Author Topic: Should I be a Generalist or Specialist?  (Read 7762 times)

echoyears

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Should I be a Generalist or Specialist?
« on: December 08, 2014, 07:35:27 PM »
Hi Everyone!

I had a question I wanted a Mustachian perspective on.

Me: I don't have much expensive tastes (except when it comes to a house, food, and spending on gifts for friends; But I like cheap used cars, used stuff, doing things for cheaper, etc). I want to have something to do with my time (e.g. work), I want to feel loved and happy and I want to help others feel that way, and I want to have hope in my life.
- I'm 27.
- I finished medical school and am finishing my residency next year in internal medicine which pays about $50k/yr.

Now what do I do?

1. I can stop residency after next year and be a general practictioner/Primary care doc and make about $180000/yr.
  Pros: lots of variety in the work, VERY flexible schedules (e.g. work 7 days on then take 7 days off), and immediate payout of a fat paycheck at age 29.
  Cons: Salary might be for rest of my career is pretty low compared to what it could have been. Not very much respected job title. Surveys of people who choose this route like only 27% said they would pick it again (compared to 61% of cardiologist who said they would pick cardiology again)

2. I can stay in residency/fellowhip for 3-4 more years making $50-$70k/yr and become a cardiologist and then make about $350000/Yr.
    Pros: Its interesting and seemingly fun work. MUCH more respected. MUCH better paid. 61% of cardiologist who said they would pick cardiology again (Compared to 27% in general practice people)
    Cons: It doesn't have as much variety (Which maybe is a good thing?). The hours are a bit longer and the schedules seem less flexible (Doubt you could do night shifts only, or 7 days on then 7 days off, "on-call" at night where you are expected to work the next day). It however will require me to remain working more than I would like for $50-$70k/yr for 3-4 more years.

3. I can do a sleep medicine fellowship for 1 more year (you get paid maybe $55K/yr). I question if I could even get a job doing this only the way the market is but I find it interesting stuff since its large sets of data, kinda not well understood, and I suffer from a sleep disorder.

4. something else


What would you do if you were me?

Thank you for your help!!

« Last Edit: December 08, 2014, 08:02:31 PM by echoyears »

socaso

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Re: Should I be a Generalist or Specialist?
« Reply #1 on: December 08, 2014, 07:51:46 PM »
From what I've seen of specialists they have all the glory. General practitioners always seem a bit stressed to me.

gimp

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Re: Should I be a Generalist or Specialist?
« Reply #2 on: December 08, 2014, 07:54:33 PM »
Wow, ain't that a hard choice. What does your heart tell you? (Ha, ha, ha, what a pun!) But in all seriousness, I think you already know the answer, you just want us to help you get to it...

SailAway

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Re: Should I be a Generalist or Specialist?
« Reply #3 on: December 08, 2014, 08:02:16 PM »
I can't help you with the financials, you'll have to decide what is important to you on that front. However, I will implore you to always advocate for your patients, don't prescribe whatever the pharm companies tell you to, and keep current in education and practices, whatever specialty you choose. I'll spare you the lecture on why I think our system is broken. :-) That being said, I find cardiology fascinating. :D

echoyears

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Re: Should I be a Generalist or Specialist?
« Reply #4 on: December 08, 2014, 08:05:44 PM »
I can't help you with the financials, you'll have to decide what is important to you on that front. However, I will implore you to always advocate for your patients, don't prescribe whatever the pharm companies tell you to, and keep current in education and practices, whatever specialty you choose. I'll spare you the lecture on why I think our system is broken. :-) That being said, I find cardiology fascinating. :D

I cannot agree enough! The system is terribly broken. To that I say it is so important for patients to know this and to advocate for themselves through it. It is incredible how easily your care can fall through the cracks and how different it can be done depending on who your doctors are and what you say to them.
« Last Edit: December 08, 2014, 08:07:36 PM by echoyears »

Taran Wanderer

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Re: Should I be a Generalist or Specialist?
« Reply #5 on: December 08, 2014, 08:15:56 PM »
I think the question comes down to this:  why are you pursuing this field?  Is it for respect?  Is it for money?  Is it for intellectual curiosity?  Or is it for enough money and flexibility to fill your life with interests and experience in addition to your medical career?

Specialists may be very visible, but flexibility gives you added opportunities for life experiences. Think Medicins sans Frontieres or other similar opportunities.

Financially you will be wildly successful either way.  This is a decision about your values and your interests.

