M3 still struggling to decide between medicine or surgery

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ChordaEpiphany

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Right now I'm set up for two different paths. I went to an MSTP program fully intending to go into IM, subspecialize, start a lab, and try to create something worth translating. However, over the course of my PhD I happened to make some amazing surgical contacts and published work relevant to the surgical and medical counterparts of a particular field. Now I'm at a cross-roads between going into surgery or IM.

I've liked nearly every rotation. I loved the in-depth discussion of diagnosis and management of IM and the close bond l formed with my patients, both of which are notably lacking from surgery. However, I also feel the OR is a magical place, and I think I may feel left out of the action if I choose IM. I'm also extremely wary of the long and difficult training pathway associated with academic surgery (likely 7 years residency + 2-3 years fellowship). I wonder if taking on another long, high-intensity training program is outright masochistic, especially since this time around I'll be doing it with a family. I also worry that the very algorithmic nature of medicine and the rise of AI will make any non-surgical specialty somewhat boring to practice in 20-30 years.

My application for both specialties is strong (H in all rotations, multiple first author papers in decent journals, NIH fellowship, etc...), however, my general surgery application would undoubtedly be stronger than my IM/PSTP application. I have close contacts with some extremely well-known people in surgery as well as research and translational activity that likely stands out as extremely unique for surgical applicants. For PSTP, I don't have a CNS paper and I have almost no contacts in IM/subspecialties. FWIW, my med school is mid-tier. Given I like both specialties clinically, and given my career goals are focused around things that require a lot of clout (e.g., academics, research, pharma/biotech collaboration, translation), being able to match at a higher tier residency isn't something I should completely ignore when making these decisions.

Just looking for general thoughts, especially from people who've been in this position. As an MD/PhD, I want to learn everything and do everything. The thought of leaving something behind and never developing a skill set (broad knowledge base/deep patient connections vs. surgical skill/excitement of the OR) is distressing. How does one go about pruning away pieces of a career?

I realize this is a bit of a ramble and definitely "first world problems" when it comes to a medical career. Thank you all in advance.

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I'm an M1 who is definitely not in your shoes but have you considered bariatric surgery? It seems to be a combination of cool surgeries, following patients longitudinally, and having meaningful conversations with patients about lifestyle and diet.
 
There are plenty of MD-PhDs in surgery as well. If that's what you want to do, then go for it. Realize that surgery is pretty diverse and your rotation as a student is skewed toward what academic surgeons and the services you are on look like. The "real world" is different, although you sound like you want the academic route. There are areas of surgery with more longitudinal follow up with patients. Surg onc (which as an MD PhD, you would be in a good place for), breast, transplant, maybe even vascular (although the patient population is difficult and noncompliant) often follow patients for years. Some residencies may not force you into doing more lab years (so you may be able to do less than 7 years) if you already have a PhD, but it depends on your interests as well as the program structure. You generally don't apply to fellowship until PGY-4 or PGY-5 clinical year, so you'd have plenty of time to rotate through all the fields as a resident and see what you like best.
 
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Right now I'm set up for two different paths. I went to an MSTP program fully intending to go into IM, subspecialize, start a lab, and try to create something worth translating. However, over the course of my PhD I happened to make some amazing surgical contacts and published work relevant to the surgical and medical counterparts of a particular field. Now I'm at a cross-roads between going into surgery or IM.

I've liked nearly every rotation. I loved the in-depth discussion of diagnosis and management of IM and the close bond l formed with my patients, both of which are notably lacking from surgery. However, I also feel the OR is a magical place, and I think I may feel left out of the action if I choose IM. I'm also extremely wary of the long and difficult training pathway associated with academic surgery (likely 7 years residency + 2-3 years fellowship). I wonder if taking on another long, high-intensity training program is outright masochistic, especially since this time around I'll be doing it with a family. I also worry that the very algorithmic nature of medicine and the rise of AI will make any non-surgical specialty somewhat boring to practice in 20-30 years.

My application for both specialties is strong (H in all rotations, multiple first author papers in decent journals, NIH fellowship, etc...), however, my general surgery application would undoubtedly be stronger than my IM/PSTP application. I have close contacts with some extremely well-known people in surgery as well as research and translational activity that likely stands out as extremely unique for surgical applicants. For PSTP, I don't have a CNS paper and I have almost no contacts in IM/subspecialties. FWIW, my med school is mid-tier. Given I like both specialties clinically, and given my career goals are focused around things that require a lot of clout (e.g., academics, research, pharma/biotech collaboration, translation), being able to match at a higher tier residency isn't something I should completely ignore when making these decisions.

Just looking for general thoughts, especially from people who've been in this position. As an MD/PhD, I want to learn everything and do everything. The thought of leaving something behind and never developing a skill set (broad knowledge base/deep patient connections vs. surgical skill/excitement of the OR) is distressing. How does one go about pruning away pieces of a career?

