Each year, the RCOG invites foundation trainees to tell us why they’ve chosen a career in O&G for the Why Obs and Gynae? prize.
This is a submission from Suzy Duckworth, an FY2 doctor.
Why I chose a career in obstetrics/gynaecology
‘Destiny is no matter of chance. It is a matter of choice: it is not a thing to be waited for, it is a thing to be achieved.’ William Jennings Bryan
My path into Obstetrics and Gynaecology, and indeed, Medicine, has not been a direct one. Perhaps this implies an element of indecision, but I prefer to view it as a considered calling. There are many influential factors at play with any individual specialty application, ranging from clinical, academic, family life, litigation and economics. As such, a wealth of research exists to investigate fluctuations over time, and there are a number of psychometric testsi available to help inform the candidate of what suits them best. Despite all these factors at play, I still feel I have been able to follow both my head and my heart and end up with the career choice that is right for me.
As a medical student, I enjoyed most rotations; they were interesting, patient focussed and varied. During my O&G attachment, however, I really appreciated the privilege of my role as a doctor. I enjoyed being involved in such poignant times in a patient’s life; a dyn amic patient demographic, unified by raw humanity. My early experiences on labour ward and in Caesarean theatre moulded my understanding of human physiology and the impact our profession has on the lives of otherwise healthy individuals; implanting in me a desire to pursue a career that can also provide support to the developing world and impact on the lives of large numbers of women and babies. This exposure was under the supervision of passionate, esteemed consultants; inspirational clinicians who opened my eyes to the opportunities a career in O&G can provide.
Within the field of Gynaecology, also, I was enthused by the study of complex underlying medical and endocrine pathology, combined with practical clinical skills required to investigate and surgically treat. I witnessed early how effective communication in this arena can impact on patient outcome. The scope of ethical debate makes the specialty challenging but also captivating; the benefits of sexual health screening in young adults, the allocation of Caesarean section for maternal choice (a debate that I published as an editorial.) I remember caring for an elderly lady with advanced ovarian cancer, working with my multi-disciplinary colleagues to optimise end of life care and the following week, assisting with a category one section for severe ante-partum haemorrhage. The range and depth of experience and practical skill, during specialty training, coupled with the opportunity for sub - specialisation later was appealing to me, so I chose to explore further.
The second stage
Much research has been carried out into the influences driving specialty choice. If the studies are to be believed, medics are becoming increasingly motivated by the pursuit of non-vocational activities and financial gain, as opposed to professional esteem and academic stimulation.ii Moreover, there has been a substantial 3% fall in surgical applications, including O&G (p<0.001) among US medical students, in recent years. Frigoletto et al discuss the impact of an increasing number of female trainees (up from 10% to 75%) inferring a negative impact on trust budgets, with part-time staff requiring full malpractice insurance, now reaching crippling proportions.iii US interns are demonstrating their family commitment and desire for academic opportunities, over a time intensive, ‘anti- social’ and stressful working life. So, has this ‘perfect storm’ yet reached the UK? Sadly, UK studies mirror these findings, with a significant overall fall in O&G applications over the last three decades, particularly in men (3%).iv Furthermore, surveys indicate that up to half of applicants will abort their training and switch to an alternative specialty. So, how does O&G fit with ensuring a ‘controllable lifestyle’? With the working time directive once again under scrutiny and an increasingly litigious society, this shadowed my new found passion.
Turner et al did, however, provide some light at the end of the tunnel; when exploring the motivation to pursue O&G, they revealed that most often, as in my case, it was due to past clinical experience and the positive influence of senior colleagues. My introspective career debates found me to suit a hospital, high risk, high reward setting, with a combination of cerebral as well as procedural demands. Despite trying to enthuse myself into an alternative clinical domain, I found myself reading gynaecological case reports, loitering on labour ward during quiet on-calls and completing O&G skills courses and seminars.
