Pediatric cardiologist and educator Dr. Josh Daily joins the show to unpack one of the most pivotal and pressure-filled decisions in medicine: choosing your specialty. From the subtle influence of faculty feedback to the emotional weight of tough rotations, Dr. Daily shares how emotional and cognitive biases often shape career paths more than we realize.

In a system that expects clarity before exposure, how can students make informed, fulfilling choices? And what happens when a choice made under pressure leads to burnout later on? Dr. Daily reflects on his own journey, the power of mentorship, and why matching your specialty to your values matters more than chasing prestige. This episode dives deep into the hidden forces behind specialty selection; from confirmation bias and emotional fatigue to the role of coaching, aptitude testing, and systemic reform. We also explore how AI and wearable tech may influence the future of care and whether they’ll help or hinder the next generation of physicians.

If you’ve ever questioned your path in medicine (or are guiding someone through theirs), this one’s for you.

Here are four takeaways from the conversation with Dr. Daily:

1. Biases Shape More Than We Realize

Medical students often make specialty decisions based on limited exposure and emotional responses. Dr. Daily explains how biases like confirmation bias, anchoring, and the affect heuristic can lead to mismatched career paths.

2. Mentorship Matters — But It’s Not Always Objective

Mentors play a powerful role in shaping students’ perceptions of specialties. However, their advice is often colored by their own experiences and unconscious need to validate their career choices.

3. Early Exposure and Reflection Are Crucial

Dr. Daily advocates for earlier, more diverse clinical experiences and structured reflection to help students make more informed, less biased decisions about their future specialties.

4. Better Fit = Better Fulfillment

A good match between a physician’s aptitudes and their specialty not only reduces burnout but also increases professional fulfillment. Dr. Daily emphasizes that fulfillment is just as important as avoiding burnout.

Transcript

Josh Daily:

And so just saying out loud that they love pediatrics, they think this is great, is very likely to actually shift their underlying attitudes and ultimately their behavior, which is really interesting — that you could arrive at a decision with stakes that big simply by saying something multiple times out loud.

Michael Jerkins:
Welcome back to another episode of the podcast for doctors by doctors. I’m Dr. Michael Jerkins joined by the one and only Dr. Ned Palmer, the third.

Ned Palmer:
It’s actually the 3.5th. We kind of landed in the middle there. We’re trying for some non-integer generations.

MJ:
Are you really the third though?

NP:
No, it’s also not Edwin. We’ve known each other for more than 10 years. At a certain point, you’d think you’d understand anything about my name. What country am I from? Let’s see if we’ve got that much.

MJ:
You were descendants from the King of the North.

NP:
Yeah, well, I’m very much a white walker. I’m an ice creature.

MJ:
Isn’t his name Nedwin Stark?

NP:
No, Nedard.

MJ:
I need to go back and read those again.

NP:
The classic. I would have bet you would have read it.

MJ:
I did, I read all of them. I forgot.

NP:
And you know, reading comprehension is supposed to be higher than watched comprehension. And yet here we are.

MJ:
It was years ago, years. Anyway, what’s interesting about that is thinking about the last time I read a book from the series was in medical school. And luckily today, what I was gonna say is I don’t remember what that was like — learning and making decisions in medical school. And that seems to be what our topic is today with the nationally renowned thought leader in medical education, the one and only Dr. Josh Daily, who’s going to enlighten us about trends that are really important on how doctors make decisions on what kind of doctor they’re going to be, what specialty they choose, and what’s good and bad about our current medical education system that potentially allows trainees to maybe not make the best choice. So I’m excited to get to talk to him. He’s always very thoughtful.

NP:
I’m thrilled to talk to Josh Daily. So much of what he wrote in this article and his other work has resonated with me, both personally and professionally. Let me ask you a quick question as we lead into this. Specifically, we’re going to be talking about how medical students make decisions for residency and the specialty choice they make. How far into medical school were you when you knew that med-peds was a thing?

MJ:
Probably a month before I applied.

NP:
Same. So what were you going to be other than a med-peds physician?

MJ:
Yeah. I for a year or two thought general surgery. I did general surgery research, if you could call it that, and went to the ACS conference and I was the only one not in a sports coat and that’s when I knew maybe this wasn’t for me.

NP:
Wow. We’re going to talk about cultural fit today with Josh Daily and how important that is.

MJ:
Then family medicine, and then landing on my feet.

NP:
Yeah, those all make sense because they’re all super generalist roles. If you had said you wanted to be, let’s say, a retina surgeon or something super subspecialized in ophthalmology and then went to med-peds, I’d be more surprised. Those are all generalist roles — you want to operate on the whole patient all the time. I get it. There’s consistency.

MJ:
Yeah, I had friends in medical school that wanted to be family medicine physicians. And then once they got their Step 1 scores back, all of a sudden they wanted to be dermatologists. So, you know, who knows — maybe they changed their mind after they got exposed to a dermatologist after Step 1, but maybe not, maybe something else, who knows?

NP:
Maybe this all has to do with the bias of decision making — that medical students make big decisions off an insignificant amount of information that affects the rest of their careers.

