Career opportunities in the smaller medical specialties ======================================================= * Alistair McIntyre Choosing a specialty in which to build a career has always been difficult. In the past the ability to rotate through a variety of senior house officer posts permitted variable delay until an appropriate specialty was identified and successful application made. In medicine the achievement of MRCP(UK) and the first, usually general, medical registrar job led to a further decision on which of the specialties should be chosen. The increasing number of medical graduates coming through for a limited number of training posts, some of the constraints in the initial introduction of Modernising Medical Careers (MMC), and the Medical Training Application Service debacle in 2007 brought the choosing of a specialty into much more focus. The constraint of a limited number of applications, by design to encourage people into less popular specialties, made the choice even more daunting. In addition, the choice had to be made substantially earlier than in the past. Despite these changes, however, the amount of competition for medical specialties has remained relatively unchanged. Some of the larger acute medical specialties have been fiercely competitive (eg cardiology, gastroenterology, respiratory medicine) and applications for these and similar ones remain in excess of 10 per appointment since early data collection in the mid-1990s until MMC applications in 2007. The Department of Health predicts that competition in 2008 will be more severe than in 2007. In contrast there was substantially less competition for many of the small medical specialties in 2007. These included allergy, audiovestibular medicine, clinical genetics, immunology, clinical pharmacology and therapeutics, neurophysiology, medical ophthalmology, metabolic medicine and paediatric cardiology. Candidates have little experience of these specialties often with only brief introductions in medical school. Some have application rates of one candidate for two posts. Many are not listed separately on the MMC website. Smaller specialties potentially have advantages for some. Specialist departments are often based in larger cities or university hospitals with excellent support and research facilities. The opportunities for teaching and training at all levels still exist. Management of the service is still required. The work is diverse, interesting and predominantly outpatient based. For some applicants the lack of uncertainty, excitement and chaos of the acute medical take as well as freedom from the potentially disruptive hours is a bonus although some smaller specialties are also required to offer emergency support. Consultant appointments occur relatively rarely in these specialties and this appears off-putting, but numbers are appropriate for the number of trainees so prospects are usually excellent. Career advisers, consultant mentors and junior doctors should be aware of these specialties when considering a career choice. Allergists deal with the very broad spectrum of allergic disease from drug, food and venom allergy and idiopathic anaphylaxis to the many organ-based allergic diseases such as eczema, rhinitis and asthma. Audiovestibular physicians diagnose and manage hearing and balance disorders arising not only from ear pathology but also presenting as a symptom of a diverse range of conditions including vascular, renal, endocrine, autoimmune and mitochondrial disease, neurological disorders and chromosomal abnormalities. Clinical genetics is concerned with the diagnosis of inherited disorders and birth defects, the estimation of genetic risks and organisation of appropriate genetic testing, and the provision of genetic advice to individuals and family members who may have, or be at risk of, a genetic or inherited disorder. Clinical immunology encompasses clinical and laboratory activity dealing with the study, diagnosis and management of patients with diseases resulting from disordered immunological mechanisms, and conditions in which immunological manipulations form an important part of therapy. Clinical pharmacologists in the UK are physicians whose patterns of work and specialist interests vary enormously and are often based in teaching hospitals. They have expertise in the development, evaluation and use of drugs applicable in many different sectors including in academia, the NHS, pharmaceutical companies, and drug regulatory authorities. Clinical neurophysiologists evaluate patients referred with neurological symptoms for diagnosis or quantitative assessment of severity. The core work is in electromyography and electroencephalography but there are numerous other investigative techniques and the list is expanding. Medical ophthalmologists treat conditions affecting the eyes, orbits and visual pathways. Training in internal medicine and ophthalmology enables them to offer a comprehensive assessment of a patient with visual symptoms or ocular signs and to monitor systemic effects of therapies. Metabolic medicine for physicians offers a way of pursuing a focused interest in one or more of the five areas of the curriculum (diabetes, lipids, nutrition and obesity, metabolic bone disease and osteoporosis, and inborn errors of metabolism). It is potentially a very attractive route for those interested in these specific areas who may wish to work in academic units. Paediatric cardiologists deal with a diverse group of conditions that can result in significant morbidity and mortality but for most there are treatments available. It is a high-risk but high-gain specialty that gives excellent job satisfaction and it remains a field where clinical skills, practical procedures and technical expertise are important. There will be a need for consultants specialising in looking after adults with congenital heart disease with the improved survival for infants and children with these conditions. To enter most of these specialties at specialty training year three a trainee needs to have completed two years of core medical training or acute care common stem (though other pathways are possible or extra experience is required) and to have passed or imminently likely to pass MRCP(UK). For those who think they might be interested in some of these smaller specialties they should seek information from the Royal College of Physicians's website (workforce section), consider contacting local specialists whom they know or the specialty representatives. Ideally they should arrange to spend a few sessions within the field to see if this helps their career choice. For those who do decide on applying for one of these smaller specialties the career opportunities look good. ## Contributors Dr Pamela Ewan, Allergy Department, Addenbrooke's Hospital. Email: pamela.ewan{at}addenbrookes.nhs.uk Dr Ewa Raglan, Consultant Audiovestibular Physician/Honorary Senior Lecturer, St George's NHS Trust. Email: ewa.raglan{at}stgeorges.nhs.uk Dr Sue Holder, Consultant Clinical Geneticist, Imperial College London. Email: s.holder{at}imperial.ac.uk Dr DJ Unsworth, Consultant Immunologist, North Bristol NHS Trust. Email: Joe.Unsworth{at}nbt.nhs.uk Dr Jeffrey Aronson, President of the British Pharmacological Society; Reader in Clinical Pharmacology and Honorary Consultant Physician, University of Oxford. Email: jeffrey.aronson{at}clinpharm.ox.ac.uk Dr Albert Ferro, Reader in Cardiovascular Clinical Pharmacology and Honorary Consultant Physician, King's College London. Email: albert.ferro{at}kcl.ac.uk Dr R Kennett, Consultant in Clinical Neurophysiology, Oxford Radcliffe Hospitals NHS Trust. Email: Robin.Kennett{at}orh.nhs.uk Dr Catherine M Guly, Specialty Registrar in Medical Ophthalmology, The Eye Clinic, Aberdeen Royal Infirmary. Email: catherine.guly{at}doctors.org.uk Dr John Olson, Consultant Ophthalmic Physician and Lead Clinician, Scotland's National Managed Clinical Network for Uveitis, Aberdeen Royal Infirmary. Email: john.olson{at}nhs.net Dr Jennifer Logue, Specialist Registrar in Chemical Pathology and Metabolic Medicine, Glasgow Royal Infirmary. Email: jen_logue{at}yahoo.com Professor Mike Lean, Professor of Human Nutrition, University of Glasgow, Glasgow Royal Infirmary. Email: M.McNee{at}clinmed.gla.ac.uk Dr Robin Lachmann, Consultant in Metabolic Medicine, National Hospital for Neurology and Neurosurgery, Queen Square, London. Email: robin.lachmann{at}uclh.nhs.uk Dr Robin Martin, Paediatric Cardiology SAC Chair, Consultant in Paediatric Cardiology and Adult Congenital Heart Disease, Bristol Royal Hospital for Children and Bristol Royal Infirmary. Email: rob.martin{at}UHBristol.nhs.uk * © 2009 Royal College of Physicians