Thursday, July 11, 2013

MiM Mail: Choosing a specialty when you like a lot and love nothing

Hello MiM,

I am new to your blog but have recently spent countless hours reading past posts to hopefully gain some insight (and to avoid studying for step 2). I am a MS4 who just finished 3rd year rotations and am desperately trying to figure out what I am going to do with the rest of my life. Honestly, I did not have that "Ah-ha" moment in medical school when I found something I absolutely loved and knew it was what I was destined to do. I liked most of my rotations, of course some more than others, but nothing blew me away, and I am very disheartened by this.

Right now I am trying to choose between applying to Ob-Gyn and Internal Medicine. Very different, I know. But I like Ob a lot - dealing with relatively younger, healthier patients, working with just women (mainly), and being a surgical and medical specialty is appealing. It was definitely my favorite rotation of third year. However, I never pictured myself as an OB and to be frank, I am quite terrified of their perceived lifestyle. I am 27 years old, married to my high school sweet heart and love of my life, and my family is everything to me. We do not have any kids yet, but definitely want 2 or 3 in the (near) future. My mother was a stay-at-home super mom who never missed a school function or dance recital. Obviously, choosing a career in any field of medicine means that that won't be me; however, I feel if I become an Ob-gyn it will be that much more difficult. I really like delivering babies, but am I still going to like it when I am 45 years old at 3am or when I am missing my child's school play?

If I chose internal medicine, I am basically saying "I haven't decided what to do yet" and it gives me an extra year to put off the decision. Internal medicine has so many different fellowships that I feel I will be keeping my options open. And although I am a big fan of the OR, a non-surgical specialty will help with my hours and my call schedule.

Basically, I like a lot, and love nothing and I am hugely disappointed by this. I have wanted to be a "doctor" since I was a young girl, and have worked so hard to obtain my MD; but, right now I feel lost.

As a woman, I feel it is so much harder to choose a specialty. At the end of the day my family is number one and I want to do what is best for them. At the same time, I have spent so much time and money and worked so hard to get where I am that I don't want to sell myself short. I feel like I have to choose between what is best for me personally and professionally.

Sorry for the insanely long rant. I just really need some solid advice - really ANY advice at all. Please help me, MiM!

One confused MS4


  1. Sounds to me like you DO know what you want to do, but are worried about how it'll affect your family life. You seem to like all the aspects of OB, but think IM would be a better fit for your future family. My advice...basically "lean in". If you like OB, go for it, and work out the details of work/life balance as they come. There are lots of subspecialities in OB/Gyn that lend to better lifestyles, too. I know Gyn only providers, Gyn-Onc, Uro-Gyn, etc... that get the OR time, the experience of working with women, but no 3AM deliveries and few emergencies at all. Call schedules are hugely variable depending on where you practice (huge academic practice with call split 20 ways vs. small group) and there is also part-time. I think its smart to consider what you want for yourself & your family's future but I think way too many women over-think this and end up compromising too much & too soon.

  2. Have you considered anesthesia? Many women who love the OR lean towards that because it allows you to care for your patients, be an integral part of the OR experience and it's shift work...much more flexible than non-shift work. Medicine can be a career choice not a passion. Some doctors enjoy science, want to help people, want a comfortable lifestyle and want to be highly skilled/trained. Note there is no "love their job every second of every moment" is missing from that list. I agree with the above comment. Sounds like you like ob/gyn. After having my own baby and some complications I second your concerns about the lifestyle. If your family comes first then do what makes you most happy as a career. Everything will fall into place. Just remember the residency/training years are temporary and a good time to hold off on having kids if it suits your needs. And don't listen to people who tell you: well if you loved your family then you wouldn't go into such a difficult specialty. I get that all the time from non-surgical spouses...seriously they say: "... my husband loved us too much to go into surgery despite his love for the OR." we have a very happy life and doctor in our house but it is hard right now because we are in training. It will get better once training is complete! :)

  3. KC,

    Wow, I started reading your question and began to wonder if someone had written in for me to help me make a decision. I too am 27, just became an MS IV, am marrying my high school sweet heart in November and know I want a family in a near future. I have all of the same thoughts about Ob/Gyn, I am so interested in it, but I never considered myself a surgeon. I am interested in MFM but I know I want to be able to spend time with my family and eventual kids. I am also interested in Pediatrics and Med/Peds. Med/peds, talking about not really making a decision! I would be interested to know what you end up applying for! I really don't know how to make my decision!

