Choosing a specialty

Impact of the recruitment and selection system

Early commitment Our study confirmed the sense of pressure to make the right career choice at an early stage and a perception that there is limited opportunity to change direction after that point. We know that, historically, a quarter of doctors have changed their career choices between one and three years after qualifying and less than half regard their choice in year 3 as definite.8 The opportunity to change direction is now much more limited, although the desire may still be there; thus the sense of pressure is understandable.

Competition Many trainees were aware of the competition for certain specialties, although this did not discourage them from applying for their preferred specialty. The willingness to compete for a specialty was related to their degree of self confidence, which derived from both positive feedback from seniors and peers, and acknowledged “natural ability” and how this matched the perceived characteristics of the specialty.

Although the MMC website urges doctors to weigh carefully the competition for specialties when considering their applications,9 other factors seem to be influencing doctors’ choices. As one trainee said, “In retrospect you think . . . ‘I was so lucky to get that job,’ . . . but at the time you just think ‘Well that’s what I want to do and I’m just gonna go for it.’”

Structure of the specialty training programmes

The availability of flexibility in both working hours and career opportunities within a specialty was an important theme. Although junior doctors have regard for their work-life balance, and for some this has had considerable influence on their chosen specialty, there was still recognition that to remain competitive, additional “non-contracted” hours will need to be worked.

In recent years there have been many calls for increased flexibility in both training and working patterns in medicine.1011 These calls are partly, but not exclusively, linked to the increasing number of women in the profession; however, several men in our study cited family commitments as a determining factor in their career choice.

MMC is founded on principles that include being flexible and trainee centred.12 Although there are examples of specialties with excellent practice in this regard, the perception is that not all specialties have adapted as well as they might.

Reality of working practice

Time to do a good job The service pressure of working in the NHS was strongly felt, and there was frustration at not having enough time to do a good job. For some doctors this has had a major impact on their choice of specialty. As one doctor explained, “I never enjoyed being on-call (in acute specialties) . . . being stressed and harassed all the time . . . I needed to go into something where I could take my time and make decisions.”

Teamwork Trainees want to work in specialties that are challenging and stimulating. Although for some this means working closely within multidisciplinary teams to solve complex problems, for others this means taking responsibility and working independently. The choice of specialty seems to be strongly influenced by which of these styles the individual considers their natural preference.

Undergraduate and foundation experience

Student versus employee When making decisions on choice of specialty, doctors are drawing on experiences both at undergraduate level and during foundation training. Work during the foundation years was much more influential than student experiences. This perception confirms earlier research findings from both the UK and Australia,413 which showed that work experience since graduation was the second most important extrinsic factor influencing specialty choice. This ranked well above undergraduate experience.

Overseas experience The experience of training in a given specialty differs between countries, and many doctors who had worked overseas had changed their specialty choices when working in the UK because of this. For these doctors, the reality of working in a specialty in the UK had not matched their previous experiences.

Perceptions of specialties

All doctors had a strong perception of different specialties, particularly the variety and complexity of conditions encountered and the extent to which different specialties impact on patient outcomes. Matching the perception of themselves to that of a specialty was an important decision making strategy used by the doctors in our study.

This strategy has been recognised for some years and is utilised by specialty choice inventories such as the Sci 59 online.14 Sci 59 online is a professionally constructed psychometric instrument designed especially for selection of medical careers. It matches an individual’s aspirations and personal and professional characteristics to appropriate specialty choices.

Use of formal career management resources and tools

In our study, the influence of formal career management advice or tools in influencing specialty choice was striking by its absence. Only one of the doctors interviewed had benefited from career coaching, and in his case this had been to enable him to change specialties at specialty training year 3 level. The MMC programme board, deaneries, and royal colleges have recently invested considerable resources into supporting specialty choice decision making; however, the doctors we interviewed had not been influenced by these resources in choosing their specialties.

Undergraduates

Make the most of undergraduate experiences Although our study and others have found that the impact of undergraduate experience is much less important than that of postgraduate experience, students should use clinical placements to explore what it would be like to be a specialist trainee or consultant working in a specialty rather than view student placements in light of their current educational needs.

Select your foundation programme with care Clinical posts at this level are likely to be the only opportunity to try out a possible career choice.

Foundation doctors

Ensure your perception of a specialty is clear and accurate Information about the structure of training and working in different specialties is available from the royal college websites. Some of these websites, such as that of the Royal College of Surgeons, have sections on career development and the nature of working in that specialty. Some colleges, such as the Royal College of Anaesthetists, run career workshops specifically targeted to foundation doctors making specialty choices.

Most junior doctors are quite clear about what is entailed in the next step of their training, but many are remarkably vague about what lies beyond that. Talking to senior trainees and consultants in a specialty is an important way of gaining insight into what it is really like to work in a particular discipline.

Plan and target taster experiences If taster experiences are to be of any value, they need to be undertaken during the first few months of foundation year 2.

Use available career management resources Most foundation schools and deaneries provide a professional career management service. This may include the use of a psychometric questionnaire such as Myers-Briggs type indexing17 or a learning styles inventory such as Honey and Mumford.18 Undertaking a specialty choice inventory such as Sci 59 online may be helpful. None of these tools will choose your specialty but they will provide a background for decision making. The London Deanery has developed a comprehensive medical career management website through which trainees can develop an understanding of themselves and the specialties.19 Last, but not least, discussions with friends, peers, role models, and mentors are invaluable.