Twelve Steps for Choosing a Specialty

Question

I need to declare a medical specialty before long, but I have so many conflicting feelings and thoughts about various clinical areas. How can I make the right choice?

Response from Anne Vinsel, MS, MFA Project Administrator, Graduate Medical Education, University of Utah Medical Center, Salt Lake City, Utah

It's time for fourth year students to get serious about choosing their specialty area. Some of you are lucky, and everything lines up: you know which clinical area interests you most, your board scores and grades/letters are all in the correct range, and you have helpful professors on your side. For you, it's just a matter of doing the paperwork on time. You can stop reading here.

But I know there are many others of you out there who aren't sure what specialty to choose. Or, you're torn between 2 or 3 specialties. Or you know what you don't want but aren't sure what you do want. Or you know what you want, but aren't sure if your qualifications are strong enough. Read on!

If you're stuck, here's a decision tree to follow:

1. Find or make a list of all the specialties available directly after medical school (ie, skip fellowships).
2. Cross off the ones you definitely don't want. You don't need a string of reasons beyond the fact that you simply can't see yourself doing it long term.
3. Perform a Google™ search with the phrase "choosing a medical specialty." When I tried it, I got about 89,800,000 entries. Set a timer for no more than 1 hour and browse through the first several pages. Take some of the "what specialty are you?" quizzes. If nothing else, they will give you some ideas and possibly make you think about specialties you haven't explored. You can safely avoid making an exact ranking of specialties at this point. Just see which specialties you seem to be most suited to and which you should rule out.
4. Now, list several specialties you can see yourself doing long term, no more than 6.
5. Research those specialties in your institution. Go to the departments and make friends with the residency program coordinators. If you haven't already done so and haven't rotated in the program, arrange to shadow a faculty member for a day. Talk with 1 or 2 residents and check out the pros and cons of the specialty. Finally, ask the program coordinator if your board scores would be in a competitive range. Most program coordinators won't share their board score cut-off, but they likely would tell you if your scores are within range.
6. Narrow your list to 2 or 3 specialties. Now, and only now, talk with family and friends. Tell them you're thinking of these specialties, and get their opinions. Listen hard, and get them to articulate the basis for their opinions.
7. Delete any reasons related to job shortages or oversupply of physicians in a specialty. You don't need 200 jobs, you only need 1, and you should be prepared to relocate somewhere less attractive if you choose a specialty that's overcrowded or not in much demand. Plus, demand can change by the time you finish training.
8. Delete any reasons related to lifestyle or money, unless those concerns come from your significant other.
9. Delete heritage reasons ("Your father is a surgeon; you should be one, too").
10. Now, write down your own pros and cons, independent of all the advice and aptitude testing and board scores. Be honest here. If your priorities are lifestyle, having children during residency, income, opportunities for foreign travel, or avoiding rough circumstances, then rank them appropriately. What fascinates you, what could you be passionate about? Don't be at all logical here.
11. But do be logical in this next step. And brutally honest with yourself: Did you barely pass the boards? Internal medicine might not be for you, even if you really enjoy outpatient medicine. Do you tend to avoid or dislike patient contact? Don't consider family medicine or pediatrics. Do you have high board scores, want a benign lifestyle, but aren't very visual? Don't pick radiology.
12. If you follow all these steps, combining thoughtful reflection on what makes you happy with an objective look at your strengths and weaknesses, one option should start singing out louder than the others. And that's your specialty.

Note that you should take other people's views of your strengths and weaknesses into account, but not necessarily follow their advice. Spouses are a special case because you are making a joint life together. Still, the final decision should be yours, informed by some actual data that help you determine "the best fit" between you and your specialty-to-be.

You can do this in a week; don't procrastinate and don't make the problem bigger than it is. If you choose a specialty that turns out to be a bad fit, you can still change after the first year.

Be practical, but don't limit yourself. I know a physician who started medical school at age 38, one who had to take the boards several times, one who barely passed one of her steps by 1 point, and another who doesn't like patient care. The first one is now practicing radiology in a large private clinic, the second is a fellow in a high-risk obstetric anesthesia program at a very prestigious academic medical center after switching from surgery because of physical limitations, the third is a fellow in a neonatal intensive care unit after completing a successful pediatrics residency, and the last is working for a large drug company doing information technology, his real love.

