In my last piece, I covered the best lifestyle specialties as a doctor. Those were the specialties in medicine you would choose if you wanted to work few, or at least predictable, hours while still making good money. This is the opposite – the worst lifestyle specialties for the masochists.
To answer which specialties have the worst lifestyle, we first have to ask what makes for a good lifestyle? The general consensus is that it comes down to three primary factors: (1) the hours you work, meaning the predictability and total number per week, (2) the amount of money you make relative to the amount of work put in, and (3) the quality or substance of your work. This may include the patient population, types of cases you most commonly deal with, or the amount of charting required. Don’t overlook these factors, as dealing with challenging patients or difficult and depressing outcomes day after day can drain you.
So why would someone choose a specialty with a difficult lifestyle? The biggest factor is simply falling in love with the field. If you love excitement, unpredictability, saving lives, and the operating room, you would love trauma surgery, and the challenging lifestyle would be very worthwhile. Another theory I’ve heard thrown around is that those who choose more challenging lifestyle specialties are workaholics at heart, and may prefer a challenging and demanding work-life balance. They’ll even brag about how bad their schedule is. Workaholism is a common coping mechanism, as it’s easier to ignore one’s inner demons when you’re working and don’t have time to think about them.
The relative appeal of a specialty’s lifestyle is also highly subjective. Most would say dermatologists have a better lifestyle than trauma surgeons, but some would disagree. Neurosurgeons have some of the most challenging hours in the hospital, but they also have the highest compensation, which is why we joke that they make the most money but have no time to spend any of it. With that being said, know that this isn’t a list of absolute truths, but rather a subjective list of stereotypes for which there are many exceptions. Let’s have fun with this list and not take things too seriously. And remember, there are always exceptions to any generalization.
If you want a challenging lifestyle, you should check out general surgery. The running joke amongst medical students is that you go into general surgery if you’re either a masochist or couldn’t get into any more desirable surgical specialty. This is obviously not the case and general surgery is a fantastic field with lots to love, but the reason medical students joke about this is four-fold.
First, general surgeons work very challenging, unpredictable, and often long hours. Second, they’re often dealing with pathologies and body parts that some would consider less appealing compared to other surgical specialties, like the intestines and its associated smells and fluids. Third, they make less money than other surgical specialists. And fourth, it’s the least competitive surgical specialty to match into for residency.
This last point is why I always find it interesting when Caribbean medical schools brag about how many of their students matched into general surgery. You can read about my thoughts on Caribbean medical schools here.
General surgery used to be more, well, general, dealing with a wide variety of pathologies. In rural settings, this is still certainly the case, as there are few surgical specialists nearby. But as the field of medicine moves further towards greater specialization, general surgeons primarily deal with gastrointestinal and endocrine pathologies. If you want to work on the heart, you’ll need to specialize as a cardiothoracic surgeon. To work on bones, orthopedic surgery. For complex soft tissue reconstruction or aesthetics, plastic surgery, and so on.
That said, general surgery remains the default path for the medical student pursuing surgery who isn’t quite sure what kind of surgery to pursue. After general surgery, you have a wide variety of options for fellowship. For example, after general surgery residency you could pursue specialized cardiothoracic or plastic surgery training, but note that this will require a few more years of training versus matching into a dedicated CT or plastics residency immediately after medical school. With the general surgery tract, the main drawback is the increased length of training. The main benefits are that you have more time to make a decision prior to committing to a subspecialization, and it’s also a far less competitive path. In fact, many CT or plastic surgery applicants when applying to residency will apply to general surgery residency as a backup, just in case they don’t match.
Next up is primary care. That’s right, primary care has one of the worst lifestyles, and you’re probably scratching your head in disbelief. Allow me to explain.
You can become a primary care physician through various avenues, such as family medicine or internal medicine amongst others. Most wouldn’t consider primary care doctors to have a challenging lifestyle since you’ll generally be working regular office hours, roughly 40 hours per week. But that’s only one component of a specialty’s lifestyle. There are three other components that translate to primary care having a poor lifestyle.
First, as a primary care physician, you’ll have lower compensation than most other specialists, averaging roughly $240,000 per year. That’s not bad, but the average specialist makes on average $350,000 per year in comparison. If $240,000 sounds like more than you’d ever need, come back to me in 10 years when you have student loans to pay off, a mortgage, family, car payments, and retirement to save for.
