Your career options in medicine: specialisms

Medical specialisms: Anaesthesia | Audiovestibular medicine/audiological medicine | Emergency medicine | Histopathology | Obstetrics and gynaecology | Paediatrics | Pathology | Plastic and reconstructive surgery | Psychiatry | Rehabilitation medicine | Rheumatology | Surgery |

All newly qualified doctors enter a two-year competence-based foundation programme – made up of foundation years one and two (FY1 and FY2) covering clinical skills, professional practice, and developing and maintaining good relationships with patients and colleagues. Successful completion of the first year will lead to registration with the General Medical Council (GMC).

Following the foundation years, doctors will enter specialty training. This will take several years (often five to eight), which will differ according to the speciality. Doctors who successfully complete this stage will receive a certificate of completion of training (CCT) and will be eligible to apply for consultant posts.

Postgraduate training for a medical specialism follows an agreed curriculum; this means that there are different standards and competences that need to be met in order to qualify in your chosen specialism. With the skills, knowledge and behaviour to be achieved at each stage of training clearly set out in the curriculum and must be passed before you can continue to the next stage. Postgraduate specialism training is approved by the GMC.

Anaesthesia

Although most anaesthetists’ work revolves around operative procedures, less than half their time is actually spent in theatre. They are also involved in acute pain rounds, in chronic pain clinics, on the labour ward and in intensive care units.

Trainees are instructed in safe anaesthesia of all surgical subspecialties (from cardiac to neurosurgery). As a consultant they can expect to have a regular working week with the same surgical subspecialty but also flexible sessions. This allows particular expertise in one area but also variety. The on-call requirement is variable but typically one night a week and one weekend.

Anaesthetists are called on for help with tricky situations. It is not a career for the faint-hearted but supportive consultants encourage the trainee to develop the necessary critical skills.

Audiovestibular medicine/audiological medicine

Audiovestibular medicine deals with the diagnosis, investigation, medical treatment and rehabilitation of patients experiencing problems with hearing, tinnitus or balance. It makes for an interesting specialty as in some areas there is little known about it, so there is wide scope for research. As an audiovestibular physician, you will often be involved in unusual cases, and because it is a small specialty, you will have the opportunity to work on a national basis to further understanding of the specialty.

Physicians in audiovestibular medicine normally work in ENT clinics or audiology departments in hospitals and a working week of 37.5 hours is standard. Cases range from patients with tinnitus and complex balance problems to autistic children in need of specialised hearing assessments.

Teams are multidisciplinary and include hearing therapists, physiotherapists, education, psychologists and speech and language therapists. There are plenty of opportunities to train others and teach. For some this means holding lecturer and professorial posts as well.

It can be very tough to get a job in audiovestibular medicine. The discipline is not very prominent in the UK, and the number of vacancies is relatively low. Generic skills that will help you include good communication skills, reflective thinking and the ability to take a good history from clients and their family. If you are looking for quick-fix cases, then audiovestibular medicine isn’t the specialty for you – treatment and rehabilitation is an ongoing process rather than a single consultation.

Emergency medicine

Emergency medicine (EM) is the name used to refer to the specialised medicine practised in accident and emergency (A&E) units, reflecting a dynamic, rapidly evolving specialty. Departments are led by a team of consultants and they will often specialise in specific areas such as paediatric emergencies, medical emergencies or sports injuries.

The emergency department depends on the teamwork of many individuals, making teamworking and communication skills essential. You have to be adaptable; most of the work is routine, but you never know what the next ambulance will bring.

Confidence is essential to make split-second life and death decisions, but you’ll need humility to realise how difficult diagnosis and treatment might be in challenging circumstances. Stamina and flexibility are necessary to cope with the physical demands of shifts.

Histopathology

Histopathology is the study and diagnosis of disease through the examination and interpretation of cells and tissue samples, including biopsies. It is an essential part of cancer screening and management.

