The Most Intellectually Challenging Specialty

[Dumpstarrian]

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[DermViser]

It all ends with the pathologist.

Q.E.D.

You just had to reply to a thread in which the last poster posted a DECADE ago.

 

[Rendar5]

toxicology (their boards are sick and esoteric) and pathology.

 

[HooliganSnail]

Internal medicine (without a doubt)

(only field where ALL of medicine is integrated). yes I KNOW family Practice ALSO integrates ALOT, but the drive is entirely directed towards funneling someone towards either referrals or prescriptions, while talking to their pimps, sorry HMO's on the phone every 5th second.

But I would also say that I personally consider all oncological subspecialties the MOST intellectually challenging of it ALL. Lotsa hardcore scientists there.

I would argue that FM integrates more things that internal med. We cover every IM specialty as well as pediatrics, gynecology, and some FMs still do Ob. Very challenging field. There is a reason that the FM shelf exam gives most medical students fits.

 

[Rendar5]

Broad but are not the moat intellectually challenging unless you really really really go academic and clinical research route

 

[thesauce]

I would argue that FM integrates more things that internal med. We cover every IM specialty as well as pediatrics, gynecology, and some FMs still do Ob. Very challenging field. There is a reason that the FM shelf exam gives most medical students fits.

It may have been a lot different 10 years ago, when he/she posted that

 

[Med Peds]

Congenital Cardiac Surgery

 

[Winged Scapula]

Congenital Cardiac Surgery

Technically challenging? Sure. But I don't know if it's the most intellectually challenging.

 

[serialsevens]

There are so many complexities associated with trying to answer this question that it's nearly futile to even unpack it. And it's not like surveying a group of totally bias people is going to get you closer to the Truth with a capital T (if there is one...FWIW, my vote = there isn't). And really, even if you could approximate, which metrics would you use to effectively measure "intellectually challenging?"

Plus, bread and butter in any specialty is going to be pretty boring and rote after a while.

 

[deuist]

Pulm/ccm Think, ~40% of ILDz is still idiopathic, you're in the middle of the heart-lung-renal circuit: rt heart failure, pulm HTN, ards, hepatopulm-syndrome as pulm. As ccm you deal with the end result of every failing system in the body from surgical, neonatal, pediatric, CV/vasc platforms. You don't exactly use run of the mill meds, you manage vents, and your patients are almost always complicated with comorbidities. DKA is consistently the easiest/fastest ICU admission-discharge. Pulm/Ccm (especially in a closed unit) requires full on understanding of every system and requires procedural skills under the worst circumstances. In top of it all, you're the one answering to family/loves ones in their worst hour. Boom.

I like critical care, too, but to say that it is the most intellectually difficult field is disingenuous. An intensivist calls on consultants frequently through ID, nephro, neuro, cardio, surgery, and the list goes on. Also, to say that ccm deals with neonates or even peds is just plain wrong. The above posters from 10 years ago got it right by saying that path, rads, neuro, and the IM subspecialties are the most mentally taxing. I don't know anything about neuro-ophthalmology.

 

[onelastpuff23]

Is there a consensus that Dermatology is not the most stimulating?

 

[Serous Demilune]

Is there a consensus that Dermatology is not the most stimulating?

I don't think consensus can exist on this website.

 

[Siggy]

Family Nurse Practitioner. After all, what could be more challenging than practicing medicine after 2 years of part time internet classes?


Seriously, though, the honest answer is what ever field you couldn't be paid enough money to go into will be the most challenging to you, the individual.

 

[FutureInternist]

Family Nurse Practitioner. After all, what could be more challenging than practicing medicine after 2 years of part time internet classes?


Seriously, though, the honest answer is what ever field you couldn't be paid enough money to go into will be the most challenging to you, the individual.

That....was....AWESOME !!

 

[Food]

My opinion:

Conceptually challenging - Cardiology, especially electrophysiology

These are hard because they require a large amount of knowledge and understanding pretty complicated basic science if you want to be good at them. Cardiology requires you to be able to visualize cardiac electrophysiology in your mind and have an intuitive understanding of it and ability to translate it into a 2 dimensional representation (EKGs).

