophtho perspective:

Yes, many boxes. Likely the best lifestyle of the three. Clinic and procedures balance well, although subspecialties like retina and oculoplastics will give you substantially more procedures than general. Incredibly visual, almost everything is diagnosed from a visual clinical exam or imaging. Plastics might fit you for procedures and worries about dexterity for intraocular work, especially since it has some overlap with ENT and still has some anatomy stuff (I make the same 3 incisions for almost every retina case). Research I can’t help you with as it’s one of the banes of my existence. I will also warn you that if you think ortho clinic is fast-paced, ophtho is an extra gear.

If there’s no formal shadowing available, reach out for a research project with someone in those departments. If you’re working with them, then hey, you have to see them sometime. Game the system, do a “research meeting” during clinic or OR time.

 

[annasofttofu]

As above, good grades and actually figuring out what you want are your first steps. From an ophtho perspective:

Yes, many boxes. Likely the best lifestyle of the three. Clinic and procedures balance well, although subspecialties like retina and oculoplastics will give you substantially more procedures than general. Incredibly visual, almost everything is diagnosed from a visual clinical exam or imaging. Plastics might fit you for procedures and worries about dexterity for intraocular work, especially since it has some overlap with ENT and still has some anatomy stuff (I make the same 3 incisions for almost every retina case). Research I can’t help you with as it’s one of the banes of my existence. I will also warn you that if you think ortho clinic is fast-paced, ophtho is an extra gear.

If there’s no formal shadowing available, reach out for a research project with someone in those departments. If you’re working with them, then hey, you have to see them sometime. Game the system, do a “research meeting” during clinic or OR time.

That’s good advice, I’ll try to ask for some research meetings where I meet them in clinic.

Can I ask you how repetitive you feel like ophtho is, and do you feel like patients feel happy despite only seeing you for a few minutes?

 

[annasofttofu]

Excellent grades and high step scores are the key to gaining entry to competitive specialties. As an MS1, make sure that you're doing what you can to take care of these two critical concerns. With that in mind, pick the specialty that most appeals to you (realizing that it may change) and seek out research experiences and other opportunities in that area. If things change, seek out research experiences and opportunities in your new area of interest. Residency programs realize that you are in a formative change, and will not exclude you if you've demonstrated excellence and interest along the way.

Unfortunately, my school has no grades, nor do we have pass with honors or high pass or anything like that. All 4 years are pass fail in every way.

I do recognize that I’ll need the absolute best Step 2 score, but it seems like my entire application is just going to be just that score and my research so I need to start research in the “correct” specialty ASAP.

 

[eyeeye_captain]

That’s good advice, I’ll try to ask for some research meetings where I meet them in clinic.

Can I ask you how repetitive you feel like ophtho is, and do you feel like patients feel happy despite only seeing you for a few minutes?

I think everything is repetitive to some degree. I see bread and butter, and zebras, and disasters in the same clinic, but retina sometimes collects the craziness nobody else wants. Most fields are the same, just a different flavor. Everyone kind of gets into a groove.

I see many patients more often than their PCP. I talk shop with my regulars all the time, and we know each others’ families through chatting. Even with short visits, if you remember folks, they’ll remember you. Nobody is happy having needles in their eyes or lasers, but I get plenty of handshakes and hugs.

 

[Dantes]

Other than the patient interaction part, sounds like your boxes would be checked with rads.

Might be a hot take on here, but attending surgeon hours/flexibility still aren't all that great if lifestyle is a top priority, at least compared to non-surgical fields.

 

[annasofttofu]

Other than the patient interaction part, sounds like your boxes would be checked with rads.

Might be a hot take on here, but attending surgeon hours/flexibility still aren't all that great if lifestyle is a top priority, at least compared to non-surgical fields.

Yeah I really can’t deal with the lack of patient interaction in rads. It was actually the 1st specialty I shadowed cause I went in already moderately interested, because my undergrad research was in machine learning and medical images.

 

[annasofttofu]

Shadowed ophtho and I’m pretty sure I don’t want to do it, I don’t really like going through patients so quickly and it felt so rushed.

Can someone comment on ENT vs ortho lifestyle? They seem to have roughly the same average hours worked per week according to AAMC CIM, but ENT is considered a lifestyle-ish specialty and ortho isn’t.

I’m not passionate about the ENT subject material at all and I love ortho material, but I’m not willing to give up my family for ortho. It sounds (from some ortho posts I’ve read like OrthoTraumaMD’s) that you work insanely hard for 5-10 years after fellowship. The ortho specialty advisor at my school said ortho can be a lifestyle specialty if I want after fellowship because you can really mold your career as an attending, and I see various Reddit threads about amazing ortho lifestyles, but threads on SDN suggest that this doesn’t happen until many many years into your fellowship.

