This time of year is always full of anxious medical students desperately trying to meet deadlines and decide what field of medicine they want to go into for the rest of their lives, even though, so far, they have only been exposed to three or four specialities on their clinical rotations. Sounds stressful. Here’s some advice, and some questions to ask yourself:

Don’t stress! You have a lot more time than you realize to pick a speciality and you are probably not going to make a bad decision. It’s okay to have two or even three favorites right now. You will just have to double-dip for a while on things like advisors, possible away rotations, etc. Eventually, things will become clearer. If they don’t by the summer months, then just flip a coin and decide (read Power Laws, Decision Making, and Anxiety if you haven’t already).

What suites you? Part of being a third year medical student is to test your temperament for certain things. Here are some to things to think about:

  • Hospital vs clinic.
    • How much do you enjoy each setting? Some specialities rarely darken the door of a hospital (perhaps Dermatology or even Family Medicine) while others never see the clinic (think Emergency Medicine or Anesthesia). Some have a mix of both, with variable amounts of each (e.g., OB/GYN, ENT, General Surgery). Some promise both, but rarely deliver (like Internal Medicine, where most docs either work in the hospital or the clinic, but not usually both).
  • Surgical vs medical care.
    • Everyone has the potential to be a good surgeon. Don’t think for a minute that you don’t have the aptitude; but you need the interest. Many students love the operating room, and procedures in general, while others can’t wait to never have to see the OR again. Don’t confuse the people with the place. Sometimes, an unpleasant experience with a person, say a brash general surgeon, gives a negative feel to an environment that you might otherwise like.
    • Specialities like OB/GYN offer a mixture of both, treating some patients with medical interventions and others with surgical interventions.
  • Continuity of care vs noncontinuous care.
    • It’s hard to really experience continuity of care during medical school, but it’s a wonderful thing. The satisfaction of seeing a patient through an entire event, such as 9 months of pregnancy or years of cancer treatments, has rewards that go far beyond the monetary benefits. Some primary care models offer you the ability to help not just single patients throughout years of their life, but even whole families. Still, many specialities offer little to no continuity of care (think ER, Anesthesia, Radiology, etc).
  • Subspeciality care versus primary/generalized care.
    • Do you enjoy being a mile wide and an inch deep in your knowledge and patient types, or an inch wide and a mile deep? The truth is, all doctors know about the same number of things, but which things they know about are different. Subspecialists are not better or smarter than primary care or generalist docs, they are just more focused. Think about your comfort level with uncertainty. Do you want to be the expert in a very narrow field or have a general knowledge that helps more people with more types of problems?
  • Critically ill versus not critically ill (criticalness).
    • How well do you deal with death and dying? Can you see yourself dealing with dying people and their families almost every day? Or would you prefer generally less critical patients, more likely to recover? Compare Palliative Care on one end of the spectrum to Pediatrics on the other. Or ICU/Critical Care versus OB/GYN.
  • Emergent versus non-emergent (acuity).
    • A generation of adrenaline junkies watching ERChicago Hope, and other such nonsense, believe that medicine is constantly fast-paced, with emergency after emergency. It isn’t, not even in the ER. The truth is, real emergencies are exhausting and taxing. Still, if you never want to deal with an emergency, there are plenty of outpatient-based, low acuity specialities that will shelter you; and if you like the occasional excitement, think Trauma Surgery or ER. How much unanticipated excitement would you like? OB/GYN is generally pretty relaxed, but is peppered with minutes here and there that are filled with life/death decisions.
  • Patients or no patients.
    • It goes without saying that some specialities involve little to no patient contact. Think pathology or radiology.
  • Low income versus high income.
    • It’s unfortunate that this is even something to think about. The answer to this one is, You should do what you love and are passionate about, not what pays the most. It always saddens me when students get back their Step 1 score and then try to determine what the highest paid, most competitive residency that they might get into is. I worry that 15 years from now, that student will be the burnt-out, twice-divorced, unsatisfied doctor telling med students not to go into medicine. Still, you should be aware of the expected earnings associated with specialities you are interested in. This is important, too, for considerations of “lifestyle.” Lots of doctors are workaholics, and higher earning specialities tend to attract more workaholics; but they don’t have to work so much. Remember this: your lifestyle will be a product of how much you are able to make per hour. If you work too many hours, that’s a different issue. A part-time career in a particular speciality might earn more per year than a full-time career in the next.
  • Call versus no call.
    • Patients have problems at night, on the weekends, and major holidays. Doctors have to be available at all times. But this might be done by shift work or by on-call schedules. Younger doctors seem to not like call that much. But remember that with call comes many of the magical and most rewarding moments: being there for the patient you have followed for 9 months when she delivers her baby, for example. Shift work also promotes cognitive errors and mistakes. Lacking attachment to and follow-up with patients is associated with increased medical diagnostic errors and more expensive care. Patients don’t like it that much either. Some specialities are more associated with call, like OB/GYN, while others rarely are (Dermatology).
  • Academic versus private practice.
    • The scope and type of practice you will have in almost any speciality will be different depending on the practice setting. You will likely see sicker, more complex patients in an academic practice than a private practice. Make sure you don’t confuse the excitement of Academic Whateverology with how things are in private practice, because most students will end up in private practice.
  • Hospital employment versus self-employment.
    • Hospital employment is increasingly becoming the norm. With hospital employment, certain amounts of loss of autonomy are inevitable. Some specialities exist almost exclusively in an employed or contracted model, while others still offer a range of employment options. If your autonomy is very important to you, this might make a difference in your career choice.
  • Urban versus rural practice setting (or small city versus larger city).
    • If your dream is to live in a small town, you probably should not become a retina subspecialist. Pediatric Surgery might have a decent lifestyle in a large city, but a horrible lifestyle in a small city. Think about where people who do what you want to do live. If you are an OB/GYN, you’ll need to live close to a hospital that delivers babies; that cuts out lots of locations.
  • Out-sourceable vs non-out-sourceable.
    • How much job security will you have in the future? How replaceable is your job by a midlevel provider, such as a nurse practitioner, physician assistant, psychologist, or nurse anesthetist? You might still be employed supervising those midlevels, but your direct role with patient care may not be what you think it will be.

