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Chapter 12 Considering the future: student-

selected components, careers, and electives

OVERVIEW

This chapter provides an overview of some of the choices that you will need to
make during your time at medical school that might affect your future career.
There are some themes running through this chapter: these include consciously
planning activities in order to inform your future career choices; being careful
not to narrow your options too quickly, and re-evaluating your career know-
ledge and career position often. As always, curiosity will serve you well; you will
have a lot to learn from others, even if theirs is not your preferred career. The
hardest message is that you should expect some disappointments along the
way; things don’t always turn out the way you expected on day one. Often
students’ childhood dreams of being a psychiatrist, or paediatrician, or what-
ever, crumble to dust during clinical attachments in those specialities. Your aim,
therefore, should not be to stick to one choice, but should be to make sure that
things will turn out well, and that your career is guided more by active choices
and less by chance.

Medical professions
There are entire text books written about medical careers, as well as entire
departments of faculty to advise you. We do not intend to replace these
valuable resources; in fact, medical careers are currently in flux and will
likely remain so for some time. The older systems of gradually advancing and
then waiting for the consultant or general practice partnership that you
were going to keep for life are no longer in place, and in their place is a fast-
track run-through system, which will likely result in specialists changing jobs
far more frequently than previously.
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These fast-track programs necessitate early career decisions: you will be

expected to make decisions about where you want to be 5 or 7 years later
during your foundation years. Many people are stressed as a result of this.
You can reduce stress in medical school by being strategic and building a
portfolio of experiences that will guide you to the areas that you are
interested in pursuing, as well as the areas that really don't 'do it' for you.
According to the current spin on the fast-track systems, there will be little
flexibility; they will function like efficient conveyor belts, with FY2 doctors
joining at the bottom and falling off the top as specialists. Of course, humans
are messy - they get sick, get pregnant, go abroad for a year, emigrate
halfway through their training, or have even been known to change their
minds about their preferred career halfway through training. Even if it is not
obvious in the formal planning, any system will need to adapt to this
messiness, will need to become organic. To put it another way, there will
always be second chances.
From day one of medical school, you should consider it one of your
primary responsibilities to be curious about other people's careers: ask
every clinician you meet how they got to their current position, and what
the best and worst parts of their job are. You may not want to pursue a
career in gynaecology, but you can learn a lot from the career path and
decisions made by a gynaecologist. When did they realize that was the
career for them? Have they taken any career breaks? How did they know
they were prepared to be consultants? If you discover that everyone you
respect has spent time abroad, for example, you may be more tempted to
incorporate this into your career plan as well.

I'm not sure what type of doctor I want to be. I'm looking forward to the next
few years and getting a sense of the variety of options available to me.

John, second-year medical student

Try to engage with all of the medical specialties to which you are
connected as a student (including general practice, general medicine,
general surgery, and so on), and if you miss out on some, think of ways to
learn more about them. One method is to arrange Student-Selected
Components (SSCs), as discussed in the following section, but there are
other options as well; talk to students who have been attached to those
specialties, perhaps during some spare time you could hang around on their
wards (introduce yourself to the nurses first) and see if you can shadow the
junior doctors, sit in on clinic, or go to departmental meetings or training.
Some students are uncomfortable approaching clinicians to inquire about
career opportunities. If you identify with this, try the following exercise.
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EXERCISE

Consider yourself a specialist in one of the smaller specialties, say tropical neurology;
you have dedicated your life to this specialty; it is your vocation and your passion. Your
one regret is that the medical school does not value it enough to include it on medical
student rotations. A medical student contacts you and asks if he or she can meet with
you to discuss a career in tropical neurology. How do you react?

Components/Modules Chosen by Students

Almost every medical school curriculum in the UK now includes core material
as well as optional components, thanks to the GMC (1993). These optional
components, known differently in different institutions, but most commonly
SSC or SSM, usually last for 2-4 weeks, but can sometimes last a half-day or a
day a week for 10 or 5 weeks. They are supposed to be opportunities to delve
deeper into a topic; for example, you could have an SSC in embryology,
haematology, or sexual health. These SSCs will occur throughout your
medical school career, with some focusing primarily on academics and
others on clinicals. Within all of this variety, there are primarily two types of
SSC: formal and self-organized.