Despite some papers implying that time constraints have reduced the quality of O&G researchv I have relished the promise this specialty holds for future discovery and the impact this can have on the lives of generations of women to come. Having embarked upon a research project exploring serum analysis for early diagnosis of pre-eclampsia, I feel enthused by the academic potential within such an evolutionary field. Ancient obstetric literature demonstrates the vast progress made to date, reflected in modern mortality rates (in 2000, global maternal mortality was 529,000 with only 1% in the developed worldvi) but scope for improvement and multi-cultural learning remains. It is a diverse specialty that, in some way, touches the lives of nearly every member of society.
No win no fee
So what about litigation? There is no doubt medical litigation in the UK is on the increase: obstetrics currently constitutes 60% of all pay outs, representing £160-200 million annuallyvii and this is often cited, by young graduates, as a reason to avoid the specialty. Indeed, this represents a change in our cultural climate and the rising expectations of patients within the developed world; borne in part, surely, from past developmental achievements and clinical improvements of healthcare in this setting? Certainly, the last decade has seen quality assurance and evidence based medicine reach the top of the government agenda, despite diminishing resources; in response the number of clinical guidelines and safety protocols has grown.viii
My own, albeit limited, experience has been of a working environment that is structured and generally well supported, yet with an on-going focus on individual capability. Certainly as a young trainee, I have been given the chance to learn in a protected setting, to ensure my decisions are justifiable and patient-centred. As a healthcare professional in any arena, outcome and expectation are key. Standardised care guidelines and individual training responsibility motivates the trainee to develop and enhance their skills. In a speciality that truly recognises the significance of this; I feel I have had exposure to excellent practical training to date. The value of the commodity furthers the ultimate privilege and fulfilment of this profession: no win without effort.
From here on
As an F2 doctor, my initial goal is to secure a specialty training post in O&G; seven years in which to hone my skills and clinical aptitude and gain a broad depth of expertise. I intend to sub-specialise in the future, perhaps in fetal medicine, but I remain open to the influence of time! I am eager to become further involved in research and academic pursuits, as well as teaching and overseas work. I feel excited about embarking on my new journey; compelled by the cases I will become involved with and the knowledge I will gain. I hope, as part of the medical team, I will enhance the hospital experience for my patients and optimise outcome.
In short, I am keen to become a competent clinician, to positively impact on the lives of women, as those have done before me.
A career in Obstetrics and Gynaecology is one that should be considered and commenced with an awareness of its potential pitfalls, but it is also a career that will provide profound and rewarding memories. Decisions should be made consciously, in conjunction with taster experience and senior discussion but will inevitably also involve some sub-conscious or even spiritual influences.ix O&G offers a varied and interesting pathological spectrum, as well as giving a precise and exacting surgical toolkit. It offers the opportunity to share in patients’ lives, expand and enhance knowledge, overseas as well as in the UK, and supplies a fruitful academic arena. In exchange, it demands commitment, training, time and pragmatism.
To me, this seems like a fair deal. To me, there is now no alternative. To me, destiny is in fact a matter of chance, but this fate is one that I will choose to strive within and accomplish.
i. Elton C and Reid J ‘The Roads to Success’
ii. Dorsey et al. ‘Influence of controllable lifestyle on recent trends in specialty choice by US medical students’ JAMA September 3, 2003 Vol 290 No 9
iii. Frigoletto et al. ‘Is there a sea of change ahead for obstetrics and gynecology?’ Obstetrics and Gynecology Dec 2002 Vol 100 Issue 6 p.1342-43
iv. Turner et al. ‘Career choices for obstetrics and gynaecology: national surveys of graduates of 1974-2002 from UK medical schools’ BJOG 2006;113:350-356
v. Frigoletto et al. ‘Is there a sea of change ahead for obstetrics and gynecology?’ Obstetrics and Gynecology Dec
2002 Vol 100 Issue 6 p.1342-43
vii. Jeffcott M ‘Examining the role of risk perception in the use of obstetric technology’ WWDU International conference 2002. Found at www.dcs.gla.ac.uk
viii. Cheah T ‘The impact of clinical guidelines and clinical pathways on medical practice: effectiveness and medico-legal aspects’ Review Articles July 1998 Vol 27 No 4
ix. Krtizer H and Zimet C ‘A Retrospective view of medical specialty choice’ Journal of Medical Education Vol 42 January 1967