BMJ  2004;329:1263 (27 November), doi:10.1136/bmj.38247.594769.AE (published 6 October 2004)

Paper

Reasons for considering leaving UK medicine: questionnaire study of junior doctors' comments

¹ UK Medical Careers Research Group, Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford, Oxford OX3 7LF

Abstract

Objectives To study the reasons given by junior doctors trained in the United Kingdom for considering leaving UK medicine.

Design Analysis of replies to postal questionnaire surveys.

Setting United Kingdom.

Participants 1326 doctors who qualified in 1999.

Main outcome measure Reasons for considering leaving.

Results Of 1047 doctors who indicated that they would stay in medicine but not necessarily in the United Kingdom, 65% (682) gave reasons for leaving that concerned lifestyle, such as a preference for living outside the United Kingdom; 41% (433) gave reasons concerning working conditions in UK medicine; and 18% (184) gave positive work related reasons, such as wanting to work in developing countries. Of 279 doctors considering leaving medicine, 75% (210) cited working conditions, 23% (63) cited lifestyle reasons, and 9% (24) cited positive interests in a different career. Of the 169 doctors who said that they would probably or definitely leave the United Kingdom but remain in medicine, 78% (132) specified lifestyle reasons. Of the 42 who said that they would probably or definitely leave medicine, 67% (28) cited working conditions.

Conclusions The wish to work abroad, but to stay in medicine, was more common than the wish to leave medicine. The preference for a different lifestyle, particularly to live outside the United Kingdom, is not readily amenable to policy changes to the medical working environment. The smaller numbers of doctors who gave work experience as a reason for considering leaving medicine might be influenced to stay by improvements in working lives.

Introduction

An increase in the number of doctors working in the NHS in England is a major policy initiative in the NHS Plan.¹ The "improving working lives" programme aims to ensure that everything is done to encourage doctors, once recruited, to remain in the NHS.^{2 3} Although loss of junior doctors from the NHS has been a longstanding concern of policy makers, the loss of young home trained doctors from the UK medical workforce does not seem to have increased during the 1980s and 1990s.⁴ However, in our regular surveys, the proportion of preregistration house officers who have reported their intention to "continue practising medicine in the United Kingdom for the foreseeable future" declined from around 90% in the 1980s to 75% in the 1990s.⁵ In the past, early expressed intentions have been shown to be a reasonable predictor of subsequent career pathways. Whether or not early indications are followed, it is important to understand why some doctors say that they may want to leave. We report a systematic qualitative study, in which we explored the distinction between the factors that would be amenable to policy initiatives to encourage doctors to stay in UK medicine and other factors that are largely beyond the influence of policy.

Methods

We used information from our postal survey of graduates of 1999 from all UK medical schools towards the end of their first postgraduate year.⁶ We recorded and coded all comments by each individual doctor. We coded the two groups separately (those who might leave the United Kingdom and those who might leave medicine).

We used the summary terms "working conditions" and "lifestyle choices" to reflect the main reasons for leaving given by the doctors. Working conditions refers to all aspects of their day to day work as doctors, such as pay, working hours, and job satisfaction. Lifestyle choices concerns other aspects of doctors' lives unrelated to work, such as domestic, family, and personal considerations; travel aspirations; or the desire to live in a location with a better climate or a higher standard of living. This distinction, as reported by the doctors themselves, was clear in most responses. Some doctors made a connection between the two, particularly in comments about long working hours and their impact on social and domestic life. We defined a third broad category, "work related purpose." For doctors considering leaving the United Kingdom, this refers to those who indicated a positive decision to seek specific work experience by working abroad. For doctors considering leaving medicine, it refers to a positive choice to explore other career options and interests. The subcategory "overseas relief/voluntary work" has been included within the main category "lifestyle choices," because the comments made suggested that the motivation for this choice was related more to lifestyle choice than to working conditions in UK medicine.

Results

Overall, 2727 (64.6%) of 4221 doctors replied to our questionnaire. Of these, 1777 (65.2%) did not definitely intend to practise medicine in the United Kingdom. The data for analysis comprised comments from 1326 of these doctors (the rest did not provide comments or provided comments that we were unable to code), of whom 1047 indicated that they were considering leaving the United Kingdom and 279 were considering leaving medicine. Overall, 16.0% (212/1326) reported that they were probably not or definitely not going to continue to practise in the United Kingdom, practise medicine, or both. The table summarises the main reasons given for considering leaving the United Kingdom, medicine, or both. See bmj.com for a more detailed breakdown of the most common reasons and exemplar text extracts of reasons given by doctors for leaving medicine, the United Kingdom, or both.

