It’s that time of year again. Erin Dean gathers some advice for trainees as they prepare to choose their area of specialty.
Neurosurgeon Adam Williams chose his specialty while at medical school after a consultant devoted the time to really show him the best and most difficult aspects of the job. ‘He was happy to take me into theatre to let me watch down the microscope rather than from the back of the room,’ said the Bristol specialist registrar, who is the current President of the Association of Surgeons in Training. ‘I experienced everything from incredible operations near the brainstem, where patients awoke with no trouble at all, to the most difficult and heart-wrenching conversations. It was humbling and awe-inspiring.’
This early exposure during a neurosurgery module, and a passion for the anatomy involved, was enough to set Mr Williams on the path to becoming a neurosurgeon. He believes that the people he cares for are what have made it the right specialty for him. ‘Doctors are ultimately drawn to their particular specialties by the patients they meet,’ he said. ‘As a trainee in neurosurgery I have had the privilege to care for everyone from tiny babies to the very elderly, patients who have suffered major trauma, and those with chronic illnesses such as Parkinson’s disease. It is this diverse array of brave patients that I find the biggest draw to the specialty I have chosen.’
Few decisions have more influence on a surgeon’s career than their choice of specialty. The choice to become a surgeon is made early on, research suggests. A study of almost 16,000 medical graduates’ early career choices and eventual specialty, published in The BMJ in 2010, found that 90% of surgeons but only 50% of general practitioners had chosen their specialty in the first year following graduation from medical school.1
After this first decision to pursue surgery, doctors then have to choose which of the 10 specialties to follow. Many factors come into play in this decision, including the exposure that a junior doctor has had to a specialty, mentorship from a doctor in a particular field of practice, and whether the specialty will involve a lot of on-call and emergency work – as is the case in vascular, trauma and orthopaedic, and neurosurgery.
Surgeons suggest that chance plays a big part in the path they choose. A brief positive stint as a medical student or foundation doctor with a particular specialty can often be enough to sow the seeds for a future career. Likewise, a negative introduction to a specialty can turn a future surgeon away from the area. These reports are backed up by a US study2 of more than 2,100 general surgical residents in 2010, which found that one of the three key factors in specialty choice was exposure to positive role models. The other two were type of procedures and techniques involved, and ability to balance work and personal life.
Gareth Griffiths, a Dundee consultant vascular surgeon and the surgical director of the Intercollegiate Surgical Curriculum Programme, says that surgeons need to remember the influence that they can have on the future of students and juniors whom they come into contact with. ‘I find that most trainees take a liking to a specialty because of a positive early experience,’ he said. ‘The biggest opportunity we have as trainers is to make that experience as positive as possible because it can have an enormous impact.’
Mr Griffiths chose vascular surgery after enjoying the time he spent in general surgery during training, but says he had little opportunity to sample other specialties. Although he has loved vascular surgery, he also wonders if he would have enjoyed cardiothoracic or plastic surgery. When he trained during the 1980s and 1990s, there were few opportunities to sample other specialties.
His advice for juniors choosing their specialties is to try as many of them as possible. ‘Try to keep an open mind and keep your eyes open. Try and get experience of as many specialties as possible and talk to trainees in other specialties. Recognise how important positive experiences are at all stages during training even right back to medical school’, he says.
Surgeons suggest that it is easier nowadays to gain experience of different specialties during medical school and foundation years, but some fear it can be difficult to really understand what the work of a consultant in that specialty is like. Mr Williams says: ‘Juniors need to be given the opportunity to experience the profession itself rather than the ward-based clerking and administrative roles that, although beneficial, do not always help our juniors understand what the specialty ultimately entails.’
One influential factor is the number of jobs available in that area of surgery, and the competition for them. General surgery and trauma and orthopaedic surgery vastly outweigh the other specialties in terms of numbers. These two specialties account for more than 4,500 of the 7,540 surgical consultants in England, Wales and Northern Ireland recorded in The Royal College of Surgeons of England’s surgical workforce census in 2011. Competition for specialty training posts varies significantly. In 2015, there were more than 10 applicants for each run-through training cardiothoracic post and almost 7 for each neurosurgery post, compared to 2.2 for core surgical training.
The underrepresentation of women in surgery is a well-known problem and gender also appears to factor in the choice of specialty, with women making up very small percentages of some branches of surgery. The specialty with the highest percentage of female consultants (at more than 21%), according to the RCS’ 2011 surgical workforce census, is the small specialty of paediatric sugery. This is followed by plastic surgery, with almost 19%, and then drops to 11% for women in general surgery. In the large specialty of trauma and orthopaedics, only slightly more than 4% of its 2,000 consultants are women, just ahead of the lowest proportion in cardiothoracic surgery. Research carried out at Exeter University, which was commissioned by the RCS in partnership with other organisations, suggests that the lack of women in surgery isn’t due to a lack of ambition or willingness to work long hours, but that they feel they are less likely to succeed in surgery.