It seems like it would be nearly impossible to me to go into ortho and spend a lot of time with my family for a very, very long time, and I just need confirmation that that’s true so that I can just drop it. I really love it but I might need to let go early. I can only really keep either the ortho or ENT door open, and one of them’s going to have to close soon.

 

[bGMx]

I would make sure your application looks great, and shadow the three specialties for at least a full week. When you get to clerkships, you'll have an understanding of what your life will look like and all the things you'll have to put down in order to pick up the specialties you mentioned (experiences with friends/family, hobbies, free-time) and at that point you can reflect on whether or not any of your memories from shadowing are still powerful enough to justify the sacrifice versus deciding that your life is better served by other things. Just my thoughts on it.

 

[mrbreakfast]

You can't "logic" your way into a specialty choice. Plenty of people try to do that, but that's why there's the anecdotal statistic that ~80% of medical students change their specialty of choice during medical school. You have to actually experience it. Plenty of people who have never stepped foot in an OR want to be a surgeon.

You should be shadowing in these fields, and talking to people/mentors in these fields. You can decide whether to focus on ENT or ortho, or whatever else you want, as an M1, but keep an open mind.

Also, you should really think about what's most important to you. You're saying you want to be an academic, clinician-scientist surgical subspecialty attending and have a good lifestyle? I'd strongly consider looking more into this career path and talking to the academic surgery attendings at your medical school about their lifestyle. This is, of course, after 6-7 years of brutal residency/fellowship training, and ignoring the fact that an academic clinician-scientist salary probably isn't going to be what you'd anticipate. Having surgery-specific research won't hurt even if you end up choosing a different field.

 

[FlowRate]

Shadowed ophtho and I’m pretty sure I don’t want to do it, I don’t really like going through patients so quickly and it felt so rushed.

Can someone comment on ENT vs ortho lifestyle? They seem to have roughly the same average hours worked per week according to AAMC CIM, but ENT is considered a lifestyle-ish specialty and ortho isn’t.

When I rotated on ortho as a med student I'm pretty sure we saw about 80 patients in clinic one day. Pretty much any surgeon is going to be oriented toward maximum efficiency while in clinic. (Actually, any physician but some specialties are more amenable to taking time with patients.)


I'll just say that it's completely normal to change specialty interests. Having a track record of engagement/success in any endeavor is valued. You don't need to be productive in your ultimately chosen field from day 1.

 

[annasofttofu]

You can't "logic" your way into a specialty choice. Plenty of people try to do that, but that's why there's the anecdotal statistic that ~80% of medical students change their specialty of choice during medical school. You have to actually experience it. Plenty of people who have never stepped foot in an OR want to be a surgeon.

You should be shadowing in these fields, and talking to people/mentors in these fields. You can decide whether to focus on ENT or ortho, or whatever else you want, as an M1, but keep an open mind.

Also, you should really think about what's most important to you. You're saying you want to be an academic, clinician-scientist surgical subspecialty attending and have a good lifestyle? I'd strongly consider looking more into this career path and talking to the academic surgery attendings at your medical school about their lifestyle. This is, of course, after 6-7 years of brutal residency/fellowship training, and ignoring the fact that an academic clinician-scientist salary probably isn't going to be what you'd anticipate. Having surgery-specific research won't hurt even if you end up choosing a different field.

Yeah you’re completely right, and I’ve been talking to some of the academic surgery attendings and getting some indirect glimpses of their family lives, priorities in life, etc.

I’ve shadowed almost every main specialty that my school has a home program for, and I’ve shadowed ortho (clinic and OR) several times. To be honest, I felt like ortho (joints, hand) clinic was really repetitive and boring, and ortho (joints, trauma) OR was kind of boring, but all OR shadowing is boring as an M1 when all you can do is stand in the corner.

I shadowed ENT (general, oto) clinic twice, and I had a blast both times. Both the attendings and the patients had such great energy, the scopes were cool, and the variety was no joke. I haven’t seen any OR yet though cause the department is closed for MS1 shadows for a few months.

Haven’t shadowed ophtho yet cause the department’s been closed to MS1 shadows for a while. The one ophtho attending I talked to lives a pretty dream lifestyle though: research, clinic, surgery, and even industry stuff, and he does it all with a wife and 2 kids that he gets to see after leaving work at a reasonable time every day.

I’m definitely aware that my absolute top priority is my family, and that I’d much rather be a top parent than a top surgeon or researcher. The academic ortho attendings don’t have great family lives for the most part (getting married in their 40s or having no kids), and the ENT/ophtho attendings have decent family lives (some residents have kids and all the attendings have kids and claim to be an active part of their lives). I’m also aware that academics/research is probably the lowest priority on my list, cause it’s a nice to have.

