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Decisions, decisions – choosing a specialty

Decisions-decisions-choosing-a-specialtyFollowing on from last edition’s focus on finding a job after community service, Professor JP van Niekerk provides some expert advice on how to make the big decision in medicine – choosing a specialty

Choosing a medical specialty? It would be great if it could be so easy! When talking to senior colleagues we hear about the influence of their teachers, who by charismatic example often significantly influenced them in their choices. But other stranger reasons for such choices abound.

Career choices in medicine after completing your internship and other commitments are perhaps even more important than the choice of entering medicine itself. And like undergraduate medical training, your choices are beset with doubts and other concerns.

Because these choices affect your lifelong professional career, they are as important as choosing a life partner (one may add that both partners need to be supportive and understanding through testing times, as further study and training are demanding of relationships, time and finances at the very time that many have the additional stresses of starting a family).

In today’s world, unlike in the past, it can be quite normal for people to switch jobs from time to time in order to further their careers. Specialisation in medicine does the opposite by locking one into a narrow, albeit demanding and satisfying, field of endeavour.

Background on medical specialties

There have always been divisions in medical practice that determine what today is known as scope of practice, ie, those aspects of practice that practitioners more or less confine themselves to. For example, barber surgeons were distinct from physicians and the title of ‘Mr’ for a surgeon in the UK is recognition of this historical fact of their more humble origins.

Medical regulators, concerned about the cost of medical care that exceeds inflation, try to discourage specialisation in favour of more generalised practitioners

Specialties were typically divided into those specialties that offered major interventions, such as the surgical disciplines, whereas the medical specialties generally did not do major interventions in their diagnosis or treatment. However, there are many other criteria for subdivisions: some are organ based, eg, ophthalmology; others are primarily diagnostic or supportive, such as radiology or the pathology disciplines.

Age is another marker of specialisation, as illustrated by the number of recognised specialties that relate to children; adult medicine has the bulk of specialties; and geriatrics caters for the elderly. Further specialties deal with communities rather than individuals, such as public health, occupational medicine and medical informatics.

Over time, the number of specialties has increased and this has accelerated with advances in medical knowledge and techniques. Medical regulators, concerned about the cost of medical care that exceeds inflation, try to discourage specialisation in favour of more generalised practitioners. Despite this, further specialties are likely to continue to emerge. Rarely, a specialty may disappear, eg, ‘physical medicine’ has bowed out to orthopaedics and physiotherapy.

A wealth of choices

A post-qualification career choice can be overwhelming given the vast possibilities:

  • In South Africa, the Health Professions Council (HPCSA) recognises some 30 specialties and 18 subspecialties.
  • Worldwide, more than 50 specialties are recognised.
  • The Colleges of Medicine of South Africa, primarily an examining body for the medical (and dental) disciplines, has 26 medical colleges that offer some 91 examinations, including postgraduate diplomas and fellowship examinations – see www.collegemedsa.ac.za
  • The universities also offer postgraduate training and qualifications in the specialties and subspecialties, but also opportunities to pursue research based masters’ and doctoral studies. The latter are more typical additions for those who pursue teaching/academic careers.

Details of the rules and regulations of specialties and subspecialties (a subdivision of a recognised specialty requiring additional experience and qualifications), including the required training periods and qualifications, may be found on the HPCSA website.

However, these do not cover all the possibilities. For instance, potentially new specialist disciplines commence with new courses and training that later may be accepted as a specialty by the HPCSA, eg, palliative care medicine that has a university postgraduate course and examination. Emergency medicine has recently been through such a process.

Making the choices

Making a choice about your future career can be extraordinarily difficult, as many factors come into the equation. Influences such as large residual student loans and the needs of your partner, whose job or other requirements may be important, may complicate matters. Some may even decide to leave medicine, perhaps to go into management by pursuing business studies.

You could take the following into consideration:

  • Personal interests and skills – Personal interests and skills should preferably be matched to the job. However, medical graduates, because of their selection and training, are often multi-talented and could be successful in most medical fields. Nevertheless, if, for example, you lack manual dexterity, it is probably best to avoid a surgical specialisation.
  • Experience in the speciality – The ideal is to have had some experience in the proposed specialty to ensure you like it before committing to it. This may be easier said than done, as relevant posts may be scarce. However, specialist training departments often give preference to candidates who have already demonstrated an interest and developed further capacity by obtaining an additional qualification in the discipline, eg, a college higher diploma in anaesthetics, before entering the anaesthetics specialist training programme.
  • Opportunities to practice – Sir William Osler, who has been called the father of modern medicine, first considered becoming an ophthalmologist but decided otherwise because there was already such a specialist in his city, Montreal. It is, of course, extraordinarily difficult to predict where there are needs or perhaps an oversupply of specialists, but nevertheless, this should come into the reckoning.
  • Availability of training posts – Having come to a considered and clear decision regarding your desired specialty direction, a lack of training posts might frustrate this desire. Surprisingly often, one hears of colleagues who had been faced with such a situation and had temporarily taken a vacant training post in another discipline, only to decide to stay on in the new direction.
  • Financial benefits – The relative earnings in specialties are obtainable, but they only tell part of the story. For instance, obstetrics and gynaecology and neurosurgery practitioners may appear to earn good incomes, but their professional practice risk premiums are extraordinarily high. One also cannot predict future system reforms that may improve incomes of, for instance, family practitioners, who are currently underpaid, such as happened in the UK.

Final thoughts

It has been said that all jobs are a routine of some kind or another and that what distinguishes one person from another is their interests beyond their work environments. My personal experience, and that of many other colleagues, is that chance and opportunity play a much larger role in our careers than is usually understood or preached. Finally, our commitment and healthy emotional and intellectual approach to our careers is essential to our happiness, in whatever direction we find ourselves.

Our commitment and healthy emotional and intellectual approach to our careers is essential to our happiness, in whatever direction we find ourselves
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