I am the medical spouse (primary care) and have some observations and thoughts that you might want to consider in your decision making:
1. Money is generally not an important consideration in general, if you are a doctor. Even as a fellow there is a fairly average salary. Working conditions for a physician can really suck if you are not in the right job, so all other factors for happiness should come first because the income difference will feel inconsequential. My first job out of residency, I took a job with a good package and hated it. I lasted 3 months. I went to another job and took a huge paycut in addition to moving to a higher cost of living area. I didn't notice the difference in pay. Part of it was because at higher pay, a lot more gets taken out in taxes anyway. Mostly it was because I enjoyed my job a lot more.
2. I chose not to specialize and have not regretted it. Some reasons are: it is easy to find primary care jobs. There are a million clinics hiring all around me that I can bike to. I can change jobs without moving. I can move almost anywhere and get a job quickly, even in another country. I can chose almost any work schedule I want. part time, per diem, locum tenens, no call, etc. I love the flexibility. My friends who have specialized have a much smaller pool of jobs to choose from. Some have commuted over 2 hours a day to get to the closest job they could find, and some have moved to other states or cities. Some have had to fly to another state (paid for by the employer) every week to run a specialty clinic there. There is a high likelihood that with a specialization in something other than cardiology, most jobs will be in HCOL areas near academic centers, or in very rural areas.
3. You don't have to do fellowship right after residency. Some people will go back later in life to subspecialize. I know many people who have done this when they have retired, or when their children are grown. At my hospital there is a cardiologist and a rheumatologist who worked in internal medicine for the hospital for most of their career, then did fellowships and came back as specialists. So if you aren't sure, this is an option.
4. You can still practice as a generalist even if you do a fellowship. You can also moonlight in primary care at higher attending pay during fellowship to boost income during fellowship.
5. If you subspecialize, you may have to maintain two board certifications, which is a PITA.
6. If I really wanted to make money I should have become a plumber or gone into finance. Med school and residency are not good for finances or early retirement. But in the end it's about doing what you love and I have no regrets, and either do my friends who have specialized.
7. One good thing about residency/fellowship is that you are so busy that you don't have time to spend money, and generally the hospital will give you food to eat and scrubs to wear since you practically live there anyway. So that helps the food and clothing budget.
Hope this helps some!