MJ:
That’s a really good segue into our wonderful guest today. Let’s get right to it. The interview with Josh Daily. Alright, Josh Daily is here with us. He is a practicing pediatric cardiologist at Arkansas Children’s Hospital and the University of Arkansas for Medical Sciences, where he serves as the program director for the Pediatric Cardiology Fellowship Program. He also co-directs a medical student course, Personal and Professional Financial Essentials for Physicians, which equips fourth-year medical students with essential knowledge and skills to manage their financial futures. He and his wife Lauren are parents to four children — Will, Caleb, Abby and Ellie — ranging in age from 13 to three. Josh Daily, welcome back to the podcast.

JD:
Thanks for having me. Great to be here. I thoroughly enjoyed the last time I was on the podcast and I value both of your friendships and enjoy catching up with both of you.

How Bias Impacts Medical Specialty Selection

MJ:
Awesome. Well, Josh Daily, for listeners who have not read the awesome paper yet — which is in Medical Science Educator, titled “The Influence of Cognitive and Emotional Biases in Medical Specialty Selection: Path to Burnout” — it’s pretty awesome. But let me ask you, what got you even thinking about this topic at all?

JD:
Well, a number of years ago, toward the end of residency, I recognized that I had devoted a significant portion of my life to learning about medicine and that I was not growing in other areas. A mentor mentioned the value of reading broadly, so I decided I was going to develop a discipline of reading a book a month. I’ve done that ever since. I read a number of books, all the initial ones on my list, and then I started picking up ones based on recommendations from others.

I came across the book Predictably Irrational by Dan Ariely — that was my first exposure to this idea that we are predictably irrational, that we deviate from rationality in very clear and obvious ways. And that’s independent of our intelligence or training. In fact, there’s even literature that suggests that those who are more intelligent and highly trained are even more prone to cognitive biases.

I like to think of myself as intelligent and rational — and I saw these same biases in my own life. So, partly out of a desire to make good decisions, and also because it was fascinating, I did a deep dive into this. I read other books, and within the last few years I’ve done a lot of writing in this space and tried to read everything out there to become an expert on high-quality decision-making and how cognitive biases get in the way.

MJ:
And I think for most listeners, they may be aware, but in case they aren’t: all the doctors you see — the physicians, the specialists — all at one point had to figure out what kind of doctor they wanted to be. First they had to get into medical school. Then once in medical school, they took the classes, and sometime before they graduated — actually, several years before — they had to figure out what to apply for, interview for residency, and maybe later for fellowship. So there are a lot of big decisions made pretty quickly, only a year or two into their medical training. What are some of the patterns you saw in trainees early on that clued you in that people were potentially making irrational decisions about what to be?

How One Doctor Picked His Specialty

JD:
Well, let me step back briefly and provide more context for those less familiar. For those who enter medical school, the first two years are primarily classroom-based — physiology, anatomy — with very little exposure to actual clinical care. Then in third year, suddenly you’re in clinical rotations: pediatrics, internal medicine, surgery, and so on. You basically have one year to make a decision about what you want to do for the rest of your life.

There’s a lot of pressure to make a good decision but also to be a competitive candidate and optimize your application. Many people feel the need to decide very early in that year. Unlike many other careers, in medicine once you pick a specialty, there’s usually not much going back.

You can’t just reinvent yourself three or four times in your career. If I wanted to become an orthopedic surgeon today, I’d have to quit my job, reapply for residency, earn significantly less, and retrain completely. One, my wife would kill me if I even suggested it. And two, the cost would keep us from doing it. So there’s this brief point in time when you have limited experience but have to make very high-stakes decisions that determine your career path, with little chance to change later. I’ve seen a lot of students make big mistakes, and as I learned more about the psychology, I saw how these mistakes showed up for me too.

So it’s easy to point out mistakes in others, but I’ll share how I made that decision and the obvious mistakes I made looking back. I was the first doctor in my family and had little exposure to medicine — a few family friends, mostly orthopedic surgeons because I was an athlete in high school and had injuries. So I thought they were cool guys, looked like me — mostly Caucasian males — so it was easy to see myself in them. So when people asked me early in medical school what I wanted to do, I’d say probably orthopedic surgery. I stayed on that path for a while even though I had no deep understanding of what it meant to practice orthopedic surgery. I hadn’t been in the OR, didn’t know if I had the skill or even liked surgery — I just thought they were cool and similar to me.

Then in second year, a lot of the first year was memorization, which didn’t come naturally to me — my background is in physics, I like math and logic. So when we learned cardiovascular physiology, it wasn’t memorization but understanding systems and equations — that came naturally. So I decided I wanted to be an adult cardiologist. I felt the need to say out loud I knew what I wanted to do, probably overemphasizing how confident I was, trying to minimize the cognitive dissonance. So I told people with certainty: I knew what I wanted.

I started third year with that intention, rotated at the VA right away, and while the VA does a lot of great things, my experience wasn’t very positive for various reasons. I spent time on cardiology and realized what I loved about cardiovascular physiology didn’t actually play out day-to-day in practice.

