By Brent Schnipke
As I have spoken with physicians, residents, and other medical students about the process of choosing a medical specialty, the near-universal reply has something to do with the fact that third-year rotations barely offer enough exposure to each specialty to make an informed decision. Third-year medical students move quickly between specialties, and are often granted only a few weeks to examine a given career choice and decide whether they like it or not. Because of this, major decisions about how a medical student will practice as a doctor are largely based on brief experiences that can be easily biased by particular patients, residents, attendings, hospital systems, and even external life factors. To control for these variables, most students will finish their third year and use the first part of their fourth year to take a “second look” at the specialty they are planning to apply for and to help those students who remain undecided.
Many students spend a significant amount of time thinking about what type of doctor they want to be and why. AAMC data suggests that while some students come into medical school knowing what type of physician they will be and stick to it, many enter undecided or change their mind. Even though medical students begin thinking about their specialty choice early on (the question is unavoidable, as I wrote about here), sometimes an unexpected experience on a third-year clerkship will leave a student questioning their decisions. Different aspects of different specialties appeal to students, and it can often be difficult to tease out the differences from the brief clerkship experiences. Because so many factors affect a student’s view of their core clerkships – timing of the clerkship, location, co-workers, clinical skills, and even academic performance – students might finish third year with an unclear picture of where they will best fit.
Because of these dilemmas, the early rotations of fourth year can be exceptionally valuable to medical students. Students who are having trouble choosing between two specialties can juxtapose the specialties, completing back-to-back rotations in each specialty of choice. Often, students will seek to make these experiences sub-internships (or junior internships, or acting internships) in an effort to more closely mimic the residents, hopefully creating a clearer picture of life in the specialty. Students might find value in revisiting a different aspect of the specialty – for example, if the original experience was only inpatient, testing the outpatient side. Several of my colleagues interested in surgery, for example, were encouraged to do a rotation in the surgical ICU. The idea is to teach them more clinical knowledge about managing complicated patients, but also to demonstrate that surgery is not just about operating. These second looks can help control for the variables of location and co-workers and ensure that the specialty itself, with as many variables accounted for as possible, is what the student is actually choosing.
Perhaps most importantly, these second look rotations help students remove the timing bias, related to the order in which third year rotations were completed. Many of my colleagues have had specialties they considered throughout third year, since they were early experiences (often the first rotation they completed) and remained high on their list. As they moved through third year, nothing compared to the first rotation, so they assumed it was their favorite. Upon revisiting the specialty as a fourth year, however, the student realized they had idealized the specialty. Although this sometimes leaves students looking for new options, most are thankful that they didn’t pursue a specialty based on a brief third year experience that (in retrospect) was misguided. Conversely, students find it rewarding and relieving when they revisit a specialty they liked – but weren’t yet sure about – and find that they are still a good fit.
Even students who don’t feel they need a formal second look at a specialty to confirm their choice will likely have the opportunity to do so – and may be grateful for it! Many students use the first few rotations of fourth year to rotate through their chosen specialty anyway, either seeking opportunities to spend further time in a field they know they enjoy, seeking more clinical experience, or seeking letters of recommendation. These may happen in the form of away or audition rotations, which simultaneously allow a student to survey an institution away from one’s own medical school (and vice versa). Even these experiences can allow students to see their chosen field through fresh eyes, confirming their choice or casting doubt. It can be intimidating to consider changing seemingly everything about one’s life course in the last few months before applications are due, especially when most other students have already decided. As mentioned, however, most students tend to appreciate, later on, that they took a second look and were open to finding the best fit.
Personally, I’m in the middle of these very processes right now, and it has been fun to see how these fourth-year rotations compare to my initial third-year experiences. Further, it has been deeply rewarding to realize how much I’ve grown as a medical student. These rotations are allowing me the opportunity to dig deeper, past the superficial content that third-years are expected to master, and consider more complex issues and more difficult tasks. As I move into the application process, I am planning to write next month about how even the process of applying can help hone down specialty choices for students on the fence. Stay tuned!
Central to the skillset of every physician is the differential diagnosis; this is the process by which new patients are evaluated to establish the most likely diagnosis. Similarly, the first clinical year of medical school is like a differential for each student, except instead of a medical diagnosis, students are seeking to determine which specialty they will choose. This column explores this differential: experiences from each rotation by a current third year student.
About the Author
Brent Schnipke is a fourth-year medical student at Wright State University Boonshoft School of Medicine in Beavercreek, OH. He is a graduate of Mount Vernon Nazarene University with a degree in Biology. His interests include medical education, writing, medical humanities, and bioethics. Brent is also active on social media and can be reached on Twitter @brentschnipke.
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