MS1 Trying to Prepare Competitive Application, Although Need Help Picking Specialty. Plastics vs ENT vs Derm

[confusedfuturedoc!]

Hi! Current MS1 thinking ahead and wanting some advice. I am trying to set up a competitive application although I am unsure of what specialty to gear it towards. At the beginning of the year, I was interested in plastic surgery, although as I have gotten involved with research projects, shadowed, and talked to different surgeons, I am unsure if I am cut out for surgery.

Why I am interested in plastic surgery:

• I am creative and have an artistic eye (fairly decent painter for many years)
• Operate from head to toe and so many options for subspecialization
• Could work with a largely female patient population if I eventually focused on oncologic breast reconstruction
• Enjoyed the OR environment when I shadowed, time flew by

Why I don’t think I’m cut out for it:

• A bit TOO innovative, too many approaches to certain problems and I fear I’m not decisive enough to make a decision quickly enough. Prefer more algorithmic problems
• Unsure if it is sustainable physically in the long run. I’m not a frail victorian child but I’m unsure if performing long cases will be feasible when I’m 50 y.o. My knees and back are already cracking and aching. Left hand shakes a little
• Not currently interested in having children, but if that changes a long surgical residency may not be conducive

Other specialties I am considering include ENT (some overlap with plastics, some opportunity for recon., can cater practice to more clinic side when older. Although Not sure if I like endoscopic procedures). I was an ENT scribe for a few years and didn’t like the day-to-day pathologies (allergies, sinusitis, LPR, vertigo) that much, also a lot of children and I’m not too keen on the pediatric population.

Also interested in dermatology (I am a visual person and like the idea of seeing what I am dealing with), although maybe too clinic-based (?). Have yet to shadow.

It’s also important to note that I do not have home residency programs in any of these, although I do have faculty for ENT and derm that I can reach out to.

I’m definitely keeping an open mind to other specialties, but with step 1 going p/f and coming from a low-tier MD school, not preparing to potentially choose something competitive makes me nervous. Grades have been fairly good, although I’m not a genius. Currently involved in some plastics research. I’d like help picking a specialty to focus on so I can start making connections and gearing research towards it.

TLDR; Current MS1 at low-tier MD school without home programs for plastics, ENT, and derm. Thought I wanted to do plastics, although getting deeper involvement has shown me maybe I’m not decisive enough to be a plastic surgeon. Maybe considering derm or ENT. No home programs, so extra motivated to prepare, but for what is the question. What to focus on? How bad is indecisiveness as a quality for someone interested in surgery?

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[operaman]

Focus on whatever excites you the most. You’re so early in training that you may not realize just how algorithmic much of surgical decision making is. It’s overwhelming when you’re new, but eventually you’ll see that despite there being a number of reconstructive options for something, there’s usually a clear winner. Even when it is equivocal, there’s often a vast difference in morbidity and the patient will usually have a strong preference one way or the other (ie do I recon this nasal defect with a full thickness skin graft or a paramedian forehead flap?).

You do have to be fairly decisive quickly in any surgical field, but even then it’s usually pretty clear what the right answer is. Remember that the more dire the situation, the easier and more algorithmic the decisions get. Patient loses pulses? Well time to run ACLS. Someone in the midst of respiratory failure despite conservative measures? Time to intubate. Fresh free flap loses arterial signal? Back to the OR you go!

When there’s more gray area it usually means the patient is more stable and you have more time to think anyhow. As a new surgeon you’ll also find yourself reaching out to more senior surgeons all the time. I’m in my third year as an attending and I frequently bounce things off senior partners or text/call mentors from training. I’m even part of a listserv with most docs of my sub speciality in the world and people post tough cases with questions all the time. You’re never really alone out there.

The decisions outside the OR tend to be where I struggle the most - when to operate? When not to operate? Challenging multi-revision cases with no obvious good option - when do you call it and tell the patient you can’t help and when do you go for the Hail Mary pass?

