Oxford Handbook for Medical School

Medical school presents numerous opportunities for students to gain further experience in a field of medicine that they find interesting. This includes either clinical or research placements that are assessed and form part of the course, to opportunities that are voluntary, such as essays and prizes. You may not know it at the time, but these selected components may be pivotal early experience that may shape your future career.

Base hospital selection

In some large medical schools, there may be a choice of teaching hospitals to use as your ‘base’ for 3 years. Each base hospital is linked with its own selection of surrounding district general hospitals and primary care facilities. Your base hospital selection will likely be influenced more by where you live, or would like to live, rather than any specific educational requirements at the time of selection. Of course, if one base hospital has a particular department that you wish to work in, or is renowned for a specialty that you are intrigued by, you may consider it an advantage to be placed there.

Student selected components

(See Chapter 56.) Student selected components (SSCs), or modules (SSMs), are programmed opportunities for student selected clinical placements. A medical degree may allow opportunities for three or four SSCs (typically of 1 month’s duration). You can either select placements in areas of career interest, to gain further insight or simply because you find the subject matter of interest, or you may select an SSC to fill a gap in the medical curriculum. You may select an SSC to address an area of weakness in your clinical knowledge or skills, based on past performance in assessments, for example. It is typical to require a supervisor report at the end of an SSC, and you may be required to write a case report on a particular patient with a literature review.

Elective

(See Chapter 55.) Your medical elective is a unique and treasured time in your undergraduate training; it is likely you have been anticipating it from the start of medical school. There is a world of possibilities, both in terms of destination and in the content of your placement. If your budget allows, considering splitting your elective to allow you to visit two destinations (developing world and developed world), and consider experiencing more than one specialty (medical and surgical). You may be able to undertake a short research project, but ensure you can complete it in the short time that you have, and ensure your supervisor has a strong publication record to minimize risk of disappointment. Read elective reports catalogued in the medical school, and browse online elective reports for reviews on placements and practical tips in organizing your elective.

Intercalated degree

(See Chapter 5.) There is a huge variety of intercalated degrees available, and they present a wonderful opportunity to step off the undergraduate conveyor belt, explore a subject matter in depth, undertake research, augment your CV for the remainder of your career (you will reap the rewards throughout), and enjoy another year at university. Intercalated Masters degrees are now available, which you are only awarded on qualification from medical school. It is possible to intercalate at an external institution, usually only if that course is not offered locally. Funding may be available, and some universities will heavily subsidize course fees for intercalating students as an incentive. External funding may also be available, such as the Wolfson Scholarship ( www.wolfson.org.uk/funding/education/intercalated-awards). An extra year is largely irrelevant in the long term, but the rewards are constant, cumulative, and lasting. Ask existing students about the course you are considering undertaking so you can gain a firm idea of the content, advantages, and challenges—and, of course, the process of application. Some full-time research degrees (Master in Research) may offer a range of established supervisors and basic science projects. You are likely to lean towards the subject matter that you are most interested in, but be reassured that the skills learnt are often generic and easily transferable to other fields should your career and research interest change in the future.

Project option/research placement

Some medical schools require students to undertake a compulsory research or audit project during the latter half of clinical school, in a subject matter of their choosing. This is a wonderful opportunity to get work published, provided you are organized and can find a suitable supervisor and project that may be undertaken within the specified time period. The work completed may be of sufficient standard for presentation at national level, and you may go on to undertake further projects with your supervisor later, depending on whether you stay local to the unit for the remainder of medical school or beyond. The medical school may have a list of established supervisors to choose from, who are likely to suggest particular projects that are suitable for the period of time that you have. The reputation and output of the supervisor, experience of recent medical and research students, and profile of the group may influence your decision to join them for this period.

Prizes

Prizes are an excellent way to distinguish yourself: they stay on your CV indefinitely, and will look impressive in future job applications, indulge your interest in a subject, and usually come with some cash. There are a huge number of prizes available, either administered internally by the medical school, or offered externally by charities, Royal Colleges, Royal Society of Medicine, etc. Some, such as the Duke Elder Prize in Ophthalmology, are well publicized and recognized at interview. Entering such competitions is a statement of commitment to the specialty in itself, even if you do not win.