Now, a lot of the answers on here allude to any specialty that requires a good understanding of physics and that's because most people in medicine suck at physics. they brushed through it in college so they could take the MCAT. Radiology - you need a cursory understanding of physics. That's why there are medical physicists (and even they are considered watered down physicists by actual physicists). Same with rad onc; you know just enough physics to do your job. Good cardiologists though I feel like have a very good intuitive grasp of electrophysiology in the heart and that is probably one of the most intellectually challenging topics in medicine (in my opinion). You can't memorize electrophysiology, you have to visualize it.

Neurology will probably become more difficult once it incorporates more neuroscience. Computational neuroscience is a pretty cool field but its not really relevant to clinical neurology yet.

 

[RadOncDoc21]

My opinion:

Conceptually challenging - Cardiology, especially electrophysiology

These are hard because they require a large amount of knowledge and understanding pretty complicated basic science if you want to be good at them. Cardiology requires you to be able to visualize cardiac electrophysiology in your mind and have an intuitive understanding of it and ability to translate it into a 2 dimensional representation (EKGs).

Now, a lot of the answers on here allude to any specialty that requires a good understanding of physics and that's because most people in medicine suck at physics. they brushed through it in college so they could take the MCAT. Radiology - you need a cursory understanding of physics. That's why there are medical physicists (and even they are considered watered down physicists by actual physicists). Same with rad onc; you know just enough physics to do your job. Good cardiologists though I feel like have a very good intuitive grasp of electrophysiology in the heart and that is probably one of the most intellectually challenging topics in medicine (in my opinion). You can't memorize electrophysiology, you have to visualize it.

Neurology will probably become more difficult once it incorporates more neuroscience. Computational neuroscience is a pretty cool field but its not really relevant to clinical neurology yet.

Ahh... So these physics boards we need to take and pass that require graduate level teaching was just easy reading. Good to know!

 

[deuist]

Cardiology requires you to be able to visualize cardiac electrophysiology in your mind and have an intuitive understanding of it and ability to translate it into a 2 dimensional representation (EKGs).

This is probably the stupidest thing I've read on SDN in quite a while. But I see that you are a medical student. Lots of doctors know how to read EKGs. You don't have to be a cardiologist to learn how.

 

[Food]

I'm not a medical student. We read a lot of ekgs in my specialty. But we aren't experts on them. Cardiologists are. Feel free to dispute that but you will only prove that you are the stupid medical student. By the way I've met plenty of medical students who far outstrip residents in intelligence. I suspect that this has happened with you frequently.

 

[Winged Scapula]

I'm not a medical student. We read a lot of ekgs in my specialty. But we aren't experts on them. Cardiologists are. Feel free to dispute that but you will only prove that you are the stupid medical student. By the way I've met plenty of medical students who far outstrip residents in intelligence. I suspect that this has happened with you frequently.

Your status is listed as a medical student. I'd suggest changing it to avoid confusion.

 

[BoardingDoc]

I'm not a medical student. We read a lot of ekgs in my specialty. But we aren't experts on them. Cardiologists are. Feel free to dispute that but you will only prove that you are the stupid medical student. By the way I've met plenty of medical students who far outstrip residents in intelligence. I suspect that this has happened with you frequently.

Your status says you're a medical student. Not deuist's fault he/she assumed you were one. Deuist's comment about it being the dumbest thing on SDN in a while may or may not be true, but the idea of needing to visualize EP in your head in order to interpret an ECG is absurd.

 

[Food]

That's not the point I was trying to make though I wrote it out like that. I should have used different wording. Yes, EKG interpretation isn't difficult. I'm not talking about knowing how to tell the rate, rhythm, intervals, st changes, progression, qrs anomalies and then doing pattern recognition to know what sort of pathology that translates to. That's not what I was really talking about.

Anyway, I'm out. No point in arguing with you or anyone who for some reason is offended by my post. It wasn't intended to be. But what do I expect, you have a bunch of egomaniacs discussing which specialty is "harder".

 

[gassyPants]

No votes for hematology/oncology? Hemostasis alone makes me want to cry.

 

[nlax30]

This is probably the stupidest thing I've read on SDN in quite a while. But I see that you are a medical student. Lots of doctors know how to read EKGs. You don't have to be a cardiologist to learn how.

