Medicine From The Trenches

Experiences from medical school, residency and beyond.

Matching and Choosing a Specialty

This is likely to be a multi-part posting but I thought that I needed to start to address this topic at some point. Speciality choice can be quite difficult for many medical students because some schools never quite spend much time on how to choose a speciality. This choice can be a source of life-long misery or it can become like a marriage with deep and passionate love in the early years only to be replaced with a wonderful familiarity that is both surprising and satisfying at the same time.

The wrong way to choose a speciality is based on what you will believe will be potential income. While it’s generally true that surgical specialties are better paying than primary care specialities, this is not always the case especially if you find that you just don’t enjoy surgery and surgical procedures after a while. Anesthesia has become very popular in the sense that people feel that this speciality pays well and had less hours than surgery but a description of Anesthesia as “hours of boredom punctuated with seconds of sheer terror” can be pretty accurate at times. Many people find that this aspect of anesthesia far outweighs any monetary rewards.

Another wrong way to choose a specialty is by how wonderful your medical school experience was in that particular rotation. While you may have loved your residents and interns, you may have not loved the patients that you were treating. This can make for a miserable residency experience and an even more miserable practice experience.

As you rotate through your required third-year clerkships, you may want to pay close attention to the types of patient that each speciality treats. Do you enjoy a long-term relationship with your patient and handling of chronic problems? If this is the case, then family medicine and internal medicine may be of interest to you. Do you enjoy treating only female patients? This brings to mind OB-Gyn but you may find yourself drawn to internal medicine with a track in women’s health.

Do you enjoy procedures? You may want to investigate the procedure-heavy specialties such as anesthesia, radiology, orthopedic surgery, ophthalmology and invasive cardiology. You might also place any of the surgical specialties in this category. Finally, do you enjoy the outpatient treatment of patients? This might lead you to emergency medicine as EM spend most of their practice time dealing with outpatient issues with a bit of trauma thrown in. Dermatology is also a specialty that has far more outpatient care than inpatient care. Psychiatry can also go into that category.

Pathology tends to appeal to individuals who love to study tissues and medical problems. Pathologists do not treat inpatients and pathologists perform few procedures other than those pathologists who subspecialize in tissue banking and transfusion medicine. If study and evaluation of tissues and medical problems are appealing to you, look into pathology.

Another way NOT to choose a speciality is by what your classmates have to say about a particular specialty. Don’t be drawn into the “the smartest people in medical school go into derm so derm is the best specialty”. This might not be the case for you if you don’t enjoy the scope of practice of the dermatologist. While dermatology is a competitive specialty, you may not enjoy much about this speciality other than the look on your classmates faces when you announce that you want to pursue Derm.

The telly shows such as “House”, “ER” and “Scrubs” have also tended to glamorize certain specialties. Do keep in mind that telly watching is for entertainment purposes. There is little reality to any of these shows no matter how compelling the characters and patient situations. These shows are written by people who are generally not in medicine with input for practitioners. These shows are written with entertainment factor built into them. Most of actual medical practice is not entertaining.

As you study through medical school years one and two, you are creating the foundation upon which you will enter your third year. It is during that third year that you will be exposed to different specialties and their patients. It’s good to keep an open mind during third year. Do not feel pressured to decide upon anything if you don’t have an idea of what type of specialty might be of interest.

I can tell you from experience, that I generally liked every rotation that I encountered during third year. Basically, I enjoy the practice of medicine and patient interaction. I saw plenty of very interesting pathology and patients on OB-Gyn but I didn’t particularly find this specialty appealing other than how I could learn to differentiate pelvic problems from abdominal problems in the course of seeing patients.

I loved my Psychiatry rotation and found the expertise of my preceptor far greater than any clinician that I have dealt with to date. I developed a very strong appreciation and high degree of respect for that multitude of psychiatrists out there that just do a good job taking care of their patients. While psychiatry was not for me, it was an awesome rotation that brought a depth of understanding as to how many medical and surgical problems might present with psychiatric symptoms.

As you go through first and second year, take the time to join one of two specialty exploration/interest groups at your medical school. By joining these groups, you ca expose yourself to residents and attendings that can assist with your exploration of their specialty. It is participation in these types of specialty interest groups that can allow you to keep your focus when you feel that you just can’t look at another histology slide or review another article for biochemistry.

