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Finding the right way

BMJ 1995; 311 doi: (Published 09 September 1995) Cite this as: BMJ 1995;311:694
  1. Margaret Price

    In Isobel Allen's report Doctors and Their Careers: A New Generation, 76% of women doctors and 58% of male doctors said that they had regretted their decision to become doctors at some point in their career. There is obviously an urgent need to develop more realistic career pathways and better career advice, particularly for women. It is economically unsound and cruel to educate people to a high level without thinking through realistic patterns of employment. Consideration should be given to three possible career pathways: the classic steady rise through the ranks with the attainment of current higher degrees, including research degrees; the same progression but with a plateau in the late 20s and early 30s, during which work is less than full time and thus senior status is reached at a later age; and, finally, a less demanding but worthwhile option producing a clinically competent doctor, a valuable member of the team who does not have the extra burden of research and management.

    For most men and women without children the current career progression in medicine is appropriate. For some doctors who become mothers and who have excellent domestic support, the conventional career pattern may also be suitable, although problems such as geographical instability in the early years still need addressing. For many, however, the dual needs of family and career impose enormous stresses on mothers and fathers. These are amplified when both parents are doctors. Some progress has been made towards providing flexible part time training, but this is still regarded by many as second best and the commitment to this form of training is piecemeal. The problem is far more one of attitude than practical difficulty. In medicine the division between full time and part time is arbitrary; full time work as a doctor means 168 hours a week.

    I see no reason why there should not be a reduced pattern of work in the late 20s and 30s allowing mothers or fathers, or both, to spend a reasonable time with their families while still maintaining and developing their medical skills. Many doctors, on reaching senior status in hospitals in their late 30s, reduce their commitment to the NHS while increasing their private sector work. This is accepted as normal practice and usually excites little comment. We also need to provide alternative and worthwhile careers for women who do not wish to attain consultant or senior partner status. There should be no shame in wishing to spend time raising a family. We all have a vested interest in happy, stable children and caring parents. It is probably unwise, however, to opt out of medicine completely for any length of time. Medicine is highly technical and skilled and it is easy to lose touch and confidence.

    There are many roles in medicine where useful work can be undertaken during fixed hours—for example, outpatient clinics, operating sessions, routine general practice surgeries. I believe we need to look again at how we train postgraduates. Instead of the staff grade being regarded as a blind alley for senior house officers who have lost their way, could this not be seen as a respectable grade requiring a set standard of training in a chosen specialty with a level of competence judged by exam or alternative formal assessment? Such doctors would be invaluable in the hospital and their presence could go some way to alleviating junior doctors' hours. Career progression could be achieved by eventual promotion to associate specialist. The mechanism for this is already in place, but attitudes towards the scheme can be negative. This might change if doctors thought that they were being given a genuine chance to choose between alternative careers, rather than being forced down one path because the other made impossible demands.

    In addition to introducing more flexible career patterns, we need to provide career guidance at the right time. Most girls contemplating medicine at 18 are worried about A level grades, which medical school to apply to, and how they will cope with the preregistration year as portrayed on television. They probably give little thought to how they will eventually cope with career and family. If at 18 they are certain they want to take 10 years out to raise their family perhaps they should be discouraged from studying medicine. If they do wish to combine both they need to plan the next 10 years carefully in the preregistration year or soon after. House jobs are demanding and if a doctor is certain that she wishes to reach consultant or senior status in general practice she would probably find it easier to complete general hospital training plus exams such as the membership of the Royal College of Physicians or the Royal College of General Practitioners or the fellowship of the Royal College of Surgeons before starting her family. But to deliberately delay a family until senior status is achieved means that babies are not born at the best time biologically.

    If, having completed registration, a doctor does not wish to face the current higher exam hurdles or to undertake research she should be given the opportunity to pursue a less demanding but properly structured career. This option should, of course, be open to men as well. Over half of medical students are women. The vast majority of women have children. I am not talking about a fringe minority group. It is high time that thought is given to adapting training and employment in medicine to the existing workforce rather than slavishly adhering to historical work patterns, which are inappropriate for many, possibly most, doctors.

    Why do I take an interest in medical careers? I was able to complete my specialist training part time. For the past eight years I have been happily and, I hope, usefully employed as a consultant in my chosen specialty, dermatology. This is a busy specialty in the daytime with an enormous outpatient load and an ever increasing surgical component. Night work, however, is rare, greatly easing the burden of on call work. I also have a supportive husband, who is prepared and able to commute almost 100 km daily to work (he is not a doctor). Not everyone has been so lucky. Parts of Isobel Allen's report make dismal reading. We must improve career structures for both men and women.

    I have a bright, happy daughter of 16 who is considering medicine. I have never regretted my career choice. I would not wish her to.—MARGARET PRICE is a consultant dermatologist in Brighton

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