Choosing the Right Medical Residency Specialty

August 14, 2012
The Residency Program Director 1

Residency BlogWhat specialty are you going into?

The day-to-day routine of your career will be shaped by this decision.  The age and gender of your patients, whether you will do procedures, and the income you can expect, are all tied to this decision.

Many students feel that the time during medical school with patients is not long enough to figure out which specialty is the best for them.  This may explain why as many as 10% of first year residents change specialty some years.

In the recent past, procedure-based specialties like Gastroenterology and Otolaryngology paid better than specialties with fewer procedures like Rheumatology and Pediatrics.  This payment pattern may be changing in the next few years.  No one can say how care will be reorganized under the Accountable Care Act.  Medicare has already reduced reimbursement for procedures in several fields like Radiology and Cardiology.

Specialty choice influences your application process dramatically.   If you choose a specialty that is oversubscribed and very competitive you may have to apply to 35 programs and then fly all over the US to go to the 5 or 6 interviews you are offered.

If you apply to a specialty that is not as competitive you may have to send out only 20 applications and then get 14 interviews.  You may decide to interview at only 10 of these programs.

You may need to apply to more than one specialty so that you can guarantee that you have a job next July.

The complexity of the process is daunting.  Some schools have excellent advisor systems where you can get real time advice often about your application process based on your needs.   Some schools do not have a well-defined process.   Some schools have their own agenda.  They want their grads to go into the most competitive fields that they can.   They may want to help you get into the most prestigious program.   Their idea of success may not involve your day to day happiness.   When I was getting advice in med school from different faculty – some were disappointed that I was going to apply to Family Medicine residencies.  They told me how my academic record could get me into prestigious residencies in competitive specialties.   They were not that concerned with what I wanted to do with my career.

The reputation of what each specialty does may be very clear however, this may not represent all the things that the current docs do in that specialty.   For example, just in the last 10 years most ENT surgeons near here do their cases at free standing surgical centers.  They do not need to be at a medical center for their surgeries or their pre op or post op care.   They may not do hospital consults with ease anymore as a result.   Some may get to a day when they do not want hospital privileges.

Internal Medicine docs are part of the great tradition of community generalist physicians in the US.  They live and work in the community and they see their patients in the office and in the hospital.   They establish long term relationships with the families they care for.   In the last 10 years the majority of IM residency grads do not become generalists.   About half of them go into fellowships and further specialize in cardiology, GI, intensive care medicine, etc.  The need for hospitalists is growing so another batch of IM grads are working as hospital coverage docs or in practices where they work only in the hospital.

Family Medicine is very familiar to me and yet it too is different year to year and state to state.  In some US states many FM docs work for multispecialty groups owned by physicians or hospital networks.  FM has taken advantage of the hospitalist movement and has been influenced by it.  A few FM grads per year will take jobs in hospital-only medicine.   More significant, however, is that FM docs are giving up their hospital work as well.   Many see their patients in the office and other docs do the hospital care for them.

Maybe you fell in love with one kind of doctoring when you were 10 years old and you can think of nothing else.  But for most it is a process of going back and forth seeing the merits and drawbacks of different jobs over and over.

As you start to break down the decision of “What do I want to be for the rest of my career?” you will see these issues come up:  What do the front line docs away from med school hospitals really do in the specialty I think I like?  What number of applications is safe for my specialty?  What do I say on interviews if I need to apply to a backup specialty?  What if I have questions that my advisor cannot help me with?

You may have a group of people to use as a resource for this process. Classmates, former grads and family members may all have helpful ideas about your specialty choice.  You may learn relevant information about a specialty on your rotations from your preceptors and their colleagues.  You just have to make sure they are aware of the issues that affect the younger physicians in their specialty.  The process is manageable if you get good advice.

Do not panic.   You will make a good decision in the end.

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