(To) Specialize, or not?

 

Let’s start by defining specialty, which basically refers to advanced training. According to the American Association of Colleges of Osteopathic Medicine, “Today, all residency-trained physicians are considered specialists, even if the specialty is a primary care specialty." Subspecialty physicians refers to physicians who have completed a residency and then chosen to continue training in a particular aspect of their specialty field, such as an internal medicine physician continuing in an oncology fellowship.

Most students in medicine understand the complicated nature of residency. It can be a scary process. If you don’t attend the "right” school, you may not even be able to pursue the specialization you have in mind. That said, your experience as a medical student can transform your opinion of where you belong and what you will practice. Should you specialize or not? A medical student in her first few years may think she wants to become a radiologist. Radiology can become a highly specialized field if the student pursues a subspecialty such as neuroradiology, musculoskeletal radiology or interventional radiology, among many others, for a total of 4 to 5 years of residency. Before we dive into how (To) can help this medical student find the right training programs along the way, let’s examine some critical factors that she should consider alongside education (largely guided by geography).

Residency is, but shouldn’t be, a bit of a “black box.” Medical students say application for residency is one of their greatest stresses. We have written about anxiety and fear surrounding "The Match" (a process we believe adds unnecessary stress to a medical student’s plate and is focused on application placement efficiency). This article doesn't center on that aspect of placement. Instead, we want to call attention to how (To) can reduce and ultimately relieve placement stress by empowering individuals during the process.

Location is a valuable component for decision making for a number of reasons, particularly as it applies to medical residency because where doctors train is often where they end up practicing (for the first few years or maybe the rest of their careers). That said, doctors should consider the transitory nature of their subspecialty training.

For example, if you become interested in a specialty or subspecialty that requires extensive training beyond the average 3-year residency, have you considered time in practice related to that specialty? Radiology is a great example of this, because it has many subspecialties and requires extensive (5 years) and EXPENSIVE training in order to practice. Radiology is also known for paying well. In a 2016 survey completed by Medscape, radiologists reported an average salary of $375,0000. Medical students know that if they can put in just another year or two, they will be paid considerably more over their lifetime versus family medicine or pediatric physicians, who in 2016 reported an average salary of $204,000. But what if those additional years of training, combined with the rigors of radiology practice, result in a lower quality of life and diminished happiness? What is the right choice?

Most radiologists will tell you they are happy in their profession and would choose it again, but also that they suffer from an oversupply in their field. While our overall physician shortage is and will continue to be an issue, growth in radiology has flat-lined. This should come as no surprise because it is a tech-centric field with little patient interaction. In a world of developing robotics and digital imaging enhancements, technology is largely replacing the human eye. This is not to say that radiologists will never again be in demand, but right now they are not.

This also means it’s less likely that public loan forgiveness programs will be available. Radiologists will probably have to negotiate a very high salary in order to relieve themselves from student debt. This might not sound important, but if someone is indifferent to the field and there really aren’t many financial benefits to pursuing additional training, why enter it? As a pre-med or med student, this should certainly be considered. A high cost of training becomes oppressive when one has nowhere to practice. And what if opportunities are not in the desired locations? What other professions or specialties should be considered to meet lifestyle and location demands?

Radiology is also not like other clinical specialties that keep doctors on their feet most of the day. The nature of the work is quite different from primary care fields. Radiologists may have some patient interactions, but their role is more about review and diagnosis performed at their workstations. Radiologists may have to join a gym or live in an area conducive to outdoor exercise to preserve their own health and fitness.

Radiology is a particularly expensive specialty to pursue, and most physicians in their “early years” (ages 30–40) are still paying back student loans that can average 3–4 times those of a family medical doctor. We interviewed one radiology graduate with almost $430,000 in student loans to repay! This of course isn’t the case for everyone, and it doesn’t mean you shouldn’t pursue radiology. Consider, however, that your desired quality of life can be deferred by difficulty with personal finances. Add loan repayment and a move to a high cost of living in city like Washington or San Francisco, and suddenly the paycheck that was “so much higher for only a few more years of training” may not be as attractive as it once seemed.

