Picking a specialty - getting more confused every day

[illegallysmooth]

To all those students who didn't walk into medical school with a mallet in hand, gunning for ortho, how are you doing with choosing a specialty? To my fellow third years, have your first couple rotations helped to start pointing you in a certain direction? To the fourth years, when did you realize what you wanted to do?

I know it's early for third years, but then again every other post I read is about "Am I competitive for ____" in which the poster has been doing research in that field since they were 10 years old.

I'm so confused. I always thought I'd do EM (after working in an ED for 4 years), but lately I've been doubting it. On my first rotation (IM), I found myself really wanting to know more about the issues we were calling consults for. Here's an example - we had a 40-something male come to the ED with flank pain. They found hydronephrosis secondary to a large obstructing retroperitoneal mass -- turns out the guy had testicular cancer years ago and didn't follow up. I think that's fascinating. But on IM, it was like "he's got hydro and a mass with ARF -> consult onco and nephro and uro -> check lytes tomorrow" --that's not satisfying to me. A good friend who is now an EM attending thinks I might feel the same way about EM. But maybe not, because I'll be initiating treatment...?

So, I know I don't like straight up IM. In addition to the above problem, I didn't like having to act as the central manager for all the pt's problems, following up on all the consults and worrying about nursing home placement and rehab, etc. The attending that I rotated with was AWESOME about all of that, in fact she seemed to love it. As much as I look up to her (for various reasons), I just can't see myself dealing with the same crap and being so happy.

Surgery - scared of the lifestyle. Want to go to my future kids' games and dance recitals.
OB/GYN - LOVE the patient care aspects, but I'm almost embarrassed to say that some of the minor procedures make me cringe so bad! I swear my own cervix hurts when that clamp goes on for an IUD placement. D&Cs under MAC just make my skin crawl. Oddly enough, gen surg doesn't bother me like that.
Peds - worked in peds office for one year. Loved the kids, couldn't stand many of the parents. Also, I will be over 300k in debt. Too much routine care and well child exams.
Psych - no
FM - I like the variety, but it's too much routine care, it's just not my bag.

I hope no one takes this the wrong way, I'm just trying to figure out what to do with my life. I have tremendous respect for all of the above professions. Different strokes for different folks, right?

So what now? I'm starting to think an IM subspecialty might be for me, maybe gastro.
I like procedures.
I like acute care.
I like hospitals.
I like direct patient care.
I like variety.
I do want to have a life outside of medicine.

Does my dream job exist? My grades/board scores are very competitive. Lots of bio and psych research experience, but just one pub (in immunology/ID) from my masters program, and not first author. Being at a DO school, I don't see myself pursuing any more research here. Maybe I'll fall in love on my surgery rotation. Hmph.

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[boopitybop]

why not a fellowship after an IM residency? CCM seems to fit kind of well.

 

[235009]

i started third year thinking i wanted to do either EM or anesthesia and decided to do IM toward the end of the year. the trick to deciding is to look at the lives of the attendings and don't take anything anyone says to you about a specialty at face value. For instance many people call EM a "lifestyle specialty" but is alternating between day and night shift a lifestyle you want for yourself when you're an attending? as third year progresses you get a picture of what you don't want to deal with and what you wouldn't mind dealing with and what best suits your personality. another caveat is that your exposure to a specialty can be vastly different depending on where you do your rotation. for instance the way you described IM isn't the way IM is at a most large university medical centers.

 

[Doctor Bob]

why not a fellowship after an IM residency? CCM seems to fit kind of well.

You can't go into a field expecting to do a fellowship. You always have to be willing to spend the rest of your life doing the base specialty in case things don't work out as planned. If you want to be a cardiologist, but would hate your life if you spent your life as a general internist, then be very careful. There are a lot of people who go into IM intending to apply for fellowships and never get them.

 

[GTP]

You can't go into a field expecting to do a fellowship. You always have to be willing to spend the rest of your life doing the base specialty in case things don't work out as planned. If you want to be a cardiologist, but would hate your life if you spent your life as a general internist, then be very careful. There are a lot of people who go into IM intending to apply for fellowships and never get them.

Exactly why i can't do medicine or GS

 

[partydoc]

Take a look at anesthesia.

Maybe one of the surgical subspecialties?

