Sample scenario 1

At school Doctor A’s favourite GCSE subjects were Latin, History and English but she was an excellent all rounder and got high grades across the board. Doctor A had originally thought about a career in nursing as she liked the idea of contact with people however her teachers thought she was very gifted academically and that she should apply for a place at medical school. Doctor A arranged a work placement at the local hospital however she did not get the opportunity to spend much time with the doctors and spent most of her time with the nurses.

During medical school Doctor A had doubts whether medicine was the right career for her and felt that she was not learning adequately even though she never actually failed an exam. Despite this Doctor A persevered and actually passed all her exams and graduated with a high grade.

Doctor A’s F1 year felt like a massive anticlimax after doing so well in her final exams. She hated her surgical rotation and felt increasingly on her own and out of depth.

In F2 Doctor A decided to apply for the GP VTS and was successful despite having feelings of wanting to be unsuccessful at interview. Doctor A coped well when based in the GP practice and found this environment very supportive but again she felt she was not learning enough. As the GP placement was nearing an end Doctor A began to dread going back to hospital and was very concerned on learning that that she was going to be on call on the first weekend back. Doctor A now felt increasingly unhappy and desperate and consulted occupational health who took her off nights. Doctor A found this embarrassing to explain to her colleagues.

Occupational Health then referred her to a psychotherapist, who felt the issues were due to being unsupported at work and were not due to an underlying depression. After a couple of weeks of working days only Doctor A decides that she has no future in medicine and cannot cope with the responsibility involved.

Doctor A has arranged a meeting with her Educational Supervisor to discuss her thoughts that it is her intention to resign.

Sample scenario 2

Doctor B is a CT2 in anaesthetics and is having doubts about whether medicine is for him and whether to carry on and apply to ST3 level anaesthetics. He is especially worried about the responsibility he will have, on-call next year, when he may be the only anaesthetist (or most senior one) to respond to medical emergencies.

Doctor B enjoyed A&E best in his foundation years, but chose anaesthetics as he wasn’t sure if he wanted the hectic life-style as an A&E Doctor and then later as a consultant.

He failed a small bit of his exam recently and this has triggered some doubts about whether he should continue on his current training path, or whether to leave medicine indefinately. Doctor B is wondering what to do.

Comments

• The doctors may be considering leaving medicine for a variety of reasons such as:
  • They may feel they are not suited to the profession
  • They do not feel up to demands of medical training (the transition from medical school or even from F1 to F2 may be hard for them).
  • They may feel unsupported in a particular placement
  • There may be something else that has knocked their confidence (e.g. Doctor B may have had their self-belief knocked on failing an exam).

Getting to the bottom of why they are considering leaving is really important, to see if it is a temporary issue that can be resolved relatively simply. It may be an issue relating to specific difficulties in a particular placement. If it seems that they are seriously considering leaving medicine, it may be necessary to refer the doctor on.

• As mentioned in the previous point, referring the doctor to the Training Programme Director, or Careers Lead in the NHS Trust might be the next step. An opportunity to speak to a fully-trained Careers Adviser may be also advisable at this stage, if the deanery has a careers department.
• In addition it may be that the doctor would benefit from seeing a trained counsellor or a psychotherapist. This is particularly the case where the doctor seems very stressed or depressed. It is important that the practitioner is adequately accredited by the appropriate professional organisation.
• As an Educational Supervisor you will be responsible ‘to’ your trainee, rather than being responsible ‘for’ them. All you can do is be supportive and make sure that they have properly thought through the decision. If you have used a structured approach in order to see if it is a temporary problem that could be remedied in some way; if the doctor sill persists in wanting to leave medicine, it does not represent a personal failing on your part.
• It is important in these situations that the doctor themselves is not made to feel a personal failure. Their self-esteem will probably be very low at this point. Selection into medicine is not completely foolproof and some people may change during their five or six years of undergraduate training and may feel at the end of it that they are not suited to the profession.
• It may be appropriate to refer the student/trainee to Specialist Careers Advice.

Sample scenario 3

Doctor C is an F2 who applied to do ophthalmology this year and although he was invited to an interview, he didn’t get the job. At present when August comes he doesn’t have a job to go to, so he plans to locum for a year, and then apply again.

Although Doctor C realises that there are very few posts available in this specialty, he hasn’t considered a plan B.

Sample scenario 4

Doctor D comes to you for career advice saying that they want to apply for basic specialist training in surgery, with a long-term goal of training in a particularly competitive surgical specialty. Yet in their F1 assessments they were graded as ‘borderline for F1 completion’ on some of the assessment tools, and in particular, their performance seemed highly variable on some of the DOPS (Direct Observation of Procedural Skills) assessments.

Comments

• This issue is more likely to occur in the supervision of foundation doctors than medical students. But if you are faced with a trainee doctor who wants to pursue a career plan that you feel is completely unrealistic – your first task is to provide a balance of support and challenge. In other words, you want to discuss where you see their key strengths as lying and the possible career implications of these. You also want to challenge them with probing questions that clearly set out your concerns about their chosen career plans.
• Rather than agonising over whether or not you should advise the trainee doctors to reconsider their career choices, you should focus on asking the following sorts of challenging questions.
  • What does the trainee doctor see as their key strengths?
  • How does this self-assessment of their key strengths fit in with some of the assessment evidence in their learning portfolio?
  • Which specialties might allow them to make the most of their key strengths?
  • In which areas have they been assessed as being less strong?
  • Are any of these areas important in terms of demonstrating their suitability for surgical training?
  • Is there a match between their areas of personal weakness and areas that are critically important in terms of suitability for surgical training?
  • Have they researched the likely competitiveness of Basic Surgical Training?
  • What are their thoughts on the fact that competition for entry into Basic Surgical Training is going to be very tough, but they have not scored highly on the relevant key competencies?
• Perhaps you are now asking yourself whether it wouldn’t be better to ‘call a spade a spade’, and just tell your trainee doctor straight out that they are not suited for further training in surgery. It can be tempting to do so. But the approach outlined above is more robust, for the following reasons:

1.  The ‘calling a spade a spade’ approach (eg saying ‘If I were you, I’d ditch surgery’), absolves the trainee from taking responsibility for their own decision making.