I had made up my mind, I told everybody I was going to be an adult cardiologist. I knew what I wanted to do. I did well in the class and was completely certain this is what I was going to do. But I realized that really, one, most of what you do is algorithmic — if this, then that. There’s not a lot of thinking about the actual physiology. Two, most of it’s coronary artery disease or heart failure, and most of it’s geriatrics. You’re caring for people who often contributed to their own disease, and they need care, but there’s something different about caring for a child — in terms of my ability to be empathetic and the opportunity for impact when they didn’t bring their disease upon themselves.

So I had a little bit of a struggle at the VA. I didn’t enjoy it that much and wrestled with what I was going to do. Then I wrote down pediatric cardiology and I had this experience where I recognized very early that the things I loved about physiology were exactly what pediatric cardiologists did day-to-day. So once again, I was uncomfortable with uncertainty and just made up my mind that day — this is what I’m going to do — and told everyone I was definitely going to do that.

I went down the pediatrics route, matched into residency, and I still remember my intern year vividly — as is the case for many interns. There’s this period in the middle of winter where your mood dips: you get to the hospital before the sun comes up and leave after it’s gone down, you’re dealing with a lot of illness, and you’re stuck in the inpatient setting. So I was experiencing all of that when I rotated on inpatient pediatric cardiology. I really wanted to impress my attendings — I showed up early, did all the reading, wanted to be on point. But at the end of the day, I felt worn out. I didn’t feel excited or energized. I didn’t really enjoy that month, and I was an intern on inpatient pediatric cardiology. This was a few years before you guys were at Cincinnati Children’s, so we were still doing paper charting, which is kind of crazy.

I didn’t recognize how much of my time was spent doing this, but basically I went around collecting lots of data, writing it down, doing tons of charting, and putting in orders. That’s what I spent the bulk of my time doing. I wasn’t actually practicing much cardiology. By the end of that month, I didn’t want to say I changed my mind, but I was really wrestling with it. Then I spent time in emergency medicine — that was my next month — and at the end of every shift I was energized and excited. I enjoyed what I was doing and really wrestled with whether I was meant to be an emergency medicine doc. Maybe I’d had it wrong all along. I enjoyed work so much more in the emergency department than I did on pediatric cardiology.

I’m really grateful I finally recognized this. At the end of that month, I was thinking about shifting gears — which was really uncomfortable for me — and I was trying to find ways to rationalize not changing. Then it dawned on me: what I loved about emergency medicine was actually talking to patients, taking all the data and figuring out what was going on, developing an assessment, and making my own plan. Basically, I liked functioning like a doctor — that’s what I loved. It wasn’t the actual practice of emergency medicine.

What did I dislike about my pediatric cardiology rotation? It was collecting tons of data every morning, doing paper charting, doing all the scut work. That’s what I disliked. What I was actually practicing as an intern had nothing to do with the real practice of pediatric cardiology.

So if I had just followed my gut and my emotions in that moment, I think I would have made a poor decision. Now, could I have had a great career as an emergency medicine doc? Yes, I think I could have — but I think I’m a much better fit for pediatric cardiology. I’m so grateful, with a little mentorship and some reflection, that I realized what I actually liked. So I doubled down, got more experience in pediatric cardiology — reading echoes, being in the cath lab, doing what pediatric cardiologists really do — and I realized it was a much better fit.

So I really almost made what I think would have been a mistake. That’s really what’s called an attribution error — it’s a mix of an attribution error and the affect heuristic. The affect heuristic is when you use your emotional state as a stand-in for whether you should pursue or avoid something. In other words, if you feel happy, you think you should do it; if you feel disappointed or sad, you think you should avoid it. You assume that emotional response is a reliable indicator of fit.

With an attribution error, what I did was misattribute my emotional state to the inherent practice of that specialty, when really it had nothing to do with it. So it was a mix of those two that almost got me off the path that led me to pediatric cardiology, which I’m so grateful for. But those are classic examples where I almost made poor decisions. I see this all the time in medical students.

Another common one is confirmation bias — when someone makes a decision, especially if their identity is tied up in it. Maybe someone decides they’re meant to be a neurosurgeon because of an early experience with a neurosurgeon. They interpret all their experiences and data in a way that confirms what they already believe about themselves — especially when it’s a core piece of their identity. So you can get through medical school and have little actual aptitude to be a good neurosurgeon, but you interpret everything to reinforce that idea. So when people draw a conclusion early, they really need to be careful about getting an outside view and not just reinforcing what they already believe. That’s another classic pattern I see all the time.

MJ:
A couple quick thoughts, Ned, before your question. One, I guess you mentioned this in one of your biases, but every time I get an email from Ned Palmer, I feel bad. So I shouldn’t trust that and should step back and say, no, this is okay — I shouldn’t trust my emotional state when I get an email from Ned. That’s just lighthearted.

Speaking Medical Specialty Choice into Reality

MJ:
But the other thing is, it’s kind of funny: when I had students rotate with me on medicine or pediatrics, more often than not when stuff came up about what they wanted to do, they all said they wanted to be an internist or a pediatrician.

Obviously, I’m giving them a grade — so there’s some weird incentive structure there — but I wonder if psychologically, just hearing themselves say that over and over affects their decision making because of how they’re graded on these rotations.

