How to Pick a Subspecialty

The question of how to choose a subspecialty is an anxiety that has insidiously been creeping into the periphery of my consciousness over the past few months. I am now midway through my ST5 training year, and thoroughly comfortable with my identity as a surgical registrar. Unfortunately, my levels of self-regard have clearly not yet reached sufficiently lofty levels, and I am still utterly unable to imagine myself as a consultant. I am therefore at rather a loss as to how to answer my TPD’s recent enquiries as to my thoughts regarding a subspecialty, and have ignominiously left that particular e-mail unanswered for an unacceptably long time.

But this is a big decision! Training feels preposterously long and arduous; but is actually only a trivial 8 years compared to potentially 30 to 40 years of sub-specialist consultant practice! Nonetheless, before the end of training, a declaration must be made as to which of the five sub-specialties is preferred; the major sub-specialties being Breast, Colorectal, Upper GI, Transplant and Hepatobiliary. Additionally, a few minor sub-sub-specialties also exist, including Endocrine, General Surgery of Childhood, Advanced Trauma and Remote and Rural Surgery. Annoyingly, my current wavering leanings are towards Emergency General Surgery (EGS), also know in other parts of the world as Acute Care Surgery; a sub-specialty that is not even a recognised sub-specialty in the UK yet!

This predilection towards EGS is motivated by a number of considerations. Superficially, it may just be the word ‘emergency’ - I do utterly love a juicy emergency laparotomy! If you see me scuttling excitedly along a hospital corridor with a glint of glee sparkling in my eye, it’s likely that I’ve heard rumour of an abdomen afflicted by perforation, strangulation, bleed, obstruction or infarction. Additionally, it is a new and evolving sub-specialty, and therefore there is arguably more scope to drive innovation, process and improvement in how departments are run than in the established specialties. Despite occasionally being little more than an after-thought for many specialty consultants, emergency patients represent the largest number of patients presenting to General Surgery. In addition they have the highest morbidity and mortality, which I feel entitles this group to a little more attention and planning than the current ad-hoc arrangements in most UK hospitals.

Lastly, whilst many of my colleagues frequently voice how much they detest being the bearer of the on-call bleep, in general I really look forward to my on-call blocks. Sure, there are times when it is so busy that there isn’t time to have even a slurp of tea or use the bathroom, and other shifts where you leave the hospital 12 hours after you should have finished. But it is also utterly unpredictable and diverse, frequently mad, sometimes heart-wrenchingly sad, sometimes upliftingly joyful, usually frustrating and always challenging. Whilst I have never got a dinner-table anecdote from a colorectal clinic, my long-suffering friends and family frequently suffer tales of the blood, pus, poo and inexplicably lost objects in the orifices of emergency patients.

So how on earth do people choose a sub-specialty? How have you tailored your CV and engineered relevant experience and competence for your chosen area of interest during your surgical training?