Career Focus

Genitourinary medicine

BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7161.2 (Published 19 September 1998) Cite this as: BMJ 1998;317:S2-7161

Not the most glamourous of specialties but you do get to hear some interesting stories. Jackie Cassell explains what drew her to the specialty, and how others may follow

  1. Jackie Cassell, specialist registrar
  1. 35 Spences Lane, Lewes East Sussex BN7 2HF

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    Over the years, the genitourinary clinic has been known as the VD clinic, special clinic, eponymous clinic, and STD clinic. The specialty that dares not speak its name is now called genitourinary medicine in Britain and venereology in other countries in the European Union. Previously viewed as a “Cinderella specialty,” it has in the past 15 years been invited to the ball, so to speak. After the appearance of AIDS, control of sexually transmitted diseases became a principal target of the government's Health of the Nation strategy.

    This brought expansion and reorganisation of the specialty, which is now settling into a much changed steady state. Almost all genitourinary departments look after HIV outpatients, but the bulk of the work is still related to general sexually transmitted infections.

    As well as seeing patients who are worried about sexually transmitted infections, the genitourinary consultant has a team to manage and a service to organise and promote. Although larger centres train junior staff, many consultants work in or near district general hospitals, where medical support is provided by clinical assistants and staff grade doctors. Health advisers (who undertake counselling, education, and partner notification), nurses, and laboratory staff are the other daily workmates of consultants. An important part of the consultant's job is educating and advising other departments about appropriate referral and the services available through the genitourinary department. Patients with sexually transmitted infections, including HIV infection, present to many departments, such as gynaecology, urology, surgery, accident and emergency, and psychiatry. Audits have shown that sexually transmitted infections are often poorly managed, even when recognised, with no attempt to notify partners. Facilitating referral, educating other staff groups, and readily providing advice are activities that contribute to public health, as well as to public relations. Each clinic submits returns to the Department of Health on the number of cases seen, and all take part in regional audit.

    This core work, along with HIV outpatients, is common to all posts. Many consultants also have responsibility for HIV inpatients, and in larger units they will have their own junior staff to help with this workload. However, only in large units are there consultant posts mainly or exclusively in HIV care.

    Many clinics liaise with family planning services and call themselves departments of sexual health. Through an increasing awareness of sexually transmitted infections in vulnerable populations, such as family planning clients and young people, prevention work can be done and the visibility and accessibility of services enhanced. Infections seen in clinics are only the tip of the iceberg, and screening of higher risk patients for chlamydia in other settings is now being piloted.

    As well as family planning, genitourinary consultants often provide specialised services - for example, clinics for colposcopy, prisons, or for sex workers - depending on local skills and needs.

    Advantages and disadvantages of GUM

    Attractions

    • Most of your patients have a treatable condition

    • Good opportunities to use communication skills

    • Tolerant, open-minded colleagues are the norm

    • Predictable pattern of the working week

    • Many doctors enjoy working with a young population

    • Clinical skills you can take abroad

    • Opportunities to work with vulnerable patients who may not present elsewhere

    Possible drawbacks

    • Much mundane work

    • Administration is an important part of daily work

    • Small range of clinical procedures

    • No knighthoods, difficult to be taken seriously as local dignitary

    Is it the job for you?

    So who wants to be a genitourinary consultant? On the whole, it appeals to those who enjoy daily contact with patients, regard sensitive situations as an interesting challenge, and do not demand too much drama in their work. Except with HIV, emergencies are few and tend not to be clinical in their nature. Distressed patients and partners and victims of assault form the more usual kinds of crisis. The specialty does not appeal to proponents of the “we came, we saw, we kicked its ass” school of heroic medicine. Nor does it provide fulfilment for those dreaming of authority over a deferential army of juniors.

    The road to consultant

    • House jobs, followed by:

      General professional training:

      Either: 24 months postregistration direct patient care, of which 18 months in acute medical admissions - and MRCP, or:

      12 months postregistration in post approved for general medicine - and MRCOG, or: evidence of equivalent experience overseas

    • Higher medical training of four years includes: Compulsory training in general sexually transmitted diseases, HIV on call, contraception, laboratory methods, epidemiology, research methods and research, management, audit, teaching, and gynaecology (if not already covered by MRCOG or 6 month post); optional development of special skills - for example, in vulval disease, colposcopy, psychosexual medicine, and especially in-depth HIV experience - and courses as appropriate; overseas experience is encouraged and up to 6 months may count towards the Certificate of completion of specialist training

    • Research protected time for research years 2-4; up to one year full time research can count towards higher training or more with deanery approval

    • Award of CCST, consultant appointment

    Sexually transmitted infections are a life crisis for many of the people who experience them, and helping them through that crisis, dispersing the stigma they may feel, is gratifying. The challenge is to provide a welcoming, sympathetic and competent service that patients can recommend to their friends as “nothing like as bad as I was expecting.” The rewards of the specialty are not glamorous. We do of course hear some lovely stories, but as confidentiality is far more strictly adhered to than elsewhere, the best ones often go unrepeated.

