Careers

Contents:

1. Specialising in Infectious Disease
2. Masters in Tropical Medicine

1. Specialising in Infectious Disease

A career in infectious diseases

Authors: Yasmin Akram

Publication date: 30 Jul 2008

http://careers.bmj.com/careers/advice/view-article.html?id=3029

Sunshine, surf, and the occasional clinic under the shade of a palm tree—is this the image of infectious diseases? The reality is much better, according to Stephen Morris-Jones, consultant in infection at University College London Hospital. “There are few other branches of medicine that so completely represent a microcosm of medicine within medicine,” he says, “after all, infections occur across all ages and disciplines of medicine.” This is echoed by Victoria Johnston, a third year specialist registrar in infectious diseases and tropical medicine on the North Thames rotation, working at the Hospital for Tropical Diseases in London. “Every day we liaise with several other specialties—I have never worked in a job that required so much knowledge of, and links with, other branches of medicine.” Add to this the possibilities of travel associated and tropical exposures and the diagnostic detective work becomes a real challenge of clinical ability, according to Anand Sivaramakrishnan, six months into a senior house officer post in tropical medicine at University College London Hospital. “At the moment, for me, every case is a fascinoma.” For Vicky, one of the attractions of the specialty is that “infections can make previously healthy people incredibly unwell incredibly quickly, and experience and fast action really does save lives and get them back to where they were.”

Bedside to laboratory and back again

The need to chase relevant possible infectious exposures, whether occupational or recreational, means that one must have a real interest in patient lifestyles or, as Vicky puts it, “what makes someone tick.” And for some, another exciting part of the clue-hunt is the close link with the laboratory. As Stephen Morris-Jones says, “I love the bedside to laboratory and back again aspect: knowing how, as well as what, to look for is part of the expertise.” Like all specialties there is a constant evolution of diagnostic and therapeutic improvements, but the added dimension is that there are new pathogens emerging (and old ones re-emerging) so that, as Vicky says, one never knows “what’s around the corner—just look at HIV and SARS [severe acute respiratory syndrome].”

Global problem

But a common theme that all three doctors mention is the enormous global impact of infection—for many countries infectious diseases still impose the greatest burden of mortality and morbidity even though cure or prevention is often possible. Increasing population movements mean that migrant and travel health are a growing problem in the United Kingdom, and one where infection specialists have an important part to play.

Training issues

Historically, infection specialists have tended to focus on community acquired infections, and microbiologists more on the hospital acquired ones. As there is, however, an ever increasing need across all specialties for more consultations on healthcare associated infections and an understanding of antimicrobial resistance patterns, many feel that this division is false. “I think that there will be, and needs to be, a blurring of these roles to some extent, and I hope that this will be reflected in changes to training,” says Stephen Morris-Jones. Currently, infectious disease training begins at specialty training 3 and constitutes a minimum of four years’ further specialisation after core medical training. Apart from those locations able to provide joint infectious diseases and medical microbiology training, he says the changes that have come about as a result of Modernising Medical Careers are “shoe horning” medical microbiology into taking specialty training 1 directly from foundation year 2. “Personally, I can hardly think of a better way to create a communication gulf between the clinician and the laboratory. Fortunately, there is a move towards providing a common infection training stem after core medical training that can then be followed by subspecialty selection.”

Pros and cons

Paradoxically, one of the greatest attractions of the specialty is also a potential weakness, according to Vicky Johnston (box 1). Specialists may end up in a huge variety of careers—from general internists with an interest in infectious diseases, to specialists in clinical tropical medicine, travellers’ health, public health, or epidemiology; links with aid agencies are strong as are those with academic and laboratory medicine. Outside clinical diagnosis, laboratory links have always existed between infection and immunology and pharmacology. Experience abroad, whether clinical or academic, is recognised as beneficial, although may become increasingly difficult to accommodate in the new Modernising Medical Careers structure. But, as Anand says, this huge breadth of career options can itself be bewildering, and a structured career path is therefore not always clear. Yet this very flexibility of training is itself stimulating as it forces the career decision onto the trainee, thinks Vicky. “So, where do I want to be in five years’ time? Tomorrow is hard enough,” she jokes.

Box 1: Advantages and disadvantages of working in infectious diseases

Advantages

• Broad specialty—Covers all organ systems and has links to all specialties
• In a position to help—Most conditions are curable or at least controllable
• Experience abroad—Many opportunities for exciting and interesting work in different settings overseas
• Strong academic links—Many specialists combine clinical and academic work to suit their interests
• Globally important—There will always be a need for infection specialists; individual “impact” may vary according to setting, but a huge variety of infection related careers available

Disadvantages

• Career structure—This is not as formalised as in other specialties, but perhaps allows for greater individualisation
• Uncertainty about future employment—This will depend upon the subspecialty area selected
• Dividing life between the UK and abroad—This may be disruptive to partners’ careers or family education, and requires careful planning

Typical week

Vicky Johnston says that her weeks are divided between ward work and clinics. She works in a large dedicated infection unit with between 20 and 35 inpatients shared between two teams for general infectious and tropical diseases. In addition to the usual ward work and ward rounds, there are regular referrals meetings, x ray sessions, grand rounds, case review meetings, and research meetings. As well as the ward patient follow-up clinics, there are a variety of subspecialty clinics—leprosy, tropical parasitology, general tropical diseases, travel medicine, and leishmaniasis. A walk-in clinic is available without general practitioner referral for patients recently returned from tropical areas. The commonest problems include diarrhoea, fever, or rashes, and patients are seen and managed by the senior house officer and specialist registrar. Dedicated time off is available for research and reading, audit, and evidence based medicine reviews.