I’m also well aware that I might not end up choosing anything surgical at all. I think I love surgery because I absolutely loved my limited exposure to “fake surgery” in MS1 anatomy and I like using my hands, but I don’t know if it’s worth the 5-7 soul crushing year sacrifice, especially for a woman who is 30-ish like myself and who needs to consider when I’m going to have a family.

 

[operaman]

So here’s the dirty little secret nobody tells students about surgery lifestyle: your quality of life will end up being directly related to your skills.

If you’re good and can get a case done by two that your partners need until 7, guess who’s getting home at a decent hour? If you have fewer complications, guess who gets called in less in the middle of the night?

I had a baller free flap attending in residency who picked up her kids from school every day at 3pm after big OR days because she was just that good and fast, and I remember one late night flap issue with her in 5 years of training. There were others who operated until much later every day and had more take backs and would likely grumble about their quality of life. I’ve seen this repeated over and over again. Even now I have some amazing recon partners who have similar skills and are home every day by 3pm.

Same goes for clinic. I had an otology attending who saw 50-60 patients in clinic, and finished on time every day with all his notes done by 5pm. Then there were the others who were 2 hours behind still charting at 9pm. Even now, I’ve arranged my clinics such that I see a full day worth of patients and finish by 1pm, notes finished by 2:30, and I’m still one of the busiest docs at my hospital. But I’m efficient and getting more so every day.

So circling back, I think you can create a great life in most any field if you acquire the skills and prioritize efficiency. Keep doing what you’re doing and explore, but you can create a fabulous life or a terrible life in any of those fields.

Residency is a bit more of a wild card. You absolutely can have a good lifestyle there too, but it’s very program dependent and you’ll need to be both competitive and selective. Find a big program with a night float system and single call pool. I was q8-10 call as a junior without night float and q12-14 as a senior. I worked 4 weekends my chief year; the rest were golden. That’s better than my call now! And we still had some of the best case numbers in the nation and I left very well trained which is allowing me a good lifestyle now.

Efficiency in residency is also a big part of QOL. If you have to get there at 4am to be ready for 6am rounds and then it takes you many hours after signout to finish tasks, then life will suck. If you can roll in at 5:30 for 6am rounds and get it all done, and get your work done during normal hours, you may end up working more normal ish hours.

I guess at this point, find something you think you’ll want to do first. Fitting it into your overall life is a matter of program and later job selection and just how efficient and skilled you can become. It’s quite possible to do it all…if you’re good.

 

[eyeeye_captain]

“You're saying you want to be an academic, clinician-scientist surgical subspecialty attending and have a good lifestyle?”

This. Since you said lifestyle is your priority, let’s go a little outside the box. Pick your specialty and then take a VA job affiliated with a university - you can’t get much easier days or call, and I think it’s like 10 weeks of vacation a year, plus your admin time for research. The problem is the sometimes soul-draining bureaucracy there, as well as there being a very limited job market.

I trained under some research-heavy folks with slow clinics who operated. Only one got to that kind of super chill status in under 10 years out from training. Even when you get to the real world, it’s going to take time to get established.

 

[annasofttofu]

“You're saying you want to be an academic, clinician-scientist surgical subspecialty attending and have a good lifestyle?”

This. Since you said lifestyle is your priority, let’s go a little outside the box. Pick your specialty and then take a VA job affiliated with a university - you can’t get much easier days or call, and I think it’s like 10 weeks of vacation a year, plus your admin time for research. The problem is the sometimes soul-draining bureaucracy there, as well as there being a very limited job market.

I trained under some research-heavy folks with slow clinics who operated. Only one got to that kind of super chill status in under 10 years out from training. Even when you get to the real world, it’s going to take time to get established.

How does the post-training lifestyle look for each of ortho, ENT, and ophtho? I know ortho is like 5-10 years of working really hard even after training, which is one of the main reasons that I’m leaning away from it. But is that true for all surgical specialties, and outside of academics/research? I know operaman said it depends partially on how good you are, but I’m just asking about averages.

 

[operaman]

How does the post-training lifestyle look for each of ortho, ENT, and ophtho? I know ortho is like 5-10 years of working really hard even after training, which is one of the main reasons that I’m leaning away from it. But is that true for all surgical specialties, and outside of academics/research? I know operaman said it depends partially on how good you are, but I’m just asking about averages.

Here again it’s going to vary quite a bit. I do like the idea of the VA job mentioned above. For the right person, it can be an ideal balance of lifestyle with incredible pathology and autonomy. You just have to be the right kind of person who can handle the bs and bureaucracy inherent in a big government program like that. And you definitely take a pay cut to work there relative to other options.

As for how hard you work after training, it’s going to depend on the job. Let’s say you want the big academic job, you’ve got or are working toward a K grant with your eye on an R01 or industry funding. Lifestyle will depend on how much protected time you have and how good an academic you are. Generally, you will have a lot of take home work early on because even with a couple protect days, there’s still too much to do to keep up with the funding and publishing requirements to establish yourself, to say nothing of the clinical burden. But if you want a more clinical/teaching academic job, then your hours may be a bit more standard.