I realize this is a bit of a ramble and definitely "first world problems" when it comes to a medical career. Thank you all in advance.
I mean, do whatever you find most satisfying. The MD-PhD route is way more common and straight forward in IM than Surgery. But I agree that because of that, your application would stand out more in that field.

The biggest question, and one that tends to be the hardest to answer, is when you are in your late 40s and 50s and the allure of any procedure has mostly worn off, will you still like the path you’ve chosen? Better yet, when that occurs, do you have a solid fallback? Certainly the PhD gives you that, but only if you maintain it. Most PhDs I’ve known who prefer the medicine/procedural aspects more… don’t. But most of them also don’t seriously consider that no one wants to be awake at 2am doing some urgent diagnosis/procedure… I think most just end up grinning and bearing it because what else are they going to do?
 
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The biggest question, and one that tends to be the hardest to answer, is when you are in your late 40s and 50s and the allure of any procedure has mostly worn off, will you still like the path you’ve chosen? Better yet, when that occurs, do you have a solid fallback? Certainly the PhD gives you that, but only if you maintain it. Most PhDs I’ve known who prefer the medicine/procedural aspects more… don’t. But most of them also don’t seriously consider that no one wants to be awake at 2am doing some urgent diagnosis/procedure… I think most just end up grinning and bearing it because what else are they going to do?
You've perfectly summarized my exact predicament. I guess my answer is... I don't know.

When I started in the lab, I was thrilled to be doing "cool" experiments. By the time I was a G4, I wanted to be cozy at home or at the very least at my desk with a cup of tea writing a grant or manuscript. On the other hand, I thought of exactly this and asked one of my mentors if, 25 years into their career, they still enjoyed the OR. They said, very confidently, "yes" and that "the OR still feels like home." They seemed deeply satisfied with their choice, and comparing life-saving surgery to cell culture maybe isn't exactly fair.

Then there is the long-term prospects of both fields. I feel that being a non-procedural IM subspecialist will, in 20-30 years, likely be quite boring. With AI on the rise and likely implemented into EMRs imminently and subsequently trained on millions and millions of patient encounters, we're headed towards a future where physicians are rubber stamping or lightly tweaking automated diagnoses and plans. Going too rogue, regardless of rationale, will likely result in liability or denied coverage for services. In this case, I will certainly want to have a "fallback," which will likely be either academic or pharmaceutical/biotech research or pursuing upper level management positions in pharma/biotech or academia. I think IM/subspecialty would likely set me up better for this, but it's likely unnecessary entirely in surgery since being co-pilot to an AI in surgery is probably at least 50-70 years away.

As a surgeon, I think I'd be quite unique. As an IM subspecialist, I think I'll be running a bit behind some of my colleagues who are working in the labs of world class physician-scientists and filling their CV with papers in Nature or Science. I'm doing well, but on the PSTP track I'm likely not headed for world-shattering success. I find both specialties equally satisfying. If surgery had an equal length of training and similar intensity/hours, I would certainly choose it over IM, but I have a sneaking suspicion that when I'm a PGY8 with a kid or two at home regularly working 15 hour days I'll probably be wishing I did IM.

I know no one can answer this question for me. I'm mostly looking for someone to poke a hole in my reasoning.
 
You've perfectly summarized my exact predicament. I guess my answer is... I don't know.

When I started in the lab, I was thrilled to be doing "cool" experiments. By the time I was a G4, I wanted to be cozy at home or at the very least at my desk with a cup of tea writing a grant or manuscript. On the other hand, I thought of exactly this and asked one of my mentors if, 25 years into their career, they still enjoyed the OR. They said, very confidently, "yes" and that "the OR still feels like home." They seemed deeply satisfied with their choice, and comparing life-saving surgery to cell culture maybe isn't exactly fair.

Then there is the long-term prospects of both fields. I feel that being a non-procedural IM subspecialist will, in 20-30 years, likely be quite boring. With AI on the rise and likely implemented into EMRs imminently and subsequently trained on millions and millions of patient encounters, we're headed towards a future where physicians are rubber stamping or lightly tweaking automated diagnoses and plans. Going too rogue, regardless of rationale, will likely result in liability or denied coverage for services. In this case, I will certainly want to have a "fallback," which will likely be either academic or pharmaceutical/biotech research or pursuing upper level management positions in pharma/biotech or academia. I think IM/subspecialty would likely set me up better for this, but it's likely unnecessary entirely in surgery since being co-pilot to an AI in surgery is probably at least 50-70 years away.

