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  Three findings, however, occur with such frequency in different specialties, and across countries and continents, that they would be hard to dispute. And whilst it is my job, rather than my clients’, to read up on the academic literature on specialty choice, these three issues are ones that doctors talk to me about, without any prompting, in sessions.

  *

  ‘So what were the reasons you decided to train as a GP?’ I asked Zac.

  After a moment’s pause, Zac launched into a long and detailed response:

  ‘I was inspired by the senior partner in the practice where I worked as a foundation trainee. She was a very good doctor; a sound knowledge base, and committed to a certain vision of general practice. Ethical – to her core. A key player locally. Quite eminent. Yet canny and streetwise. Plus she looked after all the doctors in the team.’

  Zac didn’t know it, but he’d given me a textbook description of the most common reason why junior doctors choose a particular specialty. Role models20.

  In the course of an individual’s medical school and postgraduate training they will encounter hundreds of qualified doctors – in lectures, seminars, consulting rooms, ward rounds and in operating theatres. When asked why they chose a particular specialty, junior doctors will almost inevitably refer back to one or two role models they hold in high esteem. It’s the enthusiasm, commitment, knowledge and expertise of more senior doctors that draws juniors into a particular specialty.

  Sadly, the opposite is true as well. When medical students or junior doctors encounter cynical, ill-informed, callous seniors, it corrodes enthusiasm that they might otherwise have felt for a particular specialty. This also happened to Zac. Alongside general practice, he’d considered specialising in palliative medicine. But he’d been put off by one of the senior doctors in the local hospice.

  ‘She was pedantic, and sour,’ Zac told me. ‘Stuck on detail, sarcastic and game playing. I decided I didn’t want to end up like her.’

  Perhaps if Zac had encountered a palliative care physician like Bernard he might have made a different career choice.

  Zac’s experience was echoed in the title of an academic medical education paper on role models: ‘Trying on Possible Selves’21. Juniors like Zac look to their seniors for representations of the sort of doctor that they aspire to be in future.

  *

  The second influence on specialty choice relates to the issue of role models – prior experience of that particular specialty. Medical students and junior doctors tend to choose specialties that they have enjoyed in medical school and in the early years of clinical practice22. In many ways this is a sensible approach to career decision making, and Lola’s experience (where she ignored the fact that she found her temporary post in oncology extremely distressing) shows that it is wise for doctors to think carefully about their prior experience of a specialty before opting for it in the longer term.

  But prior experience is never a perfect test. One might have been unlucky in the particular department that one was assigned to, and gained a highly skewed sense of what working in the specialty would be like. For example, one doctor who came to see me had initially discounted psychiatry because during her medical school psychiatry placement she had felt inadequately supported on a forensic ward with violent male offenders. The experience had frightened her. But in our sessions she came to see that the placement was probably an unsuitable one for a medical student so it would be a mistake to rule out all psychiatric specialties on the basis of this one experience. She eventually chose to specialise in old-age psychiatry.

  Another obvious problem with using prior experience to guide one’s specialty choice is that given the huge number of specialties and sub-specialties, there are many that a medical student or junior doctor will never routinely encounter; they may not even know that these specialties exist. In the States, medical students use the elective period during the fourth year to choose their specialty, and they have space in the timetable to choose. In the UK the elective period and specialty choice are not linked in the same way, as specialty decisions are made a few years later down the line. The whole process of finding out about some of the smaller niche specialties that aren’t routinely covered in medical school is often left to chance.

  Occasionally with doctors I’ve felt a bit like a matchmaker; I’ve suggested an alternative option to somebody who didn’t even know that the specialty existed and they go on to fall in love with this new line of work. This happened with Kate, a paediatric trainee who suffered from recurrent severe depression. Like many paediatric trainees who were having doubts about the specialty, it was the acute aspects of paediatrics, and particularly seriously ill newborn babies, that she found hardest to manage. I was unsure whether Kate would ever enjoy the demands of acute hospital paediatrics and I also thought she might struggle with the child protection aspects of working in the community; a doctor needs to be particularly resilient if their work regularly includes assessing children who have been abused.

  At secondary school Kate had seriously considered applying for speech and language therapy, a non-medical career. However, as it was clear that she was going to get excellent grades in all her subjects, her teachers persuaded her that she should instead apply for medicine. Throughout her years at medical school she had volunteered to teach refugees spoken English at a local community centre, and she had enjoyed this work enormously. Kate was gentle and empathic with exceptional communication skills. Despite feeling overwhelmed by looking after acutely sick children, she always got excellent feedback from her patients and their parents.

