Introduction

Top Abstract Introduction Method Results Discussion References

No large scale prospective national studies in the United Kingdom have followed doctors from qualification to mid-career and beyond. We summarise the career pathways of the cohort of doctors who qualified in the United Kingdom in 1977 up to September 1995, when the great majority of its members were in posts in permanent career grades.

	Method

Top Abstract Introduction Method Results Discussion References

The methods have been described in detail elsewhere.¹ The cohort was previously studied 1, 3, 5, 7, and 9 years after qualifying.² The population used for this survey comprised all medical qualifiers from all medical schools in the United Kingdom in 1977. Each doctor was sent a postal questionnaire together with a covering letter in November 1995, with up to three follow up mailings to non-respondents between February and June 1996. We analysed the data taking 30 September 1995 as the standard point in time for our respondents. The questionnaire requested current demographic information, employment details dating back to the time of the most recent information held by us for each doctor, and future career intentions (including any plans for early retirement).

In addition to our own survey data, we had information from the Department of Health's statistical records of doctors in NHS employment on 30 September 1995 in Great Britainthat is, the United Kingdom excluding Northern Ireland. Capture-recapture analysis ^{3 4} was used to estimate the total number of doctors who qualified in 1977 and who were working in the NHS in Great Britain in September 1995. Fourteen specialty groups were defined. We compared respondents' choice of specialty group at 1, 3, and 5 years after qualifying with the specialty group in which they were employed in September 1995. In analysis of part time and full time working, doctors in hospital practice who held "maximum part time" contracts were deemed to be full time. Linear regression was used to analyse time trends in the percentages of respondents in different employment sectors.

	Results

Top Abstract Introduction Method Results Discussion References

Response rates and employment status
Of the 3135 doctors who qualified in 1977, 21 were known to have died by the time of the survey and 16 did not want to participate; no current address could be found for a further 29. This left 3069 doctors (2068 men). The response rate was 78.1% (2398/3069). As in previous surveys,⁵ a higher percentage of women than men responded (83.1% and 75.7% respectively; ²=21.4, P<0.001).

Specialties and grades of doctors in medical employment
Table 3 presents numbers of doctors within the 14 specialty groups who were in medical employment in the United Kingdom or abroad in September 1995. Among respondents working in medicine in the United Kingdom, similar percentages of men and women were working in general practice (²=1.5, P=0.22). A significantly higher percentage of men than women were in the surgical specialties, and significantly more women than men were in psychiatry and community health (P<0.05 with the ² test). Of those working in the NHS in general practice, 97.9% (592/605) of men and 83.8% (280/334) of women were principals. Of those in NHS hospital practice, 96.2% (611/635) of men and 64.5% (171/265) of women were consultants. Overall, 97.0% of men and 75.3% of women working as general practitioners or hospital doctors in the NHS in the United Kingdom were of principal or consultant status (²=210.7, P<0.001).

Year by year changes
The figure shows the annual percentages of men and women respondents working in each employment sector. The proportions of men and women working in substantive NHS posts gradually decreased until about eight years after graduation; for men the proportion working in university posts increased during this period. Subsequently, for men, the proportion working in NHS posts increased and the proportion in university posts gradually decreased. For women, the reduction in the percentage working in the NHS during the first eight years after graduation reflects the increase in those who were not in paid employment or who worked in non-medical jobs during their child rearing years. About 3.5% of women were not in paid employment (or worked in non-medical jobs) in each year from year 10 onwards; almost half of women were in this category for the whole of this period. The number of men in this category was negligible. The proportion of men working in the United Kingdom in medical jobs outside the NHS and universities is higher than that of women because the doctors working in the armed forces are almost all men.

Full time and part time working
By 12 years after qualification, many of the women who had taken a break to raise a family had resumed their careers (fig 1), but 48.5% (318/656) of women NHS doctors were working part time (41.9% (106/253) of women hospital doctors, 51.2% (168/328) of women general practitioners). In 1995 (18 years after qualification), the corresponding percentages for doctors working part time were almost unchanged (48.4%, 42.8%, and 52.3% respectively). However, only 21.8% (37/170) of hospital consultant posts held by women were part time, compared with 43.7% (122/279) of general practitioner principal posts. Eleven out of 12 associate specialists and 32 out of 33 clinical assistants were working part time. The percentage of men in the NHS working part time was very small: 5% of those in general practice and 3% of those in hospital practice in 1995. The average number of hours worked per week quoted by women working part time in the NHS was 20 hours (17.7 hours for hospital practice and 20.5 hours for general practice). At this time, 92.7% of women hospital doctors who were working part time and 96.3% of women general practitioners who were doing so had children, compared with 59.2% of full time women hospital doctors and 76.5% of full time women general practitioners.

View larger version (40K): [in this window] [in a new window]   Annual percentages of men and women respondents working in five employment sectors. Sample sizes vary from 1397 to 1895 (men) and from 737 to 948 (women)

Marital status and adult dependants
Of 1947 respondents working in the NHS in the United Kingdom in 1995 (table 1), 1810 told us their marital status: 91.7% (1659) were living with a spouse or partner (men 95.1%, women 85.3%, ²=53.1, P<0.001).