Even if you are "nonstandard," you can find a specialty you will love and which will value you. Good luck!

AMA opposes SGR proposal

Based on conversations with policymakers, the AMA cannot support an emerging proposal to address the flawed Medicare physician payment formula. The result in five years would be steeper cuts for physician practices, making it much more difficult—if not impossible—to achieve the objective of permanently repealing the “sustainable growth rate” (SGR).

It is our understanding that a draft proposal developed by the U.S. House of Representatives and the U.S. Senate congressional leadership would provide for statutory updates of 2.2 percent for the remainder of 2010 and an additional 1 percent increase in 2011. Short-term positive updates are no doubt attractive. From 2012 through 2014, physician updates would be determined by two expenditure targets that were proposed by H.R. 3961. We believe updates during this period would likely produce modest increases for E&M services and no less than a freeze for other Medicare services. In 2015, physician payments would be scheduled to revert back to the current SGR formula with a projected cut of no more than 37 percent. While this cut would result in a 2015 conversion factor in line with that projected under current law, the update baseline will continue to fall during these five years as a result of the underlying SGR formula. By 2015, we believe that the price tag to permanently repeal the SGR, or even to extend the proposed 2012-2014 policy, could exceed $500 billion.

The AMA fully appreciates the fiscal challenges confronting Congress and our nation today. The cost of permanently eliminating the currently scheduled Medicare cuts is approximately $250 billion. For the last several years, Congress has chosen short-term remedies that have resulted in larger future physician payment cuts and made it much more expensive to scrap a formula that Democrats and Republicans have both said should be repealed. Five years ago, the price tag for repealing the SGR was $49 billion.

Twice this year, Congress has allowed 30-day extensions to expire, creating turmoil for patients and physicians because a 21 percent cut became the operative policy. On June 1, the current extension will expire again.

Failure by Congress and the Obama Administration to properly solve this issue will intensify access problems for seniors and military families enrolled in the TRICARE program, and severely undermine implementation of recently enacted health system reform legislation. An existing physician shortage will be magnified and steeper cuts will prevent practice and delivery innovations.

Everyone in the health care community and Congress would like to see this problem go away. However, the AMA believes that greater long-term insolvency is too steep a price to pay for a temporary solution. We believe that policymakers must once again go back to the drawing board and make the tough decisions necessary to provide the funding to fulfill the obligations made to Medicare patients and military families, without steep cuts for medical services.

Contact your members of Congress. Urge them to pass legislation to avert a 21 percent cut on June 1 without increasing the cost of a permanent solution, and preserve access to medical services for Medicare patients and military families. We should not mortgage the future of the private practice of medicine. Growing the problem is not the solution!

Will a Negative Evaluation Ruin My Residency Options?

Question

How should I deal with negative evaluations, especially ones that are written by attendings and may end up in my dean's letter?

Response from Sara Cohen, MD Polytrauma and Brain Injury Fellow, Boston Veteran's Administration Hospital, Jamaica Plain, Massachusetts

The best way to deal with a negative evaluation is the same as the best approach to any medical condition: prevention, prevention, prevention! If you're having problems during a rotation, the first time you hear about it shouldn't be while reading your evaluation. If you feel that your attending doesn't think you're performing up to speed, ask him or her what you can do to improve. Even if you think you're doing well during a rotation, it's always a good idea to schedule a mid-rotation evaluation, just to see what areas of your performance need improvement. If nothing else, the attending will likely applaud your initiative and appreciate the efforts you make to become a better clinician.

That said, if it's too late and a negative evaluation is already staring you in the face, read it carefully and be honest with yourself: Are the criticisms justified? Ask your fellow med students and supervising residents if they feel that the evaluation was fair. Sometimes personalities can clash and an attending may write an overly harsh evaluation that isn't indicative of your performance. If you feel that this is the case, it's usually a good idea to speak with the clerkship director and express your concerns. At some institutions, the burden of proof lies with the attending to demonstrate that he or she gave the student constructive feedback and allowed for a chance to improve. If the evaluation is determined to be unjust, it may be removed from your record.