  4. Have you thought about family med with an additional year to be able to do c sections? you don't get the full experience of gyn surgery, of course, but it could be a nice blend.

    -a new pgy1

  5. I was going to suggest Anesthesia, but I see someone beat me to it. There's also emergency medicine which a lot of people I know who wanted to do Ob but were scared of the lifestyle ended up in. Internal medicine is very outpatient clinic heavy unless you become a hospitalist or MICU doc, so you will need to like that. I think being a woman makes the choice easier if you like everything -- it's easier to rule stuff out!

  6. Choosing was so hard for me. It was ophthalmology vs. pathology here. I do not regret my choice for a second, and it was partially made by one intelligent and savvy woman I met at an away rotation who was unhappy with ophthalmology - seeing way too many patients in too short a time.

    My best friend from med school did ophthalmology. She is very happy in her small town field, feeling like she has plenty of time for patients and OR both. She has struggles, as we all do, but her continuing vents/rants/joys make me realize I could have been happy there. But I am also happy with what I chose.

    I know happy OB's and sad ones. I know happy IM's and sad ones. I also know pathologists with major regrets, unlike me. I guess my own rant here is to say choose what you enjoy and try to make your lifestyle work. Paths are unpredictable and contingent on jobs available at the time, but you do have some control if you work hard and find the right practice. I have been around long enough to see career arcs, and I realize that what you set out to do isn't always what you become. Having kids is a major game changer; some practices, regardless of the specialty, are more adaptable to this than others. It's tough, and it isn't always your fault if it doesn't work out the way you plan it.

    I realize as I am reading my thoughts that they aren't specific or super helpful, but I wish you the best of luck based on my experience. I loved pathology in med school and while I find it at times mundane now, 7 years into practice, I still revel in the thrill of helping surgeons and radiologists triage decision making and helping oncologists (one visited my office this morning) and specialists (a GI doc was hanging on my diagnosis today - he also visited my office and gave me his cell) make treatment decisions based on my call. The things that thrill you in med school will give your life meaning in conjunction with all important motherhood. Good luck to you!

  7. Hello there! I am an R1 in an obgyn residency program. I was 28 when I finished 3rd year, also married to my high school sweetheart, and just about to deliver my second baby. I chose obgyn (against the advice of a peer - who chose ER over ob for the same reasons you discussed) because I could not justify putting my family through all the hardship of school/residency for something other than what I loved (I didn't love, or really like, anything else). All I wanted to share was that I have met obgyns in practice who work part-time. On the other hand, I have met internal medicine doctors that work 13+ hour days 6 days a week. Now, more than ever, you can make your schedule (post-residency) more conducive to parenting. You may have to make some other sacrifices to do that (lower pay, hospital versus private practice, location, etc.), but it is possible.

  8. Thanks for all of the advice. Keep it coming!!

    Regarding some of the above posts - I start my acting internship (sub-I) in 2 weeks and my residency application is due in 2 months. I have not done any sort of elective in anesthesia, and probably won't have time to. Unfortunately that ship has kinda sailed. Also, I really like talking to people and feel I would miss some of the clinic.

    My family medicine rotation was a train wreck - obviously there are tons of awesome family med docs who love their life - but I did not have a good all. Also, I want to be specialized. If I did internal medicine I would definitely do a fellowship. I can just put off my decision for another year and figure out what sub-specialty I would want to do, and do a bunch of different electives throughout my 4th year to help me figure it out.