How to choose a specialty

A medical degree can be used a springboard to a vast range of careers. Although exciting, this degree of choice may be somewhat paralysing. Choosing a medical career is a complex decision, influenced by personality/character traits, personal attributes/skills, life aspirations, experience, and your personal circumstances—all of which may evolve and some of which may conflict. Then of course there is the nature of the job, the workplace environment, and the competition for training places to consider. The NHS is changing faster than ever, and it is incredibly important that when you are considering a future career, you take into account the likely changes within the bigger picture of healthcare provision and how they may impact on the working pattern and environment in your chosen specialty.

Career planning is not an entirely logical or linear process, but is influenced by many internal and external factors, and there is no set time when it should consciously take place. Many students feel under pressure to make an early decision, and feel concerned when others seem settled on a specialty choice, but research has shown that early aspirations are a poor indicator of an individual’s final career destination in medicine. It is natural for career aspirations early in medical school to be influenced by changing life circumstances and priorities, which of course are not always predictable! Knowledge and understanding of what you enjoy and where you thrive in the workplace can only come with experience, and this information should guide you as you work on developing your career over the years. Career planning is not about a one-off decision, but is an evolving, fluid process.

You may have colleagues who feel they have had a clear idea of their career from a very early stage: do not worry about this. Many successful clinicians were not sure of their career as a medical student, and instead enjoyed their training, were patient, and waited to make an informed decision later on. Although the Modernising Medical Careers programme has meant that decisions do need to be taken earlier, there is an increasing move towards flexibility in the early stages of specialist training (Accreditation of Competencies Framework) which is good news for the many junior doctors who are less than certain about their intended specialty. If you are currently unsure as to a specialty choice, there are many resources that may help you to narrow it down, but no magic ‘sorting hat’ to match you to your ‘perfect’ specialty. There is no right or wrong specialty for you, simply better or worse fits.

Career certainty and uncertainty

Medical students (and junior doctors) may fall into three main categories of career certainty:

The certain: ‘I know exactly what I want to do’

It can be helpful to have a clear idea of the career you wish to pursue. Early insight will help you tailor your opportunities to your interests, even as an undergraduate. Evidence of an early commitment to a specialty can be beneficial when competing for a place on some of the more sought after training programmes, neurosurgery or cardiothoracics, for example.

However, outside of the most competitive specialties this demonstration of early commitment is not necessary, as most of the requirements for a competitive portfolio can be covered generically, with commitment to a specialty being addressed closer to the time of competitive selection. It is of course extremely common for even the most focused and driven individuals to have a change of plan at some stage during the training process. If you have accumulated a lot of experience (e.g. audit projects, research, and presentations) in one particular specialty and then have a change of heart, that experience is still valuable, and likely to be looked upon as valid when applying for a different specialty.

The fairly certain: ‘I have a pretty good idea of what I want to do’

This is probably the most common position: e.g. considering yourself a physician, a surgeon, or a GP with a reasonable degree of certainty—but having not yet identified a subspecialty interest. This is fine: core-training programmes mean that for many career pathways, the detail of the final specialty choice can be deferred for a few years after foundation training. For example, if you wanted to pursue medicine but were not sure of a specialty, you would apply for core medical training, aim to pass your MRCP examinations, and understand that you will have around 18 months to choose your medical specialty (such as gastroenterology, haematology, etc.) after starting core training. The exceptions to this are those specialties with run-through training programmes, such as neurosurgery, ophthalmology, and obstetrics and gynaecology, which therefore require, in general, an earlier commitment. In addition to this, the recently introduced Accreditation of Competencies Framework has brought flexibility to early training pathways.

The uncertain: ‘I don’t know what I want to do’

Depending on what stage you are at, it may be absolutely fine to not know what you want to do. However, it may be a good idea to do a little bit of work now to ensure that the decision you eventually make is a well-informed one. Discuss your career uncertainty with your educational supervisor, or an individual within the medical school designated to provide medical careers guidance. You may find using careers tools and questionnaires helpful (see ‘Where to find out more …’ p. 1007). These generally aim to help you crystallize your understanding of yourself—strengths and weaknesses, values, drivers, and personality. Although the use of such tools will not provide you with an immediate answer to your specialty choice conundrum, it helps move you forward in the decision-making process and can help define the type of work and environment where you are likely to thrive. Combining this improved ‘self-knowledge’ with focused research into your current shortlisted specialities (e.g. taster weeks, discussion with trainees and substantives in a specialty, Strengths, Weaknesses, Opportunities, and Threats (SWOT) analyses, etc.) will help guide you towards one of the more certain categories mentioned earlier.