However, if the clerkship director does a thorough investigation and strongly feels that the evaluation is accurate, it's usually a good idea to stop there; you might earn yourself some enemies by persisting in your attempts to have the evaluation removed. Try to remember that evaluations serve a purpose: This is constructive feedback that should be used to improve your performance and become a better physician. It's better to discover your weak areas early rather than when you're farther along in your training and it's harder to change. Use the negative evaluation as a guide for the things that you must change in order to do well on future rotations in the same field. If you are interested in matching in internal medicine and you did poorly on your medicine clerkship, this will likely be outweighed by a stellar performance on your medicine subinternship.

As for how this negative evaluation will affect your dean's letter, remember that the dean is on your side. Although the dean's letter (also known as the Medical School Performance Evaluation) must accurately convey your performance in medical school, the dean has an interest in helping you and your classmates land the residencies of your choice. Every comment from every evaluation cannot possibly be included in the letter, so the dean usually will focus only on negative issues that arise repeatedly. Therefore, a single poor evaluation likely will be downplayed. Furthermore, if you can prove to the dean that you've made an effort to improve your performance in the areas where you received repeated negative evaluations, this can be emphasized in your letter.

For example, a good friend of mine had trouble waking up on time for his ob/gyn rotation, and his tardiness was noted in his evaluation. He subsequently made a special effort to show up early every morning and even was complimented in a later evaluation for his punctuality. Because he made an effort to change, the dean told him that he would emphasize in his letter that he took the negative criticism in an earlier evaluation and used it to become a better student.

Unfortunately, sometimes there's nothing you can do about a bad evaluation. Perhaps it came late in the year or it's not possible to improve on the particular criticisms. At that point, it's important to know that the evaluation may be included in your dean's letter and so you should be prepared to give an articulate explanation if asked about it during an interview. Acknowledge the criticisms and explain what you will do to improve in the future in order to make you a better physician.

The most important thing to remember is not to panic. Few medical students have an absolutely spotless application, and one negative evaluation likely isn't going to destroy your chances of matching at the residency of your choice.

Should I Disclose My Marital Status at Residency Interviews?

Question

My fiancée and I have decided to apply for the couple's match, but we are unsure about whether to disclose that information as we interview. What are our options?

Thomas E. Robey, MD, PhD Resident, Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut

As if you need any more stress than is already involved in the residency match process! You are about to do it with the most important person in your life. Make sure your harness is securely fastened; you are about to depart on a 6-month roller-coaster ride. At least, that is what last year felt like for my wife and me.

There is a lot to say about the couple's match process. First, go to the National Resident Matching Program Website for some couple's basics. That site gives a good idea of how to rank your programs. How to talk about being a couple is a harder task; like the rest of your interview, it cannot hurt to practice.

In general, I recommend disclosing that you are couple's matching. There are a few good reasons to keep mum on the match, but in most cases, the reasons to disclose overshadow these. You do not have to tell anyone, but be warned: programs often talk to each other. If your better half brings it up, it may get back to your program director that you are also couple's matching.

You have an option of checking a box on your application and writing your partner's name. If you do that, some programs may ask you about your significant other. Other questioners hesitate to bring up the issue in the interview, fearing they are walking a fine line regarding illegal interview questions. If you do want to bring it up, the interview is the safest place to do so. You can gauge the conversation, and do not have to mention it with all of your interviewers at each hospital. In the end, I am pretty sure it helped me to talk about my wife.

Here are some reasons to bring up the couple's match:

• Couples come together and are usually happier residents.
• Program directors may lobby others in the same institution or city to invite your partner to interview.
• Your department may communicate with your partner's program after making the rank list, encouraging the second program to bump him or her up on the list.

If there is talking between programs, I have heard that the stronger applicant usually carries the weaker one. In the end, rank list movement only happens if the programs communicate with each other (this is variable); they know to communicate only if you have told them.

Almost every interviewer asked me about one of the hobbies I listed on my application. It is likely that your significant other is more important in shaping you than your favorite sport or craft. So why not bring up that you are part of a couple? Here are some things to consider before telling all:

• Matching in the same department, especially if it is a small class, is tough if you are from the same school as your partner.
• Same-sex partners may be wary of announcing their orientation to strangers, even if they are future colleagues.

It is unfortunate that each of these cases still exists, but revealing yourself as a couple could still yield long-term benefit. Who would want to work at a place where there is discrimination? Programs may also make exceptions to a general policy of 1 matched student per school.

