"What do you want to be when you grow up?”

That is a question every young child gets asked at one time or another. As they get older, people ask teens where they want to go to college, followed eventually by, “what’s your major?” But for those who apply to medical school, the questions don’t stop there. Almost from the first day of medical school, students begin thinking about what kind of medicine they want to practice for the rest of their lives.

It is a constant series of decisions that come with intense pressure — and requires a fairly specific plan of action. At The University of Kansas School of Medicine, students spend their first two years of medical school immersed in basic science disciplines — a mixture of classroom, lab work and exams.

Excel at the basic science and you get two additional years. Third and fourth years are spent in clinical settings — rotations in a range of disciplines, familiarizing themselves with various physician roles. During year four, students complete additional required clerkships and courses. While some students know before they even start medical school what they want to specialize in, for many, it isn’t until later in their medical education that things start to come into focus.

Most who have gone through medical school say that third year is the most challenging — not just because of the grueling clinical rotations, but also because the pressure is on for students to answer the Big Question about how to spend the rest of their life. Once they make that monumental decision, the rest of medical school is about getting the additional experience and support they need to prepare for residency programs. After graduation, medical students can spend three to seven years as a resident at a university hospital or clinic — and even more if they opt for a fellowship.

There is no precise path to a medical specialty, and there are scores of factors that most students take into consideration. It is often more complicated than just choosing a surgical or non-surgical route. Some students may prefer patient-facing clinical work, or they might be motivated by more solitary medical careers like pathology or radiology. They might want to practice in an urban setting or serve in a rural community. There is also a choice between doing the same work consistently versus having every day be a little different, as it can be in emergency medicine. Other factors include whether a student wants to pursue research as part of their career and how competitive a particular specialty might be.

There are also a few pitfalls that many medical professional mentors counsel students to avoid making, including caving to peer pressure, rushing into choosing a specialty when you aren’t certain, ignoring work-life balance and only considering how much money they can expect to make.

The third year

It is through the rigors of those third-year rotations where many students discover something new — and often unexpected — that just clicks. Fourth-year KU School of Medicine student Nicholas Choi said as a premed student, he majored in neuroscience with the goal of immersing himself in the science and treatment of the brain. But when he got to medical school, he was overwhelmed with the breadth of career choices facing him.

“Getting into med school presented a mystery,” he said. “Choosing a specialty was pretty much the hardest thing I had to do. I was all over the place and ended up pretty much liking everything.”

One of Choi’s faculty advisors suggested one way to find where he wanted to spend his career is to simply “find your people.” That’s what happened during the last block of pre-clinical years when he discovered urology.

“I didn’t even know what it was,” Choi said. “It just clicked with me, and I meshed with the faculty there more than anywhere else in the hospital. That’s how I knew.”

That familiar advice also resonated with Jacob Lovell, a second-year student.

“When you shadow someone, you try to see yourself in that job,” he said.

Lovell had a head start on that when in undergraduate school, he worked at a psychiatric facility for children.

“My job was keeping them safe on the unit, and that’s how I found out that I wanted to go into medicine,” he said. “I was a factor in their healing and growth, and there are a lot of ways to do that. Based on my experience at that job, I want to do more than just meds management, I am interested in working with kids one-on-one.”

Lovell looks forward to his psychiatry rotation next year, because experiencing something firsthand is different than just hearing about it.

“Psychiatry is still an emerging field,” he said, “There are so many new opportunities to do procedures like cognitive behavioral therapy, electro-convulsive therapy and administer psychedelics.”

The rotation factor

Sometimes, students show up knowing since the fifth grade what they want to do. But Tyler Hughes, M.D. and dean of the KU School of Medicine-Salina, said these days, that is the minority of students.

“By the third year, during rotations, they like everything — it’s all new, fresh and interesting,” he said. “And just when they get good at something, it’s time to rotate and move on to something else.”

