How to Choose a Medical Specialty

 
Choosing a medical specialty is no easy task. You’re faced with this task as a third year medical student trying to look good on every clerkship while working long hours and often with only the view of what the specialty looks like from an academic perspective.

At one time, I thought I might enjoy pediatrics, but then I did a 180 and considered radiology. Somehow, I landed on anesthesiology, which I think was actually a great choice for me.

Today, we have a guest post from a psychologist who understands the process of choosing a medical specialty well. His brother went the medical school path en route to becoming a pediatric emergency physician, whereas today’s author, Dr. Shirag Shemmassian went the Ph.D. route.

He helps applicants matriculate to college and medical school via his business, Shemmassian Academic Consulting. We have no financial relationship to disclose, and he provided the following bio. Pretty impressive!

 

Dr. Shirag Shemmassian is a medical school admissions expert who has helped hundreds of students get into schools such as Harvard, Mayo, and UCSF, as well as top residency programs.

Growing up with Tourette Syndrome in a middle-class family, Dr. Shemmassian was often mocked by peers and teachers and discouraged from applying to elite colleges. Therefore, he taught himself everything he needed to know to graduate debt-free with his B.S. in Human Development from Cornell and his Ph.D. in Clinical Psychology from UCLA.

Dr. Shemmassian has been featured in The Washington Post, US News & World Report, and NBC, as well as been invited to speak at Stanford, Yale, and UCLA. He presents on topics including writing memorable personal statements, developing a unique extracurricular profile, and acing interviews.

 

How to Choose a Medical Specialty

 

When you were applying to medical school, the questions you needed answered were somewhat simple.

You likely asked things like, “What MCAT score do I need to get?” and “How many hours of patient exposure or research do I need to accumulate?”

Most applicants aspire to get in somewhere so they can pursue their dream career as a physician. That way, you can help people while making a good living in a respected profession.

Choosing a medical specialty is a bit more complicated. In addition to being four years older at the start of residency with new personal considerations, you must decide not only how and where to spend the next three to seven years, but also the lifestyle you’ll enjoy throughout your career.

Although the best medical specialties differ from person to person, I’ll offer five factors to consider when selecting what field to go into, in no particular order.

 

Consideration 1: Income Potential

 

Money isn’t everything, but it matters. Earning a higher salary may reduce the number of years required to achieve financial independence, allow you to pay back student loans faster, and spend more on the things you value.

So, which medical specialties earn the highest salaries?

According to the 2018 Medscape Young Physician Compensation Report, the top 5 highest paid medical specialties among doctors under 40 are as follows:

  1. Plastic surgery: $519,000
  2. Orthopedics: $424,000
  3. Gastroenterology: $354,000
  4. Otolaryngology: $342,000
  5. Emergency Medicine: $338,000

Here are the bottom 5:

  1. Pathology: $195,000
  2. Diabetes & Endocrinology: $189,000
  3. Pediatrics: $187,000
  4. Infectious Diseases: $186,000
  5. Public Health & Preventative Medicine: $132,000

The fourth most lucrative specialty, otolaryngology, came with $153,000 more in annual salary than diabetes & endocrinology, the fourth from the bottom.

While the Medscape Physician Compensation Report (which looks at all doctors, not just young ones) demonstrates that physicians across most specialties enjoy income growth over time, it also shows a similar specialty earnings pattern across doctors of all ages.

Over the years, annual income differences in the tens to hundreds of thousands, assuming reasonable saving and investing, can lead to more significant net worth differences, even after taxes.

 

Choosing_a_Medical_Specialty

 

Consideration 2: Opportunity Cost

 

Of course, residencies vary widely regarding years spent pursuing them. For instance, whereas an emergency medicine (EM) residency can last only three years, a plastic surgery residency lasts six years.

Those three years may seem insignificant but can lead to significant differences when it comes to earnings, ability to begin paying off loans, and so on.