Rhiannon Harries, specialist registrar in general surgery with an interest in colorectal in the Wales Deanery, says that a big influence on specialty choice is having role models of both gender in that specialty who are supportive and who make the subject matter interesting. ‘I had some great role models when I worked in general surgery during my final year of medical school who were very encouraging. I also think some specialties have a better work–life balance than others, which might influence specialty choice for some. Trauma and orthopaedics was traditionally seen as a physically demanding job and that likely plays a part in why numbers of females within that specialty are low. However, it's great to see the numbers of women increasing in recent years, as women can do the job equally as well as men.’
When a surgeon settles on a specialty, it does not always mean they have chosen the right one. Vimal Gokani started to train as a general and vascular surgeon in 2009 and spent six years in the specialty, including completing a PhD in perioperative risk. He followed this path after he was offered run-through training within a prestigious academic clinical fellowship and felt it was too good an opportunity to turn down. However, as time went on, he started to wonder if he was in the right area of surgery.
‘I felt that endovascular surgery is increasingly the future, and you have to really love this if you are going to do vascular surgery,’ says Mr Gokani, now a registrar in plastic surgery at St Andrews Centre for Burns and Plastic Surgery in Chelmsford, Essex. ‘So I had a chat with my mentor who was also a vascular surgeon, and he asked: “You spend a long time as a consultant, so if you are not enjoying the journey and you don’t want to get to the destination, then are you on the right path?’’
Mr Gokani, who was then an ST3, decided to retrain in plastic surgery – a specialty he had been considering when he first chose general and vascular surgery. He is hoping to secure a training post soon. Although moving specialty has been difficult, and involved stepping back in his career to retrain, he says that the level of training involved in each specialty means that switching can not be a smoother process.
‘I don’t regret doing general/vascular surgery at all, as I gained a lot of transferable skills and met a lot of great people who helped me along the way,’ he says. ‘My medical friends are surprised that I have changed specialty at all, and my non-medical friends are surprised that I stayed in a job where my heart wasn't in it for so long! It is difficult for my family, as I am now working farther away from home, so don’t get to see so much of them. You can get railroaded into thinking that there is only one way of doing things. It was a difficult decision but I am really glad I have made the change.’
Neurosurgeon Adam Williams chose his specialty while at medical school after a consultant devoted the time to really show him the best and most difficult aspects of the job. ‘He was happy to take me into theatre to let me watch down the microscope rather than from the back of the room,’ said the Bristol specialist registrar, who is the current President of the Association of Surgeons in Training. ‘I experienced everything from incredible operations near the brainstem, where patients awoke with no trouble at all, to the most difficult and heart-wrenching conversations. It was humbling and awe-inspiring.’
This early exposure during a neurosurgery module, and a passion for the anatomy involved, was enough to set Mr Williams on the path to becoming a neurosurgeon. He believes that the people he cares for are what have made it the right specialty for him. ‘Doctors are ultimately drawn to their particular specialties by the patients they meet,’ he said. ‘As a trainee in neurosurgery I have had the privilege to care for everyone from tiny babies to the very elderly, patients who have suffered major trauma, and those with chronic illnesses such as Parkinson’s disease. It is this diverse array of brave patients that I find the biggest draw to the specialty I have chosen.’
Few decisions have more influence on a surgeon’s career than their choice of specialty. The choice to become a surgeon is made early on, research suggests. A study of almost 16,000 medical graduates’ early career choices and eventual specialty, published in The BMJ in 2010, found that 90% of surgeons but only 50% of general practitioners had chosen their specialty in the first year following graduation from medical school.1
After this first decision to pursue surgery, doctors then have to choose which of the 10 specialties to follow. Many factors come into play in this decision, including the exposure that a junior doctor has had to a specialty, mentorship from a doctor in a particular field of practice, and whether the specialty will involve a lot of on-call and emergency work – as is the case in vascular, trauma and orthopaedic, and neurosurgery.
Surgeons suggest that chance plays a big part in the path they choose. A brief positive stint as a medical student or foundation doctor with a particular specialty can often be enough to sow the seeds for a future career. Likewise, a negative introduction to a specialty can turn a future surgeon away from the area. These reports are backed up by a US study2 of more than 2,100 general surgical residents in 2010, which found that one of the three key factors in specialty choice was exposure to positive role models. The other two were type of procedures and techniques involved, and ability to balance work and personal life.
