Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Obstetrics in the dark, gynae down the tubes.
- Bruce Lennox (24 January 2003)
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Initial career aspirations are not a good indicator of career destinations
- Lorelei A Cooke (29 January 2003)
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Medical career choices - lessons for undergraduate training
- Cornelius L.E. Katona, Rachel Maidment, Gill Livingston, Margaux Katona and Ella Whitaker (31 January 2003)
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Non-Training Posts for Training Doctors
- Nicholas Finer (3 February 2003)
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Re: Initial career aspirations are not a good indicator of career destinations
- Trevor W Lambert, Michael Goldacre, Gill Turner (11 February 2003)
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Managing acutley ill patients is often inadequately covered during medical student training
- Sandy Thomson (17 May 2003)
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Bruce Lennox, Retired GP Oban, Scotland. PA345TN
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Lambert's review of career preference shows numbers choosing obstetrics and gynaecology are the lowest ever recorded. He suggests the information will be useful for planners. But how can they deliver if there is no light at the end of the tunnel? Competing interests: None declared |
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Lorelei A Cooke, Research Officer BMA House, Tavistock Square, London WC1H9JP
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Lambert et al1 present the career choices of UK medical graduates for 1999 and 2000. This information ‘will help planners to anticipate whether future service requirements in different specialties will be met from United Kingdom sources’. The BMA cohort study is a longitudinal study that tracks the careers of 500 doctors who graduated in 1995. The methodology has been described elsewhere2. The study found substantial change in choice of career in the years following graduation. Seven years after graduating only 36% (179/496) of doctors had entered their initial choice of career. The main reasons for changing career direction were ‘hours of work and working conditions’ and ‘domestic circumstances’. ‘Career and promotion prospects’ specifically ‘competition for national training numbers’ were also important3. The table below shows the career choices of the cohort in 2001 compared to graduation. The most significant trend was for women to change from hospital medicine to general practice. The proportion of women choosing general practice rose from 23% (63/276) at graduation to 44% (110/251) seven years later. In comparison the proportion of women choosing medicine dropped from 20% (55/276) to 9% (22/251). The proportion choosing surgery decreased from 9% (25/276) to 4% (11/251). While this may appear to be good news for planners concerned with recruitment to general practice, it should be noted that of those doctors who have chosen general practice 81% (137/169) are either currently working part-time or plan to work part-time in the future. The increase in trainees choosing general practice over hospital medicine appears, amongst other things, to be because the secondary care sector has failed to adopt sufficient family-friendly measures. It is of concern that trainees with aptitude for specialist practice are lost to primary care because of this failure.
1 Lambert TW, Goldacre MJ, Turner G. Career choices of medical graduates of 1999 and 2000: questionnaire surveys. BMJ 2003;326:194-5. 2 Cooke L, Hurlock S. Education and training in the senior house officer grade: results from a cohort study of United Kingdom medical graduates. Medical Education 1999;33:418-423. 3 Health Policy and Economic Research Unit. BMA Cohort Study of 1995 Medical Graduates. Seventh Report. London:BMA;2002.
Competing interests: The research is funded by the BMA |
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Cornelius L.E. Katona, Dean, Kent Institut eof Medicine and Health Sciences University of Kent at Canterbury, Kent CT2 7PD, Rachel Maidment, Gill Livingston, Margaux Katona and Ella Whitaker
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Lambert et al (1) provide a useful but very worrying summary of the career preferences of recent United Kingdom medical graduates. The percentage of doctors at the end of their pre-registration year wishing to go into the ‘shortage’ specialties of psychiatry and pathology are very low (3.4% and 1.5% respectively) and show no sign of improvement. We have recently (2) examined career choice in 837 sixth form students attending a conference for prospective medical students and found very different patterns. The proportion expressing a definite intention to pursue psychiatry was 12.4%, with 10.1% definitely intending to become pathologists. Not all these sixth-formers will necessarily enter or complete medical training. The results nonetheless suggest that either medical schools select people who are less likely to go into the shortage specialties or that undergraduate education may have a negative effect on recruitment to shortage specialties, through ‘badmouthing’ (3), prejudice and poor information. We also found that though only 2.9% of a sample of 379 clinical medical students had a definite intention to go into psychiatry, a further 23.7% found psychiatry very attractive and were considering it as a possible career option (4). Most students had not yet decided what specialty they would go into. This illustrates that many medical students and house officers have narrowed down their choices but not yet made up their minds fully. Medical schools need to incorporate career advice and positive role models into their undergraduate programmes in order to foster career choices in keeping with national needs and in tune with students’ initial intentions. 1. Lambert TW, Goldacre MJ, Turner G. Career choices of United Kingdom medical graduates of 1999 and 2000: questionnaire surveys. BMJ 2003; 326: 194-5 2. Maidment R, Livingston M, Katona M, Whitaker E, Katona C. Carry on shrinking: career intentions and attitudes to psychiatry of prospective medical students. Psychiatric Bulletin 2003; 27: 30-32 3. Hunt DD, Scott C, Zhong S, Goldstein E. Frequency and effect of negative comments (‘badmouthing’) on medical students’ career choices. Academic Medicine 1996; 71: 665-669 4. McParland, M, Noble,L, Livingston, G, McManus, C. (in press) The effect of a psychiatric attachment on students’ attitudes to and intention to pursue psychiatry as a career. Medical Education Competing interests: None declared |
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Nicholas Finer, Hon Consultant Addenbrooke's Hospital, Cb2 2QQ
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The government says it is committed to training more doctors, yet inspection of the advertisement section of the British Medical Journal of May 25th shows that the majority of posts at SHO and SpR level are now service posts that are not recognised for training under the name of ‘Clinical Fellow’ or ‘Trust Doctor’. In the Medicine section, 16 advertisements were for such posts, 2 for mixed rotations in which part of the rotation does not attract educational approval, 7 for locum posts and 14 for educationally approved posts. It is understandable that Hospital Trusts have resorted to these measures in order to try and meet the New Deal and European Union requirements for junior doctor working hours. It is however contrary, that completion of specialist training will be lengthened by this move, slowing the output of the extra specialists we need now. Such posts are an abuse of the NHS responsibilities as an employer to offer training where needed for those working within it and in the long run may distort the career choices of newly qualified doctors. Competing interests: None declared |