You’re going to struggle in all of these without home programs as all are very tough matches. Plastics has the advantage of dual pathways to get there - integrated versus via gen Surg and fellowship. ENT is a wonderful field too with some robust recon options via fellowships and arguably the coolest recons anywhere as you’re rebuilding the face and skull base and whatnot. Very tough match especially without a home program. In either case you’re probably looking at a research year between M3 and M4 to build a competitive CV and make high level contacts, plus a lot of aways (start siphoning off loan money and saving it now). Given your clinical interests in female focused surgical practice, don’t forget OBGYN - 4 year residency and lots of fellowship options and an easier match relative to the 3 you’re considering.

You’re very wise to be thinking ahead. It’s really become a requirement these days as applications get more and more ridiculous and you often see people with better CVs than many assistant professors! A friend of mine who’s now a full prof at a very prestigious institution only had one publication when he got hired there as a junior faculty member! Sadly those days are long gone!

 

[Hollow Knight]

This is a classic SDN post haha

I can't help you, but I wish you all the best OP. I don't envy my classmates who are trying to walk this path. You also seem to have your head screwed on straight

 

[confusedfuturedoc!]

Focus on whatever excites you the most. You’re so early in training that you may not realize just how algorithmic much of surgical decision making is. It’s overwhelming when you’re new, but eventually you’ll see that despite there being a number of reconstructive options for something, there’s usually a clear winner. Even when it is equivocal, there’s often a vast difference in morbidity and the patient will usually have a strong preference one way or the other (ie do I recon this nasal defect with a full thickness skin graft or a paramedian forehead flap?).

You do have to be fairly decisive quickly in any surgical field, but even then it’s usually pretty clear what the right answer is. Remember that the more dire the situation, the easier and more algorithmic the decisions get. Patient loses pulses? Well time to run ACLS. Someone in the midst of respiratory failure despite conservative measures? Time to intubate. Fresh free flap loses arterial signal? Back to the OR you go!

When there’s more gray area it usually means the patient is more stable and you have more time to think anyhow. As a new surgeon you’ll also find yourself reaching out to more senior surgeons all the time. I’m in my third year as an attending and I frequently bounce things off senior partners or text/call mentors from training. I’m even part of a listserv with most docs of my sub speciality in the world and people post tough cases with questions all the time. You’re never really alone out there.

The decisions outside the OR tend to be where I struggle the most - when to operate? When not to operate? Challenging multi-revision cases with no obvious good option - when do you call it and tell the patient you can’t help and when do you go for the Hail Mary pass?

You’re going to struggle in all of these without home programs as all are very tough matches. Plastics has the advantage of dual pathways to get there - integrated versus via gen Surg and fellowship. ENT is a wonderful field too with some robust recon options via fellowships and arguably the coolest recons anywhere as you’re rebuilding the face and skull base and whatnot. Very tough match especially without a home program. In either case you’re probably looking at a research year between M3 and M4 to build a competitive CV and make high level contacts, plus a lot of aways (start siphoning off loan money and saving it now). Given your clinical interests in female focused surgical practice, don’t forget OBGYN - 4 year residency and lots of fellowship options and an easier match relative to the 3 you’re considering.

You’re very wise to be thinking ahead. It’s really become a requirement these days as applications get more and more ridiculous and you often see people with better CVs than many assistant professors! A friend of mine who’s now a full prof at a very prestigious institution only had one publication when he got hired there as a junior faculty member! Sadly those days are long gone!

Hi operaman, thank you so much for your reply. It's good to know that truly emergent situations have more straightforward responses and that there is time to think about problems in the gray area with a robust network to seek help/advice.

Would you be able to provide some perspective on the physical demands of residency and now attendinghood? How did you determine that you could physically handle surgical residency? I have a fear that I'll realize I can't handle it when on my Sub-I. I've heard my school's rotations are not representative of surgical residency, in that it's a lot more easygoing. I've worked a few 70-hour weeks in food service and could handle that but I'm sure I'm naive to compare that to surgical residency. I know it's incredibly neurotic to think this far ahead but would love to hear your thoughts on this and really value your perspective.

