A career in . . . paediatricsBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1625 (Published 06 May 2009) Cite this as: BMJ 2009;338:b1625
Doug Gillies outlines aspects of paediatrics that might appeal to a potential trainee
Over the past five years or more paediatrics has lost something of its previous allure. The specialty is often poorly understood by the public and other doctors. For most doctors, dealing with children is an acquired skill. Most trainees, finding their placement in paediatrics edging ever closer, feel anxious. Having largely dealt with adults at medical school and in initial hospital posts, thoughts of having to deal with newborns and children are enough to bring most trainees out in a cold sweat. The reality for most of us, however, is that this is a hugely enjoyable specialty with excellent working relationships (box 1). A genuine team approach is used to deal with a wide range of problems. There is also the satisfaction of developing skills and abilities relating to families, which are of immense benefit in a wide range of other medical careers.
Box 1: Pros and cons of a career in paediatrics
Always something new
Excellent relationships with other staff
Can be emotionally stressful
Part time working can be problematic
High intensity on call throughout career
Little, if any, private practice
May present difficult situations where the interest of the child seems to differ from the wishes of the parents
Child protection evaluation can be difficult
May feel undervalued by adult specialty colleagues
Although the press and the General Medical Council have not dealt sympathetically with a number of paediatricians in the field of child protection, most paediatricians skilfully steer a middle ground, respecting the rights of the families while protecting children from abuse.
What sort of person should think about a career in paediatrics?
If you have a natural curiosity, sensitivity, and a sense of humour then this could be just the specialty for you. Arrogance and a rigid attitude aren’t very helpful. Although on the face of it the skills and abilities necessary to be a successful neonatologist differ from those of a community paediatrician treating children with behavioural difficulties, there is a core need to communicate effectively with families. Sometimes this can be stressful, frustrating, and time consuming, but most communication between paediatricians and parents is excellent, with the emphasis placed on collaborative decision making.
Scope to develop special interests
The range of potential interests and subspecialisations within the field of paediatrics is huge and includes all the standard adult subspecialties.
For many years there was a very distinct split between those consultants who worked within hospital settings and those who worked in community settings. Community paediatricians might be engaged in child protection work, liaison work with community services, school health, and a variety of other areas. Some participated in the care of acutely ill children although many posts had little or no acute on call. Although this pattern of working remains in many larger centres, elsewhere there has been a tendency to bring community paediatrics back into the portfolio of the general paediatrician.
For example, in my unit we have one consultant with responsibility for child protection coordination and training, with the other consultants sharing in child protection assessment as part of their on-call duties. Similarly, other aspects of traditional community paediatrics are shared out among the consultants. There’s little doubt that recruitment to traditional community paediatric jobs has been hard hit by publicity around child protection work.
Even within a tertiary neonatal unit, where one might expect the roles of the consultants to be very similar, there is scope for diversification. One consultant might take a lead in terms of the transport service whereas another might be responsible for training and education. With such a wide range of diverse possibilities for a career in paediatrics, trainees should have a reasonable expectation that they will be able to find their own niche area (box 2).
Whatever area of paediatrics one ends up in, the need to communicate effectively with families and other agencies is likely to be a key aspect of the job.
Box 2: Views on a career in paediatrics
Sibel Ajtai (specialist trainee 3)
“Paediatrics is the most holistic of the medical specialties. It involves care of the whole family. Relationships between juniors and seniors are usually excellent and seniors are approachable. There is a high standard of teaching.
“There is a lot of diversity and a wide range of subspecialties. It is very rewarding to work as a member of the paediatric team, and there is a very positive supportive aspect to paediatric teams.”
Ian Canning (new consultant)
“I made a decision while working in accident and emergency that paediatrics was for me. You don’t really understand what it is about until you do it as a job. Experiencing paediatrics as a medical student is quite different from doing it as a six month job. As a medical student you are on the look out for teaching and I don’t think you realise what actually makes up the job. It’s important to have supportive colleagues, and paediatrics, with few exceptions, offers this. The vast majority of children also get better so there’s lots of positive feedback. It’s interesting, fun, and support is excellent. I would absolutely not do anything else.”
Currently, the Royal College of Paediatrics and Child Health is committed to carry on with run-through training. The college, although criticised by its members from time to time, does have a deep commitment to ensure a high quality training experience for aspiring paediatricians. This is backed up by structured training programmes throughout the United Kingdom. In Leeds there is an excellent well structured MSc programme, which is appreciated by the trainees.
Future of the specialty
Largely to do with problems of staffing small units there has been a move, over the past 5-10 years, to have large inpatient base units with allied smaller units, where an assessment unit operates. Typically these units are open from early in the morning until sometime in the evening. The majority of children seen will either be assessed and sent home or have a short stay. Some transfer to the base unit for inpatient care. A few may be transferred to a tertiary centre. Although these arrangements generally work well they can take a long time to establish, facing significant local opposition from both the general public and professionals.
These types of arrangements can be seen as destabilising the small local unit. Pragmatically they may have to be considered, for reasons of staffing, cost, and the ever increasing difficulty in complying with national recommendations. Alongside assessment units there may be a need to change the status of a consultant led obstetric unit to that of a midwifery led unit. This may make the issue of changing paediatric services seem like child’s play in comparison.
On a regular basis the media have implied that paediatricians find child protection issues with virtually every child that they see, and that they unjustly accuse innocent parents of harming their children. A few months later a scandal of a similar magnitude will be reported by the press where paediatricians fail to identify a child in need of protection. In reality diagnosis of child abuse is sometimes easy but often not clear cut. What is key is the understanding that in most cases it is not an individual doctor making the sole judgment. Discussion with local and sometimes regional colleagues is done if the diagnosis is in doubt. There will usually be a drawing together of the pieces of the jigsaw at a child protection conference where there will be representatives from social services, police, health visitors, and others. The aim is always to work with families wherever that can be achieved. The interest of the child, however, is paramount. Child protection issues may appear in virtually any facet of a paediatrician’s life and it behoves paediatricians to be able to deal appropriately with these issues. Many trainees have been put off the specialty because of the possibility of being vilified in the press and dragged before the General Medical Council. The reality is that this happens to only a very tiny minority of practising paediatricians and this issue should not put off the aspiring paediatric trainee.
Although paediatrics can be a demanding specialty, it is also extremely rewarding. A wide range of other specialties deal with children. For any trainee it will be a very worthwhile four to six months of experience. You never know, you may come to decide that this is the career for you.
www.rcpch.ac.uk/Training—Wealth of information including sections on why to choose paediatrics, the training pathway, and competences that will be assessed during a paediatric career. There is also a helpful section covering overseas training
www.rcpch.ac.uk/Policy/ServiceReconfiguration/Modelling-the-Future—Further discussion re possible patterns of working in the future