Specialty selection struggles

I am feeling very stressed about having to pick a specialty. I thought I would come into third year and I would fall in love with a particular specialty, that it would hit me over the head- “This is it!” However, I have managed to find things that I love and really like in several specialties.
I have it narrowed down to a few and maybe even a realistic couple. I am not usually one to have such a hard time making a commitment, but I feel like this is so final, though I know it really is not.
Making the choice between medicine and surgery was easy- for me it was medicine as it had more of the physician patient relationship I feel I am looking for and I found surgeries tedious (no offense Natalie). Within the broad spectrum of “medicine,” I have considered neurology and medicine the most. I have also entertained PM&R (physical medicine and rehab), combined med-psych, combined med-neuro, and preventive medicine.
I say neurology and medicine “the most” because the Air Force only has slots in neurology, internal medicine, and possibly a couple in preventive medicine (this years allotment list comes out in June). A few months ago, the Air Force was reviewing my medical status (I have asthma) and has subsequently given me a waiver. During that time I started considering other options I would have, such as combined residencies, out in the civilian world. Anyway, I am back to where I was before all of that started. And I am glad to say that I am very happy about being able to continue my military career.
Anyway, back to my specialty dilemma. I came into third year thinking I would like neurology and medicine and I loved my neurology rotation back in November. I felt like I was with people just like me- nerdy, hard-working, trustworthy people. I loved the material and patients also. Ever since first year I have found the neuroscience material fascinating. I love the fact that the physical exam plays such a large part in your diagnostic armamentarium. I also love how it ties in medicine, neuroscience, radiology, and pathology. However, I fear that I will only be limited to a narrow scope of clinical practice and my ability to branch out and have a larger impact may be limited. Also, I am not much interested in research and neuro tends to have leaning towards research (though I think my view may be tainted by the fact that I am at a large tertiary care center). I really like the patient base- they were genuinely nice people who had bad things happen to them. I also loved watching my stroke patients (that was most of our inpatient population) improve daily. There was great satisfaction that I had a small role in helping guide their recovery to a better quality of life. And for those patients whose stroke was terminal, working with the families in making end-of-life decisions was a privelege. I would provide more details but I made the huge error of not putting down my thoughts when I did the rotation, so I have forgotten many of them in the interim.
I am currently on internal medicine as my last rotation of the year. I loved my inpatient month last month and I enjoyed my family medicine outpatient month in December (my preceptor saw 95% adults). I love the way you logically work a patient up, though I am admittedly not very good at my oral presentations. I love the variety of patients I get to work with in medicine. In the inpatient population, it’s sometimes hard to see your patient improve over that short period, but you feel good about guiding their medical care through that crisis and coordinating their care with sub-specialists as well as their follow-up with primary care.
However, if I do go into internal medicine, it will be as a primary care physician and I want to incorporate psych and preventive medicine into my practice. I definitely feel that in primary care you can positively impact a patient’s outcome if you address any underlying psych issues (rather than just adjusting their antidepressant dose). Also, I believe that patient education can increase preventive health measures as well as patient compliance (yes, I am an idealist at heart), that we as physician’s can get to know our patients and subsequently tailor our approach to each individual patient and their learning style.
While I do like aspects of preventive medicine and psych, I don’t want to do them alone. In their own ways, I think that they would limit my scope of practice.
I have done the Careers in Medicine analysis- it came up with preventive medicine, with internal medicine second. I did the Pathways in Medicine, getting geriatric medicine as the main choice, with neurology close by and internal medicine slightly lower. I did the Medical Specialty Aptitude test again and it gave me occupational medicine, with neurology not far behind, and internal medicine slightly lower (but not way low) on the list. Two years ago when I did the Medical Specialty Aptitude test, it gave me aerospace medicine, which I would love to do but will almost certainly be disqualified from because of my asthma. So these tools have made me feel comfortable that I am in the right ballpark with my choices and now it is up to me to make the final choice.
So here I sit, trying to focus on studying for the medicine shelf exam, but completely overwhelmed by trying to make the decision about what specialty to go into. I am in the process of finalizing my two away rotations with the Air Force- neurology in August and general internal medicine in September. Part of why I feel so overwhelmed is that my Air Force residency application is due between September 15th and 30th. Also, we will meet with one of the deans this summer to work on our Dean’s letter and I feel like I am not in a position to do that because I cannot make decision on what to go into.

