Why sub-specialize?

[tiger160]

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I'm filling out the AMCAS now for fall applications. I'm definitely interested in medical research and the MD-PhD degree, and this forum has been a great resource over the last few months! Thanks to all the regular posters who help out the young'uns.

I wanted to ask about the choice of residency. In particular, I want to ask why there are essentially no MD-PhD generalists and so many sub-specialists in procedurally intensive disciplines (Cardiology, Dermatology, Ophthalmology). I think my point will be easier to express with a hypothetical example.

Let's say that Joe is interested in the heart and cardiovascular disease. His lab work is searching for a new cholesterol lowering drug or something else in the big fields like biochemistry, mol. bio., pharmacology, etc. Why should Joe sub-specialize in cardiology, instead of being a general internist with an interest in cardiovascular disease? As a cardiologist, he will be much more procedurally inclined and (generally) will not be involved with the long term maintenance that best fits his basic science research. (Of course, I'm ignoring as motivation the huge pay differential...)

Basically, if a person is going to devote most of their professional career to basic science, and has already invested 3-4 years in a PhD and will likely devote 1-3 more years in a post-doc, why spend 3+ years training for clinical skills that you will use at most 1 or 2 days a week? And is there any SCIENTIFIC reason to be a dermatologist or ophthalmologist?

(to lay my biases on the table, I'm interested in peds or med, with possible interests in cancer or juvenile diabetes. I'm trying to figure out, for instance, what would be the difference between general pediatrics and pediatric endocrinology if I focused on diabetes)

 

[the citizen]

A couple of points that may begin to answer your many questions:

First, there are many SCIENTIFIC reasons to do any specialty, including dermatology. How do you think these fields advance?

Second, fellowships in IM or Peds are not really 3 years of pure clinical training. Often much (~2 years) of that time is spent in the lab, and often strong fellows are hired as junior faculty without doing an additional post-doc. Furthermore, if you are sure you want to do say peds heme/onc, you can "fast track" your residency and fellowship into 5 years including research.

Third, if your career is in a given field, it is helpful to be an expert in that field. Sub-specializing gives you the clinical expertise upon which to build your research career.

Finally, aren't you putting the cart in front of the horse? Once you are in med school and in grad school for a few years, you will get a better feel for the type of career you wish to pursue.

 

[Vader]

Scientifically, doing a subspecialty can be valuable for a physician-scientist, especially if your research involves patients or human materials (i.e. biopsy, autopsy, DNA, stem cells, etc) because you will see patients with the particular diseases which you are investigating in your laboratory. Put another way, the particular problems you see as a clinician can lead to new hypotheses and avenues of research in the lab.

Additionally, many individuals find that focusing on a particular subspecialty allows them to become experts in their particular area. As a generalist, you would have to see patients with a wide variety of conditions. In general, it is more difficult to know a lot about everything than it is to know a lot about a focused area.

It is also more difficult to integrate the clinical and research careers if you do not subspecialize, although this is not a hard-fast rule. For example, we just heard a speaker that is an internist and has identified over 20 genes for hypertension, bone, kidney, etc diseases.

 

[Leforte]

I agree with earlier comments that it is a bit early to think about specializing now before even entering (or accepted into) an MD/PhD program.

However, when I was interviewing this year for ENT residencies, I was commenting that I was interesting in both otology as well and head and neck and was considering fellowship training in these areas (mind you I am years away from making that choice) - It was actually mentioned to me in the interviews that as an MD/PhD it may be to my benefit to NOT specialize in ENT but be a generalist within the field. This would allow my research to follow which ever path it may take or completely jump tracks if I was so inclined. For example, if I was head and neck fellowship trained, it would be unusual to focus research on mechanisms of hearing loss or the immunology of allergic rhinitis. So, yes, there are reasons to not be so focused clinically if one has research interests.

However, in a field as broad as internal medicine or pediatrics, I would think it much more difficult to NOT be more focused. Even within specialties there are further subspecialties. At some point the clinician investigator reaches what I think to be the point of diminishing returns. A 30 year old MD/PhD graduate with a 3 year internal medicine residency, a 3 year cardiology fellowship and then a 2 year EP fellowship is a very, very long road.

Think of it this way, if a person is applying to MD/PhD programs during their junior year of college at 21, their time remaining in training as stated above is equivalent to their remembering all the way back to when they were 4 years old.

As a side note, we have an MD/PhD student who was so focused on the IM/ID pathway and after getting their PhD in micro and returning to the wards has now decided to become an orthopod.

Trust me, perspective changes - often.

Best of luck in the application process.

 

[Mike22]

Just finishing up my medicine internship and will be completing one additional residency year before fast-tracking into Endocrinology for fellowship. What ended up happening to me in the final 2 clinical years of medical school was that my ideas for specialty and subspecialty were shaped not only by the medical knowledge gained in clinical rotations, but even more so by the lifestyles and attitudes of the attendings and residents seen on the rotations. With my interests in molecular based approaches and cell biology, a generalist practice just would not make much sense for me. Most generalists I know, if they do research, do soft science such as epidemiology of domestic violence, for example. I'm sure this can be interesting for the right individual. It's actually pretty interesting to see, in hindsight, how my experiences in both the clinics and my lab have guided decisions and shaped my specific goals.