Student-selected off-the-shelf components

Most SSCs are formal, school-arranged, off-the-shelf affairs in which you
read the description and sign up. Usually, there is some sort of allocation
system that appears to be fairly fair if you get your first choice and horribly
unfair if you don't. When looking through the options, students typically
choose based on their interest, likelihood of getting their preferred course,
ease of the course, and suspected grade (SSCs where most students get As
seem remarkably popular). You might want to throw some career ideas into
the mix as well. If you've always wanted to be a paediatrician since you
were a child, an early SSC in paediatrics might be useful to see if it's what you
really wanted. If you believe that an academic career in research is for you,
consider an SSM that includes some type of research; perhaps you will
discover that you dislike statistics or that academic writing is not for you. It's
better to find out about these things early on. If you can't decide between
obstetrics and gynecology and pathology as a career, an SSC in each will
provide you with more information to help you decide.
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Student-selected components that are self-arranged

Self-arranged SSCs can be especially beneficial in assisting you with career
decisions. The SSC officer/coordinator/administrator in the student office
is the most important person here. This is the person with whom you
should establish a relationship because they will be familiar with the
regulations and the loopholes. Assume you are interested in paediatric
surgery but there is no formal attachment or pre-existing SSC in that
specialty; most medical schools will allow you to arrange your own, either
at your home hospital or further abroad, as long as certain rules are
followed. Gather these ahead of time and put together a proposal - You
could send some e-mails to paediatric surgery departments inquiring about
the possibility of an attachment (make the e-mail enthusiastic but not overly
so), or you could speak with the SSC officer at your institution; he or she
might know of other students who did a really good attachment with a
certain surgeon:

Proactive students make excellent students. Many situations that students

face, whether academic or personal, can be resolved or managed, but they are
frequently ignored until they become unnecessarily difficult and
complicated. Approaching the Student Office should not be interpreted as a
failure to achieve as an individual, but rather as taking a responsible and
professional approach to managing their education, both of which are key
qualities that should resonate throughout their future careers.

Mr Robert Sprott, Bart’s and the London

When organizing your own SSCs, cheek and charm are essential. This
includes expressing your enthusiasm, commitment, and good organization
when attempting to arrange it, during it (sounds redundant, but you
should attend 110% and engage with the team, clinicians, and patients),
and after it. The time following the SSM is critical: write a brief, honest, but
constructive report and include it in your portfolio (see Chapter 7). Send a
copy (modified if necessary) to your supervisor, and consider staying in
touch with them, perhaps by sending an e-mail every term to keep them
up to date on your progress. They could be a good resource for references,
summer jobs, or career advice in the future. Importantly, send a copy of
the report to the SSM officer, thanking them for their assistance in
organizing it (even if it wasn't as extensive as it could have been). If you
organized an SSM abroad, consider bringing back something local and
inexpensive (Belgian chocolates if you were in Belgium, Swiss chocolates if
you were in Switzerland, you get the idea) for the student office and
telling them how it went. The next time you want to build your own SSC,
the student office will recognize you as the type of student who will make
the most of it, and they will be more likely to pitch in to help.
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When second best is good enough

You will be denied your first choice of SSC or even clinical rotation on
multiple occasions. Instead of the paediatrics SSC she desired, student A is
'trapped' in a General Practice SSC; ironically, student B is in the opposite
situation. They tried to change, but realized that if they pushed it too far,
they would have a falling out with the student office, so they decided to
make the best of it. Some students in this situation will do the bare
minimum to pass the SSC and spend the majority of their time elsewhere,
either physically or spiritually. We would recommend one of two other
options.
The first thing you could do is dive into this specialty, which was not
your first choice. If you want to be a good hospital-based pediatrician, you
must first understand how general practice works. Otherwise, you will be
unable to refer patients back to their GP for follow-up. In fact, it is difficult
to think of any specialty that does not necessitate a thorough
understanding of other specialties. When this is missing, things frequently
fall apart. So your first option is to dive into the SSC and see what you can
learn; who knows, you might discover that you had some misconceptions
about the subject and that it is more interesting than you thought. Even if
you despise gastroenterology, you will see a plethora of patients with bowel
problems, explain endoscopy to hundreds of patients, and probably a few
simulated patients in exams, so an attachment in gastroenterology may be
beneficial after all.
Your second option is to negotiate a change to the SSM. In our previous
example, if student A desired a paediatrics attachment but received a GP
attachment, she could request to participate in baby clinics, school visits,
or perhaps a young person's asthma clinic. Student B, who wanted to do a
general practice attachment but ended up with the paediatricians, could
ask to do some community paediatrics clinics, outpatient clinics, and
possibly baby checks with the paediatric or obstetric senior house officer.
In general practice, student A learns about paediatrics; in a paediatric
attachment, student B learns some important general practice skills.
Remember to express your gratitude for the opportunities that come
your way, especially if people agree to bend the rules for you.

