Family Medicine, Rad Onc, or OB? How to Choose a Specialty

- Written by Craig Noronha, MD, FACP

For many medical students, choosing a specialty is one of the most challenging aspects of medical school. Although many medical schools are expanding third-year exposure to different specialties to include more time in clinical rotations and a wider variety of experiences, it remains a relatively short amount of time and exposure from which to base a career choice. A few students enter medical school with the goal of becoming a vascular surgeon or rural primary care doctor, but many are swayed to another specialty by the myriad of clinical experiences and career advice they receive. Often medical students believe they have chosen a specialty only to change their mind in the next rotation.

NEJM Resident 360 recently hosted a rich discussion on choosing a specialty (Family Medicine, Rad Onc, or OB? How to Choose a Specialty). I wish there was an easy checklist or formula for making this choice, but the decision is driven by many individual factors and unique experiences. In this blog post, I review some tips offered in that discussion and add some other suggestions for choosing a specialty.

For many medical students, choosing a specialty is one of the most challenging aspects of medical school.

It’s never too early to begin thinking about your specialty career choice

Even though a specialty decision is not required until you submit your list into the National Resident Matching Program (NRMP) early in your fourth year, it’s never too early to begin thinking about your specialty career choice. Until then, take advantage of every opportunity to learn about different specialties. I recommend that you also make the most of the numerous clinical opportunities offered through your medical school (e.g., volunteering in a free student-run clinic or shadowing in the emergency room). Spend an afternoon with a primary care provider even if you see yourself going into a surgical field.

Use every opportunity to talk to attendings from different specialties

Working with physicians in a variety of settings during medical school provides you with a unique opportunity to learn about the different specialties. Also, seek advice from mentors (e.g., medical school deans and clinical attendings) to help you through the process of choosing a specialty. As you start to whittle down your choices, hopefully late in your third year or early in the fourth year, try to identify a few mentors that you can trust to give you unbiased viewpoints. Schedule a meeting with a program director or associate program director in a specialty of interest. Although residents and fellows can give you some insight into why they chose a specific specialty, their advice might be biased by limited experience or a particularly stressful rotation.

Factors to Consider When Choosing a Specialty

Clinical Experience

Clinical experience is the most influential factor in choosing a specialty. Every specialty involves a wide variety of job descriptions, depending on the practice setting, provider interest, and local clinical needs.

For example:

  • A surgeon is not only involved in surgical cases, but also sees patients in a surgical clinic, provides consults to patients in the hospital, and inserts central lines for nonsurgical patients admitted to the hospital.
  • A pediatrician working as a clinician-researcher in an urban medical center will most likely have a much different weekly schedule than a pediatrician working in a rural setting where the closest hospital is 40 miles away.

To add to the variety in careers, subspecialties in internal medicine such as gastroenterology can be even sub-subspecialized into fields such as hepatology or inflammatory bowel disease. That being said, each specialty encounters definite “flavors” of clinical cases.

During the third year of medical school, you will find yourself gravitating towards certain cases or never wanting to leave the hospital on certain rotations. Take the time to evaluate when and why you gravitate toward certain cases or rotations. Were the cases interesting, did you like the pace, or was the setting perfect for you? Identifying these factors will take you a long way towards identifying a career specialty. It is important for medical students to ask attending physicians what their work week looks like, what cases they see in a typical day, and what their job would like if they were in a different setting. Almost every field involves less-desired cases or nonclinical tasks that providers struggle with; these should not be major factors in specialty choice because avoiding them is impossible.

Take the time to evaluate when and why you gravitate to certain cases or rotations.

After residency and/or fellowship, most of your clinical care, possibly research, and learning will occur in the clinical area of your specialty. Unlike medical school, where you focus on one specialty for 4 to 8 weeks, most or all of your post-medical school training and career will be in that one specialty. Most of your colleagues, clinical care, conferences, and journals will be related to that specialty. Although factors such as work-life balance and salary are important, I cannot emphasize enough how important it is to truly enjoy the clinical work you will spend your life doing. Therefore, you should choose a specialty where you truly enjoy the clinical care. Several colleagues have said that if they could go back in time, they would choose a different career in medicine as they do not enjoy their current work. Although the prospect of choosing a “wrong” career can be daunting, you can be assured that each specialty in medicine offers a wide variety of career options. It is never too late to change practice locations or career focuses.

Although factors such as work-life balance and salary are important, I cannot emphasize enough how important it is to truly enjoy the clinical work you will spend your life doing.