JD:
Yeah, I definitely think so. One, as you mentioned, in an attempt to subtly impress you, they’re going to indicate they’re very interested in what you do and that they think your work is meaningful and interesting. Then our desire to minimize cognitive dissonance kicks in. We do everything we can to avoid pain, and loss aversion in particular says we place twice as much emphasis on avoiding pain as we do on pursuing equivalent gains. One of the most painful things is experiencing dissonance — when we believe something about ourselves but see data that conflicts with it.

When you say out loud that you believe something or that you like something, you’re very likely to actually change your underlying attitudes and behavior to align with what you said. Nobody wants to be the kind of person who says one thing and does another — that’s really uncomfortable, especially when you confront your own inconsistency. So we do everything we can to minimize that. So just saying out loud that they love pediatrics, that they think it’s great, is very likely to actually shift their attitudes and ultimately their behavior. It’s really interesting that you could arrive at a decision with stakes that big simply by saying something out loud multiple times.

NP:
Smile till you’re happy.

MJ:
Yeah, I wonder if you could actually look at the sequence of the core rotations for third and fourth year and see if that’s predictive of what people select.

NP:
First look bias — basically first exposure bias, I suppose.

MJ:
And to what Josh is saying — you get these reps of telling people what you want to be for eight weeks or twelve weeks, whatever it is.

JD:
Yeah, that’s called anchoring bias — when you anchor on your first exposure. So if surgery is the first thing you do, you anchor to that. Then status quo bias kicks in, and you tend to maintain that unless there’s a compelling reason to change. I’m not aware of research specifically in that area, but it would be really interesting to tease that out. There’s a lot of related research outside of medicine that clearly applies here and I’m sure has an influence.

Will Curriculum Changes Impact Specialty Choice?

NP:

Absolutely. What I want to talk with you about — you know, the structure that you laid out that I went through, sounds like we all went through: really two years in the classroom, two years clinical, very structured. There are some schools starting to blow that up with early clinical exposures, getting you into outpatient clinic earlier because it’s lower stakes, lower velocity. Have you seen or experienced any of these curricular shifts, and how are students — anecdotally — responding to those? Are they making their specialty choice with more confidence?

JD:
We have made some of those changes here at the university I’m at, but probably not as significant a shift as in other places that are more extreme in pushing those changes earlier in medical school. Of course, everyone says it’s good — often the people talking about it are the ones who came up with the idea and are implementing it. So naturally they say it’s great and makes a difference.

NP:
There’s some bias there too — the “it’s your idea” bias.

JD:
You got it. And then everyone went into medicine — or the vast majority of us — in part because we like caring for patients and clinical medicine. So of course medical students are going to say it’s a good idea. But someone simply saying they like it has very little to do with whether it actually brings about the change you want. If the goal is to improve the quality of decisions students make, then liking the change is a completely separate issue.

I’m not aware of anybody actually investigating that. What you’d have to start with is how we assess the quality of decisions currently — and we don’t really have a gold standard for that. We can look at things like: did you match into your residency or go unmatched? That might indicate overconfidence bias — maybe you aimed too high. We can look at burnout — whether you experienced burnout or not — although most doctors experience burnout at some point, so that doesn’t necessarily mean you made a bad decision. You can look at board passage rates. You can look at professional fulfillment down the road. You can look at how successful you are in your career using different measures. There are ways you could try to get at it, but as it stands, we don’t have a great way of assessing whether we’re actually making good decisions regarding specialty selection and its impact down the road. So it’s hard to determine whether these changes are delivering the intended result when we don’t have a good way to measure it yet, unfortunately.

NP:
Yeah — and quality has always been one of the trickiest things to measure in clinical medicine, right? Even just in care delivery, it’s a struggle to measure something that’s so multifactorial and can have these outsized impacts from confounders that make it impossible to really tease apart.

How Medical Specialty Choice Impacts Burnout

MJ:
You mentioned burnout — and I wanted to talk about that, because you led in strongly with how we make decisions and the biases that affect our own decision making. But can you connect that to burnout? Burnout is this big hydra — a multi-headed beast that affects physicians, with more than half getting it at some point in their career. How do early decision-making biases around specialty choice connect to future burnout? How strong is that connection or correlation?

JD:
Well, one, there’s an absence of robust data that shows a clear connection. I wish we had that data. A lot of connections make intuitive sense, and some conclusions are suggested by research outside of medicine, but within medicine there’s very little data to draw definitive conclusions.

Also, when you think about burnout — obviously a hot topic — the tendency is to view a physician as either burned out or not. I think there’s a better, more holistic way of thinking about it. Imagine a Likert scale from one to ten: ten being peak wellness for a physician, one being the absolute worst. Let’s say one, two, and three are in the burned out range, four and above are not. So the focus becomes: how do we get docs out of one to two and up to four or five? Oh, they’re not burned out — great!

But there’s another end of the spectrum that’s just as important but talked about less: what some people call professional fulfillment. Are you deeply engaged in what you do? Do you feel connected with those you work with? Is your work meaningful? Are you excited to go to work each day? That’s a smaller subset of doctors.

If you categorize physicians, there are basically three groups:

• Burned out and not professionally fulfilled — a big chunk, anywhere from 25% to 50% of doctors depending on the specialty.
• Professionally fulfilled and not burned out — a smaller group, maybe 20%–30% depending on what you look at.
• A big middle group — not burned out but not professionally fulfilled either. They’re not depressed, they sleep okay, but they’re not engaged at work. They punch the clock, care for patients, earn a paycheck — but aren’t excited about it.

