Selecting the Medical Specialty That Is Right for You

1. Selecting the Medical Specialty That Is Right for You Jim Holliman, M.D., F.A.C.E.P. Program Manager, Afghanistan Healthcare Sector Reconstruction Project Center for Disaster and Humanitarian Assistance Medicine Uniformed Services University of the Health Sciences Clinical Professor of Emergency Medicine George Washington University

2. Questions to Ask Yourself As You Are Deciding on a Medical Career Specialty • 1. Do I like diagnostics or therapeutics or both ? • 2. Do I like predictability or unpredictability, and can I deal with more than one case at a time ? • 3. Do I have any prejudicial dislikes of certain kinds or ages of people ? • 4. Do I need defined limits to what I need to know ? • 5. Can I work in a team environment ? • 6. Do I have verbal communication limitations ? • 7. Is my final career goal a sub-specialty or multiple specialties ? • 8. Can I tolerate the humdrum and disagreeable aspects of the specialty I have chosen ?

3. Questions to Ask Yourself As You Are Deciding on a Medical Career Specialty • 1. Do I like diagnostics or therapeutics (procedures) or both ? • If you don’t have any manual dexterity, then don’t choose a procedural specialty • “Pure procedural” specialties : Plastic Surgery, Orthopedic Surgery • “Pure diagnostic” specialties : Neurology, Preventive Medicine, Rehabilitation Medicine • “Mixed procedural and diagnostic” specialties : Emergency Medicine, General Surgery • If you won’t be happy unless you get to do big surgical procedures, then go into a surgical field

4. Questions to Ask Yourself As You Are Deciding on a Medical Career Specialty 2. Do I like predictability or unpredictability, and can I deal with more than one case at a time ? - If you don’t like or tolerate unpredictability, then you want to choose a clinic or office based practice, such as Internal Medicine, Family Medicine, or Pediatrics (perhaps without hospital admission privileges) - Specialties with unpredictability of patient presentations include Emergency Medicine, Trauma Surgery, and General Surgery - Some specialties such as Critical (Intensive) Care have clinical unpredictability but work site predictability

5. Questions to Ask Yourself As You Are Deciding on a Medical Career Specialty • 3. Do I have any prejudicial dislikes of certain kinds or ages of people (or do I want to treat all types and ages of people) ? • For example, f you don’t like kids, then don’t go into Pediatrics or Family Medicine • In Emergency Medicine you have to like to deal with all types and all ages of people • If you don’t have patience with the elderly, then don’t go into Internal Medicine or Emergency Medicine

6. Questions to Ask Yourself As You Are Deciding on a Medical Career Specialty • 4. Do I need defined limits as to what I need to know & study ? • Some people are very uncomfortable with a specialty such as Emergency Medicine in which the body of clinically important information to know and study is essentially unbounded • So if you want defined limits as to the knowledge base required for clinical practice, then choose “more focused” specialties such as Ophthalmology, Anesthesia, Otolaryngology, etc.

7. Questions to Ask Yourself As You Are Deciding on a Medical Career Specialty 5. Can I work in a team environment ? - If you’d rather work solo, then pick an office or clinic based specialty - Emergency Medicine and Rehabilitation Medicine particularly require close teamwork with other department personnel

8. Questions to Ask Yourself As You Are Deciding on a Medical Career Specialty 6. Do I have verbal communication limitations ? - If you don’t like to or are not good at quickly establishing rapport and verbal communications with patients, then you should choose Anesthesia or Radiology where these aspects are not as important as in specialties such as Family Medicine, Internal Medicine, Pediatrics, and Emergency Medicine

9. Questions to Ask Yourself As You Are Deciding on a Medical Career Specialty • Is my final career goal a sub-specialty or multiple specialties ? • - If so, you need to consider the base specialty you will need to complete first before going on to the subspecialty. • For example, you can enter Critical Care Fellowships via Anesthesia, Internal Medicine, Surgery, or Emergency Medicine. • - If you want to be certified in more than one specialty then you can enter one of several combined residencies : EM / IM, EM / Peds, EM / FM, etc.

10. Questions to Ask Yourself As You Are Deciding on a Medical Career Specialty • Can I tolerate the humdrum and disagreeable aspects of the specialty I have chosen ? • This is often the most important question to consider • For example, if you want to be a neurologist, then you must be able to tolerate patients with chronic undifferentiated headaches • Remember that in many surgical specialties you will be doing the same limited number of procedures over and over • Also remember that in most clinical practices you won’t see the variety or severity of cases you saw on inpatient services in medical school

11. Questions to Ask Yourself in Deciding on an Academic Career Versus Private Practice ? • Can I tolerate turning over care of my patients to trainees ? • Do I prefer to do everything myself to make sure it's done right ? • Do I want to listen to my spouse yell at me for working twice as hard for half as much money in academic practice as my medical school classmates are making in private practice ? • Do the rewards of teaching and scholarship outweigh the extra political hassles of academic practice ?

