Career destinations in 1994 of United Kingdom medical graduates of 1983: results of a questionnaire surveyBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7035.893 (Published 06 April 1996) Cite this as: BMJ 1996;312:893
- Trevor W Lambert, statistician and study coordinatora,
- Michael J Goldacre, unit and study directora,
- James Parkhouse, study consultanta,
- Carol Edwards, research officera
- a Unit of Health Care Epidemiology, Department of Public Health and Primary Care, University of Oxford, Oxford OX3 7LF
- Correspondence to: Dr Goldacre.
- Accepted 16 January 1996
Cohort studies of doctors' career choices and career progression since the mid-1970s have shown important changes in the medical workforce, in specialist training, and in employment. Examples of these changes are the increasing proportion of women doctors and of doctors who wish to work part time, the emigration patterns of doctors, and the development of vocational training for general practice. Studies enable the effects of longer term changes to be assessed, and sometimes they inform current debate
The number of entrants to medical school in the United Kingdom is fixed by quota. The number of junior medical posts and their geographical distribution are also tightly regulated. Control is aimed at avoiding either overproduction or inadequate supply of doctors. With a planned medical workforce it is important to know about the career intentions and destinations of medical graduates.1 We report a follow up study of the qualifiers of 1983 from all medical schools in the United Kingdom. We record their employment 11 years after qualification, paying particular attention to doctors who were abroad, those who were in the United Kingdom but not in medicine, and those who were in the United Kingdom practising medicine outside the NHS.
In 1983-4 lists from the General Medical Council were used to identify the cohort of doctors who had qualified in the United Kingdom in 1983.1 Questionnaires were mailed to these doctors one, three, and 11 years after qualification. Structured questions covered career intentions, factors which influenced career choices, and posts held. Respondents were also invited to comment on any aspect of their career choice, training, and work experience.
Employment groups were defined to distinguish doctors who worked in the United Kingdom from those abroad, those working in the NHS from those in other medical employment in the United Kingdom, those working in medicine from those in other work, and those not in paid employment. For comparison we also analysed data from earlier cohorts, obtained in similar ways, to identify career destinations of the qualifiers of 1974 in 1987 and of the qualifiers of 1977 in 1986 (the latest years for which data were available).
Specialties were grouped for analysis into 14 mainstreams, based on groupings defined in the Todd report.2 These were general practice, hospital medicine (general medicine and the medical specialties), paediatrics, accident and emergency, surgery (general surgery and the surgical specialties), obstetrics and gynaecology, anaesthetics, radiology, clinical oncology, pathology, psychiatry, community health, public health medicine, and others. A complete list of specialties in each broad group may be obtained from TWL.
The original 1983 cohort comprised 3845 doctors. Ten had died by September 1994 and 16 refused to participate, giving an effective cohort of 3819 doctors (2363 (61.9%) men, 1456 (38.1%) women). Table 1 summarises the level of response and the recorded employment status of respondents in September 1994. The overall response rate was 71.1% (2716 doctors), or 72.8% when untraceable doctors were excluded. Consistent with our previous studies, proportionally fewer men than women replied (68.2% (n=1612) compared with 75.8% (n=1104); χ21=25.1, P<0.001). More of the respondents (2680/2716; 98.7%) than non-respondents and untraceable doctors (1019/1103; 92.4%) were on the medical register in 1994, including the overseas list, suggesting that our survey returns alone underestimated the proportion of the cohort who had left medicine or gone abroad. Doctors who were abroad but working for the British armed forces in a medical capacity were regarded as working in medicine in the United Kingdom. When we included these, 92.9% of respondents (2523/2716) were in the United Kingdom and 7.1% (n=193) were abroad (table 1). Of the 2523 respondents in the United Kingdom, 2409 (95.5%) were working in medicine (table 1).
ESTIMATED NUMBERS OF DOCTORS NOT IN MEDICINE IN UNITED KINGDOM, 1994
We used the medical register, employment lists supplied by the Department of Health, and the medical directory to compile information about doctors whose employment status was unknown to us. From these data we estimated minimum, “best,” and maximum percentages of doctors who were not in practice in the United Kingdom (appendix; table 2). Using data from respondents and adding those non-respondents who were unregistered or who were registered with an overseas address, we estimated that a minimum of 10.3% of men and 14.0% of women were not in medicine in the United Kingdom (χ21=12.8; P<0.01). More women than men among the respondents were not in paid employment (table 1), mostly for domestic reasons. Our best estimate was that 16.5% of all doctors (15.4% of men, 18.2% of women (χ21=4.9; P=0.03)) were not practising in the United Kingdom.
