Dr. Ashok Raina, a noted physician, discusses in detail about one of the most important, yet difficult decisions a doctor has to make in his lifetime- choosing a speciality and the roadmap to it.

 

The man, who doctors himself with the aid of medical books, runs the risk of dying of a typographical error.

- Evan Esar

Professionalism is a combination of attributes, behaviours, commitments, values, and goals. In medicine, it comes with a strong societal role and an emotional component too.

On the other hand, ethics is the study of morality- a careful and systematic analysis of moral decisions and behaviours and practicing those decisions. It is generally believed that professionalism and ethics are caught by watching your teachers and seniors and not taught formally.

This is what most of us at the time of entering medical schools hear from our peers and seniors who are already about to reach the fag-end of their careers in medical practice and indeed one must remember that they too were advised the same by their seniors and we too shall dole out the same advice to the newcomers, thus running a continuous cogwheel of faith, trust, and a sense of superiority which perhaps vanishes with the grindings of medical school and while living the unsettled life that one leads as a doctor.

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Reasons why people choose to be doctors

There are four distinctive, universal reasons why people choose to be doctors. Each of these 4 reasons comes with its own unique set of problems and stressors. People choose to become doctors because:

• They have a personal mission, purpose, or driving force to heal people, be of service and/or save the world, e.g. people who join 'Doctors Without Borders'
• They want to heal people and be of service, but they lay equal emphasis on having a lucrative career where they can earn a healthy income
• They are success driven, have heard that being a physician is a high-paying profession and they are mostly focused on their career and income-making potential.
• They have one or both parents or grandparents who were physicians and their family expected them to become a physician too

Whether this theory is applicable to our system, remains to be seen because neither do we have any scientific data available nor is the current scenario of our education system, socio-economic structure, available opportunities, skewed and nonprofessional admission systems to medical schools conducive to scientifically evaluate why people choose to be doctors.

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Choosing a speciality

As a doctor out in the market for survival, the necessity to choose a branch for specialisation becomes invariably necessary. Many factors influence the speciality choices of medical students. A few of them are:

• Age, gender, personality type
• Elements of influence and role models
• Features of the speciality itself- types of problems and people encountered and served while in practice, continuing development of new technologies in that area
• Income
• Exposure during internship years
• Type of rotations
• Exposure to different subspecialties during internship

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Similar international studies and surveys

In the international paper titled, 'Motivation for medical school: the relationship to gender and specialty preferences in a nationwide sample', Vaglum P, Wiers et al. had reported results of a study they conducted among students entering medical school in Norway.

• The highest motivational scores were for the 'person-orientated' index and female students scored higher than men
• Female students were, however, nearly as highly motivated by status/security and interests in natural science as men
• 'Person-orientated' and 'natural science-orientated' motives exerted the strongest influence on specialty preferences
• Those who preferred family medicine were more person-orientated and less natural science-orientated, while those who preferred internal medicine were more natural science-orientated
• The father being a physician did not influence the motivational pattern but increased the preference for laboratory and internal medicine
• Frequently repeated upper secondary school exams for acceptance into medical school were negatively related to natural science motivation, and to increased preference for becoming a surgeon

Thus, concluding that in the first month of the curriculum, students regarded person-oriented motives as the most important for becoming a doctor. For example, students who chose general medicine are guided in their choice by:

• the opportunity to make better contact with patients
• the opportunity of broad and comprehensive care giving
• diagnostic challenges
• intellectual content
• satisfaction in deepening the study of patients
• ambulatory practice
• opportunity to be involved in psychological and social aspects of medicine
• desire to contribute to the community
• need to keep options open
• the little value they place on remuneration and lifestyle

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On the other hand, students who choose surgical specialties justify their choice in terms of:

• the opportunity of carrying out practical procedures and operations
• the effective almost immediate results of surgeries
• their enjoyment of emergency care
• the practical application of scientific knowledge
• the research opportunities
• the predominance of in-hospital practice
• the prestige that surgery holds within the medical profession
• the opportunity for leadership and to exercise authority
• the greater remuneration and greater respect enjoyed by residents in this field

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In a study, 'The controllable lifestyle factor and students' attitudes about specialty selection' that included medical students from nine US medical schools, Schwartz et al. found that students prefer to select specialties that had fewer practice work hours per week, allowed adequate time for the pursuit of vocational activities, and seemed to have fewer on-call nights.

These aspects were found to be more influential than traditional motivators, such as remuneration, prestige, and length of training. In addition, a study by Jarecky et al.- 'Stability of Medical Specialty selection at the University of Kentucky' suggested that lifestyle is a main factor in late-life career changes of physicians.

Recently, choosing specialities that help live achieve work-life balance has drawn increased attention. Students look for specialities in which it is possible to have a 'controllable lifestyle' that has components like personal time free of practice, for leisure, for family, and a vocational pursuit, and control of total weekly hours spent on professional responsibilities. 

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Core values and attributes attached to choosing specialities

According to the Medical Schools Council, UK, the core values and attributes are well defined for becoming a doctor or choosing a speciality. 

Core Values & Attributes
Motivation to study medicine, a genuine interest in the medical profession	Insight into your own strengths and weaknesses
Personal organisation	Academic ability
Dealing with uncertainty	Manage risk and deal effectively with problems
Conscientiousness	Insight into your own health
Teamwork	Ability to treat people with respect
Empathy, the ability to care for others	Honesty
Ability to reflect on your own work	Problem solving
Ability to take responsibility for your own	Effective communication
Resilience	Ability to deal with difficult situations

But again, while going through the literature of both MCI or IMA, nothing of this sort was found which could have become the cornerstone of the foundation of medical profession in India.

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Let's try something different!

So yet another aspect which needs to be experimented with is that rather than pre-planning on sub-speciality, doctors should be allowed a couple of years to rotate through multiple specialities for so that as a graduate student they are better equipped, trained, and masters of the specialty which suits their physical, mental, and social capacities.

But, for this to be successful, the financial requirements of a doctor needs to be taken care of. This will enable doctors to not only excel in their individual capacity but also national health indices would see much better statistical status than what it is at present.

As doctors, our professional demarcations are not, in my opinion, decisive lines that if jumped, would be detrimental to human life like it may so in other branches of science, where in an electrical engineer will not be able to do a civil engineer’s job and vice versa. 

In our profession, we are all exposed basically to one basic thing, the human mind and body, the interest of which which becomes our driving force and we solely become dedicated to the profession neither by choice nor chance but by what is ingrained in our minds right from the start of medical school- 'We deal with life and not innate matter.'

Indeed earlier in Medicine, it was just a 'Doctor' that existed. Now medical information is so vast that humanly it is impossible for one person to possess all this knowledge. 

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Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.