    I know that "you can tailor anything." I have heard "play your cards right" and "it is what you make it" about 5000 times. I know that I just need to make a decision and stick with it. At times, I tell myself Ob-gyn is it and I'm ready. But then I miss a family member's birthday party because I have to study for Step 2 (which is one week from today) and I wonder - is this what my life is going to be like as an ob-gyn? Missing out of family functions or Holidays because of my call schedule.

    I like Ob-gyn. I really do. But I don't LOVE it, and people have said if you don't LOVE it, don't do it. But again, I don't LOVE anything. I have been told by some people "It's awesome, I love my job, I wouldn't do anything else" and I have been told be others "You will ruin your life and ruin your marriage. Don't do it!" This is probably the case with anything, but I am feeling beyond lost.

    1. I just wanted to throw this out there -- I had a friend who was dead set on matching in Peds. She had her entire application complete. Then she did an EM rotation in October and loved it. She switched and applied in EM and got a residency spot in an excellent program. I guess what I'm saying is that if you really want to try something, you should go for it, and it really isn't too late. You could do IM in Aug, Ob in Sept, and Anesth in Oct. Only you can decide. :-)

      I totally feel your pain though. It took me FOREVER to decide, and I had much more time than you did. Good luck, and I hope you let us know what you decide!

    2. Sounds like the decision will end up being a gut feeling for you... You just need a little more time to figure out what that is (and you have a little).

  9. Hey. I'm from Canada so this might be a bit different here. I passed my royal college exams and finished my peds residency 2 weeks ago, with a toddler. No matter what you do, you are going to miss stuff as you are in residency and studying for exams. My heart ached every time my son told me "mommy, go study" instead of "goodnight". But having a job I love and being able to work 3 days a week to make a very decent living was the tradeoff.

    I remember feeling that our matching service was the end of everything. I had all my electives set up for internal and family medicine. My peds rotation came at the beginning of my fourth year and 2 days in, I knew I had to work with kids. I canceled all my electives and rebooked them with peds. I was lucky as some people didn't figure out that they loves something till after our matching service deadline.

    Here's the secret nobody tells you. 10% of Canadian residents switch either programs or specialities. Programs realise that people's interests develop or change or that their personal situation changes. Nobody wants an unhappy resident.

    The other secret nobody tells you is that it takes times to really figure out what you love. Really, you are supposed to know after a 6 or 8 week rotation in something when you are just beginning to understand the medicine? I have friends who didn't match in the first round and had to do something else that was still available in the second round - some of them have told me that they are so happy things worked out the way they did because they never knew they could be so happy doing their career.

    Good luck. You'll find what you are supposed to be doing. It just might take some time.

  10. I actually faced the same decision, though different reasons: OB/GYN vs internal medicine. I opted for the latter and have not regretted it as most friends who went into OB ended up loathing the deliveries. One option that may be a compromise may be family medicine with an OB fellowship. I feel like Fam Med sees younger patients than IM and you can work almost anywhere.

    Personally I think ER has the highest burnout rate. The advantage of IM as you noted is the flexibility and number of opportunities for fellowship. This is also a drawback as it tacks on an additional 2-3 years.

    This will sound really bad at first but think about it for a moment: consider the specialties with the best schedules. It can give you a better idea of where you'd like to work. To me, derm seems to be the most appealing due to the high reimbursement and excellent hours (though I hated it in med school). I had my babies in school and often wish I had gone the derm route rather than my interests. My time with my kids is vastly more important to me than my career these days. For what it's worth.

  11. If you did IM, what are you thinking that you would do a fellowship in?
    I was going to say you should do FM as well- if you are in the right state, you can do OB for however long you want to then drop it from your practice after you are tired of doing it. I trained at a program where some of the residents did enough C-sections to be able to do them without an OB fellowship, and it was EASY to get over 100 vaginal deliveries in your training- if you worked harder at it, I could see somebody graduating with 200 pretty easily. Also, I had 2 children during residency and it was not a problem AT ALL- they were super supportive.

