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Notes from a coffee exchange



It’s my first semester of medical school, and I’m having coffee with Sam, a rising fourth-year medical student. My goal is to pick his brain a little bit and – more importantly – see if he has “figured it all out.” I, a mere three weeks into my first year of medical school, have not.


Sam faces the all-encompassing decision of what to do with the rest of his life. He’s deciding between two fairly-competitive specialties: one surgical, one medical. 


When comparing the two, he discusses earnings potential, prestige, training timeline, and career flexibility. 


“The ability to go in and make a major impact is highly rewarding to me - as it would be to anyone,” he says in reference to the surgical speciality. “The interventions are just incredible and what I’ve wanted to do for so long,” he says, referring to the physical challenge and immediate gratification.


“Medicine would allow me to treat a greater variety of diseases and provide me with more fellowship opportunities,” he says. “You have the ability to pursue almost anything you wish and treat the whole person”. 


His rationale is unconvincing. I already know all of those points.


He says he is “still deciding,” but I can tell he’s already made his decision. I just don't know why.


Then, he explains his grand theory: “You see all of these smart people, brilliant people. It’s like they just keep extending their personal goalposts. You’ll hear them say, ‘I’ll have made it when...’ The only problem is, they keep going on and on. They never actually make it because their target keeps changing to another point five years down the road.”


“And that’s why I think I’m going with Internal Medicine,” he says after the next sip of coffee.


This leaves me feeling quite confused. It seems like an odd way to decide what to do for the rest of his life. Maybe he had a better elective experience with Internal Medicine. Or perhaps he just wanted to keep more career opportunities open to him in the future. For whatever reason, I imagine he thought his goalposts were more worthwhile for him in Internal Medicine.  


I don’t remember anything else we talked about at the Coffee Exchange that day.




It’s near the end of my third year, and I ask a group of residents why they’ve chosen their particular specialty. 


Each resident frames their choice through what they hope to one day be – albeit if that occurred after one or two fellowships:


“I’m essentially a GI prelim,” one senior internal medicine resident explains confidently to me. 


“I want to work at the intersection of both MIS (minimally invasive surgery) and trauma,”  a general surgery resident tells me, outlining an innovative career after gen surg residency.  


“There’s only a few combined bridge fellowship programs out there, but it’s what I really want to do,” a med-peds resident describes fascinating plans to pursue combined adult-pediatric hematology-oncology fellowship programs.


I never once hear earnings potential, prestige, competitiveness, or work-life balance. Their concrete plans stand in sharp contrast to the foggy horizons of a third year med student. 


In retrospect, I think Sam’s point had a lot less to do with specialty choice than I first thought; he could have been deciding between any two specialties. 


The future can make for a frustrating conundrum – the further people extend their end goals and dreams down the road, the greater they fail to recognize where they are in the present. Crystalizing our plans too far in the future, in an odd way, blurs the present. 


I like to think that this guy “figured it all out” as a fourth year, and hopefully we will too. But until then, moving forward one goalpost at a time sounds like a good plan to me.

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