An Appetite for Authority: Psychological Subtleties of Choosing a Specialty

I recently had an interesting conversation with three fellow medical students over a jar of nutella. Two were MS IVs training at a major academic medical center (one budding peds oncologist, one future family physician), and the third was a canadian medical student. I am an osteopathic medical student comitted to pursuing primary care. The conversation started with romantic pursuits, Harry Potter, what to dip into the nutella, but soon evolved into a dynamic discussion about medical specialization, and why we do choose to do it.

Many people believe that the temptation to super-specialize is driven solely by salary…specialties pay more than primary care; they get you out of debt quicker and may allow for a cushier lifestyle. These are undoubtedly key factors for many students choosing a career path in medicine. However, money is an easy scapegoat. When salary is taken out of the equation, much more complex issues of personal investment, ego, and authority begin to surface.

The Canadian medical student in my nutella conversation was quick to remind us that our neighbors to the north don’t pay specialists much more than primary care physicians. Yet, in her view, young Canadian doctors still overwhelmingly prefer to specialize. People want to be experts. It's human nature. The pride that comes with knowing you could be the leading authority on something, and that people would come from all over the world (or all over the hospital) to hear your opinon is incredibly enticing to students. The high salary that specialists get in America is icing on a cake that already looks deliciously prestigious.

As we overdosed on chocolate hazelnut and the jar became pretty unappetizing, our conversation shifted from what’s enticing about specialties to the other side of the coin – what psychological factors turn students off of primary care. The future pediatric oncologist hit the nail on the head. She was telling us about her current sub-internship, working under general pediatricians on complex cases. Each of her patients saw a minimum of seven consults, sometimes up to nine or ten. In most cases, her attending knew exactly what the endocrine guy or the genetics department was going to say. Even as a medical student, she could predict how these consults were going to go, and yet, the culture of a medical center with limitless resources is to cover all bases, gather as many cooks into the kitchen as possible. It made the generalist’s job seem a less important. Even though he was supposed to have the final say on the treatment plan, my friend described a shifted power dynamic that made her attending the low man on the totem pole, a triaging traffic cop. “This is why I’m glad I want to specialize,” she explained. She didn’t work this hard to not be the authority on anything.

Primary care is not for everyone. This friend is going to be a fantastic pediatric specialist, and a caring physician. It would be incredibly short-sighted for me to claim that all students who choose to specialize are motivated by pride and ego. But it would also be naïve to discount these factors in ourselves. Choosing a field of medicine is a complex process that is ideally driven by geunine interest and passion, but often heavily affected by financial and lifestyle concerns, as well as the desire to validate the years of work we have put in to achieve our goals. There is nothing wrong with wanting to practice at a prestigious institution, garner respect from colleagues and be valued as a prominent physician. From time to time, however, it is important to step back and ask ourselves how much the desire to impress others is affecting the choices we make. A primary care physician might never be world’s leading expert on nutella allergies, but family doctors are the authority on their patients. The best ones take ownership of this more subtle authority, even in a kitchen full of cooks.