SailAway

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Re: Should I be a Generalist or Specialist?
« Reply #6 on: December 08, 2014, 08:21:18 PM »
I can't help you with the financials, you'll have to decide what is important to you on that front. However, I will implore you to always advocate for your patients, don't prescribe whatever the pharm companies tell you to, and keep current in education and practices, whatever specialty you choose. I'll spare you the lecture on why I think our system is broken. :-) That being said, I find cardiology fascinating. :D

I cannot agree enough! The system is terribly broken. To that I say it is so important for patients to know this and to advocate for themselves through it. It is incredible how easily your care can fall through the cracks and how different it can be done depending on who your doctors are and what you say to them.

That makes me so happy! Go. Be a good doctor! If I had to do it over I would have gone to med school, but I'm old and it sounds miserable now, so I'll stay a precocious paramedic and let you make the big bucks. ;-)

GizmoTX

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Re: Should I be a Generalist or Specialist?
« Reply #7 on: December 08, 2014, 08:46:36 PM »
It is incredible how easily your care can fall through the cracks and how different it can be done depending on who your doctors are and what you say to them.

I would love a topic on choosing doctors & what to say to them.

DCJrMustachian

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Re: Should I be a Generalist or Specialist?
« Reply #8 on: December 09, 2014, 12:47:37 AM »
Most docs I've heard talk said it makes more sense to become a lawyer.  So maybe try rotations in each field and see which work you like the best.

RunHappy

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Re: Should I be a Generalist or Specialist?
« Reply #9 on: December 09, 2014, 06:10:24 AM »
I personally think there are too many specialists and not enough primary care docs.

RetiredAt63

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Re: Should I be a Generalist or Specialist?
« Reply #10 on: December 09, 2014, 06:26:39 AM »
When I look at your GP numbers (27%) I have to wonder how many of them are in that field because they went through the same choices you are making now and "settled" for GP.  I think an MD needs to "want" to be a GP just like they might "want" to be a cardiologist, or dermatologist, or surgeon, or whatever - that aspect of medicine fascinates them, they are good at it, and they can make a difference.

A good GP is precious beyond price - they are the first doctor someone goes to, and if they are good they can be life-saving, and if they are bored and not up-to-date, well . . . .  Some of the doctors I respect the most are GPs.

So basically, money should not be the deciding factor here (you will make lots no matter what).  What do you want to do with your education?  And where do you want to live?  Specialists usually end up in cities.  Do you want to live in a city?  A small town?  Lifestyle matters.  Personally, given the length and expense of medical training, I do not want to see doctors retire early, I want them to be so happy with what they are doing that they stay in practice (maybe part-time after a while) basically forever.  That is partly because I am Canadian, and we subsidize a doctor's education a lot more than the US does, so I want my tax dollars to give me a good return on investment, but mostly because what doctors do with that training is so important (if they are good doctors) that I don't want them dropping out.

TN_Steve

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Re: Should I be a Generalist or Specialist?
« Reply #11 on: December 09, 2014, 06:31:33 AM »
What is your student loan and family situation?  $180,000 is a lot of money, but if you owe $300,000, practice in a high C.O.L area, and are primary wage earner in a family with toddlers, it is not quite as big as people would think.  :-)

Based on the docs in our various circles of friends (in their 50s), the specialists seem to be happier, even when you try to put the money to one side. 

Lots of stress in Primary Care, unless comfortable signing on as an employee of ACO/hospital (and that too has its stresses).

OTOH, the independent Ortho and OBGs (who are the specialists we know best) feel like they have more control over their lives even with long work days.  (Well, except for lack of control on DW's OBG call!)

Who knows what will happen in this industry over the coming years though.  Lots of unknowns and the changes that have occurred in the past couple of decades have had varied impacts on practices.

You might want to post this query on Bogleheads personal finance (not investing) forum if you want feedback from a host of physicians.  Or look through archives at whitecoatinvestor.com (he also is likely to respond on Bogleheads).

In the big picture, if you keep spending under control, you are going to be ahead of the game financially either way (unless you have mega-loan debt)


YoungInvestor

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Re: Should I be a Generalist or Specialist?
« Reply #12 on: December 09, 2014, 06:32:24 AM »
So, it pays roughly double after 3 years where you'll get paid enough to get by anyway, you think it may be more interesting and the job satisfaction among people currently doing it is higher?

duck-duck

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Re: Should I be a Generalist or Specialist?
« Reply #13 on: December 09, 2014, 07:58:19 AM »
I'm guessing that when you mentioned a 7 on 7 off schedule, you were talking about a hospitalist position. This has always sounded very attractive to me if your looking for a nice balance. You work with a variety of acutely ill patients and yet have 2 weeks off every month to pursue other interests. Working in general medicine also leaves the door open for developing professional interests as previously mentioned. Do you have an interest in volunteer work locally or internationally? Maybe your retirement gig could be volunteering at a free clinic 1-2 days per week? You could work seasonally in a national park? Many different options as a generalist.