In the end, this is a decision you and your partner must make together. Whatever you decide, going through the match together is a way to grow closer. Come match day, at least you can count on being in the same city as your best friend!

How Should I Rank Residency Choices for the Match?

Question

Do you have any suggestions on how to rank residency programs for the Match?

Response from Daniel J. Egan, MD Associate Attending Physician, Department of Emergency Medicine, St. Luke's-Roosevelt Hospital Center, New York, NY

The other day I was interviewing an applicant for a position in our residency program. She told me, "I think that I know who I want to rank at the top of my list." (This program, of course!). "It's the middle of my list that I'm having trouble with. Do you have any suggestions?"

It's that time of year. All of you fourth-year medical students are wrapping up or have completed your interview journey. You may have traveled all over the country. You certainly spent a small fortune for airfare and hotels. Hopefully you accumulated some frequent-flier miles in the process. You also likely have sat through 10-15 sessions describing programs, listened to residency directors try to convince you that their program is the best, and had one too many "night before" social events with the residents in each program.

So how do you make your list? Is it clear to you which program should be first? Is it less clear to you, like my medical student, what to do with the middle of your list?

The most important thing for you to take home from this process is that your rank list should be truly that. You should rank programs in the order in which you would like to match. Many people believe that there is a way to outsmart the algorithm. Or maybe one program has given you feedback that makes you think they really want you. At the end of the day, you are dealing with perhaps the most formidable time in your development as a physician, and you should go where you want to be. So the list should be your own. It should not be the order that your dean or faculty advisor says it should be (they have their own interests in mind as well) but the rank order that would make you most happy.

There are a number of factors to consider as you think about each program. The first and foremost is something that cannot be determined by a formula or list of pros and cons. The question is, Can you see yourself as a resident in that program? As you have gone through the process, you likely spent a day somewhere where you thought there was no way you would fit in. Additionally, there were likely others that left you almost giddy with the feeling that it would be a perfect fit. I still recall the chairman of the program where I trained meeting with us on the interview day. He casually spoke about a gut feeling of whether or not the glove fits. There is something important about your gut. Frankly, it is something that will get you through many difficult decisions in medicine, and choosing a residency is certainly one of those.

Certain criteria should always be considered when evaluating a residency program: patient population, tertiary care exposure, clinic experience for the specialties with outpatient components, resident independence in regard to decision-making, electives, and where graduates go for fellowships or jobs.

Other criteria that should play a role in your decision-making include:

Location. This is not insignificant. There are many glamorous cities in the country, but not every city is made for every person. Do you know anyone in the city that you are considering? Will you have any kind of support system outside of the hospital? You will immediately establish lifelong friendships during residency, and there is something exciting about starting over in a new place. But everyone has a different personality, and some people find it easier if a network already exists during a very challenging time.

Housing and salary. Is housing provided? If not, will the program's salary allow you to rent an apartment and still have money left over for your usual expenses? (See our previous columns on the accrual of credit card debt and how this should be avoided at all costs!)

Are the residents happy? You will hear rumors along the interview trail. Pay attention. Obviously, rumors are rumors, but hearing that residents in a particular program are very happy is an important piece of information.

Do you know any graduates from your medical school who are there? We all have a loyalty to our school. We want the best for students from our school. Often, these residents will be fantastic resources as you try to get real, honest information.

What is the academic vigor of the program? If you have a long-term goal related to academics, you want a program that will help foster that. If faculty members are not doing research and publishing, it may be more difficult for you to find a mentor. What are the daily or weekly conferences like? What are the academic requirements of the residents?

Teaching environment. With shorter work hours and increased patient volumes affecting all programs, many residents feel that the clinical teaching suffers. Ask about bedside teaching. The accrediting agency mandates a core content of lectures and conferences, but it is really the day-to-day operations that help you develop your clinical skills. You may best experience this with a second look. Show up on a noninterview day. See how the residents interact with each other and their attending staff.

