Today's Q&A comes from an ongoing Bogleheads thread.


I am a medical student and will be picking a specialty in the near future.  I think I already have a few ideas in mind but I want to talk about them from a financial stand point.  My main question being… Is it worth doing one of these long residency/fellowships or is it better to just finish as soon as possible? I expect to have minimal debt when finishing which does change things.  I realize anything can happen in the future of medicine too.

It seems to me that higher paid specialists actually do work very hard despite what some may think. So in the end you are working harder/more stress anyways to get the extra money. Also the specialists are slowly but surely getting nuked on reimbursement and who knows to what extent that will continue to happen.

It seems to me that just finishing as soon as possible and making money earlier is the better option and I might be able to work a less stressful/demanding job which is always a plus. I do have some options on both sides of the playing field but I don't think I want to be in training forever.  Any insight?


The most common response on the thread aligned with my initial “short and sweet” advice:

Perhaps if there are two specialties you like equally choose the one that pays better. But mostly pick what you want to spend A LOT of time doing.

But the more I think about it, the more interesting this question becomes.  We can all readily remember the angst that accompanied us from that first lunch-time “specialty discussion” as an MSI to the required third year rotations to choosing SubIs as an MSIV before we finally figured out what we wanted to do with our lives.  Even then, lots of people still changed their mind mid-internship or even later.  Should finances have carried greater weight in that initial decision?  I applaud the thread's OP for even considering the topic- I don't recall that I did at all.  I was halfway through my intern year before I ever gave any financially-related topic more than a passing glance.

It is well-known in my specialty that pretty much no fellowship is worth it financially.  One of the longest and most popular- becoming a pediatric emergency physician, requires two more years of training in order to make less money than a run-of-the-mill emergency physician.  Toxicology, EMS, Wilderness Medicine, Ultrasound, International Medicine etc.  They might help you get an academic position easier, but that would probably also come with a pay cut compared to a community emergency medicine job.  Critical care might be worth it, but only if you spent a significant portion of your career working as an intensivist instead of an emergency doc, which seems to defeat the purpose of an EM residency in the first place.

Pediatrics finds itself in a similar boat.  Lobon, a poster on the thread, cites a study from Pediatrics that notes that only Pediatric cardiology, Pediatric Critical Care, and Neonatology seem to command salaries that justify the additional years of training.   I imagine a similar study done on internal medicine subspecialties would yield similar results.

The problem comes when you consider the logical consequences of what happens when medical students actually do consider the financial implications of their specialty choice.  Now that medical students are getting hit with the triple whammy of increased tuition costs, worsening loan terms (no subsidized loans and rates now 3-4% higher than mortgage rates), and decreasing compensation once in practice, more and more of them will consider the financial impact of this already difficulty choice.  Even when I matriculated to medical school over a decade ago it was well-known that if you couldn't get in to your state school that you might not be able to afford to do primary care.  This process will lead to a worsening shortage of important specialties that require a lot of “uncompensated training.”  An editorial accompanying the Pediatrics study notes that 13 states have zero pediatric rheumatologists.  A family member of mine recently developing a difficult to diagnose rheumatologic condition.  It took several months and a 3000 mile plane flight to get him in to see an ADULT rheumatologist.  I wonder how many rheumatologists there would be if it paid as well as invasive cardiology.  Too bad you can't stent fibromyalgia.

At the end of the day though, medical students shouldn't make finances a top consideration in their choice of specialty.  Even a poorly paid physician usually makes 2-3 times the average American household income.  Living like a resident for a few years can wipe out the student loans.  But medical training and the practice of medicine itself is too long and hard to do just for the money.  You've got to love it, and that goes for each specialty as well.

A couple other comments from the thread worth quoting:

From staythecourse:

Perfect example of picking what you like, because of not knowing what will happen in the future with reimbursement is that radiation oncology. Always considered a high paying and relaxed speciality is facing a whopping 16% medicare cut that is being proposed while everyone esle is between 1-3%.

Pick what you like because medicine, like any other job, the happiness does not come from the money, but from your interest in the field.

From am-

Tough to be “interested” in the field after working 13 days straight with one day off when I do weekend shifts every month. Just a grueling marathon that leaves you burned out. Only thing keeping me going is the still nice paycheck and the hope for early retirement one day. Kinda sad. If only the committee that admitted me to med school could hear me now…

Do not believe many docs who work outside of maybe academics really like their job or have much interest in their field as it becomes so routine and numbing after years of practice.

What say you?  How much should a medical student consider the financial implications of his specialty choice?  Comment below!