  12. Well, I could have written this post as an M4. I am basically exactly the same, except I have TWO intern years behind me, a two year old, and a baby on the way. My story is a long one... I did a year of ob/gyn, loved it, but missed my baby so much that I switched out. I wanted to switch to EM (thought I could get a lot of procedures and do shift work part-time), but I did IM to be closer to family. But my story doesn't end there. I did an intern year of IM, hated it, missed delivering babies, healthier younger patients, missed having some healthy patients, and doing women's health... found myself feeling completely stuck and resentful in IM. After spending more time with hospitalists, I knew I would never like the job, couldn't see myself doing a 3 year fellowship, so switched AGAIN.

    I ended up in FM. I am taking a little sabbatical to have a baby and had to move for my husband's training, but heading back as a second year FM resident next July. With FM at least I can deliver babies, shape my practice to have mostly female patients and hopefully do some breast feeding counseling and baby checkups too. In med school, I would have told you that I hated clinic, loved the OR, but after having my baby, the appeal of 8-5 clinic, no weekends, and light home call sounded like music to my ears. The idea of what's "boring" changes, or at least it did for me.

    If I had had better scores and more options for flexibility, I might have done ER, which I think is a good fit for procedure people, but the schedule disruptions of working nights can't be overlooked.

    I would at least consider FM if you really enjoy babies. Get out of town and go work with some rural docs who do it all. Or work with some academic FM docs who still deliver babies. I plan to really amp up my OB practice once my kids are older/ grown.. but if I don't have the energy to do it or have a change of heart, I can do a million other things with FM. OB practice in FM is very regional, though I think it can be done virtually anywhere.

    The thing with Ob in my experience is that even if you love it, it is a real struggle to juggle motherhood with OB. I saw some of the private attendings in tears after a bad call and not seeing their kids for going on 30+ hours. They would be running all night long and then have to go to clinic the next day. It was honestly brutal. Which is why I ended up switching out although it will always be my first love. If you don't LOVE it, I would look elsewhere.

    Also, my scores weren't stellar, but if you have great scores and you love the OR, I might look into a lifestyle surgical specialty- urology, plastics. Or you can even do some surgery after derm. There's a reason those specialties are competitive though =) Best of luck to you!!

  13. one more thing.. be sure you look into what "part-time" means in ob/gyn. It probably does not mean 20 hours a week with no call. The hardest part to choosing ob/gyn is deciding if you can handle the call. Some Ob/gyns will say that they are "part-time" and they are working 3-4 call nights a month with weekend call once a month. They usually have a shortened work week in the office, taking maybe 1-2 full days off. For me, sleep was a huge priority, just because I can't function without it. Other doctors I know really do ok with staying up all night and taking a little nap the next day and then they're ready to go. You have to factor in what sort of lifestyle is doable FOR YOU.

    1. The part-time ob/gyn I was referring to earlier works three days a week. I don't know what her hours are those three days. She does mostly gyn/surgeries.

  14. Courtney brings up a great point - in rural medicine, the family practice docs do it all. In my home town, they get to do ER, peds, adults, deliveries, and some Hospitalist work (with really decent schedules). Another advantage of rural medicine is that usually the town is small enough to where you never have in house call and can pop home for a bit.

  15. Do not do obgyn unless you love it so much that you can't do anything else. Even under those circumstances it is actively painful a lot of the time. I couldn't have chosen anything else, but I gave up huge chunks of my life and my childrens' lives to do it. Do an anesthesia rotation. It really is a much more sane choice. Practicing obgyn in our current health care system is hard. And I am not just talking about the hours.

  16. You sound like the perfect candidate for anesthesia: you love the OR, want a decent lifestyle (even in residency), and want some OB exposure. The ship has not sailed! You can switch into an anesthesia elective for September and still be ready to go. Letters are not due for a bit longer than that. At least see if you can talk to the chair or shadow in OB anesthesia. It might make all the difference for you.

    ER may be a great choice, too. You're in a great position: if you like multiple specialties, you'll probably be happy in any of them.