Private practice varies a lot depending on the details. If you’re flexible in location you can find something; if not, you may have to make some choices in terms of money and lifestyle.

Of my graduating residency class, we’ve got a couple clinical academics, a couple private practice docs, and I’m the weirdo in sort of a hybrid privademic setup. It certainly seems like we all have pretty good lives, work mostly 4 days a week and very few weekends. All of us have pretty active lives outside the hospital and are usually home sometime between 3-6 depending on the day.

The catch to working less is you will inevitably make less money. I could add a full Saturday clinic and add about $200k to my income, but that’s just not worth it. Ditto for seeing more patients or operating more during the regular week. The clinical burden can always expand more to take whatever you’re willing to give. I’ve set boundaries and those boundaries cost me money. At its core, a medical license allows you to trade your time for money at a very good rate. If you’re willing to make less, you can definitely work less. Thankfully the surgical subs pay very well so even at 4 days a week with sweet hours and an efficient setup, I’m able to do very well and make well above the national median.

 

[Dunkthetall]

So here’s the dirty little secret nobody tells students about surgery lifestyle: your quality of life will end up being directly related to your skills.

If you’re good and can get a case done by two that your partners need until 7, guess who’s getting home at a decent hour? If you have fewer complications, guess who gets called in less in the middle of the night?

I had a baller free flap attending in residency who picked up her kids from school every day at 3pm after big OR days because she was just that good and fast, and I remember one late night flap issue with her in 5 years of training. There were others who operated until much later every day and had more take backs and would likely grumble about their quality of life. I’ve seen this repeated over and over again. Even now I have some amazing recon partners who have similar skills and are home every day by 3pm.

Same goes for clinic. I had an otology attending who saw 50-60 patients in clinic, and finished on time every day with all his notes done by 5pm. Then there were the others who were 2 hours behind still charting at 9pm. Even now, I’ve arranged my clinics such that I see a full day worth of patients and finish by 1pm, notes finished by 2:30, and I’m still one of the busiest docs at my hospital. But I’m efficient and getting more so every day.

So circling back, I think you can create a great life in most any field if you acquire the skills and prioritize efficiency. Keep doing what you’re doing and explore, but you can create a fabulous life or a terrible life in any of those fields.

Residency is a bit more of a wild card. You absolutely can have a good lifestyle there too, but it’s very program dependent and you’ll need to be both competitive and selective. Find a big program with a night float system and single call pool. I was q8-10 call as a junior without night float and q12-14 as a senior. I worked 4 weekends my chief year; the rest were golden. That’s better than my call now! And we still had some of the best case numbers in the nation and I left very well trained which is allowing me a good lifestyle now.

Efficiency in residency is also a big part of QOL. If you have to get there at 4am to be ready for 6am rounds and then it takes you many hours after signout to finish tasks, then life will suck. If you can roll in at 5:30 for 6am rounds and get it all done, and get your work done during normal hours, you may end up working more normal ish hours.

I guess at this point, find something you think you’ll want to do first. Fitting it into your overall life is a matter of program and later job selection and just how efficient and skilled you can become. It’s quite possible to do it all…if you’re good.

Is increased efficiency due to experience? For example, is the attending baller at flaps due to more years of operating? Or just has better innate skills?

Just wondering cause I was under the assumption that most U.S surgeons of a specific speciality graduated with pretty comparable skills, with few being obviously better than others and a few obviously worse. I don’t know the details of what goes into training but I figured the training was pretty standardized among accredited programs. Plus I thought surgery is self-selecting for those that are obsessed with improving/honing skills in training, yielding a fairly equal product among programs. So interested in hearing where along the road some become more efficient haha.

 

[annasofttofu]

Here again it’s going to vary quite a bit. I do like the idea of the VA job mentioned above. For the right person, it can be an ideal balance of lifestyle with incredible pathology and autonomy. You just have to be the right kind of person who can handle the bs and bureaucracy inherent in a big government program like that. And you definitely take a pay cut to work there relative to other options.

As for how hard you work after training, it’s going to depend on the job. Let’s say you want the big academic job, you’ve got or are working toward a K grant with your eye on an R01 or industry funding. Lifestyle will depend on how much protected time you have and how good an academic you are. Generally, you will have a lot of take home work early on because even with a couple protect days, there’s still too much to do to keep up with the funding and publishing requirements to establish yourself, to say nothing of the clinical burden. But if you want a more clinical/teaching academic job, then your hours may be a bit more standard.

Private practice varies a lot depending on the details. If you’re flexible in location you can find something; if not, you may have to make some choices in terms of money and lifestyle.