To better understand the geographic and financial considerations associated with a career in medicine, let’s examine a brief case study. As a medical student, Maria graduated with $176,000 in student debt (about average), and is in the middle of a 3-year residency in family medicine in Washington, DC, as part of a Howard University program. While she has loved her time on the East Coast, she desperately wants to return to her home state of Texas. Maria chose family medicine primarily because of its extensive patient interactions and experiences, and because she knows that the world needs great, passionate family medical doctors. Compared to some of her friends pursuing other, traditionally higher paying subspecialties, Maria will not make “a lot" of money, but she knows that high demand for family doctors in her home state of Texas will lead to a higher quality of life for her over the long term. Specifically, Maria wants to be in Austin; here’s why her choices to date bode well for her future:

  1. In terms of earning potential, family medical practitioners in 2016 earned on average $186,960. In Austin, Maria’s dollar goes a little further due to the city's low cost of living, translating to $189,807. By comparison, if she were to stay in Washington she might earn $182,400 (which doesn’t sound like much of a difference), but because of the capital's high cost of living it translates to $151,495 —a HUGE difference!
     
  2. Texas needs doctors, particularly those in primary care such as Maria, and therefore she has the ability to take advantage of a number of federal and state loan repayment programs. For example, Texas offers “Physician Education Loan Repayment” to all physicians (MD or DO) in various primary care fields who agree to practice in a Health Professional Shortage Area (HPSA) for four consecutive years, which results in repayment of student loans up to $160,000 during that time. That’s almost all of Maria’s loans to date, which means that Maria will have paid virtually nothing for 7 years of medical education and training—because she decided to pursue family medicine in Austin, Texas.
     
  3. But wait, that’s not all. How does Maria identify where HPSAs are? Are there any around Austin? What are they like? Turns out there are a number of job opportunities in Austin that Maria can pursue that qualify as part of a HPSA. With (To) she is able not only to determine where those are, but also to take a look at other family medicine positions that she might want to pursue after her four years of HPSA service is complete. (To) geographically tags shortage areas by neighborhood, and presents jobs in locations based on her specialty while also introducing Maria to communities in the area where she may consider practicing (after all, Austin is a big place!).

It is for these sorts of scenarios that we designed the framework of (To). Had Maria pursued a subspecialty, she might not find herself so lucky—only specific specialties in certain areas will support loan repayment or scholarships. Had Maria chosen to pursue radiology, her path to pay off her loans and get back to Texas where her heart is would not be as clear. First, radiology is NOT one of the qualifying specialties for federal loan repayment because it does not fall under primary care. Second, in PracticeLink’s (the most widely used online physician job bank) data base for radiology in Austin, there are actually no positions currently available. While that might only reflect a temporary lack of radiology jobs in the area, it would be concerning to Maria had this been the path she chose. Currently there are only 186 radiology jobs listed on PracticeLink’s site across the United States vs. 4,855 active family medicine positions. You can see that not only is demand higher in family medicine, but also the probability of landing WHERE you want to be is far greater.

Our final thoughts: In medicine, primary care fields often lead to subspecialties. There’s nothing wrong with family medicine or internal medicine or pediatrics as a career choice, and you don’t have to specialize before you enter practice. Instead, you could enter practice as a family medical doctor, pay off your loans, and use the time to decide whether additional specialization is something you want to pursue. There’s no question that you should become the type of physician you feel called to be. That said, at every stage of your career and your life you should know your many options for the future. If you have student loans that need to be repaid, consider that your choices now can lead to the lifestyle you desire sooner rather than later. As a physician in training, you may feel like your life is "on hold," but it’s not. These are all experiences that comprise your life and lead to WHERE you’ll go next. It will help to put location to work for you (and not against you) from the beginning, so that the process doesn’t become or feel overwhelming.

 

Sarah Linden

myPlace-Seed, LLC, 901 N Washington St, Suite 208, Alexandria, VA 22314

Where matters, because place can make you better!