Within the current medical training landscape we're feeling the pressure earlier and earlier to choose a speciality. A junior doctor reflects on some useful approaches to help us decide.

Medical training is a well-oiled machine that aims to chute undifferentiated medical students into competent clinicians after years of training. Medical school leads into internship, which leads to residency, specialist training, and eventually to a job as a fully fledged consultant. 

In theory such a system works efficiently, provides job security and allows people to follow their passions along a set trajectory. For a lot of people, this does hold true, and they’re able go from babbling through a vital signs OSCE in first year to a competent cardiologist, GP, nephrologist or whatever specilaity they choose. Traditionally this whole process would take around 6-10 years, however, since 2010, as the medical training bottleneck has been getting progressively worse, getting onto training programs is taking longer and longer. An unintended consequence of an increasingly competitive training bottleneck means that pressure is placed on those in training earlier and earlier in the process, to get ahead. 

We’re told from the beginning of medical school to start “working on research” or “building your CV” so that we can work towards our dream job.  At the end of a third year orthopaedics lecture, the lecturer encouraged us to reach out for research opportunities if we were considering a career in orthopaedics, because “you’ll need the points”. 

When you get into the hospital during internship most people's opening question is ‘what do you want to do?,’ and in residency it’s ‘what are you doing next year?’. The notion of ‘figuring it out’, or taking a roundabout approach to an end point is foreign in the medical system and often gets you a surprised response if you don’t have an answer ready to fire. 

On my first day as an intern, on a surgical rotation when asked what I wanted to do, my answer of ‘I’m not quite sure yet’ was responded to with, “well it better not be plastics, because if you hadn't decided on that two years ago it’s not going to happen”. Although the plastics registrar probably had only said this in jest, it is reflective of the current training landscape. You’re told if you want to do something competitive, you'd better have decided it early. 

On my first day as an intern, on a surgical rotation when asked what I wanted to do, my answer of ‘I’m not quite sure yet’ was responded to with, “well it better not be plastics, because if you hadn't decided on that two years ago it’s not going to happen”.

As a junior coming into the system this can lead to an overwhelming feeling of being ‘left behind’, and no doubt produce some anxiety surrounding your progress through the medical training landscape. Further, medical school admissions select for academically high achieving, and well rounded individuals who have had to successfully navigate multiple applications and interviews to gain a spot. As a result the cohort applying for competitive positions within the medical field is highly competitive. In order to successfully gain a training position in a competitive training program, you must stand out in a competitive cohort. This is a factor often overlooked by individuals who may see themselves as ‘not good enough’, but the peers you’re comparing yourself to are a biased sample to begin with. 

What results is a system in which people have the option of hazarding a guess early at which pathway is best for them, or try to gain experience to find where their fit is, and pursue the relevant path. The former option works from the systems point of view, with increasingly skilled trainees with high levels of specialisation, qualification and expertise. But it’s based on the assumption that trainees from as early as medical school know the path they wish to follow. For the individual this means risking significant financial and time investment into a field that one may not turn out to enjoy. Decisions on which path to take often need to be made with very little experience in the area, or even just the ‘thought’ of doing the job.

The latter option means that individuals can have a broad range of experiences and find something that is well suited to their personality and strengths. However, it appears to be the less travelled route. In most other fields outside of medicine it is the norm to take your time on deciding a path, finding the ideal fit for you then shifting your work in that direction, trialling multiple careers along the way. The current medical training system means that someone may come across a surgical subspecialty they enjoy in PGY2, but without having done the relevant courses, research and having the right references, they won’t have a lot of jobs open to them moving forward. This can understandably mean that individuals who haven’t decided early on in their path are discouraged from considering all available options when choosing which direction to take. 

Earlier this year I came across a PGY2 resident who had a position secured for PGY3 as a urology Senior Resident Medical Officer (SRMO). Of course, naturally I thought that this must have been a position he had worked towards since early internship, as urology tends to be on the competitive end of the application spectrum. However, when he talked me through how he came to his decision I was refreshed by his approach. Going into internship he had wanted to do basic physician training, then GP training, and then in late PGY2 he had a urology rotation and loved it. He hadn’t sat the GSSE, he hadn’t done any of the courses that most surgically inclined individuals would have done through PGY1 or 2, but he genuinely thought that this was the job for him. As a result of this sincere passion for the field, he was seen as an extremely competent and engaged junior doctor. He was able to get an important reference from one of the consultants in the department as a result, and made the transition into working towards a job that he really wanted to do. 

When starting out along the training pathway it can be very easy to get caught up in requirements for the future. There often feels as though there is an expectation to have the rest of your career planned out week by week for years to come. Naturally the response is to start working towards an end point so that you’re not being ‘left behind’, and you may box yourself into an idea of what your future will look like without much consideration for what other options are available. As you start working towards a goal, you inevitably gain experience, and invest time and money, which can make it more and more difficult to step out of the path if you realise it's not the right fit for you. 

So what should one do?

I am by no means an expert (and have wrestled with this issue a lot myself), but from the people I’ve met who seem to have done it well, this is what I’ve learnt:

• On an individual level it’s important to embrace uncertainty. It is okay to not know what your future will look like.
• Gain exposure to a wide variety of experiences early, speak to as many people as possible. As students take the time to find out what working the job is really like and if you could see yourself doing it.
• Focus on building broad skills that are applicable to a range of fields
• Focus on doing your current job/studies well.
• If there is something you genuinely like or are excited by, follow it and try it out, keeping in mind that it may not be right for you and that you may need to change at some point.
• Know that every individual is different in what value they place on their career, and how much time and effort they’re willing to put in.