So when you think about the match between your specialty choice and your aptitudes, your skills, your interests, your values — there’s a tendency to focus just on the burnout end, but I think the match impacts the full spectrum. It may have an even bigger impact on the other end — your ability to be deeply engaged and really enjoy your work. That’s probably amplified by a great match. But again, it hasn’t been rigorously studied within medicine — we’re borrowing ideas from outside medicine and applying them here.

When you look at burnout, one of the main drivers is lack of autonomy. There are many contributors, but that’s a big one. If you pick a specialty that fits your aptitudes and you get great training and build excellent skills, and you’re connected to your team and your work is meaningful, all those pieces come together. You’re more likely to have autonomy in what you do.

A lot of lack of autonomy comes from feeling unequipped to handle what’s in front of you. Also, the more competent you are, the more you can leverage your skills to get a job that gives you more control — both at work and in life. Autonomy isn’t just about work; it’s also about how your work gives you control over the rest of your life. That really reduces burnout.

For example: if I’m working 60 hours a week, I have kids at home, I barely get home in time to put them to bed, I’m up late taking care of things around the house, juggling too much — I feel out of control at work and at home. That’s a recipe for burnout. So an appropriate match between your specialty and your aptitudes and skills increases the odds you can leverage that to choose a job that gives you autonomy at work and outside work.

Also, if you’re really good at what you do, you can negotiate for better pay. Money can buy time — if you’re intentional about it. Buying more stuff won’t make you happier, but using money to buy back time and create time affluence can give you more autonomy outside work.

So there’s a complex interplay of factors. But I do think a big piece is making a good decision on the front end. Now, it’s not the end all, be all — if someone listening looks back and sees biases in how they chose their specialty, that doesn’t mean they’re doomed to a bad job or burnout. There’s a lot you can do in your current job to reduce burnout, increase fulfillment, and optimize autonomy in life. It’s not one decision that seals your fate — but it is an important decision that has huge impact throughout your career.

NP:
So where you ended there was going to be my next question, and it’s really difficult — and I appreciate your description of how it’s very difficult to tie specialty decision-making directly to burnout and correlate that.

Most Common Biases in Medical Specialty Decision Making

NP:
I think what we do have a good sense of — and maybe I cheated by reading your article — is that we do see biases in decision-making. So do we at least have a rank order of some of the most common biases that you’ve seen in residency or specialty decision-making that med students are making today? It all starts with recognition. So maybe this just helps our listeners see themselves in some of these biases. I think you, Josh, and Michael and I identified in the preamble that we definitely made some of these. So, if you had to pick a top three, what are some of the most pervasive and problematic when med students pick a specialty?

JD:
Probably the most significant is what many people call the mother of all biases — confirmation bias, which we’ve already talked about a little. This tendency to interpret events and data in a way that confirms what we already believe, especially when that relates to our identity. That’s the most powerful one and the one we have to be most careful with.

In addition, there’s a flip side I’ll briefly mention: we’re often greatly influenced by advice from our mentors — and mentors tend to give advice that aligns with the decisions they made. In large part, that’s to minimize their own cognitive dissonance — that discomfort they’d feel otherwise. So probably all three of us who trained at Cincinnati Children’s are going to have a very favorable view of Cincinnati Children’s. If we talk to a medical student thinking about doing pediatrics, we’ll say, “Oh yeah, you should really consider Cincinnati — you’ll get great training there.” We’ll give advice that aligns with what we did because we like to think of ourselves as great doctors. It’d be uncomfortable to conclude, “Eh, I’m kind of average.” So we give advice that aligns with our path.

So when you get advice from a mentor, they’re probably going to recommend a path similar to theirs — that’s part of minimizing their dissonance and engaging in confirmation bias themselves. So it works both ways, which is really interesting. That’s number one: confirmation bias.

The second is this combination of the affect heuristic and misattribution errors I talked about — the tendency to rely on our emotional state and our gut. I’ll go a little deeper here: there’s a lot of confusion, especially in American culture, about the role of emotion in our lives. There’s this belief — especially in Disney movies — that your genuine self is entirely a function of your emotions in that moment, and you should just “follow your heart.” Anyone who’s been a parent knows if a kid does that, it causes all sorts of problems in the house — it’s a marker of immaturity to just do whatever you feel in the moment.

But we tend to believe emotion should be our guide. So in a complex decision, we feel uncomfortable and latch onto “follow your gut.” Some mentor may have told us that too. So we rely heavily on emotion.

The reverse is also true though — it’s unhealthy to ignore emotions entirely. Emotions are a big part of who we are. If you feel happiness, sadness, disappointment — it’s important to investigate: what were the drivers behind that? What was the context? Was something else going on in your life? Some emotions are secondary — anger, for example, is often a secondary emotion masking embarrassment, hurt, or something else. So when you feel a strong emotion, don’t let it guide you blindly, but don’t ignore it either — be curious about why it’s there and what it reveals about your beliefs, attitudes, or insecurities.

