American College of Physicians: Internal Medicine — Doctors for Adults ®

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Subspecialty vs. general medicine: Which path is right for you?

By Ingrid Palmer

It's a question you've heard countless times from housestaff, mentors interested in your future and even your own nagging inner voice: Are you going to subspecialize or go into general internal medicine?

If you came to the profession with specific career goals that have never wavered, the question produces nothing more than casual conversation. If you're like many residents and struggling to make a decision, however, the question is likely a source of considerable apprehension

"Whether to stay in general medicine or subspecialize is an incredibly difficult decision," said Michael C. Ott, ACP-ASIM Associate, a pulmonary fellow at the Mayo Clinic in Jacksonville, Fla. "Many years of thought go into it.

At the same time, it's a decision that you need to make relatively quickly, typically by the early part of your second year of residency. (For more on how to get a subspecialty fellowship, see "Tips to find a fellowship in a competitive market" ) The trouble is that if you're undecided, you don't have much time to make a decision.

What can you do to make sure you make the right decision? Here are some tips to guide you through the process:

  • Get hands-on experience- One of the best ways to explore your options is through hands-on experience in the subspecialties you think you might want to pursue. Program directors say that doing a rotation in a subspecialty area before making a definite decision not only allows you to make sure you enjoy it, but it also provides opportunities to make contacts when you apply to fellowship programs.

    "We spend a lot of time late in the first year having residents think about what they may want to do down the road," said Steven R. Craig, FACP, director of the internal medicine residency program at the University of Iowa in Des Moines. "If they have an inclination toward a subspecialty, we work with them to arrange their schedules so that they can work in that area for a month."

    Getting experience early on can save a lot of heartache down the line. It is not unusual, said Dr. Craig, for interns to be absolutely convinced that they want to work in a particular subspecialty, then change their mind after a month on a rotation in that area.

    Eric B. Milbrandt, ACP-ASIM Associate, Chair of the College's Council of Associates, cautioned against deciding on a subspecialty based on one good rotation or a particularly good experience with someone in the field. "We all have mentors we'd like to emulate," Dr. Milbrandt said, but it's important to ask questions and find out the pros and cons of the areas you're considering from a number of people who work in that area every day to make sure you'll be happy.

    Dr. Milbrandt also urged residents not to run away from general medicine. "Lots of people get turned off of general internal medicine because of their experience in residents' clinics" that are often overbooked, understaffed and full of difficult patients, he said. "But that's not really what it's like to work in primary care. You see a lot of healthy people who need regular checkups or who have general health concerns." In addition to testing out subspecialties through month-long rotations, Dr. Milbrandt said, residents should also work with a general practice doctor in a community-based setting.

  • Don't force a decision- While the competition for fellowship slots is fierce, Dr. Craig cautioned against letting application deadlines force a decision. He said that residents who need more time to decide have plenty of other options to explore.

    Even if you wait until your third year of residency to apply for fellowships, he said, you can spend the following year working as a hospitalist, volunteering, working in ambulatory clinics or emergency rooms, taking a junior faculty teaching assignment or serving as chief resident for a year. "There are always productive things you can do for an extra year before you start fellowship training," Dr. Craig explained.

    Some physicians choose to postpone the decision for even longer and practice as generalists for several years before entering subspecialty fellowships. Though there are some drawbacks to this approach--trading a fat salary for a small stipend is one--Dr. Craig said it is a good option for some physicians who need more time to decide.

  • Study the job market- Whether you are leaning toward general practice or a subspecialty area, you should consider the state of the job market. Residency program directors recommend that you spend some time researching where jobs are available and what kind of compensation you can expect in subspecialties in different geographic areas. Try to determine which subspecialties are expected to need an increase in doctors and which are already saturated.

    Like any other industry, medicine is affected by the cyclical phases of supply and demand. For instance, as the baby boomers-currently the largest segment of the population-slip into middle- and older-age, the need for physicians specializing in areas like cardiac care and geriatrics is expected to increase. Analysts have also said that as managed care reduces the demand for subspecialists, generalists should remain in high demand.

    Keep in mind, however, that trends change quickly and often without warning. In the early 1990s, Dr. Craig said, "we needed more primary care physicians and many subspecialties were oversaturated. This led fellowship programs to cut back the number of people they would train because graduating fellows were having a hard time finding jobs. It made residents think more about going into primary care."

    In the early '90s, Dr. Craig said that approximately seven out of the eight graduating residents in his program were staying in general medicine. But about four years ago, the number of residents entering fellowships went up again, with four out of eight going into a subspecialty.

    Holly J. Mattix, ACP-ASIM Associate, a second-year nephrology research fellow at Boston's Massachusetts General Hospital, said that many of the predictions she heard earlier in her training have not panned out. "When I was in residency, it seemed like everybody was trying to push you into choosing primary care," she said. "You heard how there wouldn't be jobs out there for cardiologists or pulmonary people, which is not true." What is true, she said, is that you may not get your first choice of a hospital or location in these highly competitive subspecialties.

  • Look at lifestyle- Residents may be attracted to certain subspecialties of internal medicine because of the glamour factor. Subspecialties that are more procedural and offer high-profile positions may be appealing.

    Areas like pulmonary medicine, cardiology and gastroenterology are popular because they may give doctors the chance to produce dramatic saves, they are exciting technologically, they garner respect in the community, and they offer high earnings potential.

    But Dr. Milbrandt urges residents also to consider the time commitment. "These fellowships are pretty intense and the lifestyle of some practicing [subspecialists] is also demanding." He said that residents need to think about their lifestyle down the road because there are other areas of internal medicine that are not as high pressure and emotionally draining.

  • Assess your personality- Educators recommend taking a critical look at your own desires and abilities before making a decision. (See " Can't decide whether to subspecialize? Take this test," below.)

    "Some residents really want to be more of an expert in a given area," Dr. Craig said. These physicians prefer to treat patients on an as-needed basis rather than over a long period of time. "Some people love being in the cath lab and doing major cardiac procedures, while others really enjoy being in GI and doing the different endoscopic procedures they learn in practice in that specialty," he explained.

    On the other hand, residents inclined to general medicine exhibit different traits and preferences. They often want to care for members of the same family and have a lot of variety in their day-to-day activities. "And let's face it," Dr. Craig said, "if you stay in general medicine, you have to have good interpersonal skills and like that interaction."


Can't decide whether to subspecialize?
Take this test -

On the fence between general and subspecialty medicine? Try answering the following questions before deciding whether a subspecialty or generalist career is right for you:

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  • Was your decision to become a doctor based on a love of a certain area of medicine?
  • Do you have an intense interest in or fascination for a subspecialty area?
  • Does a subspecialty or generalist career better fit your lifestyle and financial goals?
  • Do you respect and admire those you know currently working in the area that you're considering?
  • Does becoming an expert, or mastering a specific area of internal medicine, appeal
  • How do you feel about the role of consultant?
  • Do you enjoy performing procedures?
  • Do you prefer working with patients on a short-term or long-term basis?
  • How much variety would you like in your daily routine?
  • Do you have good interpersonal skills and enjoy interacting with others, especially families and extended families?
  • How comfortable were you during your general medicine rotations? Are you considering a subspecialty primarily because you disliked your general medicine experience?
  • Were any subspecialties appealing to you, either before you entered the residency program, or as you completed your first year?

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