Procedures

The number of procedures involved in each specialty varies. A specialty that requires lots of procedures is obviously important if you are a hands-on person. Some residencies (e.g., internal medicine) include career options with varied levels of procedures.

For example:

  • Internal medicine trained gastroenterologists might spend most of their week doing endoscopies while primary care physicians might only do intermittent procedures (e.g., joint injections).
  • Within a specialty such as cardiology, an interventional cardiologist spend most days doing procedures while a clinic-based cardiologist never does procedures.

Students should also consider where they like to complete procedures. Do you like working in the operating room with a team of nurses and technicians or as an endocrinologist doing ultrasound-guided biopsies in the clinic setting?

Career Goals

Some medical students will have set career goals (e.g., oncology researcher, global health, or family medicine doctor in a rural setting). If you are someone with a preference or predefined career goal, make sure that your specialty choice will give you the best opportunity to reach that goal. Even if your career goals are just beginning to formulate, consider how your specialty choice will lead you towards those career goals.

For example:

  • A student who wants to work with children and adults might be undecided about choosing between a family medicine residency and a combined medicine-pediatrics residency. If the student is not interested in obstetrics, they should consider a combined medicine-pediatrics residency.

Choosing a career that is rewarding and fulfilling is also very important. Although relatively nebulous concepts, they factor into your career goals.

For example:

  • Working as a general surgeon in an under-resourced setting might not garner as much attention as being a trauma surgeon in a big academic setting, but physicians working in under-served areas often have high levels of job satisfaction and fulfilment that far exceed their colleagues in other settings.

Work-Life Balance

Work-life balance is an increasingly important factor in career choice. Certain specialties (e.g., emergency medicine or hospitalist medicine) have set shifts that limit direct clinical duties. In contrast, specialties such as general surgery can require long work hours and less work-life balance, depending on the setting. More and more, physicians are deciding to work part time or on alternative schedules (e.g., work for 5 days on and then have 5 days off). Although some specialties do not lend themselves to these type of schedules, considering the options within each specialty is important. Also consider your long-term life goals.

For example:

  • Do you hope to be parent with 3 children with a job that offers the flexibility to attend kids sporting events?
  • Do you want to be able to travel abroad for several months per year?

Certain specialties and practice settings lend themselves to more job flexibility than others. Note that while the Accreditation Council for Graduate Medical Education (ACGME) limits all resident and fellowship training duty hours to a maximum of 80 per week, duty-hour regulations after training do not exist. Attending physicians in certain specialties (e.g., general surgery) can routinely work more than 80 hours per week, depending on the setting. But, if your work is rewarding and brings you joy, you might not think twice about an 80-hour work week. Each individual should consider factors such as expected weekly work hours and coverage for emergencies.

Salary

Between medical school and undergraduate tuition and associated costs, a medical student can graduate with large loan repayment obligations. Future salary potential is another factor to consider in your career choice. The field of medicine offers a wide range of salaries, depending on factors such as number of procedures, practice setting, and patient volume. Current physician salaries and job availability are partially based on supply and demand that can change drastically in a short period of time. Technology advancements and increased numbers of advanced practitioners have already started to affect career opportunities in areas such as radiology and anesthesiology. What will happen to physician salaries is uncertain as more hospital systems move toward Accountable Care Organizations (ACO) with greater emphasis on cost control, including minimizing the use of unnecessary tests, procedures, and consultations. One thing that is certain — as a physician you will be relatively well compensated and have stronger job security than most adults in the United States.

Personality

At some point in your training, you will realize the strong association between personality types and career choice, with some obvious exceptions (e.g., internal medicine). However, in general, certain personality types gravitate to certain specialties. As you rotate through your clinical rotations, take the time to see if you match well with the resident and attending personalities around you. The personalities you are exposed to in these settings will often correlate with the personalities in other settings.

As you rotate through your clinical rotations, take the time to see if you match well with the resident and attending personalities around you.

In closing, choosing a specific specialty in medicine can seem daunting. Your medical school training provides you an once-in-a-lifetime opportunity to work with providers and in specialties across the entire spectrum of medicine. Make the most of these opportunities to help you decide on a career. Choosing a specialty is usually not an easy stepwise decision. Each student should consider all the personal and specialty specific factors that go into making this choice. Taking the time to define your career and life goals will take you a long way towards helping you choose a specialty. Good Luck!

Dr. Noronha Dr. Noronha is currently an associate program director for the Internal Medicine Residency at Boston University School of Medicine. He has served on Association for Program Directors in Internal Medicine E-Learning and Communication Committees. Dr. Noronha is the Director for Quality Improvement Education at Boston Medical Center.