Also keep in mind that certain specialties do require a high level of academic achievement in medical school. I have often spoken to medical students who have struggled with a course or two in medical school who feel like doors have closed for them because they won’t be competitive for a dermatology residency. My first inclination when I speak to theses folks is to find out if they actually understand the scope and practice of dermatology. If they do have this understanding, are there other less-competitive specialties that will satisfy many of their need? In the vast majority of cases, the answer is yes.

Finally, as a close to this little essay which is like a part one of this issue, if you know that you are not particularly competitive for a speciality that you feel you can’t live without, spend some quality time with the program director/department chairman of that specialty at your school. Try to figure out if you have some options that can increase your competitiveness for said specialty such as research. There might even be a possibility of finding a program or two in that specialty that might be in a less desirable location and therefor less competitive.

Don’t listen to anyone except yourself when it comes to your needs in terms of the practice of medicine. In the end, it doesn’t matter what you classmates say about the specialty that interests you. It’s how you feel about what you are interested in practicing and your suitability for said specialty. It’s also about your attentiveness to your academics/boards too.

If you had a slow first year, try to have a strong second year. If you had a weak second year, then try to have a very strong third year. In short, you can decide at any point, that you are going to upgrade your work ethic and performance.

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25 March, 2008 - Posted by | graduation, Match Day, medical specialty selection

23 Comments »

  1. Hi I am a US citizen that did med school abroad. As of now I’m finishing up my internship and started reading for USMLEs. The specialties that I am interested in are Derm, Gastro, and ENT. I heard these are competitive. I know what I am capable of meaning that I’m sure I won’t be scoring so well. Is there still a chance for me to get into these specialties? I’m definitely not interested in IM, peads, and obgyn.

    Comment by anitha | 20 August, 2012 | Reply

    • To Anitha:
      You need to do some serious research in terms of the requirements of each of your specialties of interest. First, you need to look at the preparation for each of these specialties. You might want to look at the USMLE score averages + the academics of people who are likely to match into Dermatology or ENT. Gastroenterology is a sub-specialty of Internal Medicine (IM) thus you would definitely NEED to have an “interest” in Internal Medicine in order to have an “interest” in one of IMs sub specialties. The other major task is that Gastroenterology is one of the more competitive sub specialties of IM which means that you need to match into a very strong (read University-based) IM program in order to have a shot at getting into GI as a sub-specialty.

      Do also look at the situation that as a US citizen who is not an AMG (American Medical Graduate), you are likely to be held to higher requirements in terms of USMLE and grades than an AMG for most specialty programs. This means that you can’t take an attitude of “I know what I am capable of meaning that I’m sure I won’t be scoring so well” in terms of preparation for USMLE. If you do not score well on USMLE, you are likely going to be close to most specialty options even Family Medicine and pediatrics (generally considered less competitive). American medical schools have increased their graduation numbers but graduate medical programs numbers have not increased meaning that you will be looking at scrambling for fewer slots against people who have a decided advantage (AMGs and IMGs who have very high USMLE scores).

      My suggestions: 1. Research specialties and KNOW what you need to have in terms of USMLE and academics. 2. Prepare for and score as high as possible on USMLE without exception (no failures). 3. Research residency programs in specialties that you are competitive for based on your USMLE scores (Step I, Step II CK & CS) in terms of you being an FMG/IMG (some programs do not take FMG/IMG). Good luck.

      Comment by drnjbmd | 20 August, 2012 | Reply

  2. Hi drnjbmd,
    Good writing, informative and easy to understand.
    I am a foreign medical graduate post residency in Radiation Oncology, living here for past six years.
    I came to USA after marriage, for a year, but we ended up staying here for so long, and now are in the process of acquiring a green card.
    Meanwhile, I did not have a work permit to work in US, and also had my son to look after.
    I have passed Step 1 (80) in 2005, Step 2 CS(pass) in 2006 and Step 2 CK (80 after multiple attempts) 2011.
    Will be taking Step 3 in August.
    I do have a work permit now, so will not require a visa for residency.
    I will be participating in the match this year.
    The big question is, where do I start.
    As much passion as I have for Radiation Oncology, I do see clearly, where I stand, with my “un-stellar” scores, and attempts, and being “out of business” for about six years. I do crave to get back on the same track that I left, but figuratively, the track probably went too far out of reach.
    From here, where do I start? I am nearly 37 years old, and do NOT have the vigor of a 25 year old kid… and do have my son to look after.
    As regards the geographical region, my family has no restrictions, as long as we are in a somewhat family friendly area.