Personal traits

It is interesting that while, in general, we often assume that specialties tend to attract similar personalities, there is no clear evidence that particular personality types are likely to be found in certain specialties. There may be an aspect of conditioning within a speciality (your personality may adapt or even evolve to function effectively in the clinical environment you are in). One way in which personality typing can be useful when looking at speciality choice is that it can often predict particular aspects of a speciality that may be challenging for a given personality type.

Some doctors feel a ‘calling’ to a particular specialty, perhaps because of a powerful personal experience. More likely, you will tend to gravitate towards specialties that stimulate your interest at medical school and tend to play to your personal strengths, as you see them. For example, if you are a natural communicator with patients, enjoy continuity of care, and the challenge of difficult discussions, a specialty such as oncology may be naturally appealing. It is not that a certain personality type cannot work effectively within a certain specialty, but that certain specialties may present a more comfortable working environment for a given individual. Dealing with acutely ill patients in the resuscitation unit may be thrilling and stimulating for some doctors, but cripplingly stressful for others.

For another individual, the prospect of ongoing responsibility for patients may feel suffocating, making a career that requires continuity of care unpleasantly stressful. Perceiving a specialty as competitive may deter some doctors from pursuing it as a career, as they may consider their academic record insufficient for the purpose of selection. If this is the case, seek advice from your supervisor or medical careers advisor; this may be entirely erroneous and it would be unfortunate to make such an important decision on the basis of rumour or assumption. It is also worth considering how geographically flexible you are prepared to be, as there is a significant geographical variation in competition ratios within specialties across the UK

Job traits

Clinical jobs can vary tremendously in terms of the nature, intensity, variety, predictability, and continuity of the workload. The combination of these characteristics in each specialty is likely to become more important the more senior you become. These aspects of the job may not be obvious when you are a medical student, focused on the scientific and clinical aspects of each specialty, but they are very important when deciding on a medical career. Take time to observe, or ask about, the following factors when on any clinical placement:

Clinical variety

Consider the variety of patients you will see in particular specialties (age and sex), the nature of clinical problems (acute vs chronic), the variety of clinical work, outpatient consultations, ward work, and operating/procedures.

When considering whether you might enjoy a specialty where breadth of knowledge is required (GP, emergency medicine, etc.) consider if you are happy to cope with the flip side of variety, which of course is depth of knowledge. Similarly, in order to become an expert in a field and especially in a practical specialty, it is necessary to perform procedures repeatedly, which while highly rewarding for some, may spell boredom for others.

Shift pattern/intensity

Emergency medicine, general medicine, anaesthetics, and surgery involve full shift work and unsociable shift patterns, during your years of training and beyond. Consider your other priorities, and seek advice from current trainees/consultants to gain insight into how they maintain their work–life balance. On the whole, there tends to be greater flexibility with job planning after training is completed.

Continuity of care

Some clinicians value the long-term involvement with patients such as in primary care, endocrinology, renal medicine, and psychiatry. However, others value not having ongoing responsibility for patients when they leave work, such as in anaesthetics or emergency medicine.

Predictability of the workload

Some specialties such as emergency medicine, trauma surgery, or transplant surgery may have an unpredictable workload compared to specialties such as dermatology, urology, or general practice where the workload is likely to be more predictable.

Dealing with life and death

This is a reality in acute care: emergency medicine, intensive care medicine, general medicine, care of the elderly, or surgical specialties (vascular surgery, neurosurgery, cardiothoracic surgery). It may stimulate some doctors yet paralyse others. You may feel that you prefer not to deal with life-threatening situations and would prefer a specialty that is unlikely to encounter them (dermatology, ophthalmology, etc.).

Length of training

General practice is currently the shortest post-foundation training programme, at 3 years to completion of training. Many GPs are now developing a specialist interest (GPwSI), either by further focused training and experience after their certificate of completion of training or perhaps after coming into GP training from another specialty (paediatrics, O&G etc.) There is an increasing move towards delivering care in the primary care setting, and a GP with specialist knowledge and training can be a very useful asset. A specialty with a long training programme, such as plastic surgery, ophthalmology, or paediatrics, may be off-putting for some, although a run-through training programme guarantees geographical stability for a period, which has obvious advantages if you wish to settle down. Refer to postgraduate training websites if you are unsure about the duration of training in each specialty.