Electives
According to tradition, medical students spend some time away, usually
in their final year, to study at another institution for an extended period
of time
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(this varies by medical school, but it is usually a couple of months). The

majority of students choose an exotic location and combine study with travel
and immersion in a different culture. Some students stay at home, arranging
attachments in which they will be with a team long enough to take on some
responsibility and see practice in greater depth than they ever had as a
medical student.
You should take full advantage of your school's support and guidance, as
well as previous students' elective reports (usually found in the library,
sometimes online or in the student office), and you will even find some
books on electives abroad (see further reading).

Choosing an Option
Before deciding on a country or even a specialty, you should consider what
you want to get out of this time. Spend some time deciding on the
elective's objectives. You don't need to share this list of goals with anyone
else before editing it, so be honest with yourself. You might be thinking
about a career in nuclear medicine and want to spend some time
shadowing a nuclear medicine consultant to make sure you understand
what they do. Perhaps you are certain that you want to be an HIV
physician, and working in an HIV hospice in a developing country will help
you recognize late complications of the disease, which are uncommon in
the UK, and will also help your job applications. However, you may have
more personal objectives in mind. Perhaps this will be your first time away
from home, and for some, it will be an opportunity to learn more about
themselves as well as a different country; for others, it may be an
opportunity to finally lay some demons from the past to rest, and what
better place to do so than trekking across the Himalayas?
Once you've established some objectives, narrowing down the possible
locations becomes easier. You'll need to keep your options open so that you
have multiple layers of suitable back-up plans, but rest assured that by this
point in your career, you'll be highly skilled at gathering information - just
don't forget to talk to others who may have been there before and look at
some books in addition to Google searches!
Your supervisor is probably the most important aspect of an elective.
Finding the right supervisor, someone who will welcome you and provide
guidance and mentoring, will make a significant difference in your
experience, whether you are in Guatemala or Southend-on-Sea. Speak with
others who have worked with the same supervisor, seek recommendations
and personal contacts with faculty (ask 'but what is he/she like as a person?'
to get an idea), and see what kind of relationship you can build via e-mail.
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Moral considerations
If you are traveling far away, you may need to pay special attention to any
ethical issues that arise during your trip. If you are traveling to a medically
underserved population, for example, and are likely to be given a great deal
of autonomy and responsibility without support and supervision, there are
obvious ethical concerns. You may be able to find another institution in the
same country with better supervision. Similarly, if you are starting or
participating in a project while abroad, such as providing healthcare or
training, consider what will happen after you leave. It might be better not to
start something that will not last.
There are rarely clear rights and wrongs, but it is critical that you consider
the implications of your elective and discuss this with your peers and tutors.
In years to come, this will be a time to look back on with fond memories
rather than regret.

I went on elective to a small hospital in Africa expecting to have an amazing

experience. It turned out that I was sometimes the only'medical' person
available, and I ended up with more responsibilities than I could handle. I'm
not sure it was the experience I was hoping for.
Chris, newly qualfied doctor

Funding
The variety of funding options for electives may surprise you. Funders are
likely to be interested in supporting you if you are working on a specific
project or if you are undergoing significant personal development. Speak
with your student office about funding options, and consider alternative
sources such as industry, charities, and professional organizations. This
could be an excellent opportunity to learn how to write funding applications,
and remember that 'if you don't ask, you won't get' - there's no harm in
sending an enthusiastic letter or two to potential funders.

Culture
Max Chevalier is an educator who works with non-governmental
organizations (NGOs) to establish rehabilitation training centers in post-
conflict countries. He conducted a qualitative analysis of the experiences
and perceptions of Dutch physiotherapists who volunteered in
developing countries as part of his unpublished master's thesis. SSome
students returned home enriched by the experience, appreciating the
opportunity to be a part of a different culture and gaining a great deal
of respect for healthcare workers working in low-resource settings,
whereas others returned with negative experiences, often with rather
deep-seated prejudices that appeared to have developed while away. It
was difficult to identify reliable predictors of a favorable outcome, but
the following factors appeared to be useful:
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● having a positive relationship with their boss or others who have worked
or lived in the host country
● having personal characteristics and approaches such as
– flexibility
– nonjudgmental attitude
– empathy
● before you travel, learn about the country (including its history and
culture)
● knowing a little of the local language

● traveling in a pair was valued by many students because it provided

them with a safe'space' in which to reflect on what had happened,
though some felt that this prevented them from engaging with local
culture
Aside from the supervisor, it appears that curiosity is an important
characteristic for a positive outcome. Most students had a negative
experience of some kind, such as a supervisor yelling at them. Those who
approached that supervisor after enough time had passed for things to calm
down and asked for help in understanding what they had done to cause
offense tended to fare much better than those who withdrew. In Chapter 4,
we go over feedback in greater detail; the same rules apply here: describe
behaviors and avoid making premature meaning judgments.
Michael Paige and colleagues (2006) have written a nice book, primarily
aimed at Americans studying abroad, that covers cultural and cultural
adaptation topics well. This or something similar may be available in your
medical school library. You can purchase this book directly from the
University of Minnesota's website.