    Comment by Sharp Beam | 22 June, 2011 | Reply

    • To Sharp Beam:
      Since Radiation Oncology (RadOnc) is a very competitive specialty, I think you know that multiple failures on any of the USMLE steps will put you at significant disadvantage in this country. RadOnc is a very competitive match for a US grad with excellent USMLE scores thus, being an IMG with failures doesn’t help your cause. I would also remind you that many less competitive specialties such as Family Medicine, Pediatrics and Psychiatry have limits to how many years between medical school graduation and residency entry thus you need to do some research in terms of selecting programs to apply to as six years out from medical school might post another problem for you to enter specialty or additional training.

      Now what type of strategy could you adopt to get into residency in this country? You could call some of the Rad Onc program directors and explain your situation in terms of your past training and present needs. Sometimes, program directors are looking for applicants who have prior experience and will overlook your USMLE woes. The important issue is to do your homework, program research and make some phone calls. Another thing that you definitely want to avoid is any mention of your age or lack of “vigor” and childcare issues. These are not relevent to residency application and do not need to be discussed under any circumstances. In this country, you figure out your childcare needs and solve them outside of any residency programs period. Your age isn’t a factor unless you make it a factor by telling a program director that you are not able to keep up with the “25-year-old”. In residency, you have to pull your weight regardless of age or in spite of your age.

      You should also get an unrestricted license to practice medicine in any state that you can as soon as you can. do be aware that many states will require taking and passing Step 3 within 7years of taking Step1 or you have to start the process again (no those Step 2 CK failures are not wiped out). You have a year or two but be aware of this rule in certain states and make sure you get your license as soon as you can. If you intend to practice anything in this country, you need to make sure that you get that unrestricted license as soon as you can. Good luck

      Comment by drnjbmd | 23 June, 2011 | Reply

      • Thanks a million for your quick and crisp reply. It is a great talent to be a good critique. I chanced upon your website while browsing some unrelated topics, and am taking with me some very useful direction.
        God bless you.

        Comment by Sharp Beam | 23 June, 2011

  3. Am almost through with med school here in my country, and am hoping to come over to the US for a pathology residency, i just want to know, how difficult is it to get a work visa after the residency program?

    Comment by Gerald | 27 March, 2011 | Reply

    • To Gerald:
      You may need to contact an immigration attorney in this country to find out about work visas. You should also contact residency programs to see if they will sponser you for a visa or if they require that you have a visa before you apply. Many programs do not sponser thus you need to avoid them if you don’t have the proper visa before you apply. Good luck.

      Comment by drnjbmd | 27 March, 2011 | Reply

  4. Dear Dr.,
    I just completed the match and was most disturbed to discover I had matched into a categorical position in a specialty which, at one point I could tolerate reasonably, I can no longer stand and depresses me greatly. I had tried to match into radiology, but my board scores are not stellar, and I am an FMG. I am no longer sure how to proceed. Should I go through with this residency, even though I am quite certain I will not practice it, in the hope that at the end of the residency, I will become more favorable to Rads? Should I just do the first year, as per NRMP guidelines, and then request to leave the program, and do a lot of research to try and get rads? Should I just give up on Rads altogether? Is there something similar to rads that I might be able to do instead? I just feel so hopeless, and so trapped… any advice would be appreciated

    Thank you
    J

    Comment by J | 18 March, 2011 | Reply

    • To J:
      Keep in mind that you have seven years of residency funding. If you go through a complete residency in something that you KNOW you won’t do, you will have used up a good portion of your funding and won’t be able to go into another residency. A better choice for you would have been to do a preliminary year in med or surgery (prelim years don’t count) and then re-enter the match. The other thing to keep in mind is that most residency programs will not take a person into a first year slot that is more than two years out from medical school graduation thus again, you don’t want to complete three or four years of a residency. If you had matched into a good prelim program and done a stellar job both academically and clinically, you might have made yourself more competitive for radiology. As it stands now, you are not likely to become more competitive by dropping out of a categorical residency slot (kind of “craps” on your fellow residents and doesn’t make you a “star” with the program director who could open some doors for you) and you have burned up a year of funding. My advice to you would be to figure out a way to love what you matched into or see if you can find a way to get into a prelim (or research) slot somewhere(likely not going to be easy since the best places are long gone). Informing your program director that you don’t want to be in that program is going to be very, very problematic. Do not underestimate how much “grief” an angry program director (PD) can inflict upon you and your career. It would be ideal if you could go to your PD, explain your situation and have everything be wonderful but that’s a rare care these days. I can also tell you that finishing a residency isn’t likely going to make you competitive for radiology if you were not competitive in the first place even with research. You are in a very tough position. In any event, I would advise you to speak with a radiology residency program director at another institution (under strict confidence and not at your institution because PDs chat) and ask about a course of action for you to get into radiology. Good luck.

