Career choices in 21st-century healthcare: Aiming for a moving target

Modernising Medical Careers (MMC) has introduced a training pathway in which surgical trainees are required to commit to their desired specialties at an increasingly early stage.1 For many this is a frightening prospect. Medical students and junior doctors are, however, offered reassurance in the form of common ST1 and ST2 stems for higher sub-specialty training. Against this background, early decisions need only concern fundamental choices between careers in medicine, surgery or general practice. Whilst it is true that some trainees may select their prospective careers by the nature of the job, with preferences towards medical or surgical lifestyles; many will be drawn towards their career by an affinity, not towards the job per se but rather towards the treatment of a particular disease process or group of patients. Previously medics have been able to make the informed decisions necessary before dedicating their lives to a given specialty. With recent advances in technology, many specialties have been the subject of ‘turf wars’; in particular, many surgical operations have been threatened by equally effective minimally invasive procedures. This competition has resulted in a haze of uncertainty over the direction of many specialties, jeopardising accurate choices by applicants. The innovations of Charles Dotter, widely considered the father of interventional radiology, set in motion an endovascular revolution that has transformed the treatment of peripheral vascular disease. Predictions that endovascular techniques will constitute 60–90% of vascular procedures in the future,2 have resulted in competition between vascular surgeons and interventional radiologists, which threatens to become a destructive force for vascular surgery and ultimately patients. Percutaneous revascularisation of the renal arteries, for example, has almost entirely replaced open surgical management of patients with atherosclerotic renovascular disease (ARVD).3 The management of ischaemic heart disease has faced similar uncertainty. Cardiothoracic surgeons were traditionally the guardians of the coronary arteries, bypassing diseased coronary arteries and inserting grafts. When patients were offered the alternative of angioplasty, a procedure thought to be equally effective but significantly less invasive, the cardiologists took ownership of these vessels. The debate regarding the best treatment of ischaemic heart disease is ongoing. Recent trial data suggesting higher re-stenosis