You can always specialize in the future if you are unhappy. One of the hospitalists that I work with who is in his late 30's just entered a nephrology fellowship, which is 2 years I believe.

If your living a frugal lifestyle, the extra money is nice but not necessarily a game changer.

erae

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Re: Should I be a Generalist or Specialist?
« Reply #14 on: December 09, 2014, 08:05:19 AM »
My husband is in his last year of residency and we have had the generalist/specialist conversation many times in the last couple years.  Some thoughts from our conversations and your post:
  • 27% is a low satisfaction rate compared to other areas of medicine, but for those 27% who love being PCPs, cardiology may have been a fate worse than death.  Said another way, while satisfaction rates of populations are a good starting point, they don't work as well for individual decision-making. 
  • Medicine is more hierarchical and concerned with prestige than most other professions.  I've seen it affect my husband, who is more sensitive to prestige now than he was before he began his residency.  Are a resident, you're so steeped in this douchebaggery status paradigm that it can be tough to look at differed fields of medicine without invoking this connotation that this field is better or worse, rather than different.  To keep our heads on straight when we talk about his future as a GP vs. a specialist, we talk about what his daily interactions with patients and work would look like and the lifestyle we want to have.  He's got his eye on an oncology fellowship, in part because it would allow him to have fewer, more meaningful relationships with his patients than a GP.  He's also finding it tiring to keep up with all the guidelines and research for the entire field of IM and is hungry for some depth over breadth in his studies.  I would think about, if you weren't a physician, what would you be looking for from your job? 
  • Most doctors in the US decided to be physicians when they were 17 and have been on this very specific track for a decade or more.  You work hard to check off degrees and exams, and your success is defined by this medical training path, which not only tells you what to do and quantitatively how well you do it, but it follows a timeline that's pretty consistent for everyone.  You don't have to choose a fellowship right now.  You have more flexibility after your residency than you've ever had in your professional career.  You can work as a hospitalist for a few years, then go do that sleep fellowship if it's still on your mind.  These options aren't going anywhere and this conveyor belt you've been on - you're at the end of it, so you get to choose your direction and your pace.  Talking to your college buddies who didn't go into medicine might be helpful here - they've likely been navigating this ambiguity and having to define their own success for years now.   

Good luck to you!

bye-bye Ms. FancyPants

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Re: Should I be a Generalist or Specialist?
« Reply #15 on: December 09, 2014, 08:08:50 AM »
GP's are terribly needed but after being in the medical field for 13 years, my vote goes to specialist. Good Luck!

Proud Foot

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Re: Should I be a Generalist or Specialist?
« Reply #16 on: December 09, 2014, 09:46:34 AM »
Very good question. It all depends on your goals as a MD and how you want to help your patients.  If you go the specialist route I think you would want to chose one you love. Something else to consider, especially given the ide of FIRE on this blog/forum, is how long you are wanting to work/goals for FIRE, etc. If you are wanting to retire at say 35, then you would have to look at the numbers. Delaying the big paycheck 3 years may make that goal not possible, or may make it possible to retire earlier.

If you were to work until typical retirement age then my personal preference would be to select a specialty you would really enjoy and go do that.

pzxc

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Re: Should I be a Generalist or Specialist?
« Reply #17 on: December 09, 2014, 09:52:43 AM »
    "A human being should be able to change a diaper, plan an invasion, butcher a hog, conn a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a tasty meal, fight efficiently, die gallantly. Specialization is for insects."

    — Robert Heinlein

I know that's talking about general life principles and not medical specialization versus GP -- but it's still something to think about and remember :)

FLBiker

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Re: Should I be a Generalist or Specialist?
« Reply #18 on: December 09, 2014, 10:36:01 AM »
Personally, I'd throw the "respect" consideration out the window.  Maybe other folks will disagree (and I know nothing about medicine as a profession) but in my own line of work (academia) I have been MUCH happier since I stopped worrying about what other people thought of my choices.