    Good rates of partner notification are a significant contribution to public health. Through involvement in audit, education, and community work it is often possible to document the achievements of the service. And sometimes we are able to see that we have helped a young person at risk to protect himself or herself against HIV infection. The genitourinary consultant must be prepared to be pleased by numbers, as few patients will say “thank you, doctor” in the supermarket - although it does happen.

    Training

    Membership of the Royal College of Obstetrics and Gynaecology (MRCOG) or of the Royal College of Physicians (MRCP) are routes to higher specialist training (see box). Six months in obstetrics and gynaecology is useful, though not compulsory for those with the MRCP before moving to a specialist registrar post.

    In the recent past, trainees sometimes moved into genitourinary medicine as senior registrars, having left oversubscribed related specialties, such as infectious diseases. Although there are plans for dual training schemes, these have not yet been implemented.

    As with other specialist training schemes, doctors from outside the European Union without the right to indefinite residence can be appointed to a visiting specialist registrar (type 1) post, or a fixed term training appointment (type 2). A type 1 programme may lead to the award of a certificate of completion of specialist training (CCST), whereas a type 2 programme cannot. The regulations here are complex, and advice should be sought from the Royal College of Physicians.

    Academic training for home and overseas doctors has developed in recent years. An MSc in sexually transmitted diseases and AIDS has recently been established. Many avenues of research are relevant to genitourinary medicine, ranging from molecular laboratory work to health services research, and many trainees have taken the option of a three year research period with the aim of completing a PhD.

    Overseas training is encouraged in the higher training curriculum, and up to six months can count towards the CCST.

    Career prospects

    As in many specialties, it is hard to predict whether there will be oversupply or undersupply of consultants in the coming years. There are currently 85 holders of a national training number (NTN), of whom seven are in research, and 239 consultants. At the moment there does not seem to be a substantial mismatch. Part time consultants in genitourinary medicine exist, and with the increase in flexible training it is likely that these will increase in number.

    For trainees happy to work predominantly with sexually transmitted infections, prospects of interesting posts look good, as many trusts are still seeking to improve and develop their services. Those who bring extra skills are more likely to negotiate a varied working week. A job combining, say, family planning, prison work, HIV clinics, and a youth service could offer an interesting working week with plenty of variety and opportunities to educate users and other professionals.

    HIV services have levelled off, and no new large centres are planned. Advances in treatment have reduced the need for inpatient care. Specialist registrars can opt for “in depth” HIV training so that they are prepared for posts with a greater component of HIV work.

    Training in genitourinary medicine is currently undersubscribed. This has much to do with its unfamiliarity. The specialty is poorly represented in the undergraduate curriculum, and many doctors in training say that they started late because it had never occurred to them to choose it. Those who saw little of the specialty as students might find it useful to visit a local clinic and sit in on some sessions.

    A substantial and increasing number of consultants are women - genitourinary medicine offers a “family friendly” lifestyle, with a fairly predictable working week. Although evening clinics are now the norm, they are at least not clinics that started in the afternoon then overran.

    Traditionally, the specialty has been diverse in its candidature. Many consultants, particularly in district general hospitals, trained overseas. Forms of social discrimination often reported in medicine are notable for their absence from genitourinary medicine. Many GPs, family planning doctors, and others who have portfolio careers choose to work as clinical assistants. Doctors of all grades working in genitourinary medicine are on the whole a contented species with a strong commitment to the communities they serve.

    I am grateful to Professor Michael Adler and Dr Patrick French, Dr Phil Kell, Dr Charles Lacey, Dr Paul Simmons, and Dr Joseph Winceslaus for helpful information and comments on an earlier draft.

    Useful addresses

    • Joint Committee on Higher Medical Training, Royal College of Physicians, 11 St Andrew's Place,London NW1 4LE (tel: 0171 935 1174):provides curriculum for training.

    • Secretariat, Medical Society for the Study of Venereal Diseases, Royal Society of Medicine, 1 Wimpole Street,London W1M 8AE (tel: 0171 290 2968):

      educational programme runs throughout the year; a journal; opportunities to meet doctors from all over the UK working in genitourinary medicine.

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