12. Why Is Emergency Medicine A Great Career ? • Nice mix of diagnostics & therapeutics (procedures) • Wide variety of patients & medical problems • Challenging • Benefits to patients & U. S. health care are obvious • Core component of U.S. health care system • Young, vibrant specialty ; many practitioners have extensive interests outside of medicine

13. What About Primary Care Careers ? • "Classic" primary care specialties include : • Pediatrics • Family Practice • Internal Medicine • The degree of governmental support for these to the exclusion of other specialties is waning • Usually do not include any trauma training • True "longitudinal" care in these may not be practiced

14. Disadvantages of Emergency Medicine As a Career • You won't make as much money as in cardiac surgery • Limited "longitudinal care" • No ability to pre-select patients • Usually spatially limited work environment • Need to stay current in all fields of medicine • Requires a lot of political skill (the art of making other doctors actually do what you both know is the right thing to do) • "Is practicing in a fishbowl"

15. Unique Advantages of Emergency Medicine As a Career • Unlimited international development opportunity • Relatively small number of academic practitioners (easy to "rise to the top" fast) • Control over, & predictability of, work schedules • Potential for administrative involvement in prehospital care • Interact with every other medical specialty • Geographic flexibility

16. What Does the Future Hold for Emergency Medicine ? • "They may find a cure for cancer ; they may find a cure for heart disease ; but they will never find a cure for stupidity, so there will always be accidents & a need for emergency physicians " • Is currently an undersupplied specialty in the U.S. • Is just beginning to develop in other countries ; the U.S. is the unquestioned world leader in this specialty

17. Important Principles to Remember in Deciding Upon a Medical Career Specialty • Does my chosen career mesh with my personality ? • Does my chosen career match with my significant other’s long term wishes ? • Can I stand the dull, humdrum, and disagreeable aspects of my chosen field, and do the interesting or infrequent exciting aspects of my chosen field sufficiently make up for these other aspects ? • (Seriously) : It is best to keep an open mind as you are doing your third year rotations ; you may find you really like a specialty you had not had exposure to before • And certainly DO NOT pick your specialty based on how much money you think you’ll make ! (there are a lot of very unhappy rich doctors)

18. What Should I Do if I Still Can’t Decide on a Specialty Late in my Third Year ? • If you can narrow it to two specialties : for your first fourth year rotation take an acting internship in one followed by a second acting internship in the other, followed by one month each of a rotation related to each specialty ; prepare two different personal statements over the summer ; make a final decision and apply to only one specialty at the end of September. • If you still have no decision by your fourth year : apply to transitional internships, schedule rotations related to your specialty interests early in the transitional internship, then reapply to a single specialty the next year

19. My Recommendations for Students Interested in Applying for E. M. Residencies • Take E.M. elective early in 4th year, then take a rotation that will buff your clinical skills such as Surgical ICU • Then take second E.M. elective at another center with an E.M. residency • Get 3 letters of recommendation from E.M. faculty at these 2 places • Over the summer draft and edit your CV and personal statement • Complete all NRMP application materials by October • Take the time and expense to travel to any residency that offers you an interview • Do an overseas elective in March or April while awaiting match results

20. Recommended 4th Year Electives for Students Interested in E.M. (in addition to the 2 E.M. electives) • Medical, Surgical, and / or Pediatric I.C.U. • Outpatient Pediatrics • Outpatient Orthopedics • Anesthesia • Dermatology • Urology • Medicine or Surgery Subinternship • Plastic Surgery • Trauma Surgery

21. Fourth Year Electives NOT Recommended for Students Interested in E.M. • Radiology • Radiology subspecialties • Radiation oncology • Medicine subspecialties • Psychiatry • Rehabilitation • Oncology • Family practice

22. Additional Items to Consider to Bolster Your Residency Application • Get faculty to review your C.V. & personal statement • Join several student interest groups • Do some public service projects • Do a decent research project(s) • Join AMSA, AMA, ACEP, SAEM, etc. • Become knowledgeable about current affairs & political aspects of medicine • Develop some interests besides reading & sleeping

23. What Should You Do if You Apply to E.M. Programs & Don't Get In ? • Don't reapply if you're actually a dork • If you are not a dork : • - Serve out your GMO time and then reapply • Apply to transitional internships (these are required for the PGY 2,3,4 programs anyway) • Take a research position & reapply next year • Analyze what was weak in your file and try and fix or augment it • Work as an E.D. volunteer or in prehospital care where you will be seen by a residency program

24. Recognized Subspecialties of Emergency Medicine • Toxicology • Pediatric Emergency Medicine • Sports Medicine • Palliative Medicine • E.M.S. (prehospital care) • Aeromedical Care • Critical Care • Disaster Medicine • International E.M. Note the first 4 have official subspecialty certification exams

25. How to Find Out More Information on Emergency Medicine Careers • Consult the unbiased Dr. Holliman and / or Dr. Burns in the office anytime and shadow them when they’re on clinical duty • Come to "Career Night" at Dr. Holliman's house (party for students held twice a year) • Talk to the E.M. residents at GWU or Georgetown • Talk to the E.M. attendings at any of the local hospitals • Join ACEP, SAEM, & the student E.M. Interest Group