That is why it is important to be open to having new experiences during rotations — because even one day in a specialty could change everything. Quinnlyn Walcott, a fourth-year student, believed initially she would go into obstetrics and gynecology.

“In my first year I reached out for research opportunities,” she said. “I shadowed one of my mentors during a surgery where there was also a urologist. The resident was so nice and invited me to scrub in. I realized I had never thought about urology before.”

Walcott discovered urologists worked on diverse health issues like cancer care, kidney stones and sexual health, and she never looked back.

“There are so many specialties that exist, and we can’t be exposed to them all as part of the curriculum,” she said. “Once urology fell into my life, I made it my priority to choose it during my surgical rotation.”

Walcott also had to ask herself if she had the fortitude to pursue what is a very competitive specialty. It turned out she did and has since matched with a urology residency at the University of Chicago after graduation.

First-year student Sheridan Scott showed medical school potential when, as a child, she lined up her stuffed animals in a pop-up medical tent to “treat” their illnesses. Then when she was 14, her mother suffered a traumatic brain injury.

“That was when I realized that health is our greatest wealth, and I saw how my mom worked so hard to get it back,” she said.

During one of KU Medical Center’s student enrichment and remediation weeks, she discovered orthopedic surgery.

“The patients in the clinic reminded me of my mom after her injury,” Scott said “When they are in debilitating pain, they had that same look in their eyes. But I realized that a career in surgery would allow me to do for them what someone did for my mom, who is thankfully at baseline now.”

Meeting a mentor

Making a personal connection with a practicing physician can also play a role in the decision process.

“Many doctors are eager to share information with students who are interested in their fields,” said second-year student Mark Faber.

Faber started shadowing ophthalmologists during high school to measure his interest in medical school, and now he is pursuing it as a specialty. Last year he attended an event where attending physicians spoke about their specialty and invited students to shadow them at work.

“You want to shadow the doctor who you want to become, because within a specialty, you will notice certain personality traits they have,” he said. “Ophthalmologists just seem happy, and that’s really important to me.”

Mentors are valuable even if it is in a specialty that the student ultimately decides not to pursue. That is how it went for fifth-year post graduate Mathew Moreno, who was inspired to become a doctor by a group of cardiologists who he worked with before applying to medical school. His intention was to become a cardiologist, but he asked his academic advisor what specialty he would choose if he had it to do all over.

“He told me he would have become a plastic surgeon,” Moreno said. “I learned only about five percent of plastic surgery is cosmetic. Most of the work is reconstruction for cancer patients, repairing cleft palates for children and more.”

Besides finding the work rewarding, Moreno discovered that in physicians’ satisfaction surveys, plastic surgery was ranked as number one.

“The ones I know are very content and that sold me,” said Moreno, who will begin serving a plastic surgery fellowship in New York City in the summer of 2024.

A  passion for practice

Often, medical students show up with an enthusiasm for serving a certain population. Brenda Aguirre-Apodaca, a second-year student, took a gap year after college to work as a certified nursing assistant.

“I came into medical school with an open mind — wanting to experience everything. But all I really knew was rural family medicine,” she said. “What I am really passionate about is helping underserved populations — especially those with a language barrier since I speak Spanish — and also women’s health. Family medicine just seems like the perfect way to combine them — and there’s no limit to who you can help.”

Jonah Elyachar, second-year student, found his passion working in a mobile medical unit offering free health care to homeless people in Kansas City.

“I really enjoy building relationships and trust with patients,” he said. “I know their names, and they know mine — and in family medicine you get to see patients grow up and change. It’s the consistency of care that is important to me.”

Kim Pham — a first-year student — first considered attending medical school while working as an emergency medical technician during college.

“Right now, I think I have a bias toward specializing in emergency medicine,” she says. “Every day is different, and I am not interested in clinical work.”

For some students, where they establish their careers is as important as their specialty.  A significant number of KU Medical Center students come from Kansas and plan to start their career here.