2.  Posing challenging questions rather than providing answers makes it more likely that the discussion will be opened up, and the trainee doctor will start to think critically about their position.

3.  If you go down the ‘if I were you’ route, your own pet likes and dislikes might influence the advice you give. This means that inadvertently you might be more likely to encourage the trainee doctor to reconsider specialties of interest to you, and to avoid those that you particularly disliked at medical school. And of course, the if I were you’ route has a basic flaw: the trainee doctor is not you.

4.  Your opinion could possibly be wrong. (For example, perhaps something is going on in the trainee doctors private life that means that they have been sleeping poorly, and in turn, getting poor assessment results. But the trainee doctor knows that at medical school they received highly favourable feedback on their potential for surgical training).

• Avoiding the ‘if I were you’ approach, does not mean that you should avoid challenging the trainee doctors career decision making. But you should do this by encouraging them to reflect on the robustness of their career plans through posing challenging questions to them, rather than suggesting answers.

The challenging, not suggesting approach should help minimise concerns  that you might provide poor careers advice. In fact, what you should really be concerned about is posing questions that are insufficiently challenging.

• If the trainee doctor still persists in wanting to pursue a specialty that you believe is completely unrealistic, you can suggest that they should discuss their plans with somebody else. This could either be a clinician who has received additional training in career support, or a careers adviser. You should then do a brief summary outlining your own concerns about the robustness of their career plans, and give it to the person who will be providing this additional support.

Sample Scenario 5

Doctor E is coming to the end of her F1 year. She has adjusted well to her first job as a doctor after completing medical school. She is aware that the specialty application window will open in a few months time and is now beginning to feel a bit panicked about deciding on which specialty training programme she should apply for.

Doctor E feels certain that surgery is not for her and has experienced a surgical rotation. She is considering medicine but is not entirely sure of which branch of medicine she would ultimately consider specialising in and has also had thoughts about pursuing GP as a career but have not had the opportunity to experience this as yet during Foundation and is concerned that it will not be challenging enough and that she will become frustrated dealing with the “walking well”.

Doctor E has arranged to meet with her Educational Supervisor to discuss career options and to try to gain some more clarity in the build up to the Specialty application window opening.

Sample scenario 6

Doctor F is a diligent and competent F2 Doctor. The assessments carried out during the F1 year suggest that he meets all the expectations, or exceeded the expectations on all the different criteria.

During Doctor F’s F2 year he had placements in General Practice, Psychiatry and Obstetrics and Gynaecology. He enjoyed all three of these placements and is finding it really hard to say what his preference is. He is now beginning to feel no closer to deciding on a career pathway for his post foundation Training. He has arranged a meeting with his Educational Supervisor to seek advice regarding his career.

Comments:

• The first step would be to make sure that both Doctors E and F have carried out a thorough self-assessment and career exploration (see the four stage career planning model). The exercises contained in Stage 1  i.e 'Self-assessment' will help students/trainees generate ideas about specialties that might suit them. So if somebody comes to you saying that they don’t know how to start making carer decisions, you can concentrate your discussion on the exercises contained in Stage 1. 

You can ask them the following questions:

• • How much research have you done?
  • Have you spoken to trainees and consultants or taken a ‘taster’ in the areas that you are considering?
  • How have you made a career decision in the past? (this could be about how they chose their elective, or their Student Selected Components in their medical school years).
• Understanding how an individual makes their decisions is also important here. For example do they act spontaneously, deciding on a whim, or do they only commit themselves after extensive information collation and research? The 'decision-making stage' can help individuals to make considered decisions and there are plenty of decison-making tools that you could encourage your trainees to carry out. 
• You should be warned that the doctors may want YOU to make the decision for them! Avoid starting with ‘If I were you…’. You are NOT them, only THEY can make their own decisions.
• You could emphasize that keeping an open mind could be an advantage to them and they should use their foundation years to become as rounded as possible as a doctor. They can apply for two or three different specialties which will give them more of a chance to consider which would suit them best. Always encourage them to have a plan B or even a plan C. For the specialties that are more competitive however, the doctors may not be able to show enough commitment to a specialty if they choose their options too late. However this is not always the case and doctors have been successful at getting through to the next stage if they have done well in their application forms and at interview. For those who are deciding whether to apply to surgery, you could direct them to our surgical podcast here.
• Considering role-models and the part they may play in decision-making could be a useful avenue of thought. Ask them to describe who out of all the clinicians they have met they have admired the most (you don’t have to ask for names!).
• The doctors you are supervising will all be at different stages of readiness to make a decision (in careers terms we call this ‘career maturity or adaptability’). Some may feel it is too early to make such a decision and it may be that taking a year out after F2 is a sensible way forward. Locumming at home or abroad and the opportunity to try out different specialties may be a good option here.
• Above all you can remind your supervisees that a ‘career is a journey, NOT a destination’ – for some taking a longer route via a diversion or two is a sensible idea.
• But some people have great difficulty making final decisions. So if the exercises contained in the Stages 1-3 of NHS Medical Careers aren’t sufficient to help them make up their mind, then these individuals might also benefit from specialist careers advice.