      Comment by drnjbmd | 18 March, 2011 | Reply

  5. Dear Dr,

    I am IMG, 43 yo, when I arrived at US, 4 years ago, I did not speak English, and I have been learning slowly and well. I took the step 1 and I failed by 1 point. I am working currently in Research in Education with Seniors, something that I really enjoy. Since Medical school I am good using my hands, and I have been practicing medicine for 15 years, thus coming back to night shifts and residency it will be a real burden for me. But I miss the small surgical procedures with patients, and my type of personality also like to see favorable results as soon as possible. Now, I am studying again to take the step 1, just I wonder if my journey is leading me to a surgical specialty, also I realize that for a IMG that’s really tough and competitive. All I want is to give a well use to my hands and gifts, because at the end what I enjoy the most is teaching and education is really a field where I want to do. It is my deep passion. I sincerely will appreciate your comments and feedback.
    By the way your blog is a great idea and I learned from others Doctors experiences,
    Thank you for this chance to share my insights and issues.

    Comment by Miguel | 5 February, 2011 | Reply

    • To Miguel:
      Congratulations on your work and continuing to move forward. Do keep in mind that many residency programs will want you to have graduated from medical school no more than 5 years ago. You should also look into doing an observership where you can get some strong clinical experience (and letters too) since you have been doing something that isn’t clinical. Be sure to get all of your USMLE Steps done before you apply for residency (that gives you a stronger position in terms of application). You also need to look into licensure and requirements for someone who has not been practicing clinical medicine. In any event, good luck with your studies. Remember that 43 is the new 23 so don’t sell yourself short!

      Comment by drnjbmd | 6 February, 2011 | Reply

  6. Hello Dr,
    I completed med shool, due to personal health issues, and being a single father I did poorly in yr1, repeated yr 2, did well in 3rd yr, ubt my school removed me from rotations since I could not afford to take my boards by dead line, and I did great. During my fourth yr the same happened, my father died on the day I took second boards, failed by one point, took time off for family death, retook boards and did well, and of course graduated off cycle. I had an IM offer, which now was resinded, and the DME asked I do a TY and comback next year. Should I just do this, wich iwll create more problems (I’m a single father and would need to move at lezset 3 hrs away) or keep plugging through other programs. I have offers for FP, but I enjoy the depth of knowledge and hospital setting of IM.

    Thanks,
    Stephen

    Comment by stephen | 27 November, 2010 | Reply

    • To Stephen:
      If you don’t enjoy FM then don’t attempt to do a residency in FM (as a back-up). If you can manage to do the Transitional Year (these can be tough to get into) and do a great job clinically, you could go into the match and put yourself into a good position to match into IM. You might also look into getting into a Preliminary Year (IM); doing a stellar job especially on the in-training exam (takes monumental study while you are working) and then going back into the match for a categorical slot. If you have a Transitional Year offer, that would be great but if not, apply to some Prelim programs at strong places so that you get a chance to shine clinically for IM program directors. Good luck!

      Comment by drnjbmd | 29 November, 2010 | Reply

  7. Hi Dr!
    thanks for the write-up. it’s great.
    i’m in my third and had quite a ‘strong’ year.
    i’m really stressed p about choosing speciality as i can’t seem to make up my mind.
    initially i thought about rad onco, then i’m looking at OBGY recently, and ENT seems very interesting as well, but very competitive for sure. i know we’re suppose to go according to our interest, but i can’t seem to make up my mind. i actually like patient-contact & procedures.
    i would like something with good hours and decent pay.
    is there any speciality you have in mind?
    would you offer me some suggestions please?
    thank you!!

    Comment by Caz | 27 September, 2010 | Reply

    • To Caz,
      Everything goes in cycles. What looks like a well-paying specialty one year may drop in another year. With this being said, choose what you like and do it well. Even a “lifestyle” specialty can become drudgery if you hate getting up to go to work. Once you are done with residency, you can choose your own lifestyle.