 

[Dr. Anonymouss]

This is a post made every year. I get it though I was there once, but to be honest the answer never changes year to year. If you want to be competitive for a highly competitive speciality you need to pass step 1 first try, score high on step 2, honor most if not all of your clinical rotations, try to get AOA (but if you excel academically you should pretty much get it. Some schools require you to show either leadership or altruism through volunteering which adds another piece to the puzzle besides just performing well in medical school), form connections with physicians in those fields you are interested so you can get good letters of rec, and lastly do research in your desired field. You can look at the AAMC data for averages on step 2 and research. So in essence, you need to become the prototypical “gunner”.

 

[Dral]

When you shadow Derm, make sure you get some time with Mohs.

 

[operaman]

Hi operaman, thank you so much for your reply. It's good to know that truly emergent situations have more straightforward responses and that there is time to think about problems in the gray area with a robust network to seek help/advice.

Would you be able to provide some perspective on the physical demands of residency and now attendinghood? How did you determine that you could physically handle surgical residency? I have a fear that I'll realize I can't handle it when on my Sub-I. I've heard my school's rotations are not representative of surgical residency, in that it's a lot more easygoing. I've worked a few 70-hour weeks in food service and could handle that but I'm sure I'm naive to compare that to surgical residency. I know it's incredibly neurotic to think this far ahead but would love to hear your thoughts on this and really value your perspective.

Sure! Before that I will tell a story re AOA and gunning. I made an appt to meet with our AOA faculty advisor about two months into M1. I thought he would think I was a super gunner type asking that early about selection and how it’s done, but then he told me about 30 of my classmates had already been by asking the same thing! Apparently about a third of each class came by year after year asking the same question.

So the physical demands - this varies widely between programs and jobs and even within the same job. I’ve managed to find arguably the best unicorn of a privademic job in the world as an attending and unless something goes sideways I’m never leaving. I now work just under 40 hours a week most weeks, out the door by 3 most days with notes done. And I’m apparently 98th percentile for productivity out of all the docs at my institution and I get paid a truly insane amount of money. My friends at other places also have good lifestyles now as attendings, usually working about 50-60 hours a week. It’s not derm life, but for surgeons it pretty sweet.

Attending life in surgical fields depends mainly on your own skills. If you’re a plastic surgeon and doing a certain free flap takes you 10 hours, your life will suck a bit more than your partner who does them in 5 hours. If your skills and decision making are mediocre, you will have more complications and take backs that screw up your free time, but if you’re good you will find yourself home and relaxed most nights. My partner who’s the busiest free flap surgeon here works from 9-2 most days with the rare 5pm day if he’s doing multiple back to back flaps. He probably has a take back once every couple of years, if that. But he’s awesome and one of the best recon surgeons in the world, so he gets in, gets it done, makes a ton of money, and is home before his kids get out of school.

The other big lifestyle determinant is your job and the index of unpredictability. This is where derm always wins - you just don’t really have any derm emergencies that need you in at midnight. For the rest, call and trauma coverage and the nature of what you cover determine a lot. My schedule is booked solid for months, but if I did trauma and a big face crunch comes in, now I’m adding a 6 hour case after one of my cushy 3pm days. If you take a job covering a lot of trauma, you’ll come in more. For plastics, things like hand and face call can require some coming in at midnight to operate. You do have a lot of choice in what you do though, but obviously the more picky you are, the harder it may be to find the perfect job otherwise. The old adage holds: compensation, location, lifestyle - you can usually get 2 out of 3.

Residency is a different animal. Very program dependent and hinges entirely on the call schedule. I prioritized call a bit in my rank list and ended up with q8-10 call as a junior and q12-14 as a senior. So life was pretty cush there too. Definitely had some long weeks and it was physically exhausting, but having nearly all golden weekends helped. In fellowship my call was also good but I saw the residents struggling with q3-4 call and was so thankful I didn’t have that. Realize that “home” call is excluded from the acgme’s 24+4 rule even if you’re in the hospital all night. I worked quite a few 36 hour shifts as a junior resident and definitely fell asleep in clinic a few times!