Doctors who were considering leaving the United Kingdom but staying in medicine
Almost two thirds of doctors considering leaving the United Kingdom gave reasons related to lifestyle choices, two fifths gave reasons associated with UK working conditions, and almost a fifth of respondents commented on a positive work related purpose in leaving the country (table). In the lifestyle responses, the most commonly reported reasons included general comments about seeking a better quality of life, the wish to broaden personal horizons, a wish to do relief work overseas, and the desire to travel. Under working conditions, the most common comments were about poor working conditions in the United Kingdom, perceived low levels of pay, and excessive working hours. Doctors whose reasons were work related intended to broaden their medical experience by spending some time abroad. Respondents who reported that they were probably or definitely going to leave the United Kingdom mentioned lifestyle choices much more often than working conditions (table).

View this table: [in this window] [in a new window]   Summary of the main reasons given for considering leaving the United Kingdom or leaving medicine. Values are numbers (percentages*) of respondents who did not definitely intend to practise in the United Kingdom

 

Doctors who were considering leaving medicine
Three quarters of doctors considering leaving medicine gave reasons related to UK working conditions, about one fifth gave reasons associated with lifestyle choices, and about one twelfth gave a positive work related purpose for wanting a different career (table). The most commonly reported comments about UK working conditions concerned long and unsocial working hours, low levels of pay, and dissatisfaction with working in medicine. Under the heading of lifestyle choices, the most common comments were about quality of life factors; domestic, family, and personal reasons; and the desire to broaden life experiences and travel. Those whose reasons were work related reported that they were considering, or had available to them, other career interests and options. Respondents who reported that they were probably or definitely going to leave medicine also cited UK working conditions much more often than lifestyle choices (table).

Respondents who definitely intended to pursue a career in UK medicine
This study focused on the views of those doctors who did not definitely wish to pursue a career in UK medicine. We did not ask the doctors who were definite about a UK career to give their reasons. All respondents were asked to respond to several attitude statements, however, and we compared the responses of doctors who were definite about a UK career with the responses of those who were not. We thought a priori that these two groups may differ in their views of their career prospects, their career advice, their enjoyment of the preregistration house officer year and the leisure time they had available, and the confidence they had in their current career choice, so we examined the results from attitude statements related to these topics.

Presented with the statement "I am satisfied with my future career prospects," 73.3% (602/821) of those doctors who definitely intended a UK career agreed or strongly agreed, compared with 59.9% (925/1543) of those who were not definite about a UK career (P < 0.001). We found no significant difference between the two groups on the statement "I have been able to obtain useful career advice since graduation," for which the corresponding percentages were 39.5% (323/817) and 35.8% (558/1557) (P = 0.08). Those who were definite about a UK career had a mean score of 7.3 when asked to score the statement "How much have you enjoyed the PRHO year overall?" on a scale from 1 (not enjoyed it at all) to 10 (enjoyed it greatly), compared with a mean score of 6.8 for those not definite (t test, P < 0.001). Those who were definite about a UK career had a mean score of 4.8 when asked to score the statement "How satisfied are you with the amount of time the PRHO year has left you for family, social, and recreational activities?" on a scale from 1 (not at all satisfied) to 10 (extremely satisfied), compared with a mean score of 4.3 for those not definite (t test, P < 0.001).

Discussion

The number of doctors who were considering leaving the United Kingdom, but staying in medicine, was considerably greater than the number considering leaving medicine. This accords with our evidence on what doctors actually do if they leave UK medicine: many more work abroad, but stay in medicine, than leave medicine.^{4 7 8}

Lifestyle choices were more important than working conditions for those doctors considering leaving the United Kingdom. In contrast, those doctors considering leaving medicine were much more likely to cite working conditions as a reason to leave. Overall, nearly one third of the respondents who were considering leaving the United Kingdom, medicine, or both gave reasons solely related to working conditions.