  Building on Kate’s long-term interest in language, and the fact that she was a doctor with the sensitivity to discuss life-changing news with parents – such as the fact that their baby was profoundly deaf – I suggested to her that she might like to explore audio-vestibular medicine. This is a specialty in which doctors treat patients with disorders of hearing and balance. It’s outpatient-based work, in which doctors rarely have to confront an acute clinical emergency. But it requires patience and attention to detail, together with an empathic capacity to imagine the psychological isolation that deafness can cause. Kate took up my suggestion.

  Different specialties make widely differing psychological demands on the practitioner. As a psychologist I have found it profoundly rewarding when I have helped doctors like Kate who were failing in one specialty to identify an alternative in which they can thrive. Kate has now almost completed her specialty training in audio-vestibular medicine and, although she remains vulnerable to depression, moving away from acute paediatrics has transformed her working life.

  *

  The first two issues – the role models that a doctor encounters and their prior experience of a particular specialty – have always had an important impact on specialty decisions. We learn about the world and make decisions based on our experience, so how could it be otherwise? There’s evidence, however, that a third factor has grown in importance in recent years, and also that, whereas formerly it was much more of a concern to women, it is now important to doctors of both sexes. What is it?

  Work–life balance.

  Newly qualified doctors today are less willing to devote their entire lives to their patients, at the expense of their own families, than their predecessors were. The issue of work–life balance has a much more significant impact on the specialties that doctors choose to follow, than it did in the past. So for example a 2015 study from researchers in Oxford concluded23:

  Domestic circumstances were a much more important consideration when choosing a specialty for the graduates of 2008–2012 compared with those of 1999–2002. Across the cohorts, female doctors rated domestic circumstances as having greater importance than male doctors, but its sharp increase in importance over the years was observed in both men and women.

  This finding is not limited to the UK. A similar shift has been reported in the USA, with the Director of Medical Education at the Association of American Medical Colleges observing that
‘The millennials seem to be more inclined than previous generations of physicians to trade some of their income for more control of their hours.’24

  Studies in Australia and Canada have reached the same conclusion25.

  What this means in practice is that factors such as the length of postgraduate training, the possibility of minimising evening or weekend commitments and the position of part-timers are ones that many contemporary junior doctors agonise over when choosing their specialty.

  *

  In essence, choosing one’s specialty is a complex psychological decision. It’s not surprising therefore that these three major factors – role models, prior experience and work–life balance – are mentioned in studies throughout the world. Why would a doctor in Birmingham, Alabama be less influenced by having a positive experience of a particular specialty in training than a doctor in Birmingham, England? And why would doctors in one country want to spend less time with their family than doctors in another? Many influences transcend national boundaries.

  Other influences don’t travel across the globe in the same way. A 2015 study of over 15,000 doctors in the UK reported that student debt had influenced the specialty choice of 2.8% of male doctors and 2.1% of female doctors26. Concerns about paying back one’s debt therefore don’t appear to be a major factor in the UK – yet. This study followed up doctors who had graduated from UK medical school between 2008 and 2012. This means that all of the doctors in this study had left medical school before 2012 when the threefold tuition fee increase came into effect. The earliest that this increase might be detected in specialty choice decisions would be in doctors who graduate from four-year postgraduate courses in 2016 and choose their specialties in the December of the following year. Time will tell.

  In the US in 2012, the median indebtedness at graduation for medical students was $170,000, and more than a quarter of students graduate with debts of over $200,00027. Not surprisingly, these huge debts have a significant impact on specialty choice decisions. Despite going into medical school with all sorts of altruistic aspirations, financial reality kicks in, and students are forced to make some tough choices. A 2014 study in the US found that students with higher debt were more likely to choose a specialty with higher average annual income, were less likely to plan to practise in poor, under-served locations, and were less likely to choose primary care28. Even more concerning is that increasing financial debt has been shown to correlate with residents’ self-reports of increasing depression, and even suicidal ideation29.

  Historically in the UK, with state-funded university education and the majority of doctors working in the NHS, money wasn’t a major factor in specialty choice. But as with many things, sooner or later much of what happens in the US finds its way across the Atlantic. The influence of student debt on specialty choice in the US may well be a portent of things to come, as the longer-term impact of increased student debt works its way through the system.

  *

  Doctors don’t only face the challenge of choosing the right specialty. They also have to make the right decision at the right time. With some doctors, like Neil, the issue of timing has been central to their difficulties.

  On the face of it, Neil’s story was straightforward. He was at the point in his second foundation year when doctors are expected to choose their specialty, and he had decided to apply for the lab-based specialty of pathology. It takes at least five years for a doctor to progress from junior pathologist to the stage where they are eligible to be appointed as a consultant. This ordered progression through the ranks is achieved by gaining a place on a specialty training scheme.

  Neil emailed me asking for help because he had an interview the following week for the pathology training scheme and he was feeling nervous. A particular focus of his anxiety was that, eighteen months earlier, he had had some time out due to depression. Now he was worried that the gaps in his CV would result in him being marked down at the interview.