Gareth Griffiths, a Dundee consultant vascular surgeon and the surgical director of the Intercollegiate Surgical Curriculum Programme, says that surgeons need to remember the influence that they can have on the future of students and juniors whom they come into contact with. ‘I find that most trainees take a liking to a specialty because of a positive early experience,’ he said. ‘The biggest opportunity we have as trainers is to make that experience as positive as possible because it can have an enormous impact.’
Mr Griffiths chose vascular surgery after enjoying the time he spent in general surgery during training, but says he had little opportunity to sample other specialties. Although he has loved vascular surgery, he also wonders if he would have enjoyed cardiothoracic or plastic surgery. When he trained during the 1980s and 1990s, there were few opportunities to sample other specialties.
His advice for juniors choosing their specialties is to try as many of them as possible. ‘Try to keep an open mind and keep your eyes open. Try and get experience of as many specialties as possible and talk to trainees in other specialties. Recognise how important positive experiences are at all stages during training even right back to medical school’, he says.
Surgeons suggest that it is easier nowadays to gain experience of different specialties during medical school and foundation years, but some fear it can be difficult to really understand what the work of a consultant in that specialty is like. Mr Williams says: ‘Juniors need to be given the opportunity to experience the profession itself rather than the ward-based clerking and administrative roles that, although beneficial, do not always help our juniors understand what the specialty ultimately entails.’
One influential factor is the number of jobs available in that area of surgery, and the competition for them. General surgery and trauma and orthopaedic surgery vastly outweigh the other specialties in terms of numbers. These two specialties account for more than 4,500 of the 7,540 surgical consultants in England, Wales and Northern Ireland recorded in The Royal College of Surgeons of England’s surgical workforce census in 2011. Competition for specialty training posts varies significantly. In 2015, there were more than 10 applicants for each run-through training cardiothoracic post and almost 7 for each neurosurgery post, compared to 2.2 for core surgical training.
The underrepresentation of women in surgery is a well-known problem and gender also appears to factor in the choice of specialty, with women making up very small percentages of some branches of surgery. The specialty with the highest percentage of female consultants (at more than 21%), according to the RCS’ 2011 surgical workforce census, is the small specialty of paediatric sugery. This is followed by plastic surgery, with almost 19%, and then drops to 11% for women in general surgery. In the large specialty of trauma and orthopaedics, only slightly more than 4% of its 2,000 consultants are women, just ahead of the lowest proportion in cardiothoracic surgery. Research carried out at Exeter University, which was commissioned by the RCS in partnership with other organisations, suggests that the lack of women in surgery isn’t due to a lack of ambition or willingness to work long hours, but that they feel they are less likely to succeed in surgery.
Rhiannon Harries, specialist registrar in general surgery with an interest in colorectal in the Wales Deanery, says that a big influence on specialty choice is having role models of both gender in that specialty who are supportive and who make the subject matter interesting. ‘I had some great role models when I worked in general surgery during my final year of medical school who were very encouraging. I also think some specialties have a better work–life balance than others, which might influence specialty choice for some. Trauma and orthopaedics was traditionally seen as a physically demanding job and that likely plays a part in why numbers of females within that specialty are low. However, it's great to see the numbers of women increasing in recent years, as women can do the job equally as well as men.’
When a surgeon settles on a specialty, it does not always mean they have chosen the right one. Vimal Gokani started to train as a general and vascular surgeon in 2009 and spent six years in the specialty, including completing a PhD in perioperative risk. He followed this path after he was offered run-through training within a prestigious academic clinical fellowship and felt it was too good an opportunity to turn down. However, as time went on, he started to wonder if he was in the right area of surgery.
‘I felt that endovascular surgery is increasingly the future, and you have to really love this if you are going to do vascular surgery,’ says Mr Gokani, now a registrar in plastic surgery at St Andrews Centre for Burns and Plastic Surgery in Chelmsford, Essex. ‘So I had a chat with my mentor who was also a vascular surgeon, and he asked: “You spend a long time as a consultant, so if you are not enjoying the journey and you don’t want to get to the destination, then are you on the right path?’’
Mr Gokani, who was then an ST3, decided to retrain in plastic surgery – a specialty he had been considering when he first chose general and vascular surgery. He is hoping to secure a training post soon. Although moving specialty has been difficult, and involved stepping back in his career to retrain, he says that the level of training involved in each specialty means that switching can not be a smoother process.
‘I don’t regret doing general/vascular surgery at all, as I gained a lot of transferable skills and met a lot of great people who helped me along the way,’ he says. ‘My medical friends are surprised that I have changed specialty at all, and my non-medical friends are surprised that I stayed in a job where my heart wasn't in it for so long! It is difficult for my family, as I am now working farther away from home, so don’t get to see so much of them. You can get railroaded into thinking that there is only one way of doing things. It was a difficult decision but I am really glad I have made the change.’