“I am definitely going to work in rural Kansas, because I grew up in Kingman, Kansas, and I see the need for physicians there,” said Kacie Rohlman, third-year student in family medicine at the

KU School of Medicine-Salina campus, which has a medical education program tailored to students with a strong desire to practice in rural areas.

“Whenever I go back home, I realize how much growing up there means to me.”

Work/life balancing act

Choosing a specialty also means choosing how you want to live your life. Observing physicians allows students a realistic look at what their life will be like. First-year student Kameron King is still working on his decision. As an undergraduate he played football and studied broadcast journalism — he never even considering medical school. That all changed while watching the birth of his daughter, Mara, when he became fascinated with the anesthesiologist. Not long after, he changed to pre-med, applied to medical school and now is considering anesthesiology, orthopedic surgery or urology.

“The most important thing about choosing a specialty is that I want to have time for my family,” he said. “The anesthesiologists I know have that work-life balance.”

The son of two doctors, first-year student Dwayne Watkins started going to the clinic with his mother starting in kindergarten. He ran track as an undergraduate and got exposure to trainers and athletic physicians. Based on that experience, he is considering specialties in sports medicine and orthopedic surgery.

“I really enjoy traveling, and a specialty that allows me to create a schedule to accommodate that is ideal for me,” he said. “Ortho surgeries are usually planned — you don’t see many emergencies. The orthopedists I shadowed said they can plan their days off.”

In his fourth year at KU School of Medicine's Salina campus, Dawson Clark was always interested in practicing rural family medicine, and his rotation solidified that. The wide range of cases he will see every day appeals to him, as well as getting to see how patients grow and change over time.

“I enjoyed all of my rotations, but I never found one that I would enjoy doing all day, every day for the rest of my life. So that is why family medicine is perfect for me,” Clark says. “I appreciate the variety.”

The compensation question

While it shouldn’t be the only factor — or even the most important one — a practical consideration in the decision to specialize is the projected salaries for each field. Researching the levels of compensation doctors in various disciplines can expect to earn often influences a student’s choice. After all, medical school is very expensive.

According to the American Academy of Medical Colleges, the average four-year cost of a public medical school education is $268,476 for in-state students, while those attending medical school at private institutions pay around $360,000. When additional fees and living expenses are added in, choosing a specialty with higher average compensation to help pay off student loans can become a significant part of the equation.

Institutions dictate doctors’ salaries, which are procedure-based. Fields that require the most training — usually surgical specialties — are generally more lucrative. According to the 2023 Physician Compensation Report by Doximity, the highest-paid specialty is neurosurgery, with an average annual salary of $788,313. Other specialties near the top of the rankings are thoracic surgery ($706,775); orthopedic surgery ($624,043); and plastic surgery ($571,373). Near the bottom are primary care specialties such as pediatrics ($242,832); preventive medicine ($275,068); and internal medicine ($293,894).

But many practicing doctors say worries about huge student loans shouldn’t overtake other considerations when choosing a specialty.

“The truth is, any physician can make enough money to pay off their debt,” Clark said. “If any of us picked a career based solely on compensation, none of us would probably choose medicine. There are a lot more efficient ways to make just as much or more money. If any of us got into this solely for the money, we wouldn’t last very long.”

Nothing is final

While most students are confident and happy with the specialty they choose, what happens when a student picks a specialty, is matched to a residency program in that specialty and then isn’t sure it is what they want to spend the rest of their working life doing?

“The faculty wants to make sure students get enough experiences to find role models who exhibit qualities they want to emulate,” Hughes said. “It’s also important to make sure they don’t have a fantasy about their future — that they clearly understand what their job will be like.”

Hughes added that it is never too late to make a change. He said he knows of numerous residents who have matched successfully into another field after leaving their original specialty.

“It’s an inherent flaw of the system that you feel like you have to decide in a year or two what you think you want to be your entire life,” Hughes said. “I have seen people trading specialties even after earning their M.D. There’s always time to find your passion.”