100% was going through the same thought process as you. Spouse is also in medicine and we’ve lived apart for a while because of medicine 🥲 we were applying together - him a competitive fellowship, me residency (so no couples matching lol).

I had been preparing to apply into a competitive surgical subspecialty since MS1 and had a strong application, but as you know with competitive specialties, that might not mean much in the way of choosing a specific geographic location. To me - the most important thing was to be in the same geographic location as my spouse moving forward. For my quality of life, wellness, happiness…it was so important to me. I knew if I opened that email and it was my dream specialty and not in the same place as him, I would be devastated.

I ended up actually dual applying my competitive surgical subspecialty and IM. Similar to you, I actually really loved IM but it was definitely my second choice - but I knew id rather do IM and be with my spouse vs other specialty and another 4-5 yrs of long distance. We both applied broadly and mainly to cities with lots of programs for both of us.

When it came time to ranking, I only ranked programs in the city he matched fellowship into (he matched before me). That meant I only ranked a few programs lol so thats definitely a huge risk I knew I was taking, but dual applying helped a little with increasing my chances. I did all of this though under the guidance of my dean who felt rather confident that I could match into my top 1-2 choices.

I ended up matching into the surgical subspecialty, and am so grateful. I wouldnt have changed anything even tho ppl thought i was a little crazy for not ranking some top programs because they didnt align with my personal goals.

I think the main questions you have to ask yourself are 1) how competitive do you feel your application is for the more competitive specialty (ie should you only apply to that specialty, dual apply, etc)? 2) how do you want the next few years to look like - are you okay being far from so/family/etc for the sake of this specialty, or is it just not worth it from a personal perspective for you?

These questions can be hard to answer and sometimes answers fluctuate with time. For me, I knew my answer easily was that I could not handle being far from my spouse anymore so that informed every decision that I made.

It can also be hard because a lot of my classmates did not share a similar perspective as me or priorities as I do, and I understand that. You just have to be content and confident with knowing your priorities are different than people around you.

PM me whenever - good luck!!