Why Physicians Choose Specialties

Jaded Julie:

“Curmudge, now that Mack is back from the other side of the world, he might occasionally join our conversations.  He can enhance this blog with some expertise, which heretofore has been totally lacking.  Perhaps he can help with these questions: Why do physicians become specialists and how do they choose their specialty?  And do financial considerations influence their decision?”

Curmudgeon:

“Let me start with the easy answers, Jaded Julie.  We hope that all physicians have chosen medicine because they are humanists who want to be of service to mankind.  Medicine is the highest calling that matches their interests and above-average abilities.”

Julie:

“I’ll buy that.  Now can we refine our query and consider their choices of specialties?  Will you help us, Mack?”

Doc Mack, MD:

“It would seem that the easy answer comes from the medical students’ experiences in clinical rotations or possibly in a transitional internship.  They have concluded that a particular area is ‘what I’d like to do.’ “

Curmudge:

“But, Mack, other factors must come into play.  Consider surgery.  One who started med school a few years late might avoid surgery because the long residency (5+ years) would shorten his career.  Also, he would have to be temperamentally comfortable with the residency’s ‘macho’ environment.  Female surgeons must be extraordinary people.”

Mack:

“Both of those factors influenced me.  Another specialty involving mostly hands-on procedures is gastroenterology.  They are among the physician-artists that you mentioned a couple of weeks ago.  Although these docs don’t usually spend much time talking to patients, during a colonoscopy they can have the satisfaction of finding and curing cancer in 15 minutes.”

Julie:

“I perceive, Mack and Curmudge, that we are progressing from specialties that are heavy on procedures but don’t require a lot of communication with patients toward those—like psychiatry—that are all communication.”

Mack:

“The surgery part of orthopedics appears more mechanical than artistic, but the surgeon has the ability to transform a patient in constant pain into one enjoying a pain-free existence.”

Curmudge:

“I see plastic surgery as requiring a very artistic person, and like sculpture, there’s little room for error.”

Mack:

“To me, plastic surgery seems to be in a world by itself.  The docs have to have artistic ability and the dexterity to do very fine stitching, even finer than mine.  By reconstructing a disfigured face, they can restore a patient’s self-esteem.  They also set themselves apart by being paid cash on the barrelhead for cosmetic surgery, like eye jobs and tummy tucks.”

Julie:

“Also requiring fine stitching but not up-front cash was the Mohs surgery on Curmudge’s ear by a dermatologist.  A dermatologist has to have a discerning eye to distinguish a cancerous lesion from a benign spot.  It helps to have warm, sensitive fingers, which is why Curmudge’s regular dermatologist is a young woman.”

Mack:

“And of course, a dermatologist doesn’t get phone calls in the middle of the night.  Traditionally, an internist was a diagnostician.  Now many are also family physicians.  We used to joke—it’s probably an urban legend—about internists who ‘couldn’t stand the sight of blood.’  Nevertheless, it will always be a very cerebral specialty.  It often takes a lot of questioning before the patient leads the physician to the correct diagnosis.  I envision an internist as a problem-solver, and perhaps that’s what leads residents into that specialty.”

Julie:

“Clinical oncology is typically a sub-specialty of internal medicine.  In our Kaizen Curmudgeon posting on prednisone we mentioned your former neighbor, Bernie, an oncologist.”

Curmudge:

“You know, Julie, that Bernie left oncology and returned to internal medicine.  He found oncology too depressing because most of his patients died.  Of course, that was back in the 1960’s.”        

Julie:

“At the other end of the people-oriented scale are the pediatricians.  It requires a cool, competent doc to diagnose a screaming baby who can’t say where it hurts held by a distraught mother.  A new physician starting a peds residency already knows that he/she has what it takes.”

Mack:

“Right next to the pediatricians in their need to communicate are the emergency medicine physicians.  I rarely see the same patient twice, have to diagnose everyone who comes in the door, and it’s often a mother with a screaming baby.  A typical day (or night) might consist of a string of minor injuries, pains, and illnesses punctuated by a heart attack or major trauma victim who is trying to die.  This requires an encyclopedic mind, the ability to treat several patients almost simultaneously, and much of the physical dexterity of a surgeon.  This residency is popular despite the specialty’s high burn-out rate.”

Julie:

“You should know best about ER docs, Mack.  We haven’t talked about OB/GYN. Curmudge, even after having been married for 52 years and the father of three children, I’ll bet that’s a subject you still don’t know much about.”

Curmudge:

“You’re right as usual, Julie.  Many years ago I studied emergency childbirth in an advanced first aid class, but thank goodness, I never had to use it.  Here’s another true long-ago story.  When I was a graduate student in chemistry I commented to a dentist that I was glad my profession didn’t require me to work inside someone’s mouth.  His reply was, ‘you might have been a proctologist or a gynecologist.’ “

Julie:

“Curmudge!  Back to our original question.  Do you think that any physicians choose their specialty on the basis of anticipated financial security?”

Mack:

“I’ll answer that indirectly, Curmudge and Julie.  It would certainly surprise me if one who planned to live in Alaska wanted to become a specialist in tropical diseases.  Nevertheless, my hope remains that most would choose their residency on the basis of  ‘what I’d like to do.’ “

Curmudge, Julie, and guest author, Doc Mack, MD