  17. DON'T go into anesthesiology unless you really love it. I did, and it's been a great choice for me. But this is a field where things can go wrong so quickly and so horribly--you have only a very short time to figure out the problem is, how to fix it, and to take action. In the case of an airway problem, it's literally life and death. For people who don't really love it, this specialty can be an awful mix of boredom and terror. Some practices (such as mine) are in tertiary care centers which see a high percentage of aged and very sick patients--it's like doing critical care all day every day. I'm OK with that, since my major decision was between anesthesiology and pulmonary medicine/ICU. But even after 20+ years there are still days when cases go long and I don't get home until 8 p.m. even when I'm not on call. And if you value longitudinal relationships with patients and continuity of care--which you may if you're attracted to OB or IM--this field doesn't offer that unless you specialize in chronic pain management.

    I agree with the writer who said there are all kinds of different practices no matter what field you go into. When my children were small, I worked in an academic center where the hours were much more predictable. Private practice is more lucrative, but again the hours are longer and I never really know when the day will end.

    If I worked in the kind of practice where I sat in an outpatient center and provided sedation for lump and bump cases, I'd have predictable hours but I'd be so bored I'd be clawing the walls.

    The OB anesthesia people in my hospital work VERY long hours, since OB can't be scheduled in the same way that OR cases are, with the only exception of elective repeat C-sections.

    Some of the unhappiest and most burned-out doctors I know are those who chose fields for lifestyle reasons rather than real interest. Your career lasts a long time, unless you leave medicine altogether.

    If you really don't know what you want to do, take some more time. Go to work in a public health clinic where all you need is a medical license, and get some primary care experience. Or if your marriage permits, volunteer with an organization such as Doctors Without Borders and do some good elsewhere in the world. But don't sign up for any specialty for the wrong reasons--this leads only to regrets. If you really don't love medicine, quit now, and leave the residency spots for others. They are in short supply, and it's getting worse since medical schools are expanding faster than residency positions.

    Best of luck!

  18. The advice above by KSibert is golden.

    I completely agree about not choosing a specialty based solely on lifestyle. That's a recipe for unhappiness, boredom and possibly dropping out of medicine in the long-run.

    And I agree that every specialty has paths that students are not aware of during medical school. There's such a limited exposure before having to decide. This is another reason to choose based on the work and types of patient interactions that bring you the most satisfaction and meaning.

    I chose IM. Perhaps naively, I did not consider lifestyle at all. I knew I enjoyed the intellectual challenge and loved the relationship aspect of primary care. My path changed during residency, and I discovered how much I loved teaching. So, instead of primary care, I became an academic hospitalist. After 10 years, I still love my job. It is intensely satisfying and full of variety. I had no idea this model of hospitalist work existed during school or residency.

    This is not all to say IM is the answer for you. It's that there are options, many that you are not aware of, in each specialty and it's the key aspects of the work itself that are constant across different models.

    Talk to attendings who you admire in OB and IM (and have been doing it for many years, not in residency -skewed, or just out of training) and find out why they chose their field, what they love about their jobs, and what they wish were different. Ask about their work-life balance. Sift through what is individual/institution-related, and what you can generalize.

    Finally, know that you can always shift what you do as you progress in your career. For instance, you could take a leadership role that involves more administrative time if you feel you want to limit the more time-demanding clinical duties.

  19. I just want to weigh in a little here - perhaps play the devil's advocate. I agree that we should try to choose something we love - and part of the beauty of medicine is that we get that luxury to choose something we love. Most people don't really get that choice. The point I want to make is that as much as we should choose a specialty that is intellectually stimulating and exciting to us, factors like lifestyle are still important. It shouldn't be the only reason to pick a specialty, but it certainly is a consideration. Subject matter and excitement may only last so long if one is constantly tired and feeling guilty. It's kind of like marriage - the excitement and dizziness of being in love wanes but you still have to stick with it for the long haul. The specialty you choose needs to be something you can be for the rest of your life.