Not that I'm agreeing or disagreeing with him, but I think what he was getting at is that EP docs have a much different intuitive understanding or ECG when it comes to understanding vectors and origins of arrhythmias. Yea to interpret a basic ECG doesn't take much, to glance at a 12 lead rhythm strip and know that there's a bypass tract involving the the tricuspid isthmus requires a different knowledge base.

And I'm a current cardio fellow on a EP month and this is some of the most technical stuff I've seen. Even amongst cardiologists there is often disagreement among ECGs.

Not saying that is the most challenging specialty as you could make arguments for just about any specialty as each has its own unique challenges.

 

[mercaptovizadeh]

Given my limited experience on rotations in med school, nephrology seemed quite brainy.

 

[Arcan57]

Not that I'm agreeing or disagreeing with him, but I think what he was getting at is that EP docs have a much different intuitive understanding or ECG when it comes to understanding vectors and origins of arrhythmias. Yea to interpret a basic ECG doesn't take much, to glance at a 12 lead rhythm strip and know that there's a bypass tract involving the the tricuspid isthmus requires a different knowledge base.

And I'm a current cardio fellow on a EP month and this is some of the most technical stuff I've seen. Even amongst cardiologists there is often disagreement among ECGs.

Is that solely because of technical skill or is it that ECGs are not terribly sensitive/specific for many cardiac conditions?

 

[nlax30]

Is that solely because of technical skill or is it that ECGs are not terribly sensitive/specific for many cardiac conditions?

Hmm.... I'm not sure either of those is the case. Of course there is some physical skill in certain ablation procedures and maneuvering say an LV lead for a BiV, but I'm not sure that could compare with say most neurosurgical procedures for example.

The ECG can be very specific/sensitive for various conditions as it's just literally a surface recording or electrical vectors coming from the heart. It's interpreting the data that's the hard part.

During an ablation they several catheters at various positions in the heart, each one with maybe 4-10 separate electrodes each recording the electrically activity at that point. So you're standing the looking at maybe at least 15 different simultaneous electrocardiograms scrolling across the screen and with a few minutes of interpreting timing, pacing and injecting premature beats you can get a good idea of what type of arrhythmia it is and where it's coming from having a specific knowledge in detail of the conduction system. I can tell you that even a general cardiologist could walk into the room and not know where to start.

Then again that's part of the point, each specialists presumably has a very detailed knowledge of their specific organ/system and so to anyone outside that specialty it's going to seem complex.

 

[royalmedicus]

if neurology can incorporate just a little more interventions, i think neurology can win here.

 

[Siggy]

if neurology can incorporate just a little more interventions, i think neurology can win here.

 

[Crayola227]

True.

However, given that >1000 people viewed this thread (in 2 days), and asuming that the few people who took the time and energy to post (a measure of the level of interest in cognitive specialties) are future or current Neurologists, Radiologists, Nephrologists, and Pathologists, it can be argured that these fields are indeed the most intellectually demanding since these people are interested in the subject of intellectual specialties (since they posted).

After >1000 views in a General Residency forum, we did not hear from current/future General Surgeons (new, not old dudes), dermatologists, orthopedists, ENT, ect......

Maybe they are not interested in "Cognitive specialities", and this is why they are in/going into Surgery, Dermatology, ENT, Orthopedics...........?????

Or maybe the Neurologists, Radiologists, Nephrologists, Pathologists, their fields are so "challenging" that they find themselves on SDN. Maybe everyone who isn't on SDN is just too intellectually challenged by their career to make an appearance.
Is being on SDN a sign of being intellectually challenged??!! Is being on SDN a sign of cognition???

I would argue that FM integrates more things that internal med. We cover every IM specialty as well as pediatrics, gynecology, and some FMs still do Ob. Very challenging field. There is a reason that the FM shelf exam gives most medical students fits.

Sorry, I couldn't help it, but does a field's shelf exam giving med students fits a testament of intellectual challenge? Is the flummuxation of medical students now our litmus test for intellectual challenge?

My opinion:

Now, a lot of the answers on here allude to any specialty that requires a good understanding of physics and that's because most people in medicine suck at physics. they brushed through it in college so they could take the MCAT. Radiology - you need a cursory understanding of physics. That's why there are medical physicists (and even they are considered watered down physicists by actual physicists). Same with rad onc; you know just enough physics to do your job. Good cardiologists though I feel like have a very good intuitive grasp of electrophysiology in the heart and that is probably one of the most intellectually challenging topics in medicine (in my opinion). You can't memorize electrophysiology, you have to visualize it.