While I am not looking for anyone but me to be able to resolve this dilemma, I just needed to a place to vent. Like I said, I am feeling very overwhelmed right now. Anyway, now that I’ve said all of this, I am going to get back to trying to get a little bit of studying done. Thanks for listening.

Hey Tara,
I’m entertaining a similar differential.
My solution is a five-year plan. (Not just because of that, but also for several other reasons–but it’s a convenient out.) I’m guessing the Air Force wouldn’t beam down little rays of sunbeams on that plan, but you might consider how you might do it. (An MPH while you contemplate?)
Barring that, I would say that I console myself in similar ponderings (I’m right now between psych, neuro, medicine, med-psych, neuro-psych and… well, every now and then I throw trauma surgery in there, but not too often) by figuring that there is a lot of overlap between these contenders. Neuro isn’t all research-based–there’s lots of primary care-type neuro to be done in following folks with stroke, MS, seizure disorders, migraines, chronic pain, and so on. And I think there’s a great opportunity to combine the psych with the medicine. I have a great neuro preceptor who is very attuned to the psychiatric aspects of her patients, never fails to ask about domestic violence, and really emphasizes the neurology clinic as a place where psychiatry and medicine are very much a part of what she thinks about. You may want to consider getting some exposure beyond the tertiary care world of neuro. The only bummer is that most of the patients don’t get a whole lot better. On the other hand what with advances in stroke care, that is changing and there is an emergency aspect of neurology these days that is pretty cool.
Psych does feel limiting, and that’s what I also struggle with about it. You may want to consider looking at behavioral neurology fellowships as a way to combine the two. And/or psych with a behavioral neurology fellowship?
Speaking of which back to my biopsychosocial formulation.

Thanks for the thoughts. You’re right about the Air Force not being keen on my taking an extra year. It’s comforting to know that I am not the only person going through this right now though. So many of my peers at school seem so set (and have been for a while) on what they are going to do, that I have begun to think something is wrong with me
Thanks for the thoughts. You bring up some very valid points about how I can combine some of the areas I am interested in. I will definitely give them consideration as I continue down this decision making path.
Now back to derm (it’s part of our outpatient internal medicine month).

I’ll say another thing: I told one of my faculty advisors that I was frustrated to have actually expanded my differential beyond medicine to psych vs neuro vs medicine, and she said, “Oh, well, that’s pretty good, that’s all in the same territory, so it sounds like you’re pretty narrowed down.” !?! What she meant was that I’m not agonizing about derm vs radiology vs pediatric oncology or whatever. And I think the truth in her statement is that in both what you say and what I’ve been thinking about, there is a consistent sense of what we value–just a question about how to best embody those values and which of those values are the absolute most important. (I’m heading back away from psych this week because there aren’t enough lymphocytes, and I really love lymphocytes.) That is a lot different than trying to choose a specialty in order to find your values within it.
One peds guy said earlier this year,
"Choosing is really about three choices.
First, are you called to psychiatry? Not, do you want to do it, but are you called to it?
Second, surgery vs medicine?
Then, big people vs little people?
All the rest is details."
The first part of this has haunted me a bit this year because although I feel limited by psych I also sometimes feel called by it. And it’s the one thing that people keep spontaneously suggesting that I should consider. (I was insulted by this at the beginning of the year; I’m trying to better discern now when it’s an insult and when actually it’s really a compliment.) But, then another doc, a primary care internist, said to me,
"Everyone said I should go into psychiatry too. But I ended up doing this and I feel like I bring those skills to what I do here, and I’m glad that it worked out that way."

All of those specialties you mentioned – including neurology – all require internal medicine during the 1st (or internship year). Also, even if you go into a field like psych, your medicine year will not be in vain (you can get credit for this year). So, go ahead an do IM – it is a specialty that can lead to many other pathways.
By the way, there are combined programs in IM-Psych or FP-Psych or Neuro-Psych.
I did my intership year in IM, and it has always served as a good foundation for my residency in rads.
Good luck.

