“What do you plan to specialise in?” asked the pinstripe-suited consultant general surgeon to his gaggle of medical students.
“I’m really interested in surgery.”
These, of course, are the correct answers. His gaze turned to my student self, eyes expectant:
“Dermatology.” He simply let out a snort, shook his head and proceeded to ignore me for the remainder of the placement. I looked at one of my turncoat student colleagues and asked Zara, “Since when did you want to be surgeon?!” She brushed off the question…
Rocket scientist, brain surgeon…dermatologist?
For better or worse, there are certain stereotypes of a dermatologist. While I don’t wish to tar surgeons with too broad a brush, I certainly didn’t encounter many surgical folk who were impressed by my choice of specialty. There is a fairly established pecking order within the hospital: transplant surgeon, cardiothoracic surgeon, plastic surgeon, surgeon of X, Y, Z. On the second tier, sit the internal medicine specialties. Somewhere around the bottom, sit the dermatologists. Derided by many, we are often called when a patient has an odd rash or a red, hot leg that just won’t respond to antibiotics. While we can provide assistance in complex inpatient cases, your medical colleagues are not going to bow in your presence just because you’re a dermatologist. If you want to induce deferential awe everywhere your cape trails, consider becoming a superhero or an organised crime boss. Dermatology may not be the one for you.
In my previous post, I alluded to the competitive nature of medics (which I have no particular problem with) however there is also a tendency to do down those from a different tribe (e.g. the archetypal matchups – surgeon vs medic; hospital consultant vs general practitioner). In the reflexive defence of our own gang, we can lose sight of the ultimate goal: to provide the quality of clinical care that we would expect for our own parents or children. The folly of the arbitrary divisions we create for ourselves knows no bounds. Where will it stop? London versus the rest of the country? New hospitals versus old hospitals? I want to discuss with you which is better – teaching hospital or district general hospital (DGH)?
While there may previously have been clear definitions of both of these terms, there is considerable overlap in their current usage. My understanding of the teaching hospital is that it is central to the teaching of a university and has established research interests. They are usually larger than DGHs and have a greater research output. There is often a special focus on rare diseases and there may be specialist tertiary clinics.
Which is better?
This is not to say that teaching hospitals are superior to DGHs however. Case-in-point, the broad exposure that trainees can gain in a generalist hospital can be invaluable experience. You’re far more likely to be able to perform practical skills such as a lumbar puncture or chest drain in a DGH as compared to a teaching hospital. This is because there aren’t the same huge number of juniors clamouring for the next procedure. Anecdotally, there are many (including myself) who argue that DGHs are friendlier than teaching hospitals. This can make life easier when you’re a junior. If you’ve been on-call with the respiratory registrar on a weekend, and you subsequently need their help with a deteriorating patient, it’s a lot easier to pick up the phone to speak with someone you already know.
In a smaller setting, most of your colleagues (nurses, fellow juniors and consultants) will likely know you by name. Additionally, the notion that DGHs are backward or not as involved in research is quickly becoming outmoded. Illustrating this, the dermatology department at Kingston Hospital is one of the most active departments in the UK and are involved in far more clinical trials than many larger teaching hospitals combined.
There’s no right or wrong – and you’ll likely get exposed to both sorts of hospitals both as undergraduates and also as postgraduates. Your experiences will help mould the future life (and consultant post) you choose.
I had the opportunity to work in large centres earlier on in training but quickly realised that I much prefer DGH settings. I can remember being a medical FY1 in the Scottish Borders looking after patients with head injuries and having ABSOLUTELY-NO-BLEEPING-CLUE what I was doing. When put in the heat of the moment (without readily available senior support), you quickly learn to make management decisions.
Having escaped the Borders with my GMC licence intact, I still work in a DGH setting. Regardless of this, I can get my academic kicks from looking down a microscope and yet avoid the trappings of the teaching hospital. Not to generalise, but I’d rather not play pseudo-intellectual games to show people how clever I am. (Disclaimer: some of the nicest consultants I worked for were within teaching hospitals…)
Teaching hospital – pros
- Wide range of cases coming through the front door which broadens trainee experience
- Ability to rotate in niche areas – in dermatology, this could mean advanced dermatological surgery
- Generally, ample opportunities to get involved in research
Teaching hospital – cons
- Teaching hospitals are usually in larger cities which can drive up living costs
- It may be difficult to get practical experience due to the number of trainees.
- You may be a somewhat anonymous fish in a large pond.
District general hospital – pros
- Friendlier (and possibly smaller egos!)
- Ability to get hands on experience due to smaller numbers of trainees
- Smaller hospitals and their systems can be easier to understand and navigate.
District general hospital – cons
- It may be difficult to get into tertiary clinics
- There may be little opportunity for socialising
- If you don’t have a car, you may feel a bit stuck due to the locations of many DGHs.