We get this wrong a lot — letting the affect heuristic guide us. And when that combines with the misattribution error — when we have a strong positive feeling and attribute it to “this specialty is a good fit for me” when it actually has nothing to do with that — we make bad decisions. Research on specialty selection consistently shows that the most powerful determinant is mentorship. Basically, did you have a good mentor in that specialty who you wanted to emulate and who took an interest in you? If so, there’s a good chance you’ll pursue that.

So, on a rotation, you might have an upper-level resident or attending who’s kind, a great teacher, engaged with you, who says, “Hey, you could be really good at this.” That feels great and you think, “This is what I’m meant to do!” Or you might have an upper-level resident who’s a jerk, puts you down, makes you do scut work — and you think, “I hate this; surgery’s not for me.” But that has nothing to do with the practice of surgery and everything to do with not liking to work with jerks — and it just so happens you encountered one that day. So we have to be careful about the misattribution error, especially when it’s combined with our emotional state.

Those are the two biggest. The third one to be very careful of is the representativeness heuristic: “I look like them, so I must be a good fit here.” That takes many forms — gender, race, interests, age, where you’re from — lots of things play into that. But in many cases, looking like that person has nothing to do with actually practicing in that specialty. So those are my big three. In the article, I give a lot more — there’s usually a complex mix, not just one bias but several working together to lead to bad decisions — but those are the biggest, in my estimation.

NP:
Those are the biggest. So, two things: you mentioned the lookalike bias — and what I didn’t get to say is, was baldness a factor in you thinking about orthopedic surgery? Just because of the shaved-head look?

JD:
Interestingly, I was not bald then. I had hair when I made that decision. If it hadn’t been for that, maybe I would’ve been an orthopedic surgeon!

NP:
Wow, okay! Today, wearing an Under Armour polo, you look like you could have sold anybody on orthopedic surgery, Josh.

MJ:
That’s right.

JD:
Don’t I look like it? You got it.

How Toxic Experiences Influence Specialty Choice

NP:
But you mentioned — I think in that transition at the end — you called out the potential for a toxic surgical rotation, maybe because you had one; I had one, I’ll raise my hand. So when you wrote in the case study about Ellie (well named, of course) and the toxic experiences she had in surgery — poor lookalike fit, poor mentorship fit, and generally poor understanding of the actual practice of general surgery — how often do you see students mistake a toxic environment for a poor specialty?

JD:
Well, since I practice in pediatrics — and we never have any toxic environment issues — that’s not something I see a whole lot. (No, not at all.) I do hear about it from other specialties, but yeah, I think that has a big impact on what medical students pick, especially with the emphasis now on mental health and enjoying what you do. That’s probably become even more important.

As you look at shifts in the kinds of specialties newer doctors are choosing, there’s been a move toward more lifestyle specialties and away from some of the more demanding or historically more malignant ones. That shift, combined with all these biases and the way academic medicine works — the roles medical students have on these rotations often have nothing to do with the actual practice of that specialty.

We tend to believe that students do the grunt work now and “work their way up” later. But if that grunt work leaves them with a negative emotional experience, they may dismiss the entire specialty because of it — even if it could actually be a great fit. That plays out in a lot of ways — partly due to the structure of rotations and partly due to individuals.

It’s easy to give surgeons a hard time — “Oh, that attending was a jerk” — but they have their own stories. Maybe they didn’t sleep the night before, maybe a patient died, maybe something’s going on at home. So it doesn’t make them a jerk in general, but in that moment, they may manifest more toxic behavior for all sorts of reasons. But that has a huge impact on what students select.

Recognizing Biases in Your Own Decision Making

NP:
Absolutely. And then the flip side of that, to keep going: Caleb — also well named in your case studies — is someone who overly identified as the orthopedic surgeon (which now may have some personal connections here!), with that early over-identification and the confirmation and anchoring biases you described. What could Caleb have done to change the outcome? What exists to counteract these heuristics once you recognize the biases within yourself?

JD:
Well, what’s interesting — stepping back a bit more broadly — is looking at how we can protect ourselves from bias. There’s a belief that if we just teach people about biases, then they’ll recognize them in themselves and be protected. And that does help a little, but not nearly as much as you might think.

NP:
The nutrition label approach, right? Put the information out there and then let people — yeah, seeing is modifying behavior.

JD:
You got it. Especially when you look at behavioral economics and public policy, the far more powerful variables are changing the systems in a way that makes the manifestation of these biases less likely and nudges people toward better decisions. So, if I could just wave a wand and do whatever I wanted, it wouldn’t be to make sure every med student knows all this material — though I think they should learn it. I’d change the way we structure medical school: the experiences, the coaching, and how these decisions are made.

Ideally, early on, Caleb would have been paired with a mentor who recognized some of this, engaged in reflective processing about his experiences, his beliefs, how to interpret them, and would do some affective forecasting about what his future life might look like and what would be important to him. Through that process, he could draw better conclusions early about what would be a good fit or not.

There’s lots more — early exposure, the kind of exposure to different specialties — that would have helped a lot. In Caleb’s case, multiple variables came together and ultimately led him into burnout and a job he didn’t enjoy. And a lot of that wasn’t just specialty choice — there’s more to it.