Hi Tara,

I wish I had some insight to offer, but since I’m a few years behind you in the process, of course I really don’t. But it is helpful and interesting to me to read your descriptions of what you’ve thought so far of your rotations. So, thanks for “venting”! And good luck as you get closer to making the decision.

Are you definitely going to do an Air Force residency? If so, does that narrow it down to the non-combined residencies? Are you pretty sure it’s neuro vs. medicine, or are you really considering the other ones, like psych or PM&R? Maybe just stating your answer to that question out loud will be of some help.

Edited part: oh wait, you answered my question about Air Force residencies in your post.

Thanks everyone for your advice and encouragement
Joe, well said. It’s amazing how we are going down similar paths. I thought for sure when I met you two years ago that you would surely have done some type of work with the HIV community. It’s amazing to see what originally drew us into medicine and how we have modified what we are drawn to as we gain more experiences.
As for psych, I am not called to it, but I do believe that to be truly effective with patients, you must deal with their psychosocial issues also. When I came into med school, I thought there were two fields I would never do (psych and peds) and I learned on my psych rotation that I truly enjoyed seeing my patients (I did a split substance abuse and psych consult liaison month) as well as enjoyed the diseases involved. And my time on other rotations has taught me how intertwined psycosocial issues are with medical issues.
And the medicine vs surgery decision was easy for me as well as was the big vs little people decision. Though I have to say that I did not dislike peds because I didn’t like the kids. Actually, the kids weren’t bad, but I just found that I got bored after six weeks with lots of URI’s, gastroenteritis and asthma.
Pushkin and Goodcat, being in the Air Force complicates matters a lot for me. First, let me back up. For the first two years of med school, I knew that I would have limited options by being in the military, such as no combined residencies and having a limited amount of positions in each specialty dependent upon the projected needs of the military. But I was willing to accept those constraints to re-enter the military as I discovered that I really did miss it (there was a time I never thought I would think that way). And going into third year, I was comfortable with knowing I was probably going to choose between neurology and internal medicine.
In January of this year, the Air Force informed me that they were going to medically evaluate me for my asthma, which I had put on my health forms since I initially applied for the scholarship. I guess since I was getting closer to the military match, they decided they needed to make a decision as whether to keep me by granting me a medical waiver or to medically separate me. I actually thought they were going to separate me (I guess I was preparing for the worst) and thus I started to look at civilian options for residency. That is when I started getting the ideas about doing a combined residency, either med-psych or med-neuro, as well as consider specialties that are not an option in the Air Force, such as PM&R. Options became open to me that I had not previously allowed myself to consider.
Last week, the Air Force came back with their decision and granted me the waiver. So I am back to where I was before all of this started. The only difference now is it is May. In setting up my Air Force sub-internships for this summer, I realized that the window in which I must make my final decision is closing and the military matches early. Our applications are due in mid-to-late September and our results come out in mid-December.
At the end of June, the list showing the number of positions and locations for each specialty will be released (a board meets each year to determine the estimated need in each specialty). I anticipate that it may not look too different from previous years, since the past three years have all been very similar.
As for neurology, you must match into it as a PGY-1 in the Air Force. There are only two slots per year. You automatically will be assigned an internal medicine intern year when you are selected for neurology. Also, both of those slots are for Air Force residency positions.
As for internal medicine, there are lots of slots, with about a 50/50 split of those being for Air Force residency and civilian residency slots. Concurrently, I am required to apply through the NRMP match because, say I were to apply in internal medicine, there is a 50% chance that I would get a deferment and do a civilian residency. I am thus required to already be going through the civilian match. If I match into a military residency, then I would just withdraw from the civilian NRMP match.
Now say I apply for neurology and don’t get it. Then the Air Force would place me in a transitional year slot for intern year. Then I would reapply in a PGY-2 slot the following year. There are a good amount of specialties with PGY-2 slots, including internal medicine (but not neurology).
Oh, and to complicate matters even further, the Air Force gives us the option of applying for multiple specialties at the same time for just this situation. However, my fear is that if neurology is really what I want to do (hypothetically speaking), then I don’t want to list internal medicine on my match list because they may think I am not really dedicated to doing neurology.
So there is my dilemma with the Air Force. If I want to try for neurology, then I have to do it this year.
There is a piece of me that thinks, apply for neurology this year and if I don’t get it, do a transitional year, and apply for internal medicine next year as a PGY-2. But I don’t want to apply to neurology if that’s not what the best fit is for me. Moreover, I don’t have as much flexibility as people in the civilian world do to change specialties mid-course, such as the radiology resident I met who had left orthopedic surgery.
I’m sorry this post got so long, but explaining some of the Air Force issues may help explain why I am feeling very stressed about this decision. Again, thanks to everyone for their support. It means a lot knowing I have someplace to vent my thoughts with people who a traveling this journey too, no matter where they are in that journey.
Thanks again,