 

[illegallysmooth]

You can't go into a field expecting to do a fellowship. You always have to be willing to spend the rest of your life doing the base specialty in case things don't work out as planned. If you want to be a cardiologist, but would hate your life if you spent your life as a general internist, then be very careful. There are a lot of people who go into IM intending to apply for fellowships and never get them.

This is what I'm afraid of. I do have two more IM rotations this year, one is at a larger hospital and I think they have residents. I guess we will see about that.

I've looked at anesthesia, but there isn't enough patient interaction for me, and I don't really like pharm that much. In the back of my head, I can't shake the nagging feeling I should at least consider derm and try to shadow someone before scheduling my next elective. I know after what I said that sounds ridiculous. I'm not missing the obvious here- I know it's completely opposite to everything I said, but sometimes I feel like I'm being naive and too cowboy-ish. Like will I really want to be working nights or running around a hospital when I'm 50? Will I regret not trying for a specialty that will allow me the family time I want? Its not just lifestyle- I am interested in the procedural aspects of derm. Sometimes I think my boredom with clinic work comes from having to show up and work in someone else's clinic, and not doing a whole lot of hands on work while I'm there. I think the day-to-day of owning my own place, managing my own employees, keeping up with office technology, running a business, doing procedures and some surg etc would be fulfilling. I don't mean to imply that I think I would get a derm spot if I simply decided I want one, I'm not quite that arrogant, lol. I just gotta figure this out so I can start putting more effort into making myself the best candidate I can be.

Ugh I don't know. As you can see, I think a lot. I know I should do what I love, but I also want to make a smart decision. Is what I love today going to be what I love in 30 years? I hate that we have to decide this crap before we even see 80% of it. Internship here I come. Now, which kind...

 

[MedicalStudent9]

I like procedures.
I like acute care.
I like hospitals.
I like direct patient care.
I like variety.
I do want to have a life outside of medicine.

We're twins broseph.

Post I found that may be helpful: http://forums.studentdoctor.net/showpost.php?p=11952432&postcount=6

 

[VenusinFurs]

This is what I'm afraid of. I do have two more IM rotations this year, one is at a larger hospital and I think they have residents. I guess we will see about that.

I've looked at anesthesia, but there isn't enough patient interaction for me, and I don't really like pharm that much. In the back of my head, I can't shake the nagging feeling I should at least consider derm and try to shadow someone before scheduling my next elective. I know after what I said that sounds ridiculous. I'm not missing the obvious here- I know it's completely opposite to everything I said, but sometimes I feel like I'm being naive and too cowboy-ish. Like will I really want to be working nights or running around a hospital when I'm 50? Will I regret not trying for a specialty that will allow me the family time I want? Its not just lifestyle- I am interested in the procedural aspects of derm. Sometimes I think my boredom with clinic work comes from having to show up and work in someone else's clinic, and not doing a whole lot of hands on work while I'm there. I think the day-to-day of owning my own place, managing my own employees, keeping up with office technology, running a business, doing procedures and some surg etc would be fulfilling. I don't mean to imply that I think I would get a derm spot if I simply decided I want one, I'm not quite that arrogant, lol. I just gotta figure this out so I can start putting more effort into making myself the best candidate I can be.

Ugh I don't know. As you can see, I think a lot. I know I should do what I love, but I also want to make a smart decision. Is what I love today going to be what I love in 30 years? I hate that we have to decide this crap before we even see 80% of it. Internship here I come. Now, which kind...

There ain't no shame in going derm.

 

[Transmogrifier]

4th year here planning on applying to EM this fall.

I feel like I was in a similar situation. I really liked the ED from the time I had spent volunteering there a premed. I shadowed in the ED first and second year and kept liking it but was keeping my mind open. I was considering EM, IM, anesthesia, and maybe thinking about critical care at some point down the line (which is possible via all 3 of those specialties).

Then third year comes along. I liked neuro and psych much more than I ever thought I would. I had a great experience on my IM rotation. So much so that I said I was leaning towards IM over EM. Surgery was never really on the table (no pun intended) for me. Peds ended up being more enjoyable than I thought; I think I was mostly scared of kids before that. OB/GYN? I can appreciate being both the medical and surgical specialist for your patients with a mix of outpatient, inpatient, and surgery but, yeah, noooo thank you. Family medicine seemed like a lisinopril, metformin, and vicodin refill clinic and specialty referral service. I had an EM elective and really liked it.

