Choosing the Right Specialty

Choosing the Right Specialty

Choosing the right specialty: a parable

Choosing the right specialty is a challenging task, but it’s a lot of fun.

Have you ever been to a NASCAR event?  It’s exhilarating!  It’s not nearly as exciting to see it on TV as it is to watch it live.  The roar of the engines is deafening.  100,000 screaming fans are on the edge of their seats watching for each car to make the next move to put them in the lead.  

You watch your car enter the pits and get a complete overhaul of their car with new tires, fuel, and water in 16 seconds.  But, you can’t believe they didn’t make it in under 15 seconds, because now they’re falling behind!  

After hundreds of laps of cars being separated by mere 100ths of a second, the checkered flag comes out and one driver is crowned the winner.  

In that moment, when they hoist the trophy over their head, how many times have you seen a driver suddenly look around and say, “What a surprise!  How did I get here?”  Of course not!  

No one wins the Daytona 500 by accident.  It takes months and years of careful study, training, and preparation.  It includes selecting the right car, the right pit crew, the right trainers, and the right equipment.  In order to make it to the top, you’ve got to be intentional.

Choosing the right specialty requires intentionality 

As an internal medicine resident, I had a lot of trouble choosing between general internal medicine and three subspecialties: gastroenterology, infectious diseases, and hematology/oncology.  

I arranged my second year of residency electives to give me exposure to each of these areas so I could have an opportunity to determine which was the best option for me.  After just a few weeks on my gastroenterology rotation, I knew I had found my passion.  

In fellowship, I had a similar experience during my second and third years.  I tried out rotations in advanced endoscopy, inflammatory bowel disease, hepatology, and gastrointestinal motility.  Though I enjoyed all of them, I didn’t love any one of them enough to do them exclusively, so I embraced my chosen career as a general gastroenterologist.  

My career is highly stimulating, fulfilling, and engaging.  I have not regretted my career choice even for a minute, despite my occasional frustrations with some of the hassles and administrative nonsense that plague all physicians.  

It’s extremely gratifying to have the opportunity to go to work early each morning and know that I don’t have to fake my excitement for the work I do.  

Choosing the right specialty – asking the right question

I feel blessed to have landed in a specialty that is a perfect fit for me, but I know also that it was in part due to my persistence in investigating lots of career options.  I encourage you to do the same.  

If you are still in training, scratch every career itch you get.  Take time to rotate in any area you are interested in.  While you’re there, try to get a realistic idea of what to expect from that specialty.  You’ll get a lot of honesty from people when you’re one-on-one, or in demanding situations like overnight call.  

Ask everyone you meet about their reasons for going into that area of medicine and what they wish they had known prior to starting their practice.  One really good way to get people to give you a true picture of reality is to ask them the best thing and the worst thing about their specialty.  

If you force people to answer a polarized question like that, you’ll get them to give you information they feel strongly about.  If you ask enough people those questions, you can paint a reasonably accurate picture of the area of medicine you’re investigating.  

Choosing the right specialty – 6 important factors to consider

As you start to think about which medical specialty would be best for you, here are a few things to consider.  Each one of these should factor into your thinking, though each item will weigh differently for each person.  

1. Do you enjoy the people in your subspecialty?

Each specialty attracts people with certain character traits.  Therefore, many if not most of the people in each specialty will share similar personality styles.  As a result, each specialty tends to develop a specific “personality.” 

Since many of the people in your specialty will have similar personalities, you need to consider whether you enjoy being around those people.  After all, you’ll be working alongside these people for decades.  If you don’t enjoy being around them, it’s like being in a bad marriage.  You’ll find that you don’t enjoy coming to work or talking to your colleagues and partners.  

One of the things that attracted me to gastroenterology is the fact that most gastroenterologists are just fun to be around.  As a group, they tend to be happy, friendly, and personable.  You’ll find exceptions to that generality, of course, but I’ve found it to be pretty true on balance.  

Make sure that you spend a lot of time interacting with members of your future specialty.  If you don’t genuinely enjoy spending time with them for a few weeks, you’ll hate spending your whole career with them.  

2. Do you enjoy reading about the clinical material in your chosen specialty?

The amount of medical knowledge is doubling every few years.  You are going to have to read constantly just to stay up to date on the developments in your field.  

