Agreed. You have to look at med school as the different arena it is. You might be the best college football player, but when you graduate to the pros, you realize that you are quite average when playing ball with the best from all the other schools. Med school is like this. All of the weaker students who made you look so good have been truncated away. Everyone in med school got "mostly A's" during college, scored decently on the MCAT. Everybody who got Cs and did poorly on the MCAT is now gone, truncated away by the admissions staff. The credentials at each med school are a very tight range -- the best applicant isn't appreciably better than the worst, and anybody there has shown the potential to get the top A in their prior studies. So in the group of formerly A students now in med school, half are going to be in the bottom half of your class. There is a 50% chance that you will be one of them. Sure, you might have been the best in your college, but guess what -- many of your classmates will have been too, and some of you won't sustain it in med school. Also it should be noted that a lot of what worked in getting A's in college doesn't work in med school, so the people who do best aren't always the smartest, but the most adaptable in terms of learning. The volume of info you will learn is bigger in med school than anything in undergrad, and the approaches change-- memorization is stressed in the early years while application is stressed in the later years. So the answer is, you don't know how you are going to do until you get there, and you have no idea how hard you will have to work just to keep your head above water, to stay in front of the curve, let alone to be at the top. Being at the top of the heap in college isn't a great indicator for being at the top of med school, because your whole med school class was hand picked for being able to excel at that med school. So you probably aren't being realistic if you show up thinking, "I was top 10% in college, so I will be top 10% in med school". Doesn't work that way for most of the top 10%ers.
As for ROAD specialties (and no, you can't just change the letters because you like a particular specialty like EM -- ROAD is historic for a certain balance between salary and lifestyle), you aren't guaranteed one, regardless of how good you were in college and how much you want it. Of the group, Anesthesia tends to be the most volatile, being very competitive one year, not particularly competitive the next. It bottomed out a few years ago and is probably more attainable than the other three, but Derm and optho tend to be perennial impossible to get fields, along with things like rad onc (which didn't exist when the acronym ROAD was made up). Radiology is competitive, but not quite at at the derm level because there are many more spots nationally. In short, yes these are competitive, no you aren't guaranteed a spot in them regardless of how much you want them or how hard you work at it, and yes you frequently need a back-up if you are interested in one of these fields. I have said on many occasions that I probably wouldn't advise someone to go to med school if they only wanted to be a dermatologist. You might get that shot, you probably won't. Some of it is under your control (researching, working hard), some of it isn't (test taking skills on USMLE, aptitude, memorization ability). So only go to med school if you want to be a clinician first, and a specialist later, if you get that opportunity. You might not get that opportunity and so you have to be happy with whatever comes.