I don't know, I didn't just "brush" through physics in college. I actually don't find highly mathematical or algorithmic fields intellectually challenging. But as people have pointed out on this board, everyone has a different idea of intellectual challenge. But personally, I'm not intimidated by physics and I don't think anyone else should bow to it either.

Given my limited experience on rotations in med school, nephrology seemed quite brainy.

Given my limited experience on rotations in med school, nephrology didn't. OK, correct that, it's not that hard to do dx, w/u, tx, but to actually UNDERSTAND the pathophysiology and how the damn things work, sure.

I just thought I'd throw this out there for derm (I am like so not derm adjacent) but I overheard some derm guy counseling some students, and he pointed out the following:
derm is responsible for like one of the greatest number of diagnoses in a field at like at least 13,000 (I think)
derm is one of the last fields to rely almost entirely on the practitioner and not imaging/lab testing for diagnosis (ie from history and looking at it, and under the microscope, is how they diagnose the vast majority of those diseases)
derm is actually somewhat mysterious, most of the pathophysiology of how various viruses/disease cause the skin manifestations they do is unknown, so the field of research is vast
and let's face it, all us other docs, we really have no f*ing clue what that rash is, they pretty much all look the same to us

and the problem I have with the rheum vote (I actually love love the field) is that everything is so vague, it's so clinical the diagnosis, it has like one of the lowest number of diagnoses to be responsible for (there's only like 4,000 I think), and even when you do think you know what it is, it doesn't make much of a difference you end up empirically using like 5 drugs. Now, with the biologics I think that may be changing... I will say for rheum, that like with derm, there's a lot of mystery and the research vast... the immune system and connective tissue, dude

anyway, I didn't pop in here to vote but to make jokes and drop factoids

 

[j4pac]

I second nephro and neuro. They happen to be two of the most nerdy specialties as well...which I do NOT find as a coincidence.

 

[calvnandhobbs68]

Given my limited experience on rotations in med school, nephrology didn't. OK, correct that, it's not that hard to do dx, w/u, tx, but to actually UNDERSTAND the pathophysiology and how the damn things work, sure.

I just thought I'd throw this out there for derm (I am like so not derm adjacent) but I overheard some derm guy counseling some students, and he pointed out the following:
derm is responsible for like one of the greatest number of diagnoses in a field at like at least 13,000 (I think)
derm is one of the last fields to rely almost entirely on the practitioner and not imaging/lab testing for diagnosis (ie from history and looking at it, and under the microscope, is how they diagnose the vast majority of those diseases)
derm is actually somewhat mysterious, most of the pathophysiology of how various viruses/disease cause the skin manifestations they do is unknown, so the field of research is vast
and let's face it, all us other docs, we really have no f*ing clue what that rash is, they pretty much all look the same to us

and the problem I have with the rheum vote (I actually love love the field) is that everything is so vague, it's so clinical the diagnosis, it has like one of the lowest number of diagnoses to be responsible for (there's only like 4,000 I think), and even when you do think you know what it is, it doesn't make much of a difference you end up empirically using like 5 drugs. Now, with the biologics I think that may be changing... I will say for rheum, that like with derm, there's a lot of mystery and the research vast... the immune system and connective tissue, dude

anyway, I didn't pop in here to vote but to make jokes and drop factoids

Haha rheum only uses like 5 drugs but derm doesn't? "Let me give you some topical steroids for that rash" derm? Okay then

 

[Dral]

The word 'Derm' is mentioned and the field gets bashed? What?! That never ever happens on SDN. Haha

 

[royalmedicus]

The word 'Derm' is mentioned and the field gets bashed? What?! That never ever happens on SDN. Haha

80% of bashing is with "Let me give you some topical steroids for that rash".
and 20% is with dry to wet, wet to dry stuff.

 

[Crayola227]

Oh, yea gads, I never meant to exalt derm over rheum! Heresy.