The minimum and maximum estimates of 11.7% and 19.3% of doctors who were not practising in the United Kingdom were compared with estimates reached by similar methods for the two earlier cohorts (table 2). For the 1974 cohort in 1987 (2350 doctors; 1807 respondents) estimates of the minimum and maximum proportions of doctors who were no longer in medicine in the United Kingdom were 15.7% and 25.8%. For the 1977 cohort in 1986 (3136 doctors; 2495 respondents) the estimates were 13.7% and 23.8%.
SPECIALTIES AND GRADES OF DOCTORS IN UNITED KINGDOM, 1994
Table 3 gives a breakdown of respondents known to be in medical employment by location (United Kingdom or abroad), specialty group, and sex. Of the 2409 respondents known to be in medical employment in the United Kingdom, 1179 (48.9%) were in general practice. A higher proportion of women than men entered general practice, and both at home and abroad proportionally fewer women than men were in surgical and medical specialties. After general practice the most common career destinations for men were the surgical specialties, medical specialties, anaesthetics, pathology, and psychiatry. After general practice the most common career destinations for women were psychiatry, the medical specialties, community health, and anaesthetics. Almost all the doctors in community health were women.
There were 874 doctors (576 men, 298 women) with substantive contracts with the NHS in the hospital specialties. A total of 213 men (37.0%) and 86 women (28.9%) had reached consultant grade (with the exclusion of locum appointments) by year 11 (men v women: χ21=5.32; P=0.02). For specialties in which there were at least 15 consultants the figures for men and women reaching consultant status were as follows: 39 of 93 (42%) and 12 of 50 (24%) in the medical specialties; 13 of 26 (50%) and four of 24 (17%) in paediatrics; 21 of 143 (15%) and none of 21 in the surgical specialties; 45 of 105 (43%) and 17 of 53 (32%) in anaesthetics; 20 of 32 (63%) and 15 of 20 (75%) in radiology; 29 of 60 (48%) and 15 of 36 (42%) in pathology; 33 of 67 (49%) and 22 of 61 (36%) in psychiatry. Differences between men and women were significant for paediatrics and the medical specialties only (χ2 test: P=0.04 and P=0.05); women, however, generally took longer than men to reach consultant level.
Of the 2129 respondents in the NHS, 430 (20.2%) worked part time in 1994 (2.6% of men, 45.2% of women). A total of 49.7% of women in general practice (249/501) and 33.9% of women in hospital practice (101/298) worked part time.
The distribution of specialties of doctors abroad was broadly comparable to that of doctors in the United Kingdom, except that fewer of the doctors abroad were in general practice (33% compared with 49% of doctors in Britain). Few doctors abroad worked in anaesthetics, radiology, and pathology. Australia and New Zealand were the most popular destinations of doctors working abroad (65/178; 37%). The United States and Canada were next (37; 21%), followed by Africa (18; 10%) and continental Europe (16; 9%). Thirty eight (58%) of the 65 doctors who went to Australia and New Zealand were in general practice as compared with only five (14%) of the 37 doctors in the United States and Canada.
DOCTORS IN UNITED KINGDOM NOT WORKING IN MEDICINE
Sixty nine respondent doctors in the United Kingdom (56 women, 13 men) were not in paid employment (table 1). Among the women, three were seeking full time work in medicine, 10 were seeking part time work in medicine, 35 were not seeking work, and eight did not say whether they were seeking work. Of the 43 women who did not specify that they were seeking work, 11 gave their current circumstances as “planned career break,” nine as “maternity,” four as “housewife,” and three as “illness”; 16 gave no further details. Among the men, six were seeking full time work in medicine, one was seeking part time work in medicine, three were not seeking work, and three did not say whether they were seeking work. Of the six men who did not specify that they were seeking work, two gave illness as the reason, one gave planned career break, and three gave no further details. A further 14 doctors were in non-medical occupations such as business and law.
FACTORS CITED AS INFLUENCING CAREER CHOICE
Each doctor was asked, “Do you regard your current specialty/type of employment as your final choice of career?” Possible responses were “definitely,” “probably,” and “not really.” Each was then asked “How much have the following factors influenced your career choice?” and presented with a list of 13 factors. Possible responses for each factor were “not at all,” “a little,” and “a great deal.”