Interest in subject

A medical career is long, and you will spend much of your waking time devoted to doing it or reading about it! It is important therefore to opt for a career which is likely to sustain your interest for many years to come.

Advances in technology

Although new technologies are likely to change the way we practise medicine and interface with patients in every specialty, there are clearly some specialties that will be more at the cutting edge for this. New techniques, emerging technologies, breakthroughs in basic science (stem cells, gene therapy, etc.), your thirst for research, or simply engaging with the changes to clinical practice in a progressing field may be more relevant to ophthalmology or cardiology than, say, psychiatry or general practice.

Opportunities for research

Many specialties present opportunities for research. However, in some it is almost compulsory (cardiology, oncology) or the competition for jobs is such that it is often required. Take advice on this from senior trainees or consultants within the specialty.

Portfolio careers

Many doctors develop a ‘portfolio career’—pioneered among GPs, this is now a pattern of working seen more broadly across the specialties. Some examples of ways that doctors add diversity to their clinical careers include medical education, medical journalism, business, medico-legal practice, and management.

Problem-solving

This is an integral part of a career in medicine. Are you more of an analytical problem-solver, perhaps attracted to the more cerebral specialties where diagnosing provides a challenge, such as neurology, infectious diseases, general medicine, etc.? Or do you enjoy the challenge of a practical problem, such as might be found in theatre deciding how to reconstruct a section of anatomy in plastic surgery?

Pay

Basic consultant pay scales are the same across the specialties, but there is clearly more scope in some specialties for generating income from private practice. Most partners in general practice currently earn more than the basic consultant’s salary. Although this probably will not be your main consideration when choosing a specialty, if it is particularly important to you, you should take earning potential into account.

Life aspirations

Clearly there are many things to take into account when planning your career, not least your aspirations for life outside of medicine. The majority of doctors do not have family commitments at the time they make their specialty choice, and it can be very difficult to decide whether to go for something which may prove challenging at a later date if juggling family commitments, or to make a ‘compromise’ decision before it is actually needed.

Again, there are no right or wrong answers, but it is possible to work flexibly in any specialty, although the part-time training route is better established in some than others. Take time to sound out senior colleagues and trainees in the specialty who appear to be managing to balance work and family commitments. There will usually be a lead within each Local Education and Training Board (LETB) for less than full-time training and a discussion with this individual ahead of time may be useful. If geographical location is very important to you, e.g. your partner has a job tied to a specific location, then having a ‘plan B’ specialty that is less competitive, such as general practice, may be a sensible option. If you are determined to go for something highly competitive such as neurosurgery or ophthalmology, you may have to compromise on location in order to secure a training post. Competitive specialties tend to stay competitive throughout, even at consultant level—again, you may have to be prepared to go where the jobs are. The location of your family and friends may be pivotal in where you wish to work, and you may have to account for this in your choice of career. You may wish to spend time working abroad, either in the developed or developing world. Taking time out of a training programme is often possible but requires a lot of early planning and organization (12–18 months in advance). You may already have identified an organization you wish to work with.

Role models

You are likely to come across individuals who stand out and are in some way inspirational to you. Being inspired by an individual is a perfectly valid reason to be initially attracted to a specialty, although it is important to attempt to deconstruct the basis of this appeal: what is it about this role model that is so inspiring? Do they have exceptional surgical skills, is it their ability to lead a team, their capacity for analytical thinking, or their interaction with patients? Identifying the traits that have stood out for you can be an important part of crystallizing your own values, but the attributes identified may not necessarily be specialty specific, so it is important not to assume they are. This is where spending some time on written reflection around your observations and thoughts can be particularly useful.