Finally, I'll share some advice that I got from my med school dean. He told us to put Post-It notes around our apartments with each program listed in order. Put them somewhere that you will see every day, preferably multiple times. Believe it or not, that gut will start talking again. Imagine yourself opening the envelope with each program named inside, and likely you will have a different response to each one. Looking at this list and thinking about that feeling may help you tweak the order. It certainly helped me solidify my final list, as I grew more excited about the prospect of my first choice. And remember, the formula should work in favor of you, the student. Don't try to play a game. Do not shorten your list because you think you are guaranteed a spot based on program feedback. Take a phone call or email from a program with a grain of salt. Do what YOU want to do with your list!

Whom Should I Ask for a Letter of Recommendation?

Question

When I apply for residency, whom should I ask to write a letter of recommendation? Are these letters really important?

Response from Daniel J. Egan, MD Associate Attending Physician, Department of Emergency Medicine, St. Luke's-Roosevelt Hospital Center, New York, NY

As someone who routinely reviews applications to our residency program, I can tell you that letters of recommendation are very important to a successful match. The initial screening process typically involves board scores, rotation grades, medical school grades, and Dean's letter summary statement. However, after an applicant has made that cut, letters of recommendation play an important role in the evaluation process and truly give insight beyond the standardization in the rest of the application.

Several approaches to letters of recommendation can be taken. The most obvious person to ask for a letter is a mentor who knows you well. If you have worked with a mentor on a research project or have formed a relationship outside of a rotation or the classroom, this person should write a letter on your behalf. Most likely, his or her letter will provide more personal insight about you as an individual and capture the reader's (ie, the interviewer's) attention. I often pull interview questions from these letters to ask about the mentorship or project on which a student worked.

The second most obvious “letter writer” for you should be someone involved in a position of leadership in the clerkship of your specialty choice. Hopefully you have done well in the clerkship of your future specialty, and you will need to have someone from the faculty speak on your behalf. If you do not include a letter from someone in your specialty, it will be a glaring red flag to those of us reading through your application. In fact, some specialties have requirements about a certain number of letters from staff in your specialty. Be sure to find this out. Additionally, some specialties (such as emergency medicine) require a specific form letter; obviously, it is important to make sure you follow these guidelines.

The question becomes, Who should write your letter within a given rotation? A letter from a resident is not an option. A brand-new attending in his or her first year out of residency may also not be the ideal candidate. It may be to your advantage to approach someone who is more senior within the department. Ultimately, the content of the letter is important, but supportive statements from a chair, associate or full professor, or residency director will be taken seriously. Additionally, many of these faculty are nationally known, and the reader next to me may know them personally or by name, giving more credence to the letter.

Faculty members are frequently asked to write letters. People who routinely write letters include the medical student director for a rotation and members of the residency leadership. Those of us reading a letter look for certain phrases and comments. If a faculty member is not familiar with letter writing, he or she may not include these statements and it may be hard for an interview committee to interpret the letter. A medical student clerkship director will also probably include statements or at least a summary from multiple faculty members and give a consensus opinion. One individual faculty member can only speak for himself or herself. Another tip: if you are unsure of a person's opinion of you, avoid asking him or her to write a letter. Clearly, you do not want a “bad” or even mediocre letter in your file.

Some tips for deciding whom to ask:

• Speak to upperclassmen who have completed the rotation. Some faculty members in your school have letter-writing reputations.
• Consider your approach to the faculty member. I have been asked explicitly, “Do you think you would be able to write me a strong letter of support?” Many faculty will tell you that they are not comfortable writing a letter even without this specific question, but it is always hard to say "no" to someone. However, if you deliver this more directed question using the adjective "strong," it gives someone an out to say "no" if they do not think they can write you an adequate letter.
• Ask the residency director at your school for advice. Tell the residency director whom you are considering asking to write letters for you. He or she may steer you in another direction if that faculty member may not be the best option.
• Speak openly with your Dean of Student Affairs. The medical school is acting in your best interest, and the leadership wants students to be successful and match at competitive programs.

One last piece of advice: Ask for your letter as soon as possible after your clerkship, when you are still fresh in the mind of the faculty member. Also, remember that every letter you collect does not ultimately need to be included in your application. Better to have more than you need than not enough.

How Should I Plan an Audition Rotation?

Question

Can you tell me about audition rotations? When should I apply, and how can I ensure a successful rotation?