For those who regarded their current employment as definitely or probably their final choice of career we examined the responses for each factor (table 4). We were interested to know which factors had most influence on doctors' choice of careers and to see whether there were differences between doctors who were working in the United Kingdom (within and outside the public sector) and those abroad. Doctors outside the public sector included 22 in the pharmaceutical industry, 11 in private clinical practice, six in industrial medicine, and four in medical journalism. Table 4 shows the proportion in each group who answered “a great deal” for each factor. Factors specified as having the greatest influence were self appraisal of skills and aptitudes, experience of chosen career, hours and working conditions, and domestic circumstances. Experience as students and the influence of a particular teacher or department were rated as important by only a minority of doctors. Inability to secure qualifications for a previous choice of medical career was a negligible influence.
Doctors abroad showed a similar pattern of responses to those of doctors in the United Kingdom public sector on almost all factors, with no significant differences between them. Only 39 doctors worked in medicine outside the public sector in the United Kingdom; these doctors were more likely than others to ascribe importance to hours and working conditions (26 doctors) and financial prospects (14 doctors).
DECISION TO LEAVE UNITED KINGDOM
In 1984, 1986, and 1994 doctors in the cohort were asked whether they intended to work in the United Kingdom “for the foreseeable future.” Table 5 gives their responses stratified by whether they were in the United Kingdom or abroad in 1994. Even in 1984 those who would be working abroad in 1994 were significantly less definite in their intention to stay in the United Kingdom (Mann-Whitney U test, P<0.001). Those in the United Kingdom in 1994 were progressively more definite in their intention to stay in the United Kingdom in 1986 and 1994 than they were in 1984 (Wilcoxon test for 1986 v 1984 and 1994 v 1984, P<0.001 and P<0.001). By 1994 only 3% of doctors in the United Kingdom did not intend to stay; 22% of those abroad stated that they definitely or probably intended to return.
One hundred and sixteen (60%) of the 193 doctors known to be abroad completed a comment form. Of the 97 who commented specifically on reasons for working abroad, 44 gave reasons which we scored as positive (for example, to widen their experience) and 23 gave reasons which we scored as negative (for example, lack of training opportunities in the United Kingdom). The remainder gave reasons which we scored as professionally neutral (for example, accompanying a spouse). Of those in the United Kingdom public sector who were considering moving abroad and who commented, almost equal numbers of positive and negative reasons were cited (88 and 84 doctors respectively).
Eleven years after qualification most respondents were practising medicine in the United Kingdom. Of those who were not, most were abroad and most of them were in medical practice. Though more women than men were not in medical practice, differences were small and most women were working in medicine. Medical unemployment was very low among respondents, most doctors who were not in paid work having domestic reasons for not seeking work at the time of the survey.
Because of non-response from some doctors it was difficult to establish the exact proportion of a particular cohort who were not practising medicine in the United Kingdom. We assembled available information from various sources on non-respondents and others whose career destinations were unknown. Taking account of this, we know that between 11.7% and 19.3% of the 1983 cohort were not practising medicine in the United Kingdom in September 1994. Our best estimate is about 16%. We undertook similar calculations on historical data on the career destinations of the qualifiers of 1974 and 1977. Follow up data from these two cohorts were not entirely comparable to those of 1983. The information available related to their careers in 1987 and 1986 (13 and nine years after qualification, respectively) rather than after 11 years. There was also less precise historical information about the non-respondents. However, on the available evidence it seems likely that the proportion of doctors from the 1983 cohort working in medicine in the United Kingdom was a little higher than that of doctors from the 1970s cohorts.
The Todd report gave a target figure of 3850 medical graduates in Great Britain for 1983.2 Subtracting the 171 graduates from Queen's University of Belfast from the 3845 graduates in the United Kingdom shows that the 1983 cohort for Great Britain actually numbered 3674. The “loss” of 16% from the base of 3845 means that the 1983 cohort provided about 3230 doctors in medicine in the United Kingdom. The second report of the Medical Workforce Standing Advisory Committee estimated that up to 20% of any given cohort of doctors may not be working in the NHS or University sector five years after qualification.3
RELEVANCE OF PART TIME WORK
The loss of 16% of doctors from medicine in the United Kingdom plus the fact that about 5% of doctors in the United Kingdom are outside the NHS and University sector (table 1, rows 16-18) means that the 1983 cohort was close to the figure of 20% 11 years after qualification. Those concerned with planning the medical workforce also need to take account of patterns of part time work. We have shown that at this stage in this cohort's career substantial numbers of women were working part time. Our data also confirm that women take longer than men to reach consultant status,4 5 6 at least in some specialties. We plan to compare career progression for men and women in the 1974, 1977, and 1983 cohorts to determine the extent to which time spent not working or in part time work accounts for the differences.