Of my graduating residency class, we’ve got a couple clinical academics, a couple private practice docs, and I’m the weirdo in sort of a hybrid privademic setup. It certainly seems like we all have pretty good lives, work mostly 4 days a week and very few weekends. All of us have pretty active lives outside the hospital and are usually home sometime between 3-6 depending on the day.

The catch to working less is you will inevitably make less money. I could add a full Saturday clinic and add about $200k to my income, but that’s just not worth it. Ditto for seeing more patients or operating more during the regular week. The clinical burden can always expand more to take whatever you’re willing to give. I’ve set boundaries and those boundaries cost me money. At its core, a medical license allows you to trade your time for money at a very good rate. If you’re willing to make less, you can definitely work less. Thankfully the surgical subs pay very well so even at 4 days a week with sweet hours and an efficient setup, I’m able to do very well and make well above the national median.

It sounds like everyone in your residency class was able to not do 5-10 years of post training grueling years to get established, and I’ve never heard of “privademics” as an option actually.

So research aside, not having to go through the 5-10 post training years and having a decent life right after is an option for all 3 of the specialties that I’m considering, and it’s dependent on skill and also finding oddball options like the VA? So should I not be considering that so much as a factor? Or is it different for each one?

I’m also 100% ok with not making much money. “Not much money” for a doctor like $100k is still a lot for a non-doctor, and I’m fortunately not going to graduate with much debt because of scholarships.

How hard is it to have a good family life as a no-fellowship ENT vs sports ortho (probably the fellowship I’d like the most) vs no-fellowship ophtho in an urban area, and how does adding in research affect each of those choices?

 

[operaman]

Is increased efficiency due to experience? For example, is the attending baller at flaps due to more years of operating? Or just has better innate skills?

Just wondering cause I was under the assumption that most U.S surgeons of a specific speciality graduated with pretty comparable skills, with few being obviously better than others and a few obviously worse. I don’t know the details of what goes into training but I figured the training was pretty standardized among accredited programs. Plus I thought surgery is self-selecting for those that are obsessed with improving/honing skills in training, yielding a fairly equal product among programs. So interested in hearing where along the road some become more efficient haha.

Great question. I think training varies widely between programs. You learn skills and efficiency by working with highly skilled and efficient surgeons. There’s also some innate skill, and there’s also patient selection.

The baller attending I mention was 5-6 years out of fellowship when I started, so not green but not a 20 yr veteran surgeon either. Everyone is slow when they start but if you prioritize speed and efficiency you can get better. I personally find that I’m super fast in cases within my fellowship subspecialty, but much slower outside of that. So experience is definitely a big part of it.

But most of all it’s who you learn from. If residents say they’re always operating way into the night and another program says their cases wrap before 3, do some digging and figure out if it’s volume or if one is just slow. I’ve seen a straightforward hemigloss/neck/forearm flap take 5-6 hours in one set of hands and 18 hours in another. Personally I’d rather learn from the former.

 

[eyeeye_captain]

Agree with above, surgical speed is a combination of planning, training, case selection, and experience/skill. It’s also not the be all end all to getting home early in ophtho at least as we tend to have 1 full day or 2 half days in the OR, although some high volume people have 2 full days.

Absolutely no difficulty having a good family life in general ophthalmology, urban or not. Plenty of folks work 4.5 day weeks from the get go. I work 5 fulls with a family and don’t think I’ve broken 40 patient care hours in a week since fellowship, and that’s doing retina, which leads to more emergencies. Barely remember the last time I went in overnight on call, see a patient maybe every other weekend that I’m on. I will say that if you are thinking academics still, most of the job openings I see are for fellowship trained docs.

 

[DarkHorizon]

From your posts, it’s apparent you really want to do Ortho but are having second thoughts due to lifestyle.

Ortho is what you make of it. Residency will be busy but it’s not like you’re a hermit. Residency was some of the best time of my life. It’s a necessary grind, but you only train once. Also you’ll be a doing a fellowship. Fellowship year is busy but prob the best.

Once you’re out, it largely depends what you wanna do. If you want to just focus on lifestyle really, then you can take a community, hospital based job with good number of surgeons in cAll rotation. You can do as little or as much as you want. Remember, if you don’t grind, you likely won’t get too busy, but still do good amount of stuff.

Also, you may not like this. But you can’t have it all. If you’re all about lifestyle, look into psych or derm or PM&R. Even those guys have to work hard at times. You can have a fairly manageable lifestyle as a surgeon, but you’re still a surgeon with fairly uncontrollable issues arising from time to time. My $0.02. Let me know if you have any specific questions regarding Ortho.

 

[annasofttofu]

From your posts, it’s apparent you really want to do Ortho but are having second thoughts due to lifestyle.

Ortho is what you make of it. Residency will be busy but it’s not like you’re a hermit. Residency was some of the best time of my life. It’s a necessary grind, but you only train once. Also you’ll be a doing a fellowship. Fellowship year is busy but prob the best.