But I would focus on the system side if I could do anything. From the perspective of actually helping individual learners when I can’t change the whole system, helping them understand how we make decisions and adopt a few practices can help. One thing: I created a tool in the manuscript that a third-year medical student can use to help them assess. For example: I just spent eight weeks on surgery — what emotions did I experience? What did I like? What did I not like? Why? How strong a candidate would I actually be? What other steps can I take to get more experiences that help me decide? Those kinds of reflections can be really helpful at an individual level.

Changes Dr. Daily Would Make

MJ:
So let me ask: you mentioned systems are more powerful than just providing information. So, Dr. Daily is chancellor for a year — you can take it down to the studs and rebuild it. What would you rebuild to limit the amount of bias med students have to navigate to pick their — I don’t even know what adjective to use — their specialty that they would enjoy and find the most joy in?

JD:
There are a number of things I’d do, but at the top of the list: I’d develop evidence-based aptitude testing for physicians. We often select specialties based on interest, not aptitude. Aptitude is your underlying capacity — how quickly you can learn a given skill or task, your ability to excel at it. Sure, sometimes through brute force you can develop knowledge and skill, but it may not come naturally and your top-end performance may be lower than in a better-matched area. The better the fit between your specialty and your aptitudes, the better the choice and the more likely you’ll experience high fulfillment.

We often mistake interest for aptitude. For example, maybe I like sports, so I think orthopedic surgery would be a great fit — when actually the aptitudes needed for ortho are fine motor control, three-dimensional visualization, thinking in space, and so on.

If we had actual testing that showed where you score high or low, that could help match you to specialties that would be a good fit. Not that there’s one perfect specialty and everything else is bad — but some are clearly better fits than others. I’d want this testing very early in med school, before all these opinions and biases form and push you down a path that’s hard to change.

Next, I’d ensure intentional clinical exposure from day one, in a diversity of settings. So you wouldn’t have your only internal medicine rotation at the VA, for example. You’d also have time at an academic hospital, maybe a private hospital, maybe an outpatient clinic — so you get a more accurate sampling of what’s actually possible in that specialty.

There’s another bias, the availability heuristic: we assume our limited exposure equals the whole truth. As an internist, Michael, you know there’s a huge breadth in internal medicine. As a third-year med student, I might have thought internal medicine was just inpatient or a clinic with chronic disease. That may have been my only limited experience, when actually there’s a lot more to it.

Some areas — like radiation oncology — I never rotated on. I’m not sure I even knew that was a specialty because I had zero exposure. So you have these limited third-year experiences and think you know all of medicine — when really there’s so much you haven’t seen. So I’d design rotations to broaden that exposure — you can’t cover everything, but there’s lots of room for improvement.

Then I’d train attendings in basic coaching skills and basic decision-making practices, with some tools, and have them meet regularly with each student to process experiences and guide them toward specialties that might be a good or bad fit. It would ideally be driven by data: if someone did poorly in grades or USMLE but wants dermatology, they’re probably not going to match. You do them no favors by encouraging false hope. A data-driven component would help them make high-quality decisions with a realistic chance of matching.

I’d bring all that together — starting from day one — instead of having this 12-month period in third year where you go from knowing nothing to having to make a major decision at the end.

MJ:
Makes sense. It’s probably better you didn’t know about radiation oncology — given your love of physics, you might have skewed that way. But that makes a lot of sense. I think the teaching attendings piece would probably be the biggest lift — or the biggest challenge — but I love that model.

If Bias Affected Your Specialty Choice

MJ:
I had one more question before we go to our true/false section: How do you recommend — because we’ve talked about people who might look back and realize bias affected their specialty choice — but what about people who’ve done all this, recognized the biases, and say, “Yes, I definitely know I want to be a urologist,” but then they take Step 2 or see other objective data that says, “You’re probably never going to be a urologist.” How do you coach those students?

JD:
First, you have to be willing to step into the discomfort of having an honest conversation. You do them no favors by saying, “Oh, it’ll be okay. Everyone struggles with that test. You’re still a great candidate.” That doesn’t help them — it just discharges your discomfort in that moment. It’s a selfish approach — it’s more about you than them.

So you need to have an honest conversation. And in almost every area, if you distill down the aspects of a specialty that are a good fit for you and that you want, you can almost always find those in another specialty that you’d be a good match for. It’s not like you go back to square one: “What do I do now?”

If it’s a surgical specialty you were planning to pursue and you really like the procedural aspect — there are other, less competitive specialties that still offer a lot of procedures. Or maybe you like longitudinal patient relationships, or the inpatient setting — drill down to those aspects you’re drawn to or that fit you well, and find other specialties that offer them too. In almost every case, there’s an alternative you can match into that would still be a good fit and let you have a good life.

MJ:
I love it. That’s great — great tidbits. Now I’m going to move on, Dr. Daily, to our true/false section, where I say a statement and you tell me if you believe it’s true or false.

True or False with Dr. Daily

MJ:
First true/false: the longer the review of systems is in a medical record, the more likely it is to be false. Do you agree?

JD:
That is a true statement.

NP:
Yeah, I don’t think anybody would —

MJ:
Anybody who’s actually filled out a review of systems —

JD:
Some of that’s just odds: if you know how math works, if you ask 30 questions, the odds that one is incorrect are much higher than if you ask five questions. So, I mean, some of that is just basic probability.

