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|Year : 2009 | Volume
| Issue : 4 | Page : 294-295
The medical students' dilemma: Which postgraduate specialty to pursue?
MBBS Student, Seth GS Medical College and KEM Hospital, Mumbai, India
|Date of Web Publication||14-Jan-2010|
S U Shah
MBBS Student, Seth GS Medical College and KEM Hospital, Mumbai
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shah S U. The medical students' dilemma: Which postgraduate specialty to pursue?. J Postgrad Med 2009;55:294-5
At the time of joining medical school, I had little knowledge about the spectrum of medical specialty choices available. My only joy at that moment was the reassurance that I will be a 'doctor' one day. As I sailed through the learning process, both in the textbooks and the wards, I gathered bits of information about the realm of medical specialty career possibilities. The competitive medical practice of the present era strengthened my motivation and desire to specialize in 'some' postgraduate (PG) medical specialty.
Towards the end of the internship, I am faced with an important question-'Which medical specialty should I opt for?' With the understanding that the decision is likely to influence and shape my future years, it is easy to understand the gravity of this question. However, hardly any help is available to guide me to make the right choice.
I decided to explore the factors that make a medical student decide what is best for him/her. From formal studies, I concluded that numerous factors interact to determine the preference for a particular specialty. These include gender, intellectual content, individual's competencies, anticipated income, reputation of a specialty, illness in self or close others, doctor-patient communication, focus on urgent care, respect for family member in the profession, physician role models and preclinical experiences. , For example, a recent Canadian study suggests that male students were more likely to express interest in a surgical specialty than their female colleagues. Students interested in a career in surgery were less likely to demonstrate a social orientation and more likely to be hospital-oriented than students interested in either family medicine or a medical specialty.  While discussing the various medical specialties, I consider it worth mentioning the need of "general practitioners" or "family physicians" who practice medicine at the community level. I remember a lecture at the Community Medicine department on infectious diseases and sanitation where the speaker explained how it is possible to eliminate more than half of the health problems India faces with mere propagation of water hygiene and basic sanitation and how many of the remaining health problems can be tackled by basic medicine practitioners, leaving a small role for specialists. The lecture ended with a strong statement-India does not need specialists and super-specialists; it needs basic community medicine practitioners who can counsel about preventive strategies. Many of the Western countries have a PG specialty in "Family Medicine" to serve this purpose.
I feel that every moment spent in the process of medical learning has the potential to alter the student's preference of medical specialty. Reading a textbook, attending a conference, attending ward rounds, the bedside clinics, presentations and research experience may all contribute to it. An important aspect is the experience gained during the clinical clerkships and the internship. Besides teaching about the practice of medicine, the clerkships allow the students to relate their specialty preferences with real-life setting.  In India, the clinical clerkships have a predetermined fixed schedule, content and duration of exposure to various specialties. This is in contrast with the clerkship protocols in some Western countries like the US, where the clerkships are more flexible, allowing a student to spend more time in a specialty of his choice. Exposure to a specialty encourages the student to opt for a career in the corresponding specialty.  As such, the clerkship protocols may play a role in the student's preferences. Compounding the above scenario is the Indian setup of postgraduate entrance examinations under which rank is the sole criterion that determines and limits the PG choices available to the students. On the one hand, this may dampen the interest in a specialty a student cultivated a liking for; while on the other, a student with a treasure of medical knowledge may step into a specialty that doesn't interest him or that demands skills which he finds himself incapable of. A need to test the clinical skills along with the medical knowledge has been felt and amendments in the present system may be imperative in the future. A Dutch study that analyzed the relation between the subjective knowledge and the specialty preference of medical students found poor correlation between the two parameters and concluded that students' preferences about specialties cannot be trusted and they are in need of career counseling.  Non-cognitive attitudes may be more predictive of success in a specialty than cognitive abilities. This viewpoint is strengthened by a new system of "foundational period" of two years that has been introduced in the UK to preselect students with the necessary attributes of a surgeon based on psychometric assessment.  Recent evidence also suggests that expert performance at a specialty depends on deliberate practice in the form of focused training, learning opportunities and timely feedback from teachers; and not on the conventional parameters such as reputation, length of experience or perceived mastery of knowledge. 
Making available to the students the resources to help them take the right decision is a grim necessity. This has been attempted in the Western countries in the form of counseling programmes, career development programmes, student mentoring programmes, interactive websites and discussion forums which have had a primitive success.  Such programs enrich the culture of medicine by helping the medical students to reflect on their own professional development.  Overlooking this important aspect could prove counterproductive as the students may be vulnerable to informal discussions with family, friends and residents. Doctors badmouthing each other, for instance, was reported an unattractive part of the learning milieu of medical students which had an influence on the career choices of 21% of the students in an Australian study. 
Most studies on this subject have been done in the Western countries and direct extrapolation to the Indian setup of medical education would be unrealistic. The choice of the PG medical specialties in India is also likely to be driven by the number of PG positions available every year which is a fragment of the actual demand. The large chunk of aspirants left out may succumb to many pressing matters that lead them into 'some' PG specialty in the next attempt. My interaction with the seniors at my institute creates a firm impression on my mind that rank at the entrance examinations determines the specialty one pursues. This is supported by my review of the rank-list versus specialty-list of the past few years. I am uncertain as to how reliable this trend is to ensure that the specialty is apt for a candidate and vice versa. Besides, the commercialization of medical education further complicates the matter. The more I explored this issue, the more complex it became! I realized that the choice of PG specialty is a dynamic process worthy of critical analysis.
| :: Acknowledgment|| |
I am grateful to Dr. Nithya Gogtay for her guidance and encouragement.
| :: References|| |
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