Working hours have been subject to recent government policy initiatives. The reduction of working hours, and changes in working patterns to accommodate this reduction, have been progressing as a result of the "new deal" and the European Working Time Directive.^{9 10} Compliance with targets on reduced working hours has improved nationally: from 61.6% in 2000 to 79.0% in 2003.^{11 12} This suggests that very long and unsocial working hours should soon no longer be a fundamental feature of UK postgraduate medical training. However, problems remain in fully complying with working hours regulations within the timeframe required. In addition, the reforms to training at senior house officer level, and the need to ensure that there are enough doctors at all grades to provide 24 hour cover,¹³ probably means that problems related to working hours and their unsocial effect will continue for some time. Concern also exists about whether the reduction in working hours will reduce doctors' opportunities to gain enough experience to become adequately trained.¹³ Current policy documents make it clear that the Department of Health and the NHS are attempting to tackle adverse working conditions.^{2 3 10} If the benefits of the recent large increase in the numbers of UK medical students are to be fully realised in the NHS, measures must be taken to minimise avoidable attrition.

What is already known on this topic The loss of UK trained junior doctors to work overseas has been a longstanding concern of policy makers The reasons why some UK trained doctors wish to leave the United Kingdom or the NHS, or to leave medicine altogether, have not been explored systematically among recent graduates What this study adds Of the junior doctors who may leave UK medicine (almost half of those studied), the wish to work in medicine abroad is much more common than the wish to leave the profession Two thirds of doctors wanting to work in medicine abroad gave personal lifestyle reasons, whereas those wanting to leave medicine altogether mainly gave reasons related to UK working conditions Changes of policy to tackle adverse working conditions and to improve working lives are important in minimising avoidable attrition from the UK medical workforce

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This is the abridged version of an article that was posted on bmj.com on 6 October 2004: http://bmj.com/cgi/doi/10.1136/bmj.38247.594769.AE

We thank all the doctors who participated in the survey. We also thank Karen Hollick for administering the surveys and Janet Justice and Alison Stockford for data preparation.

Contributors: See bmj.com

Funding: The UK Medical Careers Research Group and the Unit of Health-Care Epidemiology are funded by the Department of Health.

Competing interests: None declared.

Ethical approval: The design and content of the surveys has been overseen by an external advisory group, convened by the Department of Health, including representation from postgraduate medical deans and the British Medical Association.

References

1. Department of Health. The NHS plan: a plan for investment, a plan for reform. London: Department of Health, 2000.
2. Department of Health. Investment and reform for NHS staff—taking forward the NHS plan. Department of Health. London, 2001.
3. Department of Health. Delivering the NHS plan: next steps on investment, next steps on reform. Norwich: Stationery Office, 2002.
4. Goldacre MJ, Lambert TW, Davidson JM. Loss of British-trained doctors from the medical workforce in Great Britain. Med Educ 2001;35: 337-44.[Medline]
5. Lambert TW, Goldacre MJ, Parkhouse J. Intentions of newly qualified doctors to practise in the United Kingdom. BMJ 1997;314: 1591-2.[Free Full Text]
6. Lambert TW, Goldacre MJ, Turner G. Career choices of United Kingdom medical graduates of 1999 and 2000: questionnaire surveys. BMJ 2002:326: 194-5[Free Full Text]
7. Lambert TW, Goldacre MJ. Career destinations seven years on among doctors who qualified in the United Kingdom in 1988: postal questionnaire survey. BMJ 1998;317: 1429-31.[Abstract/Free Full Text]
8. Davidson JM, Lambert TW, Goldacre MJ. Career pathways and destinations 18 years on among doctors who qualified in the United Kingdom in 1977: postal questionnaire survey. BMJ 1998;317: 1425-8.[Abstract/Free Full Text]
9. NHS Management Executive. Junior doctors: the new deal. London: Department of Health, 1991.
10. Department of Health. Guidance on working patterns for junior doctors, Nov 2002. www.dh.gov.uk/assetRoot/04/06/63/66/04066366.pdf (accessed 28 Sep 2004).
11. Department of Health. Junior doctors' contract compliance rates: summary 2000. www.dh.gov.uk/assetRoot/04/03/46/16/04034616.pdf (accessed 28 Sep 2004).
12. Department of Health. Junior doctors' contract compliance rates: summary 2003. www.dh.gov.uk/assetRoot/04/03/45/17/04034517.pdf (accessed 28 Sep 2004).
13. Royal College of Physicians. The further implementation of the European Working Time Directive to cover junior doctors in training. London: Royal College of Physicians, 2003.

(Accepted 6 September 2004)

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