Hey Tara,
I think Joe kind of hit a good idea for you. You might really enjoy Neurology with a Chronic Pain fellowship. You have long-term relationships with your patients and you really get short-term feedback in terms of seeing the immediate results of your efforts. In today’s climate, Chronic pain is a hot fellowship no matter if you do if from the base of PM & R (plenty of money and relaxation )Anesthesia or Neurology. The patients are quite interesting and some have been undertreated for years with complex histories to iron out. The neuro exam is pretty interesting especially after you have spent the night sawing on someones skull. I did a Neurology elective because I wanted to be good at this exam.
Also very high demand for Neurology/Chronic Pain on the civilian side if you every want to come out of the Air Force Blue.

I’ve always wondered what this means–how does it work?

Transitional year: a general internship which then allows you to go into any one of several specialties. There are a bunch of transitional interns at the hospital where I am this year: they are general internal medicine interns, doing intern stuff, but then will go on to radiology, opthamology, etc.–in this case, at different hospitals. (I think there are surgical equivalents of this too, general surgical internships after which people enter a specific program–nat or mpp would know more about this than I do.) Neurology programs can either be entered at PGY2 from a transitional year internship or via an already arranged internship that is affiliated with that neuro program. In the civilian world, the need to set up transitional year programs is the basis for the San Francisco Match–an early match process for a few specialties, including neurology and neurosurgery, which in theory is a match to PGY2 programs that happens before you have to match to the transitional programs via the regular match. In reality I think more and more of the San Francisco Match programs also have PGY1 programs as part of an integrated package–am I wrong about this? http://www.sfmatch.org/

Hence Tara’s dilemma(s).

So, Tara, I still think I’ll be involved in HIV in some way, but I’ve expanded the set of ways I might do that. If it’s neuro or psych it would be in a more particular kind of way. But it’s also true that I’ve opened up my list of possibilities a lot more… I said when I started this that if medical school didn’t change me I’d be disappointed, and… I’m not disappointed!

It sounds to me like you are really leaning towards neuro in your last message. I think you should go for it. As far as the strategy of whether to list internal med and neuro residencies both, I think this is where good and specific advising will come in handy… Could the Air Force put you in touch with those neuro residents who are also doing it through the Air Force? I would bet they could be really helpful and probably interested in being helpful, especially about this kind of strategic thinking. Neurologists are interested in making there be more neurologists… and I’ve found them to be enthusiastic about the prospect of people entering the field in a way that not all fields are.