The job combines the use of knowledge and experience with advanced laboratory techniques to solve clinical problems, which allow patients to receive the most effective treatment. Many pathologists also perform post-mortems to determine causes of death.

Pathologists can be generalists or specialists. They may perform purely diagnostic work, be involved in scientific research or a combination of both. A pathologist needs to have breadth and depth of knowledge, an inquisitive mind and a willingness to keep up to date with the ever-advancing scientific frontiers of all medical disciplines. It is also necessary to be thorough and precise. There is a significant administrative and teaching commitment and the work involves frequent liaison with clinicians through regular patient management meetings. Research activities are optional.

You will need a thorough approach in order to make sure that every stage of the evaluation is completed correctly. You will need attention to detail in order to identify abnormalities on a cellular level and understand what they mean. Good lab skills are important, but communication skills are also vital, particularly as you may be asked to explain results to patients.

Obstetrics and gynaecology

Obstetrics and gynaecology (O&G) is a broad specialty with many areas of interest ranging from largely surgical, such as gynaecologic oncology, to largely medical, such as maternal medicine, with plenty of variety in between.

O&G also involves research; for example, research into infertility, stem cell research and genetics, with the many ethical and moral dilemmas associated with conception and the antenatal period. All the different areas of O&G have in common a stimulating and fulfilling contact with patients.

Since O&G has many parts, there is a niche for virtually everyone. The common requirement, however, is the ability to relate well to patients who are often anxious and need careful explanations and reassurance. People who choose this specialty, therefore, tend to be sociable and keen to enjoy life both inside and outside of work.

There are good opportunities for progression in a career in O&G. There is usually flexibility in the training – with opportunities to gain further experience abroad and to take out-of- programme experience to learn special skills. Most of the on-call in hospital is done by training registrars with good consultant cover; most labour wards now have direct consultant presence during the day to help training. Consultant expansion has occurred to cover this on-call commitment.

Paediatrics

Paediatrics is a large and diverse specialty, which includes high-technology specialties such as neonatology and paediatric intensive care as well as community-based specialties such as neurodisability. Trainee paediatricians gain experience in many areas of practice that help them decide where their interests and strengths lie, as well as gaining experience of working in multidisciplinary teams, which is fundamental to paediatric practice.

Consultants are either hospital-based general paediatricians, community-based paediatricians or subspecialists in the following:

• endocrinology and diabetes
• neurology
• neonatology
• gastroenterology, hepatology and nutrition
• respiratory medicine
• paediatric intensive care
• metabolic medicine
• nephrology
• oncology
• neurodisability
• rheumatology
• emergency medicine
• palliative medicine
• clinical pharmacology and therapeutics
• allergy, immunology and infectious disease

The training pathway is flexible to accommodate the training of general and subspecialist paediatricians, and to cater for the variable rates of progress amongst trainees. Research is encouraged and can be undertaken at any stage.

Paediatricians need to be good communicators who enjoy working with children and their families. Good teamworking is crucial and a good sense of humour is welcome. Having the potential to become an excellent diagnostician is important because infants and children often present with undifferentiated illness, which they may not be able to describe.

Emotional resilience, patience and sensitivity are needed when managing critical illness or disabilities in infants and children. An aptitude for managing neonatal and paediatric emergencies is required as well. Fortunately consultant paediatricians are renowned for providing good support and supervision, which allows trainees to develop these skills without feeling vulnerable.

Pathology

Pathology comprises a variety of specialties, each with a variable degree of laboratory and clinical exposure, which form the foundations of medical and surgical diagnoses alike. Specialties such as metabolic medicine and haematology can involve running clinics and advising on ward rounds.

Imagine being forced to make a definite diagnosis in the absence of pathology investigations: no chemical blood test results, no haematology results, no medical microbiology results or sensitivities, no histopathology or cytopathology reports on biopsies or cancer resections.