Once you’re out, it largely depends what you wanna do. If you want to just focus on lifestyle really, then you can take a community, hospital based job with good number of surgeons in cAll rotation. You can do as little or as much as you want. Remember, if you don’t grind, you likely won’t get too busy, but still do good amount of stuff.

Also, you may not like this. But you can’t have it all. If you’re all about lifestyle, look into psych or derm or PM&R. Even those guys have to work hard at times. You can have a fairly manageable lifestyle as a surgeon, but you’re still a surgeon with fairly uncontrollable issues arising from time to time. My $0.02. Let me know if you have any specific questions regarding Ortho.

Yes, you’re 100% right. Ortho is the only one that’s really calling to me, and my main hesitation is the lifestyle. I also have other hesitations — lack of variety and potential monotony post-fellowship, and that I love spending time with and talking with patients (it’s why I chose to leave my old career and go to med school), and it seems like ortho is much less about clinic compared to ENT or ophtho. I’ve also felt pretty bored shadowing ortho clinic and OR (although MS1s just stand in the corner in the OR).

I definitely recognize that I can’t have it all, and I’ll have to work a *lot* for every thing that I do want, I recognize that life as a physician will be a balancing act and that sacrifices will have to be made. What makes it hard is that it’s not clear how much I’m signing up to sacrifice by following ortho, ENT, or ophtho at this point in time. What I can tell is that ophtho sacrifices less than ENT which sacrifices less than ortho, but it seems nearly impossible to say how much. I know an exact measure is obviously impossible and that the issue is extremely complex because many choices exist as an attending. I almost wish I could see some life breakdown like this comic, and I wish could know how much each specialty will cost my future (or current) family.

What I do know is that it’s not feasible for me to simultaneously juggle research in ortho, ENT, and ophtho at the same time, and that I’m going to have to close 1 or 2 of those doors right now, and doing that while being unable to understand the full ramifications of what I’m doing is scary. I’m scared that I’ll follow ortho and realize MS3 year that I should’ve done ENT or ophtho, or vice versa. I see lots of Reddit/SDN threads about how ortho is a hard life even as an attending, and also a lot of threads about how you can have an easy life as an attending, and I just feel even more lost and confused. I’ve already wasted about 4 months of precious MS1 free time that could’ve gone towards productive research, but instead, I’ve just been standing at the same intersection week after week without any progress on what specialty/PI to work with.

If it helps, at my school I’ve got an absolutely fantastic potential mentor/PI in ophtho, a good mentor/PI in ortho, and no clear mentor/PI in ENT yet. I feel like I need to decide what mentor to start researching with ASAP and this decision is what’s pushing me to try to decide so early.

 

[DarkHorizon]

Yes, you’re 100% right. Ortho is the only one that’s really calling to me, and my main hesitation is the lifestyle. I also have other hesitations — lack of variety and potential monotony post-fellowship, and that I love spending time with and talking with patients (it’s why I chose to leave my old career and go to med school), and it seems like ortho is much less about clinic compared to ENT or ophtho. I’ve also felt pretty bored shadowing ortho clinic and OR (although MS1s just stand in the corner in the OR).

I definitely recognize that I can’t have it all, and I’ll have to work a *lot* for every thing that I do want, I recognize that life as a physician will be a balancing act and that sacrifices will have to be made. What makes it hard is that it’s not clear how much I’m signing up to sacrifice by following ortho, ENT, or ophtho at this point in time. What I can tell is that ophtho sacrifices less than ENT which sacrifices less than ortho, but it seems nearly impossible to say how much. I know an exact measure is obviously impossible and that the issue is extremely complex because many choices exist as an attending. I almost wish I could see some life breakdown like this comic, and I wish could know how much each specialty will cost my future (or current) family.

What I do know is that it’s not feasible for me to simultaneously juggle research in ortho, ENT, and ophtho at the same time, and that I’m going to have to close 1 or 2 of those doors right now, and doing that while being unable to understand the full ramifications of what I’m doing is scary. I’m scared that I’ll follow ortho and realize MS3 year that I should’ve done ENT or ophtho, or vice versa. I see lots of Reddit/SDN threads about how ortho is a hard life even as an attending, and also a lot of threads about how you can have an easy life as an attending, and I just feel even more lost and confused. I’ve already wasted about 4 months of precious MS1 free time that could’ve gone towards productive research, but instead, I’ve just been standing at the same intersection week after week without any progress on what specialty/PI to work with.

If it helps, at my school I’ve got an absolutely fantastic potential mentor/PI in ophtho, a good mentor/PI in ortho, and no clear mentor/PI in ENT yet. I feel like I need to decide what mentor to start researching with ASAP and this decision is what’s pushing me to try to decide so early.