The Medscape Residents Salary & Debt Report, last published in 2014, offers the following data:

  • Average plastic surgery resident annual salary: $58,000
  • Average emergency medicine resident annual salary: $54,000

After three years, the plastic surgery resident will earn $174,000 or $12,000 more pre-tax than the EM resident. However, because the EM resident will begin earning their attending-level salary ($338,000) after three years, here’s how their earnings will look at the end of year 6 post medical school:

  • Plastic surgery resident: $348,000
  • Emergency medicine resident/attending: $1,176,000
  • Difference: $828,000

Of course, the plastic surgeon will be able to catch up and even surpass the EM physician’s career earnings during year 11 post residency.

However, the EM physician will have had seven to eight years—in their 20s and 30s—during which they could have paid down their loans more quickly, invest more, etc. Compounded over time, the numbers would add up.

 

Consideration 3: Interest in Day-to-Day Work

 

While finances are a major factor when choosing a medical specialty, you’ll of course want to enjoy what you do day in and day out.

AAMC provides a useful Clinical Rotation Evaluation questionnaire that can help you reflect on what you liked and disliked about your various M3 and M4 rotations.

If you disliked a meaningful aspect of a specialist’s work during a 2- or 3-month stint, those issues are likely to be magnified during your multi-year residency. The same may also be true for aspects you enjoyed.

There are also non-trivial differences regarding the percentage of physicians who would choose the same specialty. According to the Medscape Physician Compensation Report, specialty satisfaction ranges from 52% (nephrology) to 98% (orthopedics). Overall, only 62% of physicians would choose their specialty again.

Unfortunately, we don’t have data to help us explain why certain specialists would or would not again choose the same area. The takeaway, however, is to be thoughtful about what you see yourself doing for decades in most cases.

 

Consideration 4: Work-Life Balance

 

Most physicians I know would rather work to live than live to work. That said, one physician’s idea of good work-life balance will differ from another’s.

It’s not just the number of work hours you should consider when making your decision. You should also think about when you work.

Certain specialties like radiology, dermatology, pathology, and neurology offer predictable, controllable work schedules, whereas specialties like EM require shift work. While the total number of weekly work hours for a specialty like EM may be less than many other specialties’, you may have to switch between day and night shifts, which will throw off your internal clock.

Surgical specialties are often associated not only with long hours, but also early morning hours. It’s not uncommon to have to report to work as early as 4AM or 5AM to complete long procedures. If you’re a night owl, surgery may be a rough fit. Remember that the decision you make in your 20s—when you’re closer to your peak physical shape—will impact your middle-age years and beyond.

Medscape also publishes a Physician Lifestyle & Happiness Report that provides some insight on which physicians are happiest outside work. According to their survey, the happiest medical specialists are rheumatologists (65%) and otolaryngologists (60%), whereas the least happy are infectious disease physicians (46%) and neurologists (45%).

Although we shouldn’t infer any causal relationships from these data, I encourage you to ask various specialists about their work-life balance in addition to their professional fulfillment.

 

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Consideration 5: Competitiveness of Medical Specialty

 

Residency match comes down to several factors, including medical school attended, grades, recommendation letters, residency applications, interviews, and USMLE Step 1 and Step 2 scores.

 

Mean USMLE scores by specialty table

 

Unsurprisingly, the trend is that high-paying specialties (e.g., dermatology, plastic surgery, and radiation oncology) require some of the highest Step 1 and Step 2 scores, whereas lower-paying specialties like family medicine and pediatrics tend to be more academically forgiving.

You’ll have to apply realistically. If you have less-than-competitive stats for your desired residencies, you should either apply to more sites, sites in less desirable locations, or both. On the other hand, if you’re equally interested in less competitive specialties, you may prioritize location, work-life balance, and other factors.

 

Final Thoughts

 

Choosing a medical specialty is an incredibly personal decision. The five considerations clearly require value judgments and are meant to guide what will likely be an impactful decision for decades to come.

