Medical students’ selection of specialty is one of the most important choices they will ever make. But the decision of which medical specialty to enter can be difficult for many students. One of the difficulties lies in the fact that it is impossible for students to sample all their options while in medical school (approximately 20 specialties in total, not including subspecialties), let alone determine the ideal location to undertake training — assuming they match to their first choice.
Another reason choosing a specialty may be problematic is that medical fields change over time. My specialty of psychiatry, for example, was founded on the principles of psychotherapy — psychoanalysis in particular. But there have been significant declines in the provision of outpatient psychotherapy by U.S. psychiatrists over the past two decades. In the 2010s, about half of psychiatrists did not incorporate psychotherapy into their practice, yet psychotherapy training continues to be required by psychiatric residency programs in order to maintain accreditation.
To choose a specialty, medical students need to think like Wayne Gretzky, a hockey player considered the greatest of all time. When asked how he managed to play so well and score so many goals, Gretzky said he skated to where he thought the puck would be, not where it was. By focusing on the future — where the puck is going to be — students can set themselves up to remain ahead of the curve and enjoy a specialty that will hold their interest for a lifetime. Choosing a specialty with staying power can also help them avoid burnout.
I’m no Wayne Gretzky, but I did tend to think like him when it came time to choose my specialty. I majored in psychology in college, and I always had an interest in the relationship between the brain and behavior. In my final year of medical school, I was well aware that the field of psychiatry was loosening its grip on psychotherapy and gravitating to an understanding of the biological basis of behavior. In hockey terms, my specialty choice was based on where I thought the puck was going to be, i.e., where the field of medicine was trending, particularly the practice of psychiatry.
There is an underlying assumption contained in Gretzky’s quote: We can predict an outcome (where the puck is going to be) based on the detection of certain signals (where the puck is and what is happening at the time). To make sure I had a full view of the hockey arena, I consulted one of my mentors — a neurologist. I was equally as interested in neurology as I was in psychiatry, and I vacillated between the two disciplines.
I shared my dilemma with my mentor, and he replied, “Well, Art, if you want my opinion, one day psychiatry will become a subspecialty of neurology.” The neurologist’s forward-looking comment did not come true — at least not yet — but it is a fact that we now consider serious mental illnesses the equivalent of brain disorders, and both neurology and psychiatry have long been governed by the same Board of the American Board of Medical Specialties — namely, the American Board of Psychiatry and Neurology.
Today, the landscape of medicine looks vastly different than it did when I trained in the 1980s. Back then, artificial intelligence, telehealth, genetics and gene editing, and complementary and alternative medical practices were barely on the horizon, if at all. In my eventual area of specialization — pharmaceutical medicine — clinical trials were conducted at the site of the principal investigator, usually an academic medical center. Nowadays, decentralized clinical trials are the big rave. We are in the process of enabling clinical trials to be conducted at the home of subjects, much like making house calls. Decentralized trials aid in the recruitment and retention of subjects, increase the speed of the trial and diversity of subjects, and facilitate data collection.
Whether in practice or in industry, predicting how clinical scenarios will unfold is key to choosing where and how you may want to spend your working time. Unfortunately, critical areas of medicine are often the least satisfying specialties because advances in those fields tend to occur at a slow pace. On the other hand, specialties perceived to be dynamic and rapidly changing, and that offer a diversity of work, often provide the greatest personal fulfillment. Paraphrasing Bob Dylan, you don’t have to be a hockey superstar to know which way the wind blows. But you do have to do your homework and consider whether a given specialty is likely to innovate or remain stagnant.
As I previously mentioned, consulting with mentors — often academic faculty — can be helpful in arriving at a decision. Ironically, in my case, a physician who was not a specialist in my field influenced my decision. But just to be certain he had guided me in the right direction, I sought the advice of a well-known psychiatrist on staff at my medical school. I told him what the neurologist had said about how psychiatry is becoming absorbed by neurology. The psychiatrist paused and commented, “No, Art. The neurologist is wrong. Tell him one day psychiatry will become a subspecialty of toxicology.”
I think they were both correct!
As you think about your current or intended specialty, can you visualize its future and how it will impact your practice and career satisfaction?
Arthur Lazarus, MD, MBA is a 2021-2022 Doximity Luminary Fellow. He is a member of the Physician Leadership Journal editorial board and an adjunct professor of psychiatry in the Lewis Katz School of Medicine at Temple University in Philadelphia, Pennsylvania.
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