As a surgeon, I think I'd be quite unique. As an IM subspecialist, I think I'll be running a bit behind some of my colleagues who are working in the labs of world class physician-scientists and filling their CV with papers in Nature or Science. I'm doing well, but on the PSTP track I'm likely not headed for world-shattering success. I find both specialties equally satisfying. If surgery had an equal length of training and similar intensity/hours, I would certainly choose it over IM, but I have a sneaking suspicion that when I'm a PGY8 with a kid or two at home regularly working 15 hour days I'll probably be wishing I did IM.

I know no one can answer this question for me. I'm mostly looking for someone to poke a hole in my reasoning.
At the end of the day, I think it comes down to which do you prefer more patient care or science? Realizing that while you can do both, most people don't (or can't) draw satisfaction from both. Of course, you can do medicine/surgery to supplement your income while you pursue scientific endeavors, but you can't do science while you pursue medical endeavors.

And while I've been doing this long enough to be mid-career (or senior compared to other people in my group), there certainly are people like your surgical mentor who actually love the medicine part of it (I'm using medicine as an all-comer in comparison to science-based careers). But in my experience, at least in academic medical centers, those tend to be the minority and not the norm. Again, most people don't want to be awake all night dealing with some catastrophe when you reach your late 40s to 50s. Even in my mid-40s, waking up to do things (granted I'm ICU, so that's putting tubes/lines in, not exploratory laparotomies) at 2 am sucks. I do it because I have to, not because I want to. But pediatrics is also different than adult medicine where trainee supervision and expectations are also different, so there's that to consider. But still, most don't want to be awake at god awful hours sans a few. And the people who do are just straight clinical. This is as opposed to my boss, who is the only other NIH-funded person in my group who literally abhors doing clinical time and will often say it does it just to pay the bills and keep his salary where it is. He is later in his career and his NIH-funding covers most of his salary, but the few shifts he does he hates. So there's a curve, but its not bell-shaped.

The AI part I think is probably unrealistic. I only say that because protocols in medicine have existed long before AI. And we follow them and deviate from them when people don't fit the protocol. That's the way its always been and I don't see how AI could fix that in the immediate future. What's more, AI is only as good as the data you input into it. At this current stage and the actual knowledge you can feed it, it's really not that helpful. I mean, it certainly could be with better and more detailed data, but often that comes at a financial expense to institution with little reward. Where I do see AI being more helpful is in the business of medicine, particularly regarding staffing needs and supply chain issues. But I think people will continue to create "prediction tools" that are now more AI driven, but will be ignored just as they always have because if the AI-tool says this person is going to do great, and because of the bad or inaccurate data it was fed, the person dies or has a bad outcome, then the no one is gonna trust it. This was true for current protocols anyway. They work great for most, but they don't work for everyone and occasionally can cause problems when followed blindly.

I will end this by saying that doing a PhD and doing science is a time and financial sacrifice than can only be offset by a sense of personal accomplishment. I think the people I've seen who do well in science and enjoy it, get that. But it's also unrealistic to suggest that works for everyone. And when people have done the extra training and extra knowledge development and finally graduate in their mid to late 30s, whilst their peers have long moved on and sacrificed far less, it feels like rubbing salt in a wound. And for many, they just say f-ck it and take the track that gets them to make up for lost time and hope that when they're in 50s and 60s they are done with medicine altogether.
 
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In this case, I will certainly want to have a "fallback," which will likely be either academic or pharmaceutical/biotech research or pursuing upper level management positions in pharma/biotech or academia.

If your fallback is pharma/biotech then one of the internal medicine specialties would be a better choice. Pharma tends to be therapeutic area aligned. The hot ones nowadays are: oncology, immunology, rare disease, diabetes/obesity, CV, respiratory. While surgery does have similar specialization paths, the medical specialists tend to dominate the pharma leadership positions. I have seen several surgeons work their way up the ladder in pharma, but it is more difficult. Having MD-PhD is definitely a plus. I'm an MD that started off with 2 years of surgical training, then switched into FM, joined pharma right after residency. I've been in pharma/biotech for 20+ years.
 
Definitely something that you should decide soon. I don't think anyone here will be able to substantively help you, although at its core, it comes down to one thing. Would you rather spend the rest of your life thinking about problems and working with your brain or doing things and working with your hands? Surgery is more hands than thinking (although thinking certainly occurs) and medicine is more thinking than doing things with your hands. If you don't think you can give up using your hands, then surgery. If you can, then medicine.

Surgery is not only a hard residency but also a hard lifestyle. Even when you're an attending. Surgical services are not capped and you take a lot of call. The kind of call where you realistically could come in for an emergent case depending on your specialty. IM docs don't really have that kind of call. For example, you could get jobs as a hospitalist where you work certain weeks and are off certain weeks without the possibility of getting called in. That's another thing to consider.
 
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medicine >>>>> surgery
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