While it can be hard to block out others’ thoughts and opinions on what you “should” do, think deeply about what you want for your personal and professional life now and 10, 20, even 30 years from now.

 


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Physicians, how did you choose your medical specialty? Are you happy with your choice? What additional criteria would you add?

20 comments

  • The first 2 reasons listed are about the money you’ll make. I can’t disagree more about using this as a consideration. If money is your driving factor, pick an easier profession. You’ll end up looking for ways to get out early instead of ways to enjoy your job. This is a difficult profession, it will demand a lot of you, so you better like what you do. It takes a long time to get there and involves a lot of your life in the process. Don’t let money be a driving factor. It certainly doesn’t deserve the top two slots for picking a specialty. You will make good money in every specialty so pick the one you like to do. Even the bottom of his list makes $132k which is better than double the ave American household. You can live a good life on that.

    Dr. Cory S. Fawcett
    Prescription for Financial Success

    • Peds Rez

      The author mentions that the considerations are listed in no particular order but I find that the first consideration listed is appropriate–this is Physician on FIRE after all.

      I’m a third year Peds resident and even though it will not be as financially rewarding as other specialties, I absolutely love the work I do and wouldn’t change a thing.

      That said, I know many of my friends in med school considered income potential (in addition to other factors) when choosing a specialty. We attended a private medical school on the East coast with no scholarships (i.e., massive student loans).

      Hopefully over time income potential will be less of a consideration, with more schools beginning to offer free tuition (like NYU).

    • Thanks for sharing your thoughts, Dr. Fawcett. While I agree that all physicians earn a healthy income–certainly more than most Americans–I disagree with your point about money not being used as a consideration, for the reasons outlined in the article.

      In addition, the article does not focus on whether to pursue medicine vs. an “easier profession” but rather things to consider when choosing a speciality within medicine. A physician can “like what [they] do” while considering their earnings.

      Peds Rez – congrats on choosing a specialty you enjoy! NYU’s decision to waive tuition is indeed a step in the right direction for medical education.

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  • Doc for life

    These rankings are very off. I know family practice docs with extensive ancillary service line making over a million and cardiologists going broke making under 300 because they live in expensive towns with large numbers of competition Geography makes more impact than specialty. A plastic surgeon in Miami where there is one on every corner may make less than gi in Iowa who gets an offer for 600 starting salary since there is a service need. I moved across the state I live in to a more rural area and my income increased fifty percent and my costs were cut by two. Now I can be worth over two million in less than ten years and I’m out if u are too if your game in any specialty you can make 500k plus there are also side hustles like research in the office, moonlighting, speaking engagements for industry, that can all add significant income on the side for any specialty. I’ve met nephrologist with research protocols running in their clinics making over 600. Don’t believe these charts. I’m a cardiologist I’ve seen low end 280 and high end 800 plus this is very superficial what is published here. A good plastic guy will make over three million. The orthopedics guy in my town owns a private jet. Business makes money not working and getting a pay check. Go to an underserved area and run a good biz and an internist can make a million a year. Stress tests, ultrasound, wound care, xrays, veins, etc.

    • Doc for life, you make valid points about the impact of geography not only on earnings, but also cost of living. In fact, my brother is an EM physician in a medically underserved area who enjoys a higher income and lower expenses vs. if he had accepted job offers in popular major cities.

      Perhaps geography can be the topic of a future article. But for the purposes of this piece, the data clearly demonstrate that certain specialists, on average, earn higher salaries than specialists in other fields.

  • When I graduated medical school I prioritized the wrong things when choosing my specialty. A part of me was the prestige factor, I wanted to become a surgeon because I thought that the profession was exciting and it was cool to say you are a surgeon.

    However 2 years into my residency (out of 5) I knew it was not a great match. The lifestyle for a surgical resident (before they had work hour limitations) was pretty brutal with early morning rounds coupled with late nights and frequent call). The fact that I saw that the attending lifestyle was not that much better also had an impact on me as I did not want to continue like this into my 50s-60s.