# of dx and # of tx options aside,

I can't come up with specific examples for you, but the most frustrating cases on the floor for me are always when I hear the attending and senior say to one another, (in their deep grown up sounding voices, which sounds like Dave Chappelle when he's impersonating serious white people) "We've done every test. None of it makes sense. The only other clue is this rash... but we don't know what it is."
Me, the intern, pipes in with the Mickey Mouse voice, "Oh boy, how do we find out?"
They barely glance my way, shrug. I continue, "well, is there like any way to figure out what this rash is?"
"Not by just looking," they tell me, as though to say, silly intern, that is the end of this story.
"Well, could derm help us figure it out?" I press. I know they can, I believe they can!! I know that if derm looked biopsied swabbed they would have the answer! No one else believes in them, but to me they are like magicians, reading patterns in the tea leaves we can only imagine. If only we knew what this f*ing rash was, the work up would be done, the diagnosis made, we could start a more sure treatment, the patient, on day 5 of their hospitalization, would have an end in sight. I don't understand; when we reach the limits of our knowledge and still have questions, we always have someone to turn to for help, the cardiologists, the endocrinologists, even the surgeons give us answers. I'm afraid I may have angered the attending by pointing out that there does indeed exist a magic mad man with the skill we do not; to diagnose the baffling rash.
But no, the attending is not irritated. He does look at me with a sort of wonder. And not wondering how I could be so dumb, as I know that look well. Almost as though I were a strange creature of fragile innocence and naivety, as though I am a child that does not know that there are no unicorns, and he never expected to be faced with such a question with all sincerity.
"What? Get derm in the hospital on consult? On a Friday afternoon?" The attending laughs, not in derision, but seemingly delighted that anyone could have so fanciful a notion.

 

[NeedToStudy]

I'm sure the haters will have a field day with this but....... wait for it........ Psychiatry.

 

[Crayola227]

psych, God, intellectual? That field is a like a zebra amongst the horses of medicine.

Funny how everyone ****s on psych, but like I'm the intern (with psych love in my heart) that's the only one to remember that the f*cked up Parkinson's patient shouldn't get Seroquel for being an a*hole on the floor.

Like if you're going to **** on psych then you should at least have a grasp of basic psych **** whoever you are. If you're in another field and can't hold to the basic **** in someone else's field you were supposed to know from med school then who are you to look down on anyone?

 

[Crayola227]

Psych is the least appreciated specialty if you ask me
I'm not going to say most intellectual, (by the standards of somatically focused med) but easily easily the least appreciated

 

[NonTrad Journey]

Neurocritical Care in a place where the consult services are limited. They are often the primary team and manage ID, Pulm, Neuro etc....

 

[psych md jd]

I'm sure the haters will have a field day with this but....... wait for it........ Psychiatry.

Forensic psychiatry. Where else does the typical report run 100+ pages typed? The interview takes 20+ hours? The records get delivered in multiple banker's boxes and take weeks to review?

And don'the forget the direct examination and cross examination in court. Nothing quite like having your whole career challenged in order to testify and then be challenged on your findings.

 

[Doctor Bagel]

Forensic psychiatry. Where else does the typical report run 100+ pages typed? The interview takes 20+ hours? The records get delivered in multiple banker's boxes and takes weeks to review.?

And don'the forget the direct examination and cross examination in court. Nothing quite like having your whole career challenged in order to testify and then be challenged on your findings.

That sounds so painful. I guess I didn't miss the boat by skipping on that fellowship. My attention span is not long enough for that.

Now for those haters on psych, it's actually surprising hard to do it well even though a lot of the stuff we do seems amazingly easy (and yes, amazingly screwed up over and over by other specialties -- no, your 90 year old ICU patient does not have schizophrenia).

 

[ThoracicGuy]

That sounds so painful. I guess I didn't miss the boat by skipping on that fellowship. My attention span is not long enough for that.

Now for those haters on psych, it's actually surprising hard to do it well even though a lot of the stuff we do seems amazingly easy (and yes, amazingly screwed up over and over by other specialties -- no, your 90 year old ICU patient does not have schizophrenia).

But she does!!!!!~`1~!!

 

[RustBeltOnc]

Is there a consensus that Dermatology is not the most stimulating?

yes

 

[RustBeltOnc]

I'm sure the haters will have a field day with this but....... wait for it........ Psychiatry.

psych is awesome. no hate from most of IM, only appreciation and envy.

