Career Focus

On the early career choices of medical graduates

BMJ 1997; 314 doi: (Published 29 March 1997) Cite this as: BMJ 1997;314:S2-7085
  1. Jon Ford, head
  1. health policy and economic research unit, British Medical AssociationLondon WC1H 9JP

    The second year's results of the BMA's cohort study of medical graduates became available this month. Its author, Jon Ford, outlines the trends in early career choice that are starting to emerge.

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    In June 1995 the BMA's health policy and economic research unit began a longitudinal study of a sample of 1995 UK medical graduates. The project will track the sample for at least ten years, recording their career paths (and intentions) as well as their views on undergraduate and postgraduate education, and the professional values which underlie their choice and pursuit of a medical career.

    Just over 600 graduates were selected for the study. They were drawn from the 1400 who responded to a mass mailing of final year students. The sample was constructed to be representative of the total population of final year students principally by sex and ethnic origin. Replacements for those who failed to graduate were chosen to reflect the characteristics of those they replaced. The detailed methodology of the study was described in the first report of the project published in December 1995.(1)

    The first report, published in two parts, covered the initial career preferences of the doctors and dealt also with their professional values - an extension of a separate study of the core values of the medical profession. In March 1996 two focus groups of cohort members were held with two intentions. Firstly, the health policy and economic research unit was anxious to gain some further insight into the climate in which attitudes and career preferences had developed. Secondly, the groups would help to design the second year's questionnaire by flagging up issues which might be further explored. As a result of this process the second year of the study has examined the content of the undergraduate course in relation to the preregistration year, the year itself, as well as the issues of career preference and strength of desire to practise medicine.

    Parkhouse study

    There have been other studies of cohorts of medical graduates, most notably those conducted by Parkhouse.(2) The health policy and economic research unit study differs from these in being longitudinal and continuous. As such it is capable not only of observing change at more frequent intervals but also of linking data to individual characteristics. I should stress that the study is a confidential one and that data relating to individuals are not accessible to anyone not on the unit's staff. The benefit of our approach is seen in the data relating to career choice. Although it is still very early to be examining change of career preference (and these preferences may not be firmly formed so soon after graduation) the second report is able to tell us that 111 doctors out of 496 for whom linked data are available have changed career choice since the first questionnaire. Hospital practice was the principal beneficiary of career choice change, attracting 57 doctors for a net change of 27, general practice attracting 22 for a net loss of 10 (see table 1). Much will doubtless be made of the finding that only 16% of the cohort favours a career in general practice as compared with the 26% found by Lambert et al for the 1993 cohort at a similar stage of their careers.(3) Although not directly comparable, these data (table 2) will add ammunition to the continuing debate about the future of general practice.

    Table 1

    Career aspirations and change of choice

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    Data on career preferences are interesting, and one aim of the study was to alert the profession to early signs of potential difficulty for workforce planning purposes. Nevertheless, arguably the most interesting information relates to educational matters. These doctors are at the end of their preregistration year and their views on their preparedness for that year and its educational value to them are important to those charged with designing the undergraduate curriculum and those responsible for postgraduate education. The findings will come as a disappointment to them. For example, one in five of the cohort learnt the practical skills and procedures necessary for the job from house officer colleagues or were self taught and over one quarter of the young doctors felt they were asked to undertake tasks beyond their capabilities.

    Table 2

    Career choice: breakdown by sex

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    The preparation received for the preregistration year by the doctors as students varied considerably and clearly depended on the relevant school's approach. Only two schools received a rating of adequate or above from a majority of their students across all the areas they were asked about. Those areas where a significant minority of doctors felt underprepared included working conditions (48%), medicolegal issues (45%), and communicating with relatives (39%).

    Focus group discussions

    The focus group discussions had uncovered a general feeling that the surgical house job was less favourably regarded than its medical counterpart. This was generally confirmed by the main study, which found that 91% of the cohort felt that the medical post offered good or acceptable educational value as against 76% for the surgical post. The main study found, paradoxically, that teaching hospital posts were less highly regarded than those in district general hospitals in this respect. Among a minority of doctors who thought that an alternative could be found for the post they valued less, general practice and accident and emergency were the overwhelming choices.

    The work of the pre-registration house officer appears to be dominated by routine practical tasks, many of which the doctors felt could be transferred to other hospital staff and it is perhaps unsurprising that during this year the cohort has experienced an overall decline in motivation, with only 74% of the cohort now having a strong or very strong desire to practise medicine as compared with 85% at graduation. This overall decline hides however some more complex movements, the preregistration house officer year having strengthened the desire of some doctors.

    Lack of contact with postgraduate deans is another depressing finding of this year's study - less than half of the doctors overall having some contact during the preregistration house officer year. Those who did have some contact found this most helpful where it took the form of group and individual sessions

    All is not doom and gloom: many positive findings emerge from this year's study. The doctors valued the support of medical colleagues highly and of nursing staff only marginally less. The working environment in the form of team spirit and working atmosphere was highly rated and although there was a significant drop where working conditions, particularly in teaching hospitals are concerned, over three quarters of the doctors rated these good or adequate. Furthermore, the numbers of doctors thinking of working permanently overseas has fallen substantially since the 1995 questionnaire although 62% of the cohort intend to travel or practise overseas temporarily. Indeed some of this temporary migration has already begun. 29 of the doctors had arranged to practise overseas in the coming year.

    This study is already shedding valuable light on the complex issues of medical education, training, and workforce planning and will continue to do so.

    If you would like to know more about the cohort study contact Sharon Hurlock at the health policy and economic research unit at BMA House (hperu{at}


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