    I then made the difficult decision (but the right one) of changing specialties and switched to radiology. Best decision I ever made. Much more lifestyle oriented plus I think the added bonus was I probably have earned more as a radiologist than I would have as a surgeon.

    Money is definitely not the reason why you should pick a specialty. You can earn a great living regardless of specialty, but if you are burned out by following the money and working in something you don’t enjoy you will end up having less lifetime earnings than a lower paying specialty you can have a much longer practice in.

    • Thanks for sharing your journey, Xrayvsn! I’m so glad to learn that you made the difficult decision to switch to radiology and that you anticipate enjoying your career more than if you had continued with surgery.

      I agree that money should not be the reason you select a specialty, but I think it should–and does–play a role. Of course, the ideal is choosing a specialty you love that allows you to enjoy your desired lifestyle.

  • saildawg

    Is Ophthalmology no longer considered medicine? I just don’t see it mentioned on any of the reports, which makes me question the data. I was hoping it would validate my experience of being paid extremely low out of residency and then growing into the income over 5 years.

    • Hi saildawg, I was likewise surprised that ophthalmology was not listed in the data I referenced.

    • eyebulls

      +1.

      Ophthalmology salary, practice buy-in policies, and ultimate earning potential occupy a wide spectrum on the career timescale: residency graduation to partnership to full career maturity (perhaps up to 10-15 years out, or longer if you’re among the 50% who change jobs early on). I doubt it’s ever been quantified accurately for newcomers, and I bet a lot of us have similar experiences with really low initial salaries which then blossom after partnership buy-in. Opportunity cost is a legitimate consideration, but I would argue it’s offset by work-life balance and autonomy. In fact, it’s the autonomy that correlates with such a wide variance.

      Another paradox: the earning potential and autonomy are contingent on maintaining a longterm (15-20 year) “marriage” to a single practice and location – to the chagrin of younger FIRE-oriented physicians.

      • saildawg

        Couldn’t agree more. Medicine in general is not an efficient path toward FI, and in particular small private Ophthalmology practices are an even less FI friendly. Graduate with a ton of debt, make significantly less money than your peers upon graduating (especially compared to those in competitive specialties similar to Ophthalmology), then go further into debt to buy into expensive practice with expensive overhead/equipment. Later down the line hopefully will make significantly more and then find someone to buy it from you.

  • The best advice that I got, I thought was a bit pessimistic at the time. However, I have seen how it plays out and it was very wise. The person who gave it was actually a very positive person who was near the end a long career and stuck out as someone still loving it.

    It was to not worry too much about what you like about a specialty. That is easy and there are parts about every specialty that are really great. Make sure that you either enjoy or aren’t at all bothered by the patient-type or task of that specialty that drives most people crazy. Each specialty has them and they are usually politically incorrect to talk about because that wouldn’t be altruistic and endlessly empathetic. If that gets to you, it can steal the joy from the rest. We all have finite wells of altruism and empathy to draw upon and it is easier to empty the well than to refill it. Over-drawing is what usually drags doctors down in the end.
    -LD

    • Loonie, I appreciate you sharing this atypical and insightful piece of advice! Essentially, the person who gave it to you was advising you to protect against the downside risk. If your professional lows never get too low, you can be set up for long-term career success and fulfillment.

  • Income is an important factor that should not be overlooked.

    I agree that there is significant variation in your income based on how and where you choose to practice your speciality. But this doesn’t mean that the average income of the specialties is not an important factor to consider.

    I would venture to say that the majority of physicians could conceivably be happy doing any number of specialties. Things like income, expected schedule and workday, and length and intensity of training are all important.

    I thought this was a thoughtful and good breakdown of some important factors to consider when thinking about your specialty choice.