The specialties of pathology (subspecialties in brackets) are:

• chemical pathology (metabolic medicine)
• haematology (haemato-oncology, haemostasis/thrombosis, disorders of blood production and destruction, transfusion medicine, paediatric haematology)
• histopathology (cytopathology, forensic pathology, neuropathology and paediatric pathology)
• immunology, medical microbiology and virology (mycology)

In order to build a career in pathology you will need self-discipline and determination. You will also need strong lab skills, which means good attention to detail, organisation and a methodical approach.

Plastic and reconstructive surgery

Plastic surgery is about the restoration of form and function. It has been a hugely innovative speciality over many decades. The five main areas of work are: burns and trauma, cancer, congenital deformities, tissue degenerative conditions requiring reconstruction, and normalisation and improvement of appearance. It includes craniofacial surgery, tissue expansion, microsurgical free tissue transfer, breast reconstruction, smile surgery, ear reconstruction and vaginal reconstruction to name but a few procedures. It’s a speciality defined by concepts. Plastic surgeons look at a problem such as a wound and decide which reconstructive technique to apply.

Often a surgeon might apply a number of techniques but careful consideration of what might achieve the best functional outcome, aesthetic outcome or, indeed, the safest outcome allows the surgeon to select which is appropriate for the patient. Tools include grafts, local flaps, microsurgical free tissue transfer, tissue expansion and prosthetics.

Anatomy is the key if you are an undergraduate considering a career in plastic surgery. Plastic and reconstructive surgeons work closely with a vast array of other surgical specialities, but experience in breast surgery, otolaryngology, neurosurgery, orthopaedics, vascular surgery and paediatric surgery are all beneficial.

Surgeons in this area will need a good bedside manner in order to explain to patients how their procedure will work and what the potential side effects will be. Honesty and conscientiousness are important for the same reasons. Plastic surgeons have to be dedicated to schedules as well.

If you want a rewarding career helping people with disfigurement or traumatic disability then this may be the specialism for you.

Psychiatry

Psychiatry is a large, diverse specialty. Psychiatrists work in hospitals, community clinics, care homes, prisons, schools, people’s homes etc. Numbers are expected to rise further due to population ageing, increasing emphasis on reducing crime by treating substance abuse and mental illness in prisoners, and changes to mental health legislation.

There are six subspecialties:

• general
• old age
• child and adolescent
• learning disability
• psychotherapy
• forensic

In psychiatry you have more time with patients and can provide more continuous long-term care after discharge. There are many training schemes throughout the country, some very competitive to get onto, but in general there is a shortage of psychiatrists. Specialist training takes six years: three years of core psychiatry training and three years of higher training.

Ability to communicate is key in diagnosing (and treating) psychiatric illness and in working with staff and patients from a variety of backgrounds. Teamwork is increasingly important – psychiatrists work with nurses, pharmacists, occupational therapists, social workers and so on.

An ability to cope with uncertainty is useful – human nature, the basis of work in psychiatry, can be unpredictable. Self-awareness and self-monitoring is vital in an area where emotions can run high but patients’ interests should be paramount.

Rehabilitation medicine

Rehabilitation medicine focuses on reducing disability and enabling people with disabilities to fulfil their potential, as well as managing their medical conditions. Rehabilitation medicine has two main areas of activity: neurological and locomotor rehabilitation. Neurological patients include those with spinal injuries, brain injuries (including strokes) and progressive disorders. Locomotor rehabilitation deals with patients who have limb loss and musculoskeletal conditions.

Rehabilitation is not necessarily about making people better but helping them to live with their condition and to become as independent as their condition allows. Even simple changes can make a difference to the lives of patients.

Doctors in this specialty look after patients in rehabilitation or spinal injuries units, run outpatient clinics and see people in the community. Inpatients include those who have had strokes or sustained head injuries, and patients with multiple sclerosis and other progressive diseases.

Outpatient clinics serve patients with a variety of conditions. For example, doctors may administer botulinum toxin injections to patients with spasticity, run a clinic for young people with physical disabilities or see people who have limb loss.