Strategies for the undecided

Choosing a career involves consideration of some or all of these complex factors, but it is also important to allow time and space for creative thinking before important decisions are made. Doctors tend to be very good at getting things done and being efficient, and the benefits of carving out some ‘empty time’ may not be immediately apparent. However, if you reflect on when and where you have your most creative ideas, it is likely to be when you are in the shower, or out on a walk, rather than when you are sitting at a desk writing a list of ‘pros and cons’. Give your brain the chance to think creatively—make sure you are not constantly on the go! If you are undecided on your career, seek out as many opportunities for discussion as possible. This may be with trainees, or substantives in the specialties you are interested in, your educational supervisor/tutor, or a careers counsellor at your university. Chat to people who know you best both inside and outside of medicine.

Such conversations are likely to bring you progressively closer to understanding your unique set of values and strengths, and which specialties may provide a good fit for you.

There are several tools that you might find useful, yet none are overarching. The Myers–Briggs Type Indicator is a popular tool to characterize personality types, often used in industry, leadership, or team working contexts. It may be helpful in identifying how you think, express yourself, and respond to your environment—and therefore which clinical context may be naturally more challenging to you. It may provide valuable insights. Formal use of this tool requires an investment of time and money as the completed questionnaire needs to be fed back and discussed with you by a trained Myers–Briggs practitioner. However there are simpler versions available based on the original theory which you may find useful (e.g. in Anita Houghton’s book ‘Finding Square Holes’; see ‘Where to find out more …’ p. 1007).

The Sci59 is an online questionnaire which attempts to identify your most suitable specialties based on responses to 130 questions. This is not evidence based but may be a useful starting point for considering or rejecting career possibilities for those who are completely stuck. Its recommendations are based on responses from individuals already established within the different medical specialties.

The SWOT analysis is a useful way of structuring your thoughts around a particular event or process. It can be a useful tool to look at a proposed career path, particularly if you have already done some work on self-assessment. For example, if you were considering general practice as an option, armed with your insights from self-assessment exercises, you might want to sit down with a local GP trainer and work through a SWOT analysis together. This gives you a framework to consider your strengths and weaknesses in the context of the opportunities and threats of the rapidly changing primary care landscape.

Top tips

1. Choosing a medical career is not a simple logical choice, and there is no tool which will tell you the answer.

2. Make the best of your opportunities and use your clinical placements to ask the key questions on careers that are most important to you.

3. Networking by talking to people (at work, even informally) will help you collect perspectives to make a well-informed decision.

4. Be positive. Choosing a career is an exciting process. You will find many specialties fulfilling, and there is not a single correct answer.

5. There is always a way out! Rest assured that even if you have decided your speciality since the age of 10, made the wrong choice of specialization down the line, or want to leave the field altogether to pursue an entirely different career, there is always a way out and back in again.

Where to find out more …

Websites

• Specialtytraining.hee.nhs.uk—the official site for details on the specialty selection process. Competition ratios for the different specialties, person specs.

• Accreditation of Transferable Competencies Framework—introduces more flexibility into early medical career pathways and guides those who wish to switch to a different specialty: http://www.aomrc.org.uk/reports-guidance/accreditation-of-transferable-competences-0914/.

• The Gold Guide—useful information on practical details of specialty training such as time out of programme, inter-deanery transfer, and less than full-time training: https://www.copmed.org.uk/gold-guide-7th-edition/the-gold-guide-7th-edition.

• BMJ Careers—career news, features, and events: https://www.bmj.com/careers/careers.

• Sci59—if you are a BMA member, you can access this tool via the BMA website: https://www.bma.org.uk/advice/career/applying-for-training/sci59-medical-specialty-psychometric-test.

• National Institute for Health Research—for information about academic career pathways: https://www.nihr.ac.uk/funding-and-support/funding-for-training-and-career-development/training-programmes/integrated-academic-training-programme/integrated-academic-training/academic-clinical-fellowships/.

• Alternative roles for doctors. Ideas of jobs where a medical degree and clinical training or experience are valued. https://www.healthcareers.nhs.uk/explore-roles/doctors/career-opportunities-doctors/alternative-roles-doctors.

• Royal College websites often have useful career information and many organize annual career events for students and foundation doctors: www.rcpsych.ac.uk; www.rcseng.ac.uk.

• The NHS Careers website has recently replaced the excellent NHS medical careers website: www.healthcareers.nhs.uk.

• Myers–Briggs personality type tool: www.myersbriggs.org/my-mbti-personality-type/mbti-basics.

• Faculty of Medical Leadership and Management provides advice and guidance on medical leadership in the UK: www.fmlm.ac.uk.