I would do Ortho research. Just accept that you’ll work hard as a resident, regardless of which surgical field you choose. You seem to have a significant interest in Ortho and restoring patients lifestyle.

Once you’re an attending, you’ll have a fair amount of control. Consider doing sports/hand/F&A fellowship. You can have a largely outpatient based practice and have a very decent lifestyle. You’ll just have to accept that you may not reach your income potential or be the busiest surgeon, but that’s ok as long as you have a good work/life balance. It’s a holistic way of looking at it.

Edit: you can have variety in Ortho. You can sub specialise and still do a fair amount of general ortho, including trauma on call. My sports friends do joints and trauma, and even simpler hand/F&A. Recognize that it’ll come at some cost i.e lifestyle. Monotony is boring, but it also means you’re efficient and really focused on handful of procedures, and therefore, have more time outside of work.

Similary, you can set up your clinic to be 20-30 mins per patient, but it’s not conducive to having a good lifestyle or being productive. I’m not saying you don’t talk to your patients, but recognize that more time you spend with each patient, less patients you’ll see and less surgery you’ll book. Not to mention, your days will likely be longer. It’s a balancing act.

 

[annasofttofu]

I would do Ortho research. Just accept that you’ll work hard as a resident, regardless of which surgical field you choose. You seem to have a significant interest in Ortho and restoring patients lifestyle.

Once you’re an attending, you’ll have a fair amount of control. Consider doing sports/hand/F&A fellowship. You can have a largely outpatient based practice and have a very decent lifestyle. You’ll just have to accept that you may not reach your income potential or be the busiest surgeon, but that’s ok as long as you have a good work/life balance. It’s a holistic way of looking at it.

Edit: you can have variety in Ortho. You can sub specialise and still do a fair amount of general ortho, including trauma on call. My sports friends do joints and trauma, and even simpler hand/F&A. Recognize that it’ll come at some cost i.e lifestyle. Monotony is boring, but it also means you’re efficient and really focused on handful of procedures, and therefore, have more time outside of work.

Similary, you can set up your clinic to be 20-30 mins per patient, but it’s not conducive to having a good lifestyle or being productive. I’m not saying you don’t talk to your patients, but recognize that more time you spend with each patient, less patients you’ll see and less surgery you’ll book. Not to mention, your days will likely be longer. It’s a balancing act.

So if I do ortho research during my first year, will I be able to potentially pivot to ENT or ophtho if I change my mind during my second year as long as I’m really productive, or would it be too late?

Here again it’s going to vary quite a bit. I do like the idea of the VA job mentioned above. For the right person, it can be an ideal balance of lifestyle with incredible pathology and autonomy. You just have to be the right kind of person who can handle the bs and bureaucracy inherent in a big government program like that. And you definitely take a pay cut to work there relative to other options.

As for how hard you work after training, it’s going to depend on the job. Let’s say you want the big academic job, you’ve got or are working toward a K grant with your eye on an R01 or industry funding. Lifestyle will depend on how much protected time you have and how good an academic you are. Generally, you will have a lot of take home work early on because even with a couple protect days, there’s still too much to do to keep up with the funding and publishing requirements to establish yourself, to say nothing of the clinical burden. But if you want a more clinical/teaching academic job, then your hours may be a bit more standard.

Private practice varies a lot depending on the details. If you’re flexible in location you can find something; if not, you may have to make some choices in terms of money and lifestyle.

Of my graduating residency class, we’ve got a couple clinical academics, a couple private practice docs, and I’m the weirdo in sort of a hybrid privademic setup. It certainly seems like we all have pretty good lives, work mostly 4 days a week and very few weekends. All of us have pretty active lives outside the hospital and are usually home sometime between 3-6 depending on the day.

The catch to working less is you will inevitably make less money. I could add a full Saturday clinic and add about $200k to my income, but that’s just not worth it. Ditto for seeing more patients or operating more during the regular week. The clinical burden can always expand more to take whatever you’re willing to give. I’ve set boundaries and those boundaries cost me money. At its core, a medical license allows you to trade your time for money at a very good rate. If you’re willing to make less, you can definitely work less. Thankfully the surgical subs pay very well so even at 4 days a week with sweet hours and an efficient setup, I’m able to do very well and make well above the national median.

How far out from your training are you, and how does “privademics” work?

 

[ProReduction]

ENT is the best fit for you.

 

[aldol16]

Those are really different specialties and you really need to get experience in each one to make a decision between them early on. You can shadow physicians not at your school if you have to. These are also all surgical specialties and you're going to have to have some sort of manual dexterity to do them. Some of it is teachable, some of it is not. You should get involved in the surgical interest groups at your school and see if you are interesting in the manual things that each specialty offers. The science and anatomy is always cool but you have to like the day to day work and the surgeries that you will be doing.

 

[Wordead]

ENT is the best fit for you.