    — TDD

    • I’m glad the article resonated with you, The Darwinian Doctor! You make an excellent point that most physicians can work in a number of suitable specialties. It’s important that physicians-to-be weigh the factors you listed according to their priorities and values.

  • Remuneration is related to practice structure. When I got out of the Navy I started with locums because I didn’t know how practices work. My locums experience allowed me to see several practices generally under duress, which is why I was there. My eventual job was FSPP as a solo practitioner. A group of us formed a co-op that shared billing and business expense. As an anesthesiologist I didn’t need an office just a billing office. This is a fact not covered in this article. My income was my billing minus a very small billing office fee and malpractice. I never made less than the plastic surgery guy listed above because my cost was shoe string. I also taught myself pain management while in the service, so I started a limited scope pain practice where physicians could send their patients for pain procedures. That practice added about 2 hours a day to my day 4 days a week (8 hours) and added an extra 300K to the bottom line. Pain procedures were done in the hospital and surgery center in the special procedure area, so the hospital got the facility fee and paid for the trays I needed again low overhead. My billing office kept my book and set up the procedures with the hospital.

    It was hard work and I was busy doing my share of the anesthesia practice and the pain on the side, but the key was I was the boss. I didn’t work for anybody but myself. I ended my career running a surgery center and sill had a pain practice. My partner was a couple years older and started talking about retirement so we sold the practice to a national corp and we continued as employees. I immediately took a 50% pay cut which was skimmed by the national corp, but we didn’t want to quit before there was a succession plan in place, and the job had great bennies so I stayed employed to cover my family until I turned 65. I still did pain but didn’t get paid for it but no problem. After 25 years I had a huge number of patients and was known far and wide in the community a good enough reason for me to continue. The point is you can make medicine into anything you want. You want an employee job you will get a salary, benefits and a lot of work, working for the man. If you want to be your own boss figure it out. You get to keep all the risk and no guarantee of income. Changing insurance contracts and medicare changes were always on the horizon and the pressure on reimbursement was always pointed into the ground. If I had started as an employee not sure how long I would have lasted. I had friends who cleaned up doing locums, work 6 months a year vaca 6 months. Again it’s what you make it.

    • Thanks for sharing your wisdom, Gasem! Chosen specialty is just one piece of how your career satisfaction and earnings will turn out. The different settings in which you can practice and arrangements you can have will significantly impact things.

  • morpheus

    I’m a bit surprised to not seen mentioned (and from a psychology guy particularly) what, for me, seems essential.
    That is: the emotional connection with the task.

    We all have different personalities, from wildly exuberant to deep introverts.
    Some of us can connect with anybody while others cannot stand the contact of humans beyond superficial encounters and many of us hate the emotional drama of some specialties.

    There is no recipe of course. Just a feel for what resonates deeply, what makes us happy or unhappy.

    I started as ER doc but the repetition of what seemed to be always the same stuff (from twisted ankle to chest pain) bored me to death (contrary to the TV hype) and most importantly I did not like to interact with the families, especially the parents.
    I went into an introvert specialty where I have no contact with the patients other than procedures.
    And am very happy I did.
    I have a brilliant friend who is a master at autopsy: the ultimate in human contact.

    Hard to quantify, but to click with a specialty is an overwhelming feeling. And usually the right one.

    I agree that income is essential. Critical.

    • morpheus, I agree that emotional connection plays a role in work satisfaction. This would fall under “Consideration 3: Interest in day-to-day work”. You’re right that I should’ve been more explicit in highlighting emotional interest in day-to-day work in addition to intellectual interest.

  • JSA

    I’d also add job availability. It’s irrelevant if you’re fine working anywhere in the country. But if you have someplace specific you’d like to work, due to family, interests, personal reasons, etc. I think the local market for particular specialties plays a role. I have MD colleagues who want to live/work near family but can’t because their specialty is saturated, they’re hyper-specialized, limited options, etc. In many cases, had they done primary care or at least stayed more generalized, they would’ve had more options.

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