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Sean Schafer, MD
UCSF-Fresno Family Practice Residency Program, University Medical Center, Fresno, Calif

William Shore, MD; Norman Hearst, MD,MPH
Department of Family and Community Medicine, University of California, San Francisco

JAMA. 2001;285:2782-2783.

The choice of a specialty by the new physician is important on many levels. The student's career satisfaction and personal fulfillment will be affected by the specific attributes of his or her work. Physician satisfaction has been found to be correlated with both patient satisfaction¹ and clinical outcomes.² Society also has an interest in medical student career choices. The efficiency of the US health care system and access to care for urban poor and rural populations depend on the number and ratio of generalist and specialist physicians.³ Unfortunately, the current process of specialty selection by medical students serves neither the student nor society optimally.

Most future physicians make their final specialty choice during the third year and early part of the fourth year of medical school, after only 2 or 3 years of professional socialization.^4-5 Choosing a specialty has been described as assessing one's fit with the perceived attributes of potential specialties,⁶ which might include personality, income, lifestyle, intellectual challenge, technological orientation, clinical skill, geographic options, and potential for research or leadership. Students must accurately understand both their own needs and the characteristics of the specialty they are considering.

For some students, preexisting impressions of their preference for a particular specialty are confirmed, while others may reject early preferences when they acquire new or refined images of specialties or discover some they had not previously considered. Other students may develop a new understanding of themselves that no longer seems compatible with earlier preferences.^6-7 Additional predictors of specialty choice may include demographic characteristics,⁸ aspects of the medical school experience,⁹ and personality traits.¹⁰ For example, an older female student from a small town who attends a publicly funded medical school with a required third-year family medicine clerkship is likely to choose a primary care residency. A younger male from a suburban upbringing who values technology over humanism and attends a privately funded school is more likely to choose a hospital-based specialty.⁸

These characteristics may predict choice, but may not always lead to goodness of fit. Students are pressed to decide early, usually after only slightly more than a year of brief exposure to specialties in clinical clerkships. Gaining insight into one's aptitudes and professional priorities, especially at a young age, is a difficult task. Guessing how those strengths and needs might evolve over a lifelong career is even more challenging. Some students, despite what they believe to be the best choice of specialty, choose otherwise because of practical barriers such as grades, family preferences, and finances.¹¹

Furthermore, except for those students who will choose an academic career, the image of a specialty may be distorted by the filter of the traditional academic setting.¹² This is because most teachers and role models in medical school have careers that are quite different from their more numerous nonacademic counterparts. Clearly, the rewards and pressures are different in community practice and academic medicine. Also, the prevalence and acuity of disease at academic medical centers is different from that in the community. In our university hospital, for example, pituitary surgery and liver transplants are performed more often than appendectomies. This can hardly give an accurate picture of the life of a typical surgeon.

A popular book devoted to familiarizing current and prospective medical students with medical careers advises " . . . when contemplating your choice, familiarize yourself with the common, daily tasks that are a part of the job and ask yourself whether doing them day in and day out will engage you and keep you happy. It may be fun and challenging to repair the weekend athlete's ruptured tendon, but you may find that you cannot stand evaluating low back pain ten times each day."¹³ Unfortunately, most students do not have the opportunity during the critical third and early fourth years to experience in representative ways the life and work of community-based physicians, be they general surgeons, family physicians, pathologists, or any other specialist.

There is evidence that a more accurate perception of the lifestyle and work of a given specialty can alter the types or numbers of students choosing that specialty. Most of this research has been conducted in family practice. Prospective studies indicate that requiring participation in a third-year family practice clerkship or longitudinal clinical placement increases the likelihood of selecting that specialty.¹² In New Mexico, students assigned to a primary care curriculum that included long-term community-based clinical placements beginning in the first year were more likely to retain prior interest in family practice than their colleagues in a traditional curriculum.¹⁴

Greater exposure to family practice does not always increase student interest in the specialty. Many students who enter medical school interested in family practice are discouraged by the relatively low prestige of that specialty in the academic environment.^15-16 One study concluded that as some students gain a more accurate perception of lifestyle and practice characteristics, their level of preference for family practice declines.¹⁷ But whether more knowledge and exposure results in more or fewer students choosing the specialty, it is likely to be beneficial if the chance of a better fit is enhanced. Selection of other specialties has been less well studied, but there is also evidence that the academic medical center distorts images of daily life in specialties other than family practice.¹⁸

The stakes for choosing the right specialty are high. Physician dissatisfaction and frustration are common and appear to be increasing.^19-20 At least 1 of 3 physicians leaves or changes practice within 5 years of completing training.²¹ Approximately one quarter of medical school graduates change specialty or make a major career change after graduation.⁷ Among women physicians, 31% would "maybe, probably, or definitely" decline to enter medicine again if given a second opportunity and 38% would "maybe, probably, or definitely" change their specialty.²² While this is commonly attributed to the stress of practicing under managed care, increasing threat of litigation, and downward salary pressures, it is also possible that some of the dissatisfaction comes from mismatches of physician and specialty that may have their origin in distorted images of the specialty from medical school.²³

Students facing tough choices between specialties can benefit greatly from the opportunity to work with physicians outside the academic medical center environment before making their final decision. Individual students should aggressively seek such opportunities, and medical schools should do everything they can to assist them. We believe that renewed consideration should be given to delaying specialty selection for all students, perhaps by returning to a universal internship that could include practice in community settings and rotations in areas such as public health and preventive medicine.

More research on specialty selection increases the likelihood that students will have sufficient information to make the best choice for themselves and society. Meanwhile, providing students with better opportunities to form realistic impressions of their potential future careers would be a good first step.

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