Mark Wilson offers some alternative ways to get ahead

Medicine, as I always say, is your passport--and this time I don't just mean to travel. You are embarking on a fascinating career that really knows no boundaries. You can become a clinician, an academic, jack it all in and become a businessman, get involved with politics, the media, the armed forces... the list is endless. Sounds fantastic doesn't it? But hang on, can it be that much fun? You've probably heard that some hospital specialities are highly competitive, and wondered if your CV will be good enough. Should I be doing a BSc now? Am I doing enough "extra" work? And you thought finals were going to be your biggest hurdle.

Sadly, most of what you have heard about the competition is true. There is a severe shortage of national training numbers (NTNs) in some of the more popular specialties, and in this time of formal pathways the coveted numbers go to those best qualified. But do not despair, there are other ways.

In 1942 Donald Matthews set out on a very interesting life. Having qualified from Edinburgh, he became a ship's doctor. He subsequently worked as a general practitioner, a gynaecologist, a radiologist, and a surgeon in all four corners of the globe. He wrote a book that has been my inspiration, entitled Medicine: my passport (you won't be able to find a copy--I think I have the only one, and I found that by chance in Kathmandu). A fascinating chap whom it would be great to have round for dinner. Would you want him operating on you? Of course not, you'd want a specialist, and hence, sadly, the medical career ladder has changed.

If I was having a hernia repair, I would love to have it done by someone who was fascinated by hernias as a child, did medicine with the lifelong goal of repairing hernias and did extensive research into hernias before becoming a hernia specialist. He'd probably be fantastic at repairing hernias, although slightly boring at dinner parties when talking about prolene meshes. I have a personal fear about the change in training of doctors and surgeons. The process of specialisation is occurring much earlier than it used to. Generalists used to become specialists in their field. Now, you choose your specialist field, do research in it and stick to it. This system reduces the opportunity for entrepreneurism and the transfer of techniques or ideas from one speciality to another. This system doesn't produce many modern day Donald Matthews, that's for sure. Medical schools have a pivotal role in maintaining the wide interests of medical students, be it in sport, drama or music. The merging of medical schools in London, the subsequent loss of identity (and camaraderie) and the constant emphasis on academic achievement seem to be destroying this. You may not realise it yet but your working life will also make it difficult to maintain outside interests. Did you play an instrument? Why have you stopped? Was it lack of time?

There is a conveyor belt now that will take you from your house jobs into a rotation as a medical or surgical senior house officer (SHO). The standard is to do an extra job in your area of interest, some research and then apply for an NTN.

You may be thinking "I don't even know what I want to do, so how can I start planning now?" Here's my advice. Think hard while doing your clinical rotations about what you enjoy and what you could happily do for the next 40 years. It is the only opportunity you will get to experience all the specialties. If you can't decide, think about what you can exclude. Casualty is always a good first SHO job since it gives experience in a broad range of all specialties. At some point though you will have to decide and at that point it may well be worth remembering that you don't have to be right, just as long as you're sure. Pick your specialty and go at it with guns blazing.

Now you may also be asking: "Where does all the travelling and excitement of being a doctor fit in to this pathway?" The answer is to use such "frivolities" to enhance your CV and make you a more interesting person.

The rigid pathway outlined above produces many candidates that are very similar. You want to be different, don't you? Well, use "extracurricular" activities and interesting pursuits to enhance yourself. If you want to do plastic surgery but fancy some time in the Caribbean, doing a little project looking at rates of keloid scars will easily make six months out there look like "research" rather than "holiday." The more experience you have, the more use you'll be.

You can do SHO jobs overseas now that count towards membership of the Royal College of Physicians or the Royal College of Surgeons (although check with the royal college before accepting a job). So if you're in a rush to get up the ladder, you can still make working overseas count.

If you're really stuck for a career pathway, here's another idea suggested by a top London consultant: "Go down the pub, have five pints of beer, not enough to get drunk, just enough to be truly honest with yourself, and write down the five things you must do in your life." Tough stuff, but if "be a consultant in neonatal neurophysiology" is not on there--don't do it. If "work overseas" or "become the prime minister" is, then do that. Alternatively, you could read So you want to be a Brain Surgeon.¹

So don't despair if you don't quite know where you are going. If you do what you want at the time, a pathway will emerge for you.

The most important thing to remember is why you did medicine. It is a fascinating career, but you must remember that you are always being sucked on to a conveyor belt. Fight it if you can. Think big and wide. Medicine is your passport--but you will have to choose to use it.