  As there were only a few days before the interview, I immediately got back to Neil and offered him an appointment. In our email exchange Neil expressed his gratitude for my prompt response. On the day itself, however, he was about fifteen minutes late. Pressed for time, because we now had just forty-five minutes rather than the normal sixty, I cracked on with the stated task of helping him prepare for the interview. We didn’t manage to finish by the end of the session, so Neil asked if we might schedule a further meeting at the beginning of the following week. While he was still in the meeting room I phoned a colleague, rearranged my diary and squeezed him in.

  When Neil arrived twenty-five minutes late for our second appointment, I was irritated, not least because I had reorganised my day to fit him in. With some effort I managed to park my irritation, and started to think about the psychological meaning of his lateness.

  ‘I wonder if your lateness is your way of communicating to me that you don’t want to go to the pathology interview this week?’ I commented.

  An immediate look of relief spread across Neil’s face. He began to tell me that he didn’t feel ready to commit himself to one specialty and wished he could get a bit more clinical experience before he made a final decision. What he really wanted to do was to stop the clock, and withdraw from the application process. For my part, I felt as if he had unconsciously been trying to get me to understand these doubts by turning up late to the first session, but I had been swept up by the practical task of helping him prepare for the interview. So he then had to be really, really late in order to get through to this dense psychologist – and luckily, the second time around, I got the message.

  Sometimes, with clients, you will have a few sessions and then never hear what happens in the longer term. But on other occasions doctors will keep in touch, and tell you the next chapter of their story. This is what happened with Neil. Once it had become clear that he wanted to withdraw from the interview process, we agreed to broaden the focus beyond interview preparation, and scheduled some additional sessions to review his future career choices. At the end of these sessions Neil decided that he was indeed still committed to pathology, but he wanted to have a bit more experience in general medicine before he headed off to the lab. He also wanted to spend three months travelling, as a much-needed break, before he embarked on his five-year pathology training.

  So that is what he did. And he kept in contact, emailing me about a year later to say that this time he had successfully gone through the interview process and was looking forward to starting his training as a pathologist.

  Neil struggled to articulate (or even to know) what he wanted in his working life. He needed an extra year after foundation to make up his mind. In the past this would have been unremarkable, as it was common for junior doctors to do short-term jobs in different specialties, for a number of years, before they made their final specialty decisions. Previous experience of the specialty, although not perfect, is probably the most reliable way of finding out whether one is suited to that line of work. Nowadays medical training across the world has become packaged into a one-size-fits-all system predicated on the notion that all doctors take the same amount of time to progress through the different stages. We know that other developmental milestones (growth, sexual maturity, finding a long-term partner) don’t happen according to a rigid timetable. Not everyone gets married at the age of thirty-one. But in both the UK and the US there are set points in medical training when people are expected to choose their specialty. The idea of taking extra time over this decision is often poorly received. And trainees are frightened to ask.

  At least in the UK, however, junior doctors seem to be forcing the system to allow them more time. When the new system of training was introduced in 2005, the expectation was that all juniors would progress straight from foundation into their specialty training. But as we will see later, year on year, more trainees opt to take an extra year before they pin their colours to the mast and continue with their specialty training. This is good news if it increases the probability that doctors
will end up in a specialty that suits them.

  *

  It’s not surprising that some doctors need more time before they are ready to commit to one specialty. A sound choice can require a doctor to take so many different factors into account: previous experience of different specialties; length of training; money; finding an option that will fit in with family demands; minimising aspects of medical work that one has previously found particularly stressful; personal and family illness; bereavements. And of course this is not a complete list – merely some of the most common issues that doctors have talked to me about over the years.

  But an appreciation of the psychological richness of the task hasn’t permeated medical training. Despite all the studies showing that significant numbers of doctors regret their specialty choice, many consultants see the whole process as unproblematic. So sometimes, when running training workshops for senior clinicians on how best to support their trainees, my psychological approach has been rejected outright.

  On one memorable occasion, a consultant obstetrician sitting in the back row of the seminar room raised his hand and said, ‘I would be mortified if one of my trainees came to talk to you about their career. It would be a failure on my part, because I can’t see what they could learn from you that I wouldn’t be able to teach them.’

  ‘Humility?’ I suggested.

  (Actually I didn’t say that – it only came to me as I was biking home. In the moment I was so outraged that my jaw clamped shut and I said nothing.) This particular consultant’s question was predicated on a simplistic notion of how one helps somebody to reach a robust decision. Undoubtedly he would have known much more about the comparative prestige of different training schemes, or how best to build one’s CV. But would he have cared about anything else? Specialty decisions are sedimentary: layer upon layer of personal and family influences, the chance factors of who one encounters, the role models who inspire one or turn one away from a specialty for life. And as with rock formation, these layers build up over a long period of time.