      Comment by drnjbmd | 4 October, 2010 | Reply

  8. Dear Doc,
    I am really having a hard time understanding the material that we are studing in my second year.
    specially that I study the material in English ( which is not my first language)
    so i was wondering if you can guide me to easy methods for a better understanding.
    like vedios and where to get them ( i am a visual learner).
    any websites that are good and easy.
    thanks in advance

    Comment by janna | 25 August, 2009 | Reply

  9. um ok doc,? i am still a teen 16 of age, but the field of neurosurgeon really inspires me and base on the videos from youtube about getting a tumor out of a brain and such a like, i really enjoyed it! how much more if i am the one who is operating on a brain?!! um my point is i really wanted a specialty such as this one but my friends discouraged me that it would take me a lot of years for me to graduate into a neuro although my parents are of full support but i really don’t know what to do. should i continue into neurosurgery or should i choose another specialty? my friends already chose onco, cardio, and opto while me a neuro, what would you suggest?

    Comment by donn | 16 June, 2009 | Reply

    • To Donn:
      When you get thorough third year of medical school and you still love neurosurgery, then do it.

      Comment by drnjbmd | 22 June, 2009 | Reply

  10. To 911:
    You have plenty of options other than Family Medicine if you find that Family Medicine is not what you wish to do. First of all, you can have a very strong third year which will greatly increase your competitiveness in terms of residency application. Second, you can really make the most of your repeated second year and ace your board exams which will make you more competitive for residency application.

    While you might have great difficulty matching into Derm, Optho, Anesthesia,Rads or the surgical specialties, there are specialties such as Peds, Psychiatry, and Medicine that will be possibilities if you do well with your repeated year, have a strong third year and keep moving forward.

    Medical school is far different from undergraduate school in that once you complete the program, you are on pretty even footing with the rest of your class. When it come down to specialty selection, rely heavily on the advice of faculty at your school in terms of great programs to apply to. Medical school is not about what you are “limited to” but what you can accomplish from here.

    No matter what has happened to you in the past, learn from it and keep moving forward. You have plenty of options as long as learn from your previous challenges and grow into the physician that you want to be.

    People who wind up not matching generally ignore good advice given to them by faculty or grossly overestimate their competitiveness for a particular specialty. Just make sure that you look at yourself realistically and you should be fine.

    Comment by drnjbmd | 18 May, 2008 | Reply

  11. Hi,
    I’m in a PBL curriculum and will now be repeating my second year of med school, I also failed one course during first year. Basically I already have two red flags against me. While I am only a second year student I am concerned about getting accepted into a decent residency program. I realize that I will probably only have a shot at FP. I know I will have to do well on the boards and on my rotations and shelf exams. I was having a difficult time learning in PBL. Now I have purchased live audio and video lectures that I have been using to help me tie topics together. I’m afraid that I will not match into a residency program. I have heard of students completing med school and not matching or matching but into a poor program and then having their career end because they did not finish. It seems that if you are struggling when you begin medical school it will most likely lead to a never ending struggle. I am trying my best to find resources that will help me fill in the gaps. I just don’t know if I’ve created a gap that I will inevitably fall through.

    Comment by 911 | 18 May, 2008 | Reply

  12. To TC:
    If you want to enter a particular specialty, you should be able to site down and write several statements that indicate why a particular specialty is of interest to you. After you get your declarative statement written, make bulleted points under them as to why those statements are true. For example:

    I enjoy Internal Medicine because of the variety of patients that I will be able to treat.
    – I can treat patients with heart disease.
    – I can treat and manage problems in the elderly.
    – I can treat and manage adults with congenital diseases.
    – I enjoy management of multiple problems at the same time.
    – I enjoy having a long term relationship with my patients.

    If you are able to do the above exercise, you can take each one of your bulleted points and flesh them out into a personal statement.

    When you are done, have many people edit your statement especially those who are in the specialty that you seek. You want to be sure that your Personal Statement is well-written and accurate about the specialty.

    You can do the same for letters of recommendation. Why would you recommend yourself to anyone for anything? Write down some of you good qualities and back them up with evidence.

    Comment by drnjbmd | 3 May, 2008 | Reply

  13. Dear Dr, I was wondering if you could help me with guidelines in writing a personal statement & letters of recommendation. Im an IMG & the college requires us to provide with our own format. Im not too sure as to what would make a good format. could you pls give me some guidelines into writing one. thanks.

    Comment by T.C | 1 May, 2008 | Reply

  14. I really appreciate the wisdom that you are willing to share on this blog. As a soon-to-be PA, I should be so lucky to work under someone such as yourself.

    Comment by Dan | 4 April, 2008 | Reply


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