 

[NeedToStudy]

psych is awesome. no hate from most of IM, only appreciation and envy.

Then what's all this I hear about psychiatrists not being real doctors?

 

[Crayola227]

Then what's all this I hear about psychiatrists not being real doctors?

I hate to say it.... but they lose a lot of knowledge/skills regarding a lot of other aspects of medicine, somatic med if you will, whereas most of the other specialties have so much overlap that they retain a lot more.

For example, your neurologist is quite familar with blood pressure management, hyperlipidemia, anticoagulation, arrhythmias, etc because that's all related to stroke risk. Doesn't mean they do the management themselves, but they're definitely on the same page when they read the PCP and hospitalist notes. Same with anesthesiologists, intensivists, etc, even surgeons. Even the derms know a lot about medications because so many cause skin reactions. A lot of these fields never hang up the stethoscope, and still rely on PE.

Psychs, no offense, usually up the steth and a good deal will not do another PE for God knows how many years.

On psych rotation, we had a young patient, no other meds or conditions, got tased like 50 times by cops to bring in for a psychotic episode, then had AKI, muscle aches, had a CK ordered, was greatly elevated. Clearly rhabdomyolysis. Had to consult hospitalist to figure out that the treatment was aggressive fluid resuscitation, after I pulled up UTD article on it. I'm not saying that was inappropriate, I don't know if that's its just outside of scope of practice/medmal, just that I was a little taken aback at the kinds of things that had to be consulted out on in psych.

Psych just has such a different and less somatic approach, the umbrella doesn't overlap with so much of the rest of what other docs do, that it has that reputation.

 

[psych md jd]

Can I still read an EKG? No.

Can I still draw labs? Probably.

Can I evaluate/treat people who decapitate their parent or kill someone because they think they were replaced by a double? Yes.

 

[RustBeltOnc]

I hate to say it.... but they lose a lot of knowledge/skills regarding a lot of other aspects of medicine, somatic med if you will, whereas most of the other specialties have so much overlap that they retain a lot more.

On psych rotation, we had a young patient, no other meds or conditions, got tased like 50 times by cops to bring in for a psychotic episode, then had AKI, muscle aches, had a CK ordered, was greatly elevated. Clearly rhabdomyolysis.
Psych just has such a different and less somatic approach, the umbrella doesn't overlap with so much of the rest of what other docs do, that it has that reputation.

For many of us in hem onc, after medicine residency, our ability to manage things like rhabdo are second nature and not rewarding (like riding a bike).
At the same time, I don't care if a psychiatrist cannot really do IM. (No more impressive then riding a bike)

What I really wish I could do is get patients with Axis II pathologies, etc, to buy into treatment for curable/manageable malignancies.

 

[Crayola227]

I agree which is why I have a lot of respect for psych.

I joke that if we people got all the appropriate mental health care they needed, especially towards substance abuse, lifesyle, it wouldn't matter if psychs could manage anything else because 90% of what the rest of us treat as damage control could be avoided and we'd be out of jobs.

Seriously, the medicine floor would be empty. There goes my ESLD'ers (booze and hep C from needles), COPD'ers (smoking), CHF'ers (lifestyle factors in cardiac risk) ESRD'ers (obsesity more or less leading to poorly managed DM and HTN) strokes, MIs, IVDU, the list goes on and on. Some of that stuff would still happen and be admitted, but I would get a lot more LOL (little old ladies or little old people) s/p hip fracture, obtained because they were healthy otherwise and living independently, PNA admits because when you get old enough something's gotta do it and you were watching a lot of Judge Judy in your chair, hopefully dying at home from a stroke in their sleep at 95 and never making it to the floor.

My favorites are the little old people in their 90s that just shrivel up and go from something simple in the span of a week.

 

[filhodeinferno]

Any Ideas?

Thanks

EM. Flame away.

 

[Apollyon]

Can I still read an EKG? No.

Can I still draw labs? Probably.

Can I evaluate/treat people who decapitate their parent or kill someone because they think they were replaced by a double? Yes.

Capgras syndrome? (That's off the top of my head - no pun intended. I'm not looking it up, 'cause that's cheating!)