I just finished another outpatient IM rotation as part of fourth year and I actually liked it. I think the difference was that my knowledge and experience had increased enough that I could contribute more ideas to workup and management.

So, how did I decide on EM after all of that?

The one thing that made me wary of picking EM was lack of continuity. I don't feel like I need to be an FP that sees someone from cradle to grave, but it might be nice to see what happens with my patients. Two things made me stick with EM over IM on this issue. First, many people leave the ED with a diagnosis. You have pneumonia? Ok, get admitted and have some antibiotics. Appendicitis? To the OR with you. Broken bone? Let me cast that for you. There are lots of things that leave the ED without an answer and require further inpatient and outpatient workup, but there is plenty that's pretty much wrapped up in the ED as well. Second, I discovered I really don't have the mind or personality to be the internist who thinks of the 10 things on the differential for hypokalemia. I got bored on the floor when my patients were worked up but not ready to be discharged. In the end, In the end, I think I'll be satisfied with peeking at the charts of patients I was particularly interested in.

Perhaps if I were going into medicine 50 years ago I would do family practice so I could do some outpatient, ED, ICU, inpatient, catch babies, and help with minor surgeries. But that doesn't happen anymore.

So that leaves us will all the cool stuff about EM! There's acuity, undifferentiated complaints, breadth, procedures, etc. I'm not making any decisions on fellowship yet, but critical care, toxicology, and wilderness medicine all seem interesting.

Another word of advice on trying to figure out what you like and why you like it. Try to tease apart what exactly you like/dislike about each rotation. Did you like your residents and attending? Was it a cushy new hospital with great hours or were you stuck in a **** hole for 12-14 hours a day? Was the medicine interesting to you? Were you at a busy academic center or a community hospital? Did you like it because you thought you did a good job? Did you dislike it because you got pimped and always seem to get things wrong? It's hard to make decisions based on one month of doing a specialty at one hospital with one set of people, but hopefully some careful thought can help you sort it out.

 

[Mass Effect]

Have you thought about neurology or PM&R?

 

[joeDO2]

http://doccartoon.blogspot.com/2010/04/how-to-choose-medical-specialty.html

 

[45408]

I think that's fascinating. But on IM, it was like "he's got hydro and a mass with ARF -> consult onco and nephro and uro -> check lytes tomorrow" --that's not satisfying to me.

That's also institution and attending specific. We have some hospitalists who know how to appropriately work things up to a great degree and then make a single referral to follow up as an outpatient, and then we have others who just do shotgun consults and expect everyone to do their work for them. In the above situation, you probably still would have called urology, but once they stent the ureter, the ARF will probably resolve, so the neph consult was probably not necessary, and oncology can be an outpatient follow-up. Also, if you're in a smaller facility, you simply can't consult all of those specialists because you might not have them.

A good friend who is now an EM attending thinks I might feel the same way about EM. But maybe not, because I'll be initiating treatment...?

Again, depends on where you work. We get transfers from critical access hospitals, and the EM docs up there will do cricothyroidotomies for an emergent airway, chest tubes, central lines, etc. That's pretty cool. Or you might be somewhere that sees a lot of sniffles and sneezes, and anything cool gets referred to the MICU/SICU/trauma team.

So what now? I'm starting to think an IM subspecialty might be for me, maybe gastro.
I like procedures.
I like acute care.
I like hospitals.
I like direct patient care.
I like variety.
I do want to have a life outside of medicine.

Does my dream job exist? My grades/board scores are very competitive. Lots of bio and psych research experience, but just one pub (in immunology/ID) from my masters program, and not first author. Being at a DO school, I don't see myself pursuing any more research here. Maybe I'll fall in love on my surgery rotation. Hmph.

You sound like an anesthesiologist or PM&R doc.

 

[illegallysmooth]

Thanks to everyone for your replies. I've been reading and digesting everything and I appreciate all the advice.

I'm on outpatient peds right now and feeling like I have to double my dose of Focalin to stay awake. I actually like caring for the kiddos, though. Unless I figure things out sooner, I'm going to avoid committing to anything for my late 3rd year elective until after my vacation month, during which I can do a little shadowing in gas and derm. As transmogrifier suggested, I'm trying to pick apart what I like or dislike about everything. So far it looks like I've been the most enthusiastic when a patient's problems are either severe or somewhat mysterious, both of which command my focus and spark my interest. I am falling asleep when the patient is healthy or has minor complaints.