For example, I had been putting a lot of pressure on myself to publish / get very involved in a lot of professional organizations / climb the departmental hierarchy.  I resisted doing what I really liked and kept trying to do what I thought I should be doing.  About two years ago, I had a chance to redefine my position as part of a re-org.  At the time, I supervised a couple of program coordinators and was responsible for about half of the departmental admin.  And I was always thinking about how I should get another degree to add some more letters after my name.

When I sat down and thought about it, though, I realized that my "prestigious role" in the department wasn't what I enjoyed.  So I built a new job description around the part of my job that I really liked -- database development and data analysis.  I no longer supervise anyone, and (as I have moved out of the classroom) I am much less involved with publication / professional organizations.  And no longer worry about adding another degree.  I now work almost entirely unsupervised and at my own pace.  I don't really know how folks respect of me has changed over the years, but my guess would be that my new role is less prestigious.  And I absolutely love it.

Zarya

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Re: Should I be a Generalist or Specialist?
« Reply #19 on: December 09, 2014, 10:56:08 AM »
We LOVE our GP and would gladly pay significant amounts to keep her as our primary care doctor. (Fortunately we don't have to, because she's covered by the national health care system we enjoy here in Slovenia.) It was so hard to find someone like her: up-to-date in her field, willing to treat the patient as a partner, actively interested in preventive care and patient education, and well-networked with all the local specialists. I've also had the privilege of translating and editing papers for her that she presents at conferences (she presents in English so she appreciates my help in getting the language up to par), so I know something about her other interests and her motivations for doing general medicine.

All this to say that I know she loves her job and finds it constantly challenging and interesting, and the amount of respect she receives from both patients and colleagues is immense. (She is also active in training new doctors -- there are usually two or three in her office working with her and learning.) So this is my patient-perspective "love letter" to GPs: they are way underrated in the "respect hierarchy" when you compare their role in patient welfare to that of specialists.

I think for you the decision may also rest on where you see yourself happiest living and working: small town, big city, hospital, private practice, clinic? Choose the place and then the job may be obvious.

mama

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Re: Should I be a Generalist or Specialist?
« Reply #20 on: December 09, 2014, 11:23:45 AM »
Why is cardiology the specialty you are considering?  How about radiologist!  Those dudes seem to have lots of flexibility and great pay, too.  They have less relationship/patient interaction (to me that would be a plus).  How about psychiatry?  That would be super fascinating and you'd have such opportunity to change lives for the better.

Really, as others have said, you will be more than fine financially.  It's about what career you will enjoy more.  Personally, I would think being a generalist would be less satisfying just due to the nature of the work - you're either seeing healthy-ish people who are there for a check up every year or less, or you're seeing people who have health issues for which they'll see a specialist for management anyhow; many will just want a referral from you or a re-prescribe.  Or best yet, the healthy-ish ones who go to the doctor all the time anyhow.

Manguy888

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Re: Should I be a Generalist or Specialist?
« Reply #21 on: December 09, 2014, 11:55:13 AM »
I don't have any knowledge of the medical industry, so I won't wade into those waters. I just want to make two points

1. You mention the word prestige a few times. Forget prestige and do what YOU enjoy. Prestige is based around what other people think of a profession, but only YOU can make yourself happy.

2. Both jobs will pay enough to live a comfortable life with a chance at ER, if that's what you want. Don't take the higher paying job just because it pays more. That would be like buying something you don't need because it's marked 50% off.

Sarita

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Re: Should I be a Generalist or Specialist?
« Reply #22 on: December 09, 2014, 01:14:46 PM »
Interview at least five GPs and five specialists, and ask about their lives.  Personal insights can give you more context than just percentages of those who would choose or not a certain way. 

mozar

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Re: Should I be a Generalist or Specialist?
« Reply #23 on: December 09, 2014, 06:39:35 PM »
Yes there is a higher need for GPs but its getting harder to be reimbursed by medicaid/medicare, and paperwork is a biotch. Any interest in working in a rural area?
There is such a high need in rural areas for GPs but less so in cities, where more and more of GP work is being done by nurses at clinics. I haven't been to the doctor in years. But I did visit a robot at a grocery store that took my vitals. The robot told me I was too fat.

vagon

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Re: Should I be a Generalist or Specialist?
« Reply #24 on: December 09, 2014, 08:58:22 PM »
So, it pays roughly double after 3 years where you'll get paid enough to get by anyway, you think it may be more interesting and the job satisfaction among people currently doing it is higher?

+1

No-brainer.