Under the current system, on calls are one in eight non-resident and provide cover for infectious diseases, tropical medicine, and HIV, but other systems are operated in other hospitals.

What attributes do you need?

“A non-judgmental attitude certainly helps, because for sure your ideas of medical health care will be challenged by patients with very different perceptions along the way,” says Vicky. “Enthusiasm, enthusiasm, enthusiasm—I can’t think of a single colleague who isn’t an out and out enthusiast,” adds Stephen.

And why do it?

“An endless supply of maggot and worm stories?” says Vicky. “What made me think of doing infectious diseases? Three reasons: an eye opening elective spent in Bhutan; the fact that the infectious diseases consultant who taught on my MRCP course was the only one to turn up in a rollneck sweater and not in a double fronted pinstripe suit; and my first experience as a senior house officer in infectious diseases walking onto the ward and seeing an enormous wall mounted map of the world.” And why should you do it? “Well, I try to think of myself as open minded, but deep down I really still can’t quite understand why anyone would not want to,” says Stephen.

Box 2: Additional information

• Joint Royal College of Physicians Training Board—http://www.jrcptb.org.uk/Specialty/Pages/InfectiousDiseasesandTropicalMedicine.aspx
• Royal College of Physicians—http://www.rcplondon.ac.uk/specialties/Infectious-Diseases/Pages/Infectious-Diseases.aspx
• Royal College of Pathologists—http://www.rcpath.org
• British Infection Society—http://www.britishinfectionsociety.org
• Training in Infection—http://www.trainingininfection.org.uk

2. Masters in Tropical Medicine

Tropical medicine is the branch of medicine that deals with health problems that occur uniquely, are more widespread, or prove more difficult to control in tropical and subtropical regions.

Many infections that are classified as “tropical diseases” used to be endemic in countries located in temperate or even cold areas. That was the case for leprosy, cholera, malaria, polio, measles, hookworminfestations, amoebiasis, among others. A Tropical doctor is a medical doctor who finished the Tropical Medicine Training. The setup of this training differs from country to country.

The training in Tropical Medicine is quite different between countries.

Here in the UK training in tropical medicine comes in the form of a Masters (MSc). Students interested must first complete their medical degree followed by at least 2 years of clinical employment before being eligible to enroll. Specialising in Infectious Disease (ID), which is highly competative with relatively few positions in some parts of the country, is not necessary – a Masters in tropical medicine simply supplements your medical degree.

There are two schools in the UK that offers training in tropical Medicine, the London School of Hygiene & Tropical Medicine and the Liverpool School of Tropical Medicine. The London School of Hygiene & Tropical Medicine offers an MSc Tropical Medicine & International Health and the Liverpool School of Tropical Medicine an MSc in Tropical and Infectious Diseases. Both courses last one year and develop the careers of doctors whose interest is the practice of medicine in tropical and developing countries and global health.

LSH&TM’s MSc Outline:

“The MTID has emphasis on the diagnosis, management and control of the most prevalent diseases in developing countries. This is an exciting programme that will provide you with new insights into working in a very challenging but rewarding area of medicine. Alumni from this programme have become well established clinicians, pursued international careers (eg WHO and MSF) or have become leading researchers in their field. The programme (previously called the Masters in Tropical Medicine) has particular reference to high burden diseases such as tuberculosis, HIV, malaria, respiratory infections and diarrhoea. Emphasis is also given to the development of research skills applicable to a wide range of problems in clinical and epidemiological settings and participants complete a short project overseas. The study location depends on the nature of the project and the participant’s interest. Recent locations have included Brazil, Ethiopia, Yemen, Nepal and Nigeria, among others.” http://www.lshtm.ac.uk/prospectus/masters/mstmih.html

LSTM’s MSc Outline:

“The MTID has emphasis on the diagnosis, management and control of the most prevalent diseases in developing countries. This is an exciting programme that will provide you with new insights into working in a very challenging but rewarding area of medicine. Alumni from this programme have become well established clinicians, pursued international careers (eg WHO and MSF) or have become leading researchers in their field. The programme (previously called the Masters in Tropical Medicine) has particular reference to high burden diseases such as tuberculosis, HIV, malaria, respiratory infections and diarrhoea. Emphasis is also given to the development of research skills applicable to a wide range of problems in clinical and epidemiological settings and participants complete a short project overseas. The study location depends on the nature of the project and the participant’s interest. Recent locations have included Brazil, Ethiopia, Yemen, Nepal and Nigeria, among others.” http://www.liv.ac.uk/lstm/learning_teaching/masters/MTropID/index.htm

Why get the MSc?

If you are interested in working temporarily or permanently in the tropical world, a good understanding of tropical medicine is not only hugely beneficial but often stated as a necessity in working for various health care organisations. Although volunteer organisations such as MSF and Médecins du Monde do not require that applicants have formal training in tropical medicine, having the MSc can greatly increase your chances of selection for certain programmes and open up many more opportunities for working critical posts in the tropical, developing world.

Not only this but tropical medicine represents a highly active area of research in modern medicine. Huge amounts of time and money go into researching new diagnostic tools for tropical diseases and new, cost-effective treatments to combat them. Research is important to any clinical doctor hoping to build their CV and career and an MSc in Tropical Medicine can open the door onto a new portfolio of diseases for study.

Finally, for those interested in later pursuing careers in international health such as within World Health Organisation, a MSc in Tropical Medicine is often stated as a requirement for all applicants being that the developing, tropical world relies so heavily on international health organisations to assist in combating these terrible diseases.