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Trevor W Lambert, Satsitsician / Study Co-ordinator Institute of Health Sciences, Oxford University OX3 7LF, Michael Goldacre, Gill Turner
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We agree with Lorelei Cooke that early career intentions do not necessarily translate into eventual career destinations. Other papers from our group document changes in choice and eventual career destinations. Some doctors change direction from choice and others from necessity. Initial choices cannot universally turn into career destinations, because the job opportunities may not be available. Lorelei Cooke reports that only 36% of the BMA cohort of 500 qualifiers from 1995 were in their initial choice of specialty 7 years after graduation. Our evidence from large-scale national cohort studies is different. In 1997 we reported that, for the UK graduates of 1983 eleven years after graduation, 65% of doctors were working within their first year career choice (the choice expressed at the end of their PRHO year) and that 79% were at that stage employed in their third year career choice (reference 1). We note in passing that the amount of change in career choice depends on the level of detail at which specialties are analysed. In our own work we mainly use 14 standard groupings that assign specialties to broad categories (e.g. general practice, hospital medical specialties as a group, surgical specialties as a group). We have also studied changes of choice between years 1 and 3 (reference 2). Of doctors who initially chose hospital specialties, and then changed their choice, there has been a substantial decline over time in the percentage who have chosen general practice (see table). Increasingly over time, those who changed an initial choice of a specific hospital specialty have switched to another hospital specialty. Over the same period of time, a substantial and increasing percentage of doctors who chose general practice in year 1 retained that choice in year 3 (table). Table: Choice of career expressed by graduates from all UK medical schools in each graduation year: career choices at year 3 after graduation of all those who chose a hospital specialty, and all those who chose general practice, in year 1
In summary, it is true to say that, historically, many doctors who started their careers in the hospital specialties moved into general practice. All our evidence suggests that this is now far less common and the initial level of choice corresponds much more closely to the eventual percentage working in general practice (see table). Table: Percentage of graduates from all UK medical schools in each graduation year who chose general practice as a career in their pre-registration year, compared with the percentage working in UK general practice ten years after graduation
Whilst, in detail, initial career choices may not ‘match’ later career outcomes, study of early choices has allowed a number of major issues in recent years to be identified. An important example is general practice, where the decline in choices for general practice was highly predictive of a crisis in recruitment (reference 3). Further examples are the substantial differences in the career choices and destinations of men and women, manifest in choices at an early postgraduate stage, particularly in respect of general practice and the surgical specialties; and the observation that, in recent years, the percentage of women choosing surgery has now increased. In obstetrics and gynaecology the recent fall in choices is informative in a different way, in that it indicates that career structure problems in the specialty now affect the career intentions of new graduates
Competing interests: None declared |
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Sandy Thomson, SpR Geriatric Medicine Royal Bolton Hospital BL4 0JR
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Editor - Goldacre et al discuss the attitudes from graduates of different medical schools on whether their undergraduate training adequately prepared them for their pre-registration jobs.(1) The translation of undergraduate teaching to the practicalities of the job itself has never been easy. In particular, the exposure of undergraduates to the variety of medical emergencies they will encounter as a doctor does not get the priority it should. Recognising a sick patient and instituting early treatment is crucial knowledge for any pre-registration house officer. Unfortunately it does not seem to receive the same attention at medical school as knowing the causes of atrial fibrillation, the differential diagnosis of a lump in the neck or communication skills training. It has previously been established that providing an organised schedule of emergency medicine training for undergraduates may improve their ability to cope with medical emergencies as junior doctors.(2,3) Advanced life support courses currently provide some training in this area, however these are of limited availability to mot students. Training targeted at recognising and managing critically ill patients before they deteriorate to the point at which they require advanced life support, would be more relevant. Courses such as ALERT (Acute Life-threatening Events – Recognition and Treatment) (4) should be employed at undergraduate level to deliver both knowledge and practical experience in this area. This would increase pre-registration doctors confidence in this aspect of their work and clearly benefit patient care. Although this piece of work highlights the difficulties involved in the change from student to practitioner, it should be used to encourage medical schools to re-examine those aspects of their curriculum needing further development. The delivery of training in the management of medical emergencies is a vital part of this debate. Sandy Thomson Specialist Registrar in Geriatrics and General Internal Medicine Royal Bolton Hospital Minerva Road Farnworth Bolton BL4 0JR No competing interests. 1. Goldacre MJ, Lambert T, Evans J, Turner G. Pre-registration house officer’s views on whether their experience at medical school prepared them well for their jobs: national questionnaire survey. BMJ 2003;326:1011-1012. 2. Kelly AM, Ardagh MW. Does learning emergency medicine equip medical students for ward emergencies? Med Educ 1994 Nov;28(6):524-7. 3. Harrison GA, Hillman K, Fulde GW, Jacques TC. The need for undergraduate education in critical care. (Results of a questionnaire to year 6 medical undergraduates, University of New South Wales and recommendations on a curriculum in critical care) Anaesth Intensive Care 1999 Feb;27(1):53-8 4. Smith GB, Osgood VM, Crane S. ALERT—a multiprofessional training course in the care of the acutely ill adult patient. Resuscitation 2002 Mar;52(3):281-6. Competing interests: None declared |
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