Tara and Joe,
It’s kind of comforting to know I’m not the only one going through this dilemna! I started third year pretty certain that I wanted to do EM, but then absolutely loved my IM rotation. Two very different types of medicine, but there are aspects of each I really like. I’ve considered a combined residency, but I need to be realistic about the fact there are very limited, very competitive slots. While my performance in med school has been solid, I certainly don’t want to pin my hopes on one of those slots. And then, just when I thought I had it narrowed down to those two, I find I really enjoyed Peds as well. I hadn’t even realized there was a neuro-med option, another area I think I would enjoy, though I haven’t had the opportunity to do a neuro rotation yet. I’m currently finishing a rural FP rotation. It’s fun, but it has made the point to me that I don’t really want a practice that is primarily ambulatory. I am interested in hospital medicine more than out patient, and I have no interest in surgery, but beyond that I’m still undecided. While my situation is not as complex as Tara’s, I need to make decisions about electives, because I am at a hospital that is several hours from any other large hospitals and I need to make travel and housing plans for these. So this isn’t exactly a low stress period!
Like Tara, I guess I just wanted to vent (of course in any body has any input I’m listening!)
Good luck to you guys in your decision making process. I think it will be interesting to see where we all end up.
MS- Hmmm, am I a fourth year yet?

I too came into med school thinking I was going to go into EM, but deliberately kept myself open to my options. I think it’s neat to see how we have all grown and changed our perspectives as we have traveled through the various experiences of medical school.
For electives, we had to make our fourth year schedules earlier this year. One good piece of advice our class received from our Dean of Student Affairs was that electives, and even possibly sub-I’s, are an opportunity to do things that you may not have a chance to do again. For example, I picked a psych elective where you are on a community action team that goes out into the homeless community and treats the homeless mentally ill population. I am very excited about that elective. Though psych isn’t what I want to do, I do enjoy aspects of it and so this will give me an opportunity to do something I won’t have the chance to do once I start training in a specialty. I am also taking a nutrition elective because I think understanding nutrition and being able to teach your patients about nutrition in a way that is meaningful to them is important.
So just some food for thought about picking some things that are “out-of-the-box” but that are personally rewarding to you.

Ah, yes, my world of daily changes. When I wrote my previous post, I was very much having a go neurology day. Then Friday night I was surfing around the internal medicine website at Wilford Hall Medical Center (the Air Force’s flagship hospital) where I would like to train if I went internal medicine. I read about how residents can do rotations on humanitarian missions as well as various other military deployments, how they can do their geriatrics rotations at different sites, including the Soldiers Home in DC (it would be a chance for me to come back close to home, plus I love working with older vets), and that they have an opportunity to do training for critical care air transport (the docs who care for patients in transit when flying from the battlefield to higher level hospitals)…plus a myriad of other cool training opportunities. These training opportunities appeal to me because one of the reasons I went back into the military was for the adventure, amongst many other things. But with that adventure comes a need for balance; I don’t want to spend all of my time away from my home station. They also do a lot the same standard rotations that trainees in every other program get, just peppered with some cool rotations in between.

In traveling the journey of trying to discover “What do I want to be when I grow up?,” I’ve re-discovered the fact that I need variety. I cannot imagine myself having an office and going to that same office and doing the same routine, day after day. Now that is not to imply I cannot see the same subset of illnesses in different settings but that I just do not want to feel like I am reliving the same day over-and-over (like groundhog’s day ). I have felt like that on some of my rotations.

And that is one of my fears about neurology. I have taken your advice and will be shadowing my resident from my inpatient neurology rotation in his outpatient clinic this week. I am just afraid that too much of neurology will be just a back-and-forth between inpatient and clinic. Don’t get me wrong, I want a field that has both ambulatory and inpatient; that helps feed some of my need for variety.

I am also taking some other steps to branch out and get some of my questions answered from those who are doing these very jobs I am considering. I’ve realized that I have lots of areas/values that are important to me in my career and that I need to discuss those with the people who are already in those jobs to see which may be compatible with me. I am writing the neurology program director at Wilford Hall to link me up with one of the residents there to answer some questions for me from their perspective. I met him at the military residency fair last December and he seemed very open to students learning more about neurology in the military (Just like you said Joe, neurologists love getting people excited about neurology). Also, I’ve already been in contact with the chief resident at Keesler AFB where I am doing a medicine rotation in September and he also seems very open to answering questions students may have.

Thank you to all of the people who have been chipping in and helping me a long here. Sometimes we get so wrapped up in what is happening to us that others around us have the ability to see things that we do not.

