By: Sakhi Shah
One of the strangest parts of fourth year is that people assume you must feel certain by now.
By this point in medical school, the expectation is almost that your story should make sense. You are supposed to know who you are, what field fits you, and where you are going next. There is something comforting about that idea, I think, for the people around us and sometimes for us too. It suggests that all of these years of exams, rotations, shelf studying, applications, and interviews build toward clarity.
But for me, choosing a specialty did not feel clear in that way.
It felt personal. It felt slow. It felt less like arriving at a neat answer and more like noticing, over time, which parts of medicine kept following me home.
Narrowing down specialties
At different points in medical school, I considered PM&R, Internal Medicine, and Psychiatry. PM&R was ruled out relatively quickly. That part of the process felt more straightforward. But deciding between Internal Medicine and Psychiatry was something else entirely. What made it difficult was not that I felt lost. It was that I felt pulled toward both for real reasons.
Internal Medicine had always been part of the picture for me. Some of that came from familiarity. My sister is an Internal Medicine resident, so I had more exposure to the field early on than I did to most others. But it was more than that. I genuinely loved the way Internal Medicine asks you to think. I liked that you could not reduce a patient to one complaint or one organ system. I liked the breadth of it, the way it asks you to hold so many moving pieces at once, to think across systems, to step back and try to see the whole person through the complexity of their medical problems. There was something deeply satisfying to me about that kind of thinking.
Psychiatry arrived differently.
My interest in psychiatry as a career came later in medical school, and because of that, I think it surprised me more. When I started my psychiatry rotation, I did not fully realize how much it would stay with me. But by the end of it, I knew something had shifted. I loved the rotation in a way that lingered. Even after it was over, I could not stop thinking about it.
What struck me most was not just that I enjoyed the experience while I was on service. It was that psychiatry stayed present even when I had moved on to other rotations. I found myself looking at later patients through a psychiatry lens. I paid more attention to affect, to anxiety, to the emotional undercurrents in an encounter. I noticed medications differently too, especially SSRIs, in a way that made me think more carefully about how mental health was threaded through so much of what we do in medicine. Psychiatry changed the way I was seeing patients even when I had completed the rotation.
That stayed with me.
And that was what made this decision difficult: I could genuinely imagine a life in both fields.
What kind of doctor am I becoming?
I think people sometimes talk about specialty choice as though the challenge is simply figuring out what you like best. But that was not really the question for me. The harder question was what to do when more than one field feels meaningful, when different parts of you come alive in different places.
In Internal Medicine, I felt drawn to complexity, to systems-based thinking, to the challenge of working through the body as an interconnected whole. In Psychiatry, I felt drawn to a different kind of whole-person care, one rooted in conversation, in listening, in trying to understand suffering that does not always show up on imaging or in lab values but is no less real.
It is easy, in medical training, to talk about choosing a specialty as if it is mostly a practical decision. And of course, part of it is. We think about lifestyle, training length, job opportunities, patient population, the shape of daily work. But underneath those practical questions, there is also something quieter happening. At least for me, there was. I was also asking: What kind of presence do I want to have with patients? What kind of work feels sustaining to me? What kind of doctor am I becoming?
Fourth year gives you a little more space to ask those questions, but it also brings a different discomfort. By then, the decision starts to harden into reality. There are applications, personal statements, away rotations, mentors’ opinions, interview invitations, rank lists. Reflection becomes tied to consequence. You are not just imagining a future anymore. You are choosing one, or at least trying to.
Dual-applying as honest listening
For me, dual-applying became the most honest response to that reality.
I know dual-applying can sometimes be framed as uncertainty, and maybe in some ways it is. But I do not think uncertainty is always a sign of weakness. Sometimes it is a sign that you are taking the decision seriously. I dual-applied because I could not pretend one of these interests mattered less than it did. I could see myself in both Internal Medicine and Psychiatry. I could imagine being fulfilled in both. Dual-applying was not a way of avoiding reflection. It was, in many ways, the result of it.
Still, there is a particular emotional tension in reaching this point in fourth year. Choosing a specialty is one of uncertainty. Waiting for Match Day is another. Once the rank list is submitted, so much becomes quiet in a way that almost feels unnatural. For years, medicine trains us to keep moving: one more exam, one more note, one more rotation, one more hurdle. Then suddenly, we are asked to wait.
And in the waiting, everything feels louder.
You replay conversations. You think about the patients and preceptors who shaped you. You wonder whether you interpreted your own experiences correctly. You imagine multiple futures and realize that soon, one of them will become real. Match Day sits on the horizon like both a culmination and a question.
As I get closer to it, I find myself thinking less about whether I chose “correctly” and more about what this process has revealed to me. It has shown me that my relationship to medicine is shaped both by intellectual curiosity and by human connection. It has shown me that I am drawn both to complexity and to meaning-making. It has shown me that sometimes the path forward is not obvious, not because you are lost, but because more than one direction reflects something true about you.
If I were speaking to a student earlier in training, I do not think I would tell them to chase certainty. I would probably tell them to pay attention instead. Pay attention to what keeps echoing after a rotation is over. Pay attention to the patients you keep thinking about. Pay attention to which forms of exhaustion feel empty and which feel worthwhile. Pay attention to the versions of yourself that emerge in different clinical spaces.
Sometimes that is where the answer begins.
Valuable lessons learned in decision-making
I do not know exactly what Match Day will bring, and I think that is part of why this season feels so emotionally charged. There is excitement in it, but also vulnerability. After spending years trying to become someone, there is something so exposing about waiting to find out where that becoming will continue.
What I do know is that this process of choosing has mattered. Even before the outcome, it has mattered. It has asked me to look more honestly at what draws me, what sustains me, and what kind of physician I hope to be.
And maybe that is part of what fourth year really is: not just a transition into residency, but a final season of learning how to listen closely to yourself before medicine asks you to move faster again.
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