    My story is that I liked internal medicine as a medical student, then got caught up with the excitement of surgery/OBGYN as an intern (we do that here) and almost chose one of them but returned to internal medicine and eventually became a Endocrine attending. I enjoy that I make a difference to people's lives, am intellectually stimulated and have lots of clinics (which may break others) and yet have great work life balance.

    Might I have enjoyed OBGYN at first? For sure - and I believe I would have been ok with it. But would it have been ok for the long haul, no I don't think so. I know that I need life outside medicine. And I'm not afraid to say it. There shouldn't be any reason to be afraid to say it. I think that having a life outside medicine as a person, as a mom (not yet for me), as a wife, actually makes me a better doctor. I remember what it's like to love and to care for another person. (I contrast this with pre-husband days) It makes my approach more human. I think we could do more for ourselves by admitting, as women, that we need more than just medicine. It doesn't necessarily make us less.

    1. Just out of curiosity - how many years in IM practice before pursuing your Endo fellowship? Thanks!

  20. Coming late to this all matters. Yes, choose what you love, but think about what, specifically, you love about it. OB/GYN was my first rotation in med school and I LOVED delivering babies and doing prenatal visits. Adored it. But I would have been the world's worst surgeon, and I didn't want to do a residency that was more than three years - my then-fiancé was in grad school and we needed to finish sort of at the same time. I was very drawn to FP but I was destined to be the trailing spouse to his academic career, and FP is very different in an urban or suburban area. I would have loved it if I could have done everything, but I wasn't going to get to choose where we moved. So I did IM, and I've been happy, but I've also been a bit of a misfit because I do believe that the family is the unit of care.

    I've made it work in several ways. I always saw adolescents, and I did primary care IM and office gyn. I love teaching and I've taught in a variety of settings, and I developed an interest in communication skills, pursued that as my academic focus, and ended up in Hospice and Palliative Medicine. The family is the unit of care (yay!), it's team-based, communication-centered and I love love love it.

    Everything matters. Lifestyle matters, Your life during residency matters - but very few things are irrevocable and you can find a niche in almost any field.

  21. I think you have gotten great advice (that I also value) but since I truly understand this post as I am also a MS4 that was left so confused and complicated by the fact I'm a single mom with a 5 year old I wanted to comment. I too liked everything but found that I liked being in the OR most... but single mom general surgery resident?! So sigh, I was between a surgical specialty (OB or gen surg) or something I thought would be lifestyle friendlier(med or peds). In my school our 4th year starts very early so I did an AI in medicine and one in surgery and the decision became very apparent. It is not too late to go until even October (I've seen the stories)so try them both out at a subinternship level. And follow your heart and gut because in the end a happier YOU is better for your patients AND your family as it all works out in the end. It looks like I will be doing the general surgery route unless I get wooed by EM in see still right there with you :)

  22. I'm very late to the game but this is the toughest decision and I think you are right to take your intellectual stimulation, physical skills and lifestyle into consideration. I worked for OBs in undergrad as a medical assistant and loved it but could see it getting old and as I went through rotations being in the OR for surgeries hours on end was not appealing --- the thought of getting older and transitioning a practice from OB to GYN doing hysterectomies all day was NOT appealing. I wanted to do OB but not to the exclusion of the rest of medicine. Well, I've been a practicing Army FP for 3 years now and get to do a bit of everything I want to do.... inpt medicine and peds hospitalist at our community hospital, "regular" clinic with NB to hospice care, I've become a lactation counselor, vasectomies/colposcopies/skin/GXT procedures, I have an US machine so new OB appts are fun and I can deliver the baby then continue to care for mom,dad, baby and siblings........... I have also some administrative functions ...... anyway, I don't regret it. I get out of the Army next year and have lined up a position in a rural setting doing everything I am doing now with a 4day work week so that I can gain some more family time as that's what I'm missing at this point.

    Ultimate question, what do you want to do? OBGYN or Medicine? For me Family Med = both.....


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