Current employment and early career intentions
Overall, 2367/2398 respondents had replied to at least one previous survey. Of these, 1548 doctors (1047 men) currently in medical employment had previously supplied career choices at 1, 3, and 5 years after qualification. We compared their choices in each of these years with their current employment (table 4). As with the 1983 qualifiers,⁶ the relation between early career choice and eventual destination varied considerably between the specialties. The high level of concordance of early choices and eventual destination is particularly striking for surgery. Of the 193 doctors working in the hospital medical specialties in 1995 (table 4), 49 had expressed a year 5 choice for other careers. Most of these had specified general practice as their long term choice in year 5. 

Factors influencing career choice
As in previous studies,⁵ respondents were asked to indicate which of a range of specified factors had influenced their choice of career a great deal, a little, or not at all. In all, 2171 respondents (1403 men, 768 women) provided information about at least one factor. The factors that were scored as having the greatest influence by both men and women were appraisal of their own skills and aptitudes (70.2% (985/1403) of men and 67.9% (521/768) of women) and enthusiasm for or commitment to the specialty (62.3% (874) and 62.2% (478) respectively). Other factors considered by women to have influenced choice of career a great deal were domestic circumstances (56.3% (432) of women v 32.1% (451) of men respectively; ²=119.5, P<0.001) and hours and working conditions (56.3% (432) v 33.5% (470) respectively; ²=105.8, P<0.001). Experience of jobs in training was the next highest influential factor: 47.5% (666) of men and 42.2% (324) of women said that it influenced their choice a great deal.

Intention to work until normal retirement age
Altogether, 1714/1947 of doctors who worked in the NHS answered our question, "do you intend to practise in the NHS until normal retirement age?" In all, 22.9% (392) of these respondents answered "no" (table 5). Proportionately more women than men in hospital practice definitely or probably intended to continue working in the NHS until normal retirement age (70.6% of women, 61.7% of men; ²=5.4, P=0.02). In general practice there was no significant difference between women and men (63.5% v 68.9% respectively; ²= 2.3, P=0.11).

	Discussion

Top Abstract Introduction Method Results Discussion References

This survey was undertaken about 10 years after the previous study of this group of doctors. They are now in their mid-40s, and the great majority are in career positions. Those in senior hospital posts are involved in implementing the Calman changes to postgraduate medical training.⁷ Those in general practice have worked through major changes to general practitioners' contracts and have worked through fundholding.

The reforms to specialist training in the United Kingdom will promote shorter periods of specialist training and may be advantageous to doctors who make definite career choices early. This survey shows that most of the 1977 qualifiers made their choice of eventual career fairly soon after qualification, but a noteworthy minority did not. More women than men were influenced in their choice of career by factors relating to home and lifestyle.

The percentages of doctors working in different employment sectors became stable in this cohort about 12 years after qualifying. The main trends up to this time were, for men, a shift into university employment in the early years followed by a return to substantive NHS employment; and for women, an increase in those not in paid employment followed by a return to medicine.

We estimated that participation in the NHS among these doctors in 1995, including those with honorary NHS contracts, was 80% (table 2), with little difference between men and women. However, almost 50% of women had settled into a pattern of part time working by 12 years after qualification. This had not changed subsequently. The self reported hours worked by women in part time jobs averaged 20 hours a week. Assuming this is about half of the whole time equivalent and given that 33% of the cohort were women, the loss of the whole time equivalent workforce attributable to women's part time work was about 8%. The attributable loss from this cohort is smaller than it will be in more recent cohorts, in which the proportion of women in medicine is much higher.

We asked the doctors currently in the NHS about their intention to remain in the NHS until normal retirement age. The phrase "normal retirement age" may be interpreted differently in different sectors of the NHS, and differently by men and women in the light of recent European directives. Nevertheless, the results show that almost a quarter of these doctors expressed an intention to retire before they are required to do so. An investigation of intentions to retire early, doctors' plans to support early retirement, reasons for wanting early retirement, and factors that would influence doctors to stay, would be valuable.

	Acknowledgments

We thank Carol Edwards for her work during the early stages of this study, Janet Justice and Alison Stockford for their careful data entry, Karen Hollick for her administration of the survey, and all the doctors who have participated in the study. James Parkhouse directed the earlier surveys of this cohort.

Contributors: TWL and MJG contributed to the design of the survey. TWL coordinated the survey and provided statistical advice. JMD analysed the data and wrote the first draft. All the authors contributed to further drafts, and all act as guarantors for the paper.

Funding: The UK Medical Careers Research Group is funded by the Department of Health. The Unit of Health Care Epidemiology is funded by the Anglia and Oxford Regional Office of the NHS Executive.

Competing interests: None declared.

	References

Top Abstract Introduction Method Results Discussion References

1. Parkhouse J. Doctors' careers: aims and experiences of medical graduates. London: Routledge , 1991.
2. Parkhouse J, Ellin DJ. Reasons for doctors' career choice and change of choice. BMJ 1988; 296: 1651-1653.
3. Hook EB, Regal RR. The value of capture-recapture methods even for apparent exhaustive surveys. Am J Epidemiol 1992; 135: 1060-1067[Abstract/Free Full Text].
4. 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: 1429-1431[Abstract/Free Full Text].
5. Lambert TW, Goldacre MJ, Parkhouse J, Edwards C. Career destinations in 1994 of United Kingdom medical graduates of 1983: results of a questionnaire survey. BMJ 1996; 312: 893-897[Free Full Text].
6. Edwards C, Lambert TW, Goldacre MJ, Parkhouse J. Early medical career choices and eventual careers. Medical Education 1997; 31: 237-242[Medline].
7. Department of Health. Hospital doctors: training for the future. In: London: HMSO , 1993.