If you understand where you are on these choices, picking a speciality is often very easy. For example, if you like a mix of hospital and clinic, surgery and medicine, continuity of care in a field with a narrowed scope of knowledge, few critically ill patients with only occasional emergencies, and a little bit of call, then OB/GYN might be perfect for you! But work through these questions for yourself.

Other things that you may consider include how long the training is and how difficult it is to get into the training program. Be realistic about what specialities are a good match for you academically. Also be prepared for the commitment of time necessary to do the speciality (plus perhaps a fellowship).

Still can’t decide? Oh my; well, keep reading I guess.

Find a role-model. Find a person who is doing the job, right now, that you would like to do 5 years or so from now. Don’t imagine that you are going to change the speciality to your liking or do it in a way that no one else does so that you have all of the perks but none of the disadvantages. Find someone who is similar to you in values and personality who is practicing the speciality you are interested in and have a talk with him. But don’t go just to one person. Doctors are jaded now more than ever. Steer clear from people who don’t love their jobs. They may dislike their jobs for reasons that have nothing to do with their speciality choice, like money, personal relationships, etc. Avoid negativity. There are passionate doctors in every field. Find one.

Write a personal statement for each speciality you are considering. No prep work; just sit down and start writing. Talk about what you love about each speciality, why it makes you passionate, what led you to fall in love with it. After a day or two, re-read them. You’ll find that the one that was easier to write and the one that feels more genuine and passionate probably corresponds to the speciality you should pick.

Do an away rotation or two. If you aren’t sure about your speciality choice, go see it somewhere else and figure out if you love it there too. You can even do an away in two different specialities, if necessary, to decide; but you’ll have to simultaneously prepare applications for both because you’ll be behind on time a bit if you haven’t decided for certain until the end of August.

In the end, do what you are passionate about. Your speciality choice is actually a small part of your life. Many physicians can’t see themselves being any other kind of doctor except the kind that they are; but realistically, they would have been just as happy (maybe happier) in another speciality. Don’t dwell too much on what you perceive as negatives of the field. If you love it, the negatives will seem trivial.

PS. Curious how the match works? Read my post about that here