If you don’t enjoy reading about the clinical material of your specialty, you won’t try to find time to read the latest journal articles on the diseases you treat.  Over time, you’ll fall behind and your clinical competence will wane.

A comical view of choosing the right specialty. (credit to B Veysman, BMJ 2005).
A comical view of choosing the right specialty. (credit to B Veysman, BMJ 2005).

3. Do you find the clinical material intellectually stimulating?  

If you are able to completely master your profession in less than a year, you probably need to find something else to do.  If there’s hardly anything new to learn over the course of your career, you’ll be bored out of your mind.  

GI offered me a huge range of clinical diseases to treat.  Hardly a week goes by that I don’t encounter some new clinical entity, or an unusual variation on the diseases I know well.  

I love that!  

It made fellowship incredibly frustrating, feeling like I was never quite “arriving” at the end of my training, but it’s also what keeps the specialty interesting to me so many years later.  

4. Is it important to you that procedures are a part of your specialty?

It frustrates me to no end when people refer to GI as a “procedural subspecialty” while some of the others like endocrinology are referred to as the “cognitive subspecialties.”  Having rotated through most of the medical specialties during residency, I can tell you that GI is also a HIGHLY cognitive subspecialty.

However, procedures are a big part of what we do too.  That was a big part of what attracted me to GI – the ability to offer immediate therapeutic interventions to suffering patients.  I also love having a mix of hands-on work in addition to talking with people in clinic.  

Maybe you think you want the opportunity to do procedures on a regular basis in practice, such as with anesthesiology, critical care, GI, or cardiology.  If so, spend some time shadowing folks in those specialties to learn whether that’s something you really want to do.

5. Love the 1% too!

What attracts us to our specialty is the 99% of the medicine that we love.  However, the mistake physicians often make is failing to account for the 1% of the specialty that is more difficult to enjoy.  

Every specialty has an aspect that is a potential turn-off for physicians.  In gastroenterology, the 1% is managing irritable bowel syndrome (IBS).  

IBS is one diagnosis that many gastroenterologists have a hard time enjoying.  In general, patients with IBS tend to have more severe symptoms which are hard to treat.  Because we don’t understand IBS as well as we would like to, our therapies are less effective than we wish.  

Many gastroenterologists struggle to find joy in treating IBS because of these frustrations, which leads to resentment of our patients.  

Every specialty has this “1%” problem.  For cardiology, it’s “atypical chest pain.” For OB/GYN and urology, it’s “interstitial cystitis.”  If you love 99% of the specialty you choose, but you can’t tolerate 1%, you’ll find that 1% will consume you.  

You’ll resent your patients, you’ll be unhappy at work, and you’ll tend to carry that resentment home to your family.  

A mentor advised me in medical school to identify the 1% in any specialty I considered.  He said to make sure it was something I could live with or I would end up hating my life.  So, I made a conscious choice in fellowship to find a way to enjoy treating IBS.  

Truthfully, I love my IBS patients.  I worked hard to make it intellectually interesting for myself to find enjoyable methods for educating patients about IBS.  I genuinely enjoy 100% of the patients I see now.  

Whatever specialty you choose, you need to find a way to love or at least tolerate the 1%, or you’ll end up 100% miserable.   

6. Financial compensation

I deliberately saved this one for last.  I strongly advise against picking any specialty just for the potential income.  However, if you have >$500,000 in student loans, financial compensation is an important consideration.  

That’s ok!  

You should definitely take that into consideration, but don’t let it be the only factor in making your decision.  

Final thoughts

The decision of which specialty to choose will define the majority of the remainder of your life.  It’s an incredibly weighty decision and deserves a lot of time and thought.  

Take time to rotate through any specialty that interests you and consider carefully whether it would be right for you.  If you can figure out that a specialty isn’t right for you after only a few weeks, you needed to be convinced.  

You need to love almost everything about your future specialty and also not hate anything.  Those aren’t the same thing.  If you don’t love almost everything, you’ll have no joy at work.  If you hate anything, that 1% will consume you.  

Choosing the right specialty isn’t easy, but I hope that you find the specialty you’re looking for.  I hope that your decision brings you as much joy as my specialty brings to me.  

Further Reading

Leave a comment below and tell us what factors you considered when choosing your specialty.

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