- ENT: I had an extraordinary shadowing experience where the attending walked patients through feeds of scopes down their nose to diagnose deviated septums, and where she walked me through a sleep apnea genioglossus stimulation surgery. The attendings I’ve met in ENT have been so nice and energetic, and I always feel such positive energy when around ENT people at my school. I also love the anatomy, especially the face because I was a hobbyist portrait painter. The potential for research and technology is massive and the variety is wonderful. But I’m not terribly passionate about ears, noses, or throats, I’m not terribly dexterous, and I’m a bit averse to unpleasant smells.

Not dexterous and ortho are practically synonymous! Perfect fit.

 

[operaman]

So if I do ortho research during my first year, will I be able to potentially pivot to ENT or ophtho if I change my mind during my second year as long as I’m really productive, or would it be too late?

How far out from your training are you, and how does “privademics” work?

I’m 2 years and change out from fellowship which I finished June 2021.

Privademics is where you have an academic affiliation but your primary compensation is derived from full time clinical work. In my case, I’m hospital employed by a tertiary care center/academic hospital. We are also the hospital that’s the primary teaching hospital for our medical school, but the way the money works out I’m paid by the hospital and not the medical school.

The end result for me is that I get all the cool academic level cases sent to me from all over, I get to teach medical students and residents, I don’t have to do research or serve on bs committees or go to tons of meetings in the quest for tenure, and I get paid substantially more than most academic docs - as in 3-4x as much. I made more in my first year than my last three dept chairs, and rarely broke 40 hours a week.

For me it’s perfect because I love teaching and complex cases but I hate doing stupid low level research that doesn’t mean anything, and my own shortcomings don’t lend themselves to running a well funded lab churning out meaningful work. I like being research adjacent - I like the ideas and talking with other smart people, but I detest doing the actual work of research.

There are true private practice docs with thriving research endeavors but it’s the exception. In the end, to do research you need funding and time and it’s hard to get those outside of academia where you have the support and resources to get up and running.

 

[percyeye]

It seems weird to say Lifestyle and Family are your number 1 priority... but then you are only interested in surgery fields.

And then the most favorable Lifestyle and Family field (Ophtho) you say isn't interesting enough for you.

If Lifestyle was actually the most important thing you'd be considering something like Psych or Allergy etc.

So I think a job you enjoy is secretly your #1 priority and you feel bad about it, but I think a lot of people here will tell you that it is okay to enjoy your career even if that means you will be a bit busier than some other specialties.

 

[annasofttofu]

It seems weird to say Lifestyle and Family are your number 1 priority... but then you are only interested in surgery fields.

And then the most favorable Lifestyle and Family field (Ophtho) you say isn't interesting enough for you.

If Lifestyle was actually the most important thing you'd be considering something like Psych or Allergy etc.

So I think a job you enjoy is secretly your #1 priority and you feel bad about it, but I think a lot of people here will tell you that it is okay to enjoy your career even if that means you will be a bit busier than some other specialties.

Yeah, I agree with you that it’s weird and hard for me to reconcile. Each of the non-surgical specialties have something that I’m a little scared of or turned off by:

IM: From my shadowing experiences, it seems like you don’t spend nearly as much time with patients as I imagined and hoped, and it really is a lot of rounding and paperwork

EM: I don’t think I could handle that level of urgency and adrenaline my whole life.

FM/Peds: I’m definitely considering these, but they’re not that competitive so I can focus on a different specialty and then change my mind to peds later. Peds also seemed a bit repetitive and routine, and I don’t like the broadness of FM.

Rads/path/anesthesia: I really need clinic.

Neurology: I’m definitely considering this, but my school’s neurology department is absurdly difficult to shadow in. I’m also pretty worried about the fact that you can’t do that much for a lot of the patients and it’s a bit sad.

PM&R: I think this fundamentally doesn’t fit with my values cause you’re just treating the symptoms and not the root cause. I also really don’t like the idea of pain medicine.

Psych: I don’t like the idea of leaving medicine behind, and it felt like you can’t really do that much for the patients from what I saw when I shadowed. You’ll just see those same patients again routinely without much improvement.

Derm: The derm department at my school is pretty malignant, and I feel like I personally don’t like what I’ve seen of derm culture outside med school as well. I also don’t like how fast derm clinic is. I should probably consider derm more, but it feels a bit late for me for my subpar interest level in it, and there’s no great mentors at my school for derm anyways.

This image made me think maybe I could pick ENT or ophtho and still prioritize my family and lifestyle. I recognize that this might be a bit naive of me though, which is why I posted in SDN for some insight and advice.

I’m planning on doing 1 longer term basic science research project alongside smaller clinical research topics. Would it be a good idea to do that basic science project in one specialty (i.e. ophtho) and then the clinical research in another (i.e. ENT) to hedge my bets a little, or do I need to just make a call now and do both projects in one specialty?