And I am sure that after neurology clinic I will be having another one of my “go neurology” days …lol



Your post sounds so much like my thought process that I smiled, (with the exception that I am not, at this point considering neurology–although that could change at anytime in the next twelve hours ) I especially relate to not wanting an office type practice. That is a major factor in my decision-making process (aka my indecision!)
Your suggestions for “out of the box” type of rotations were good. I do plan to do a variety of fun, personally beneficial electives. We, too, had to turn in our electives already… sort of. I’m in a small program, so as long as they know in enough time to process paperwork, I can change things without too much trouble. Right now the only thing I know for certain is that I’m going to do EM next, and I’m doing an internal med elective somewhere (probably heme-onc), and an IM Sub I somewhere.
I have another factor in looking at electives, though. Because my program isn’t the traditional medical school set up I want to see how internal medicine residencies are in more academic centers. I have worked directly with attendings all year and I need to get a feel for the real “hierarchy” that exists at most places, the whole “pre-rounding for the resident who is pre-rounding for the attending” thing is totally foreign to me.
Tomorrow night we’re having a presentation on residency selection, personal statement writing, etcetera, by a great speaker, so his advice may change my thinking and planning some.
Oh, dang… where has the time gone? I need to work on an oral case presentation for Friday. Let me know how things are going in the decision making process.
Good luck,

Please refresh my memory - which med school are you in? Sounds like a great game plan.

I’m at Michigan State University College of Human Medicine, doing my clinical rotations at the UP Campus.

Hey Tara,
I think you are right to get in touch with people in the specialties and programs you’re interested in, and directly ask them about the concerns you’ve been raising here. Don’t hold back! One thing I’ve noticed whenever I’ve spent time searching the residency forums on SDN is how often the same questions seem to come up within certain specialties. For example, I bet that by talking to enough people, you might actually be able to ANSWER the question of whether neurology would get repetitive. You could probably even find some adventure-minded people who have been in your exact same situation and see what they think.

I have a question for those of you that have been through the residency interviewing process already. At my school, during fourth year we can take up to 3 blocks off (each block being four weeks long). Frequently people take one block for Step II/Vacation, and one block off for residency interviewing, as many of the elective rotations specify that you can’t take time off during the rotation to interview. People generally select either December or January for this. My question is… is it better to interview early (assuming you have the chance), or later-- and thus closer to the match, as to be “fresher” in the interviewers minds? Does it even matter?
The other question I have is, given that I know the first year of residency will be a challenge, and exhausting, should I try to fit in “extra” electives, or is is wiser to take off that 3rd available block, to have time for family and self?
I wish I had more time to do electives before interviewing and the match–I’ll have plenty of time afterwards for electives, but I can only fit in a few things before Novemeber. I’m still torn about what I want to do, and frankly don’t like the idea of ruling either of my top choices out.
It’s hard to believe that as of yesterday I am officially a fourth year, and I’m exactly one year from starting residency. Ee gads!

Hey Epidoc,
It really does not matter when you interview. When we did interviews this year, we immediately had a rank meeting right after the interviews were done. We had one more rank meeting once everyone had interviewed and re-ranked some folks(only one or two). Time your interviews when you can get them in. Do be aware that sometimes if you wait too late to get your application in, the interview slots are all full but other than that, if you have an invitation, pick any date that works in your schedule. Also beware that the weather up North can get you trapped in a city or two so don’t schedule too tight during the “snow months” (from November to May in Cleveland this year )

Deb, it’s definitely nice to get in some R&R before intern year starts. How much time is available to you, and how much you need, is dependent on a couple of things. One big one is where you’ll be moving for residency - I’m in that very fortunate minority where I didn’t move, but for most folks, the reality is that you’re going to be consumed with hunting for a place to live and dealing with moving (ugh on both counts, I hate moving). Another minor consideration is the date of your graduation. If your graduation is one of the later ones, say in June, I’d definitely go for the vacation time!
Finally know that by the end of fourth year, even if you have great intentions of taking a truly fabulous elective that you know will just enlighten the heck out of you in your future practice, the reality is that the sense of impending doom is going to make you want to do a whole lotta nothin’. Follow the slacker impulse without guilt, shame or regret! It’s your last chance to be a slacker for a looong time.