MJ:
I love that. Yeah.

NP:
It’s further from reality — the longer the pan-positivity of the ROS. But maybe that’s my cynicism.

MJ:
All right, next statement: true or false — tuition to medical school will eventually start to decrease.

JD:
In real dollars — is that what you’re asking?

MJ:
In inflation-adjusted dollars.

JD:
I think that could go either way. I’m neutral on that. I think it’ll probably remain constant in real terms.

MJ:
And not go up?

JD:
Not in inflation-adjusted dollars, on the median. I think the average might go up because outliers influence it — some schools can charge insane amounts and pull up the average. But I think the median — the 50th percentile — will probably stay about the same in inflation-adjusted dollars. But I could be completely wrong — that’s my best estimate.

MJ:
Yeah, it’s optimistic. Actually, that would be optimistic. Ned, as you said, I think it’s going to be a lot cheaper — but I don’t believe that’s likely either.

NP:
Optimistic. Might be unrealistic, though.

MJ:
Okay, next statement — true or false: The future of medicine is bright.

JD:
True.

MJ:
Why do you say that?

JD:
Well, for a variety of reasons. First, we have an underlying psychological tendency to say that things are worse now than they were 10, 20, 30 years ago, and then we project that into the future. So we fixate on the negatives and assume they’ll keep getting worse. But if you actually look at objective data — there’s a book called Factfulness that unpacks this — overall, the world is better than it used to be and every indicator suggests that will continue.

So, partly because I know some of that data and how we tend to think. Also, I’m really excited about how AI will likely improve medical care and how we practice — hopefully offloading a lot of the tedious, time-consuming tasks doctors don’t enjoy.

MJ:
What’s interesting is that’s my next statement: True or false — AI will ultimately result in making patients healthier.

JD:
There will be ways in which it does and ways in which it doesn’t. The net effect will probably be about even. I think the quality of care will improve, but actual patient outcomes may not, partly because AI may encourage behaviors that aren’t in the best interest of the overall population.

MJ:
Like what? What would AI encourage that could harm patients’ health?

JD:
I think AI will push us to spend more time on devices and be more reliant on screens, which has a net negative effect on the quality of our relationships — which is actually the primary driver of human flourishing, according to the research. So, I worry about that downstream effect: more screen time and computer interaction might reduce meaningful connection with real people.

MJ:
True or false: Wearable devices that measure things like heart rate variability and pulse ox improve patients’ health.

JD:
There are ways in which they help and ways in which they hurt. Tracking your daily exercise, for example, probably increases how much you exercise. But more data in an otherwise healthy person just increases false positives. If you put an Apple Watch on a teenager — where the underlying prevalence of arrhythmias is very low — and it flags an arrhythmia, the odds of that being real are unbelievably low. I see patients in my clinic for that all the time, and it doesn’t really improve care overall. So: benefits and downsides.

MJ:
Last true or false: Most doctors, if they could do it over again, would choose a different specialty.

JD:
I think that’s false. For a lot of reasons we’ve discussed, it’s really painful to say, “This huge decision I made that shaped who I am — I got it wrong.” We like to believe we’re great doctors in our specialty. It’s painful to say, “I’m an okay cardiologist. I’m not that great.” So, we’re drawn to conclude, “I’m a great cardiologist and I made great choices.” That’s different from whether we really ended up in the optimal specialty — but I think most doctors would say they’re glad they did what they did. Unless something really egregious happened, people rarely conclude they made a bad choice and wish they’d done something different.

MJ:
Got it. Alright — final question we ask every guest: Dr. Daily, what’s one thing you’ve recently changed your mind about?

JD:
This is pretty specific, but I’ve been doing some financial modeling on physician compensation and found that some of my assumptions aren’t supported by the data. For example, as an academic doc, it’s easy to say, “I’ve sacrificed higher pay to teach the next generation.” I just finished an analysis looking at lifetime earnings for pediatric cardiologists — and basically, academic pediatric cardiologists don’t really give up much at all. We make about the same, in discounted dollars, over a lifetime as those in private practice. So this belief I’ve held for a long time just isn’t true — at least in my field. There are other fields where it is true, but not in pediatric cardiology.

NP:
But you get to believe you’re a martyr and feel better about the work you do. I wish you still had that blissful ignorance!

MJ:
Well, Dr. Daily, thank you for shedding light on all of this. If people want to find out more about you and your work, where should they go?

JD:
You’re welcome to reach out to me directly — my contact info is on the pediatric cardiology fellowship program site at University of Arkansas for Medical Sciences. I also write for The White Coat Investor — you can find my articles there in the columnist section. And I’m happy to answer individual questions via email — that’s probably easiest.

MJ:
Awesome. Well, Dr. Josh Daily, thank you for joining us. We appreciate your time.

JD:
Yeah — enjoyed being here. Thanks for having me.

NP:
Thanks for joining us for this episode. You can catch The Podcast for Doctors, By Doctors on Apple, Spotify, YouTube, and all major podcast platforms. If you enjoyed this or learned something, please give us a rating and subscribe so you don’t miss an episode. Thanks for listening — and next time you see a doctor, maybe prescribe this podcast. See you next time!

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