Bigger ENT programs are going more and more to a night float call system - even my old program has done that. I think this is probably the nicest system out there - do all your night calls in a single block and be done so you can focus entirely on your training the rest of the year. I don’t know if there are any plastics programs doing that yet. But either way, you can have some control over life in residency by ranking cushier programs higher.

And don’t ever believe anyone who says all that extra call is educational - no it’s not. You’ll learn all there is to know about most overnight emergencies early on and the rest of the time is just grunt work. Rarely are truly interesting cases being done at midnight because the attendings don’t want to do them so late either. Plenty of things happen during the day or can wait til morning and youll see all of those during regular hours.

 

[confusedfuturedoc!]

Sure! Before that I will tell a story re AOA and gunning. I made an appt to meet with our AOA faculty advisor about two months into M1. I thought he would think I was a super gunner type asking that early about selection and how it’s done, but then he told me about 30 of my classmates had already been by asking the same thing! Apparently about a third of each class came by year after year asking the same question.

So the physical demands - this varies widely between programs and jobs and even within the same job. I’ve managed to find arguably the best unicorn of a privademic job in the world as an attending and unless something goes sideways I’m never leaving. I now work just under 40 hours a week most weeks, out the door by 3 most days with notes done. And I’m apparently 98th percentile for productivity out of all the docs at my institution and I get paid a truly insane amount of money. My friends at other places also have good lifestyles now as attendings, usually working about 50-60 hours a week. It’s not derm life, but for surgeons it pretty sweet.

Attending life in surgical fields depends mainly on your own skills. If you’re a plastic surgeon and doing a certain free flap takes you 10 hours, your life will suck a bit more than your partner who does them in 5 hours. If your skills and decision making are mediocre, you will have more complications and take backs that screw up your free time, but if you’re good you will find yourself home and relaxed most nights. My partner who’s the busiest free flap surgeon here works from 9-2 most days with the rare 5pm day if he’s doing multiple back to back flaps. He probably has a take back once every couple of years, if that. But he’s awesome and one of the best recon surgeons in the world, so he gets in, gets it done, makes a ton of money, and is home before his kids get out of school.

The other big lifestyle determinant is your job and the index of unpredictability. This is where derm always wins - you just don’t really have any derm emergencies that need you in at midnight. For the rest, call and trauma coverage and the nature of what you cover determine a lot. My schedule is booked solid for months, but if I did trauma and a big face crunch comes in, now I’m adding a 6 hour case after one of my cushy 3pm days. If you take a job covering a lot of trauma, you’ll come in more. For plastics, things like hand and face call can require some coming in at midnight to operate. You do have a lot of choice in what you do though, but obviously the more picky you are, the harder it may be to find the perfect job otherwise. The old adage holds: compensation, location, lifestyle - you can usually get 2 out of 3.

Residency is a different animal. Very program dependent and hinges entirely on the call schedule. I prioritized call a bit in my rank list and ended up with q8-10 call as a junior and q12-14 as a senior. So life was pretty cush there too. Definitely had some long weeks and it was physically exhausting, but having nearly all golden weekends helped. In fellowship my call was also good but I saw the residents struggling with q3-4 call and was so thankful I didn’t have that. Realize that “home” call is excluded from the acgme’s 24+4 rule even if you’re in the hospital all night. I worked quite a few 36 hour shifts as a junior resident and definitely fell asleep in clinic a few times!

Bigger ENT programs are going more and more to a night float call system - even my old program has done that. I think this is probably the nicest system out there - do all your night calls in a single block and be done so you can focus entirely on your training the rest of the year. I don’t know if there are any plastics programs doing that yet. But either way, you can have some control over life in residency by ranking cushier programs higher.

And don’t ever believe anyone who says all that extra call is educational - no it’s not. You’ll learn all there is to know about most overnight emergencies early on and the rest of the time is just grunt work. Rarely are truly interesting cases being done at midnight because the attendings don’t want to do them so late either. Plenty of things happen during the day or can wait til morning and youll see all of those during regular hours.

Hi operaman, thank you again for your insights. I appreciate the candid advice and the glimpse into the realities of residency and attending life. Wishing you continued success and fulfillment in your career!