To work in rehabilitation medicine you need a good grounding in general medicine as you see a diverse range of patients. Other useful areas to provide experience include:

• neurology
• rheumatology
• neurosurgery
• psychiatry
• general practice
• care of the elderly

Rehabilitation medicine requires a great deal of patience. If you’re the sort of person who needs instant gratification then it’s probably not the specialty for you. The ability to empathise with your patients is also important. This speciality is for people who see medicine as an art as well as a science.

It is also important to have a good deal of perseverance. Both you and your patients will depend upon it. Rehabilitation medicine is a good option for those who want a good work-life balance, as there is very little out-of-hours work involved.

Rheumatology

Rheumatology is a specialty in which patients of all ages are treated. Patients have a wide variety of acute and chronic musculoskeletal problems including rheumatoid arthritis, osteoarthritis, autoimmune rheumatic disease such as lupus (SLE), scleroderma and vasculitis and osteoporosis, metabolic bone disease, back pain, soft tissue problems and sports injuries.

Rheumatology is a practical specialty that includes performing:

• joint aspiration and injection
• synovial fluid microscopy
• soft tissue and joint ultrasound
• epidural injections
• nerve root blocks
• nerve conduction studies

Doctors in this area liaise closely with primary care doctors, orthopaedic surgeons, and the multidisciplinary team that includes nurses, physiotherapists, occupational therapists, chiropodists and podiatrists. Rheumatology can be practised as a single specialty or in combination with general medicine.

An individual who can apply knowledge in anatomy and immunology is likely to enjoy this specialty. There are also opportunities to develop a subspecialty interest and combine this with research or general medicine. There are good opportunities for flexible training in rheumatology and the on-call duties are manageable.

A good knowledge of immunology is important as this forms the basis to understanding the pathology of many rheumatic diseases and the rationale for biological therapies. During medical school, training programmes will include exposure to orthopaedics and rheumatology. If you find the subject interesting, it may be worthwhile undertaking a BSc in a rheumatology-related discipline such as immunology.

A person with good communication and diagnostic skills makes a good rheumatologist. Having empathy, patience and the ability to deal with complex psychosocial issues is important. It is vital to have an aptitude for clinical procedures and to be able to work in a team.

Surgery

Operations range from the most simple, such as adenoidectomy (curetting a child’s adenoids) to the most complex, such as a liver resection for cancer. Surgery is carried out with the traditional tools of surgical knife, scissors and forceps and with modern stapling devices, endoscopes and microscopes.

A typical week for surgeons involves operating lists (one to two days), clinics, patient administration (phone calls, letters), management (organising operating lists and clinics) and teaching. There are ten surgical specialties within the Royal College of Surgeons of England:

• general surgery
• trauma and orthopaedic surgery
• otolaryngology (ENT)
• vascular surgery
• urology
• oral and maxillofacial surgery
• plastic surgery
• cardiothoracic surgery
• neurosurgery
• paediatric surgery

Academic surgery is also an option to specialise in, which involves clinical work and research.

Within each surgical specialty there are subspecialties. In general surgery, these are especially numerous: upper gastrointestinal surgery, lower gastrointestinal surgery, vascular surgery, breast surgery, endocrine surgery, transplantation, general surgery of childhood and trauma.

Surgeons need to have both good communication skills and the ability to work well in a team. When someone’s life is potentially on the line, the group needs to be working perfectly. You also need confidence and sound decision-making skills in order to react to developments that may occur.

Most surgical trainees are selected onto a surgical programme during their F2 foundation year. It is not necessary to have done a surgical post during foundation years to enter surgery and selection is based upon demonstration of appropriate qualities of character, ability and commitment. Most surgical specialties will involve two years of core surgical training, which may be linked or themed to a particular specialty or could comprise a generic surgical training programme to equip you with the required competencies to progress onto specialty training.