It is difficult to know whether any one year of medical graduates is typical of its generation. A higher proportion of the 1983 cohort than of the 1974, 1977, or 1980 cohorts expressed a career preference for general practice at the end of the preregistration year.1 Of all respondents from the 1983 cohort working in the NHS, 53.9% were general practitioners in 1994. Department of Health figures for 1993 show that in England and Wales there were 28 481 hospital doctors at registrar, senior registrar, and consultant levels plus 30 310 general practitioners.5 This means that 51.6% of doctors in these categories were in general practice. The comparable proportion for our 1983 respondents, calculated by excluding hospital doctors of grades other than registrar, senior registrar, and consultant, was 59.5%. It is not necessary for the qualifiers of any one year to seek careers in proportion to the general national requirements as long as entry to different careers evens out over a number of years.
Most doctors who leave the United Kingdom do so to practise abroad and most seem to have positive rather than negative reasons for going. Our evidence indicates that it was common for doctors who emigrated to have expressed an interest in doing so from early in their careers. Apart from this, however, we found that doctors going abroad did not differ much from those who stayed in their comments about the NHS or in the factors which influenced their career choices (table 4). A comparatively large number of those abroad in this cohort were in general practice in Australia or New Zealand. Doctors who currently work abroad are not necessarily “lost” to the NHS. Our detailed data on patterns of emigration and return indicate that a substantial proportion of doctors abroad do not stay abroad permanently.
Doctors not in paid employment were predominantly women. This does not equate with permanent loss from the profession. Particularly in the early years after qualifying, just as there are doctors who go abroad for a time and return there are doctors who leave work for domestic reasons with every intention of resuming. Among the 1983 respondents there were 13 women not in paid employment in 1994 who had been working in the NHS in 1993, but there were 24 women working in the NHS in 1994 who had not been in paid employment in 1993. Some women wished to return to work part time after having children but had failed to find a suitable post or training opportunity. A study of vocationally trained general practitioners also found this.7 In our study only nine of the 2716 respondents were seeking full time employment in medicine without success, confirming that in the United Kingdom medical unemployment of full time doctors is rare.
LOSSES FROM UNITED KINGDOM MEDICINE
There is debate about possible recent losses of doctors from medicine in the United Kingdom. We conclude that, though doctors commonly commented about dissatisfaction with work circumstances, there was no evidence of recent large scale loss of doctors from the NHS in this cohort. However, the qualifiers of 1983 were well established in their careers and our findings cannot necessarily be extrapolated to more recently qualified doctors.
We thank all the doctors who participated and Janet Justice and Alison Stockford for their accuracy and diligence in coding data from the questionnaires.
There were 1013 non-respondents, 90 untraceable doctors, and 31 respondents who gave incomplete data (table 1)—that is, 1134 doctors whose employment status in September 1994 was unknown. Of these doctors, 85 were not on the medical register in September 1994 and 86 were listed with an overseas address (table 6). If we assume that these 171 doctors were not practising medicine in the United Kingdom, adding them to the 276 known not to be in practice (table 1, rows 6, 9, and 10) gives a minimum estimate of 447 doctors (11.7% of the cohort) who were not in medicine in the United Kingdom.
A total of 963 doctors remained (table 6, rows 3-5) registered with addresses in the United Kingdom whose occupation was unknown to us. We matched these doctors' General Medical Council registration numbers against lists of employment data in September 1993 (the latest available) supplied by the Department of Health. This showed that 674 were in NHS practice in the United Kingdom (table 6, row 3). This left 289 doctors (table 6, rows 4 and 5) who were registered but of unknown recent employment status. If we assume that none of these 289 doctors were practising medicine in the United Kingdom and we add them to the minimum estimate of 447 the maximum estimate is 736 doctors (19.3% of the cohort) who had been “lost” from medicine. From the 1994 medical directory we inferred that 107 of the 289 doctors were probably working in medicine in the United Kingdom. It seems reasonable to give a “best guess” estimate of doctors lost from medicine in the United Kingdom in 1994 of about 629 (736 minus 107), or 16% of the cohort.
Funding The Medical Careers Research Group is funded by the Department of Health and the unit of health care epidemiology by the Anglia and Oxford Regional Health Authority.
Conflict of interest None.