Second, the amount of charting and paperwork in primary care is abnormally high, in some surveys averaging over 18 hours per week. In comparison, ophthalmology and anesthesiology are close to half that.
And third, scope creep issues primarily affect primary care physicians, although anesthesiologists have also been subject to difficulties.
My mentor in medical school, who was an internal medicine primary care physician, advised me and his other students that while medicine is a fantastic profession, he finds the changes in primary care quite disconcerting. He pointed to these three issues of reductions in reimbursement, increases in charting, and midlevel scope creep as primary concerns.
OB/GYN is an often misunderstood field, and most in medicine would warn you about its terrible lifestyle implications. Some obstetricians and gynecologists have extremely challenging lifestyles, and it doesn’t help that their residencies have a reputation of being more malignant than average. It’s often a dreaded rotation by many third-year medical students.
But as an attending, your lifestyle will be highly variable depending on your practice type. It used to be the case that obstetrics was extremely challenging since babies don’t care about your sleep schedule, and you would have to rush to labor and delivery at a moment’s notice. But in recent years, OB has moved more towards the shift work model – a welcome change in most people’s eyes.
Gynecologists, on the other hand, could have a great lifestyle if they wanted to focus on primarily a clinic-based practice. Certain gynecologic fellowships also offer a more procedural or surgical focus with relatively few emergencies. You can learn more about the field in my So You Want to Be an OB/GYN article.
It’s no surprise that surgical specialties have challenging lifestyles, but not all surgical specialties are created equal.
Trauma surgery gets a bad rap since traumas are unpredictable and can come in at any moment, seemingly at the most inopportune hours of the night. Many trauma surgeons have shift work schedules, particularly at larger and more established institutions. It’s not like you’re relaxing on your day off and you suddenly get called in. You’re either on or off service, but still, the hours can be long and challenging. But others in smaller groups may have to manage their own patients in-house and aren’t able to rely on more predictable shift work schedules.
Vascular surgery also comes with a particularly challenging lifestyle. You’re specialized enough that you’re covering a large catchment area, meaning there will be emergencies happening just about every night that require intervention. And unlike other specialties where you act as a consulting service and hand the patient off for management to the primary team, as a vascular surgeon you will be rounding and managing your own patients.
Neurosurgery is similar to vascular surgery in that regard, with the added complexity and burden of dealing with very sick patients with often poor outcomes. When you think about the types of patients that require brain surgery, you realize how many outcomes aren’t as rosy compared to some other surgical subspecialties. That was a surprisingly large factor that actually pushed me away from the field. Neurosurgeons are widely known for working the craziest hours in the hospital, but they’re also the highest-paid specialists. If you want to know more about neurosurgery, I wrote a So You Want to Be article on it.
Overlooked but Critical Factors
There are certainly exceptions to all these trends. The ceiling for any given specialty is limitless, meaning you could always work more hours. Many of my friends and colleagues from medical school are now attending physicians, even in supposedly great lifestyle specialties, but because they’re young, hungry, and want to set up a strong foundation for their future professional and financial lives, they’re willing to grind extra hard for a year or two before dialing their hours back.
Your practice type will also influence your lifestyle. In the early years, those who enter private practice will be working much harder than those who are employed by a larger community or academic group. After all, they need to slowly generate a patient census, be hard working to get referrals from other physicians and worry about all the aspects that go into running a successful business.
While private practice may be more common in something like plastic surgery, being employed is the norm, and straight out of residency you will be working more reasonable hours this way. Shift work is another arrangement that is more common in something like emergency medicine. With shift work, it’s easier to dial your hours down or up, depending on your desired work-life balance. With surgery, shift work is less common, and you’ll often have to stay late if there are intraoperative complications. It’s very rare for surgeons to work fewer than 60 hours until later on in their career. Although within surgery, there are some that are more conducive to clinic, allowing for reduced weekly commitments, like urology. If you want to learn more, we covered this in So You Want to Be a Urologist.
Lifestyle should not be your primary consideration when choosing a specialty, but it is important. In fact, I would say most in their early to mid-twenties underestimate its importance.
If you disagree with the specialties listed, try not to take it too hard and remember that this is purely subjective!