Response from Megan L. Fix, MD Assistant Professor, Tufts University School of Medicine, Portland, Maine; Director, Medical Student Education, Maine Medical Center, Portland, Maine

Also called an "away externship" and "away rotation," an audition rotation is defined by the McGraw-Hill Concise Dictionary of Modern Medicine as "a clinical rotation by a 4th year medical student interested in a specific residency program and/or target specialty in a location other than that of his/her medical school."^[1]

More simply stated, an audition rotation is a chance for you to shine and show the residency program of your choice that you are top notch.

When to Apply

Many students ask when they should plan their fourth-year audition rotations. As important as it is to plan when to do the rotation is when to apply for the rotation. Popular rotations fill up quickly, and many require a formal application. Some rotations even require an essay and a letter of support. Students should start thinking about planning an audition rotation as soon as a career choice has been made -- early to mid-third year. Ask graduating fourth-year students and mentors in your chosen specialty which rotations are desirable. Look online for the deadlines and application processes for these rotations and work with your home institution to make sure the dates will work with your required fourth-year clerkships.

When to Complete the Rotation

Most audition rotations are best completed after at least 1 solid rotation in your chosen specialty at your own institution. This valuable clinical experience allows you to perform well during the audition rotation. Schedule your audition rotation early in the fourth year before interviews, but close enough to interviews that the faculty will remember you. Typically, the months of July through December are best.

Some students choose to do an audition rotation during interview months in the hopes of doing a residency interview during the rotation. This saves money and helps the residency director really remember you when it comes time to make a rank list. Avoid scheduling your audition rotation in February because that is when most Match lists are due.

Where to Do the Rotation

Where you plan to do your audition rotation is just as important as where you plan to do your residency interviews. Remember, many graduating residents tend to practice close to where they completed their residency. Think about what is important and make your priority list first. For example, if geography is the most important priority for your residency choice, then you should make every effort to obtain an audition rotation in that geographic location. Residency directors tend to be close with their regional counterparts and frequently call each other to discuss candidates. So, even if your top rotation is unavailable, try to arrange for a rotation in that region. Alternatively, if program reputation is the most important priority for you, then you should apply early to get into an audition rotation at a particular residency.

How to Stand Out During the Rotation

An outstanding performance during your audition rotation may increase your chances of matching at that program, and a poor performance may reduce your chances of a match. Almost as important as your clinical skills during the rotation are your interpersonal skills. Know that you will be watched by everyone: the clerkship director, the residents, the residency coordinator, the nurses, the faculty, and the staff in the hospital. They want to make sure that you will be a good colleague for the next 3-7 years.

Before any audition rotation, it is a good idea to meet with a mentor in your chosen specialty and ask for specific feedback on your strengths and weaknesses. Make sure you bring a good textbook to read while you're on your audition rotation so that you can research your cases. You may be asked to give a presentation. Make this count! Consider using evidence-based articles and include handouts on your presentation topic. Everything you do during this month will be important. Be reliable. Be on time for everything, complete all tasks, and do your absolute best.

Letters of Recommendation

It is very important to obtain a strong letter of recommendation from a faculty member at your audition rotation. Some clerkships will extend offers for letters to all students on the first day. If this does not happen, try to wait until a week or so has passed and then ask a key member of the faculty (clerkship director, program director, associate program director, research director) after you have met this person. Be prepared with your CV, personal statement, and release form for your letter of recommendation.

Details

• Arrange for travel and start dates to fit with your home institution. Missing days on your audition rotation can look very sloppy;
• Ask early about housing options: Some rotations offer free or reduced-cost student housing. If that is not available, ask the residency coordinator for residents' addresses and email a few of them to ask for suggestions.
• Be appreciative of the clerkship director and coordinator;
• Be a good team player with the other students on your rotation. Do not try to sabotage other students to make yourself look good;
• Attend all didactic sessions;
• Arrive on time and plan on staying late;
• Ask for feedback early in the month so that you can correct deficiencies before your grade is assigned. Make all efforts to earn honors during your rotation;
• Try to socialize with residents and attendings outside of the hospital during your month;
• Attend journal club even if it is not mandatory;
• Be prepared for your first day. Make sure you have the proper identification, passwords, attire, parking, mental map of the hospital, etc.; and
• Be professional and respectful toward everyone during your rotation. Ask if you can do anything to help others, be kind to your patients, and communicate well with your supervisors.