Balance
Most students take advantage of their elective period to travel to another
country or culture, and round-the-world tickets are popular. Remember that
this is also an opportunity to investigate a career in greater depth than you
would normally be able to, as well as to investigate the possibility of working
in a different country; both of these opportunities are unlikely to be
repeated, so make the most of them. Review your goals on a regular basis,
negotiate with your supervisor, and make sure they are aware of your
progress. If you've chosen your boss wisely, they'll understand the need for
you to take long weekends off now and then.
Clearly, if you view your elective as merely a vacation period, you will not
only miss out on a valuable experience, but you will also risk failing to reach
an adequate assessment, which could lead to problems back home.
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Follow-up
Consider keeping a diary or starting a blog. Many blogs allow you to e-mail
or even text entries, making it easier to access if you are traveling or if your
Internet connection is slow or intermittent. This will allow you to keep a
record of events and reflections, as well as reassure those at home that
everything is fine.
When you get home, write a report about your experiences, both good
and bad, and include contact information for useful contacts. Consider what
advice you would have appreciated before going and write it down. You
may want to include some personal reflections, or you may prefer to keep
them to yourself; either way, it is worthwhile to write them down (see
Chapter 7 on portfolios). Send thank-you letters to everyone who was
involved, along with a copy of the report. Some will read it, some will not,
but they will most likely appreciate your thanks.
If something stressful happened on the elective, consider discussing it
with others, either with your friends or more formally with your tutors. If
your colleagues have had difficult experiences on elective, you should
consider how you will make it easy for them to talk to you.

Summary
We attempted in this chapter to suggest that you consider a career angle in
everything you do from the beginning of your time at medical school,
without being career driven or single-minded in your thinking. You will learn
a lot from all of your clinical attachments that will benefit your future
career, regardless of which specialty you choose, but only if you view each
of these attachments as an opportunity.

Further reading and references

General Medical Council (1993). Tomorrow’s Doctors: recommendations on
under graduate medical education. London, GMC. Paige, R.M., Cohen, A.D.,
Kappler, B., Chi, J.C. & Lassegard, J.P. et al. (2006). Maxi-mizing Study Abroad: a
students’ guide to strategies for language and culture learning and use.
Minneapolis, MO, Center for Advanced Research on Language Acquisition.

Answers to questions
Q: I've always known I wanted to be a psychiatrist, but I just finished my fourth year
psychiatry attachment and I hated it. I'm at a loss for what to do now.
A: This is a fairly common situation; students who enter medical school certain of a
particular career path can be taken aback when they learn more about that specialty
and discover that it is not for them after all.
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This frequently has a negative impact on motivation, and some students may become
depressed as a result. These are normal reactions, but they must be quickly followed
by a period of re-evaluation. Consider going to your careers service, talking to friends,
and spending time writing down the things you like about medicine and the
specialties you've tried that you liked.

Q: Finals are approaching, and I still haven't decided on a career path; what should I
do?

There are three types of students who are in this situation. Some people struggle
to make a decision because they are 95% certain that they want to be a GP, but
that 5% prevents them from committing. It's simple advice; all you have to do is
commit! Suck it and see what happens. For students who can't decide between
vascular surgery and plastic surgery, and have had attachments in both and asked
around a lot, try to find a job that would provide a common entry point to either -
such as a common 'general surgery' start to specialist training or even a teaching
fellow or demonstrator job in anatomy, clinical skills, and so on. If you have no idea
what you want to do, consider applying for a 'holding job,' such as a non-training
position that will provide you with valuable experience no matter what you end up
doing.

Q: What if I don't get the FY position I wanted? Will my career be jeopardized?

No. Final-year medical students are very concerned about getting the most
prestigious FY jobs. There is no harm in applying for these positions, but in the long
run, you will value positions where you had good supervision and training, where you
learned a lot and had a positive experience. Surprisingly, most "prestigious jobs" do
not fit this description. The same is true for job interviews: describing what you did
and what you learned in a busy job will impress the panel more than having done a
professorial job where you learned nothing.