Career Focus

Analysing specialty career trends

BMJ 1996; 313 doi: (Published 13 July 1996) Cite this as: BMJ 1996;313:S2-7049

Which route gets you a consultant post quickest? Medical demographer Trevor Lambert reads the runes in the Department of Health's figures.

A medical degree can open many doors, not only those to a conventional career in one of a wide range of medical specialties. Medical graduates can also pursue careers allied to medicine, together with many that are open to all graduates (see list).

Just as some people book last minute holidays, while others make firm plans for the next two or three years, so attitudes to career planning vary between individuals. In the professions the individual will normally remain in broadly the same field of work, if not within the same organisation, for most of his or her working life. Within this, the concept of a “career” implies an orderly progression over time towards sustained success. At interview; candidates feel that they have to conform to this model of career progression, by presenting each job move as a logical and deliberate step towards further goals. Yet for some, a change of career direction may be a valid and indeed essential choice.

Doctors occupy a specialist niche in the labour market, undergo lengthy training, and generally focus on increasingly narrow areas of work as they progress, all of which make it difficult to change direction. An early and appropriate choice of specialty has therefore been important if a doctor is to maximise his or her job satisfaction and potential. The major restructuring of postgraduate training following the implementation of the Calman report may increase the importance of this.

The length of postgraduate training in hospital specialties will reduce, more quickly in some specialties than others, towards a target of about seven years in line with European Union medical directives. There is intended to be an emphasis on choice of career pathway,'; both within the period of specialist training as well as at entry to and exit from it At an early stage opportunities may exist for a change of direction, although this is more likely to take the form of a refinement of choice within an initially broader group of specialties rather than a complete change. Early definite choices are likely to retain their present value.

Knowledge of the marketplace may help: some specialties are oversubscribed or undersubscribed, more career opportunities may exist in some parts of the country, progression to a career grade appointment may be quicker in some specialties and locations, and openings for part time or flexible working may vary.

Finding information

For a number of years Health Trends, a quarterly publication of the Department of Health, has published an annual review of medical staffing prospects in the NHS.(1-3) The most recent article, published in 1994, contained prospective information for 1994, and beyond in each medical specialty, together with extensive tables detailing numbers of staff in post in each specialty in 1993.(3)

The articles in Health Trends identify the specialties with the best prospects, in the sense of having high demand for consultants or principals, though there is little information on the geographical distribution of posts. The picture may change with time, but there is little evidence of change over the two or three years before 1994, so it is reasonable to assume that the 1994 picture is still substantially accurate.

Filling and emptying the specialty pool

Staff may be in high demand in a specialty for a number of reasons: it may be numerically large, it may have high numbers of its senior members retiring, and it may be expanding. In 1994 general practice training schemes were described as undersubscribed and there was good, though regionally varied, demand for newly qualified principals. In the surgical specialties, while demand was described as generally steady there were shortages in accident and emergency and urology, and some trusts were said to be keen to establish new posts in some sub specialties such as breast and day surgery Opportunities in paediatrics were described as “excellent', and those in palliative and rehabilitation medicine were “good”. Psychiatry particularly of old age, anaesthetics, and obstetrics and gynaecology also had high demand at the consultant level.

Openings in some specialties were considered to be more restricted. In nephrology and oncology, while medium term prospects were thought to be good because some reorganisation of services was underway, the short term was more doubtful. In thoracic medicine recruitment had been frozen, and the future was uncertain. Pathology had intense competition for consultant appointments. The number of posts in public health medicine was falling as a result of health authority mergers.

The time taken to reach consultant status varies between hospital specialties. The age profile of consultants may also vary by specialty, so there may be a varying number of opportunities arising from retirement Planned growth also varies as perceived shortages are addressed and as clinical practice changes and creates new demands.

Growth should result in openings for younger doctors.

According to the 1994 article, specialties in which the number of consultant posts created by growth will be larger than those available through retirement include paediatrics, genitourinary medicine, accident and emergency trauma and orthopaedic surgery urology, mental illness, and the psychiatry of old age.

Priority specialties identified by the NHS Executive

  • Accident and emergency medicine

  • Anaesthetics

  • Diagnostic radiology

  • Forensic psychiatry

  • General surgery

  • Medical oncology

  • Obstetrics and gynaecology

  • Old age psychiatry

  • Ophthalmology

  • Orthopaedic surgery

  • Paediatrics

  • Palliative medicine

  • Psychiatry (mental illness)

  • Radiotherapy (clinical oncology)

  • Urology

Using age to locate opportunity

Department of Health figures for all hospital specialties in September 1992 showed that 20% of consultants were under 40 years old.

This does not necessarily indicate the level of opportunity to achieve status early; it may simply reflect cohort effects of appointments to the specialty in the past, and past appointments to expanding specialties. The ratio of consultants to senior registrars at age 35-39 might be a better indicator of the likelihood of early appointment to consultant status.

Measured in this way, radiology, with a ratio of five consultants for each senior registrar, and anaesthetics with four, had the highest proportion of early consultant appointments. Psychiatry, pathology, and accident and emergency medicine each had roughly two consultants per senior registrar, and the other specialty groups had ratios of between 1.2 and 1.6. This variation by specialty probably reflects long term organisational factors rather than short term differences in opportunities.

Data from recruitment advertising

The numbers of consultant posts in each specialty advertised in the BMJ in the year from November 1993 gives some indication of demand. The crude numbers show the surgical specialties (497 posts), psychiatry (452), anaesthetics (424), and the medical specialties (384) to be the most frequently advertised, followed by paediatrics (165) and obstetrics and gynaecology (101). The picture was slightly different when assessed relative to the total number of consultant posts in England and Wales in each specialty. The number of posts advertised at consultant level in psychiatry was the highest, at 210/0 of the total number of consultant posts in the specialty, and the medical specialties were lowest with 10%.

Flexible careers

Opportunities for part time and flexible training and career grade posts will interest many doctors, particularly those with domestic commitments. A total of 574 full time equivalent senior registrar posts to be held by doctors wanting part time or flexible work had been established by July 1994, but only 442 were filled, most vacancies being in paediatrics and surgery; A limited scheme to provide additional part time consultant posts introduced 85 posts in June 1994. In general practice 10% of all unrestricted principals are now working part time.

Women now make up just over half of all medical students, but only 29% of hospital medical staff are women. Within this, the proportion of women in the consultant grade varies substantially between specialties-for example, from 40% in child and adolescent psychiatry to under 2% in trauma and orthopaedic surgery and 4% in surgery overall. Initiatives such as the Women in Surgical Training scheme,4 and the more widely targeted Opportunity 2000, seek to enable more women to move into specialties in which they are currently under-represented. The proportion of women principals in general practice rose from 17% to 27% between 1983 and 1993, and the proportion of women registrars from 37% to 53%.

Comparing the 1994 review with the equivalent articles published in 1992 and 1993 shows little change in the variations in demand for consultants between specialties, although a number of centrally funded initiatives have been undertaken to expand consultant numbers, targeting new posts to the shortage special ties.

More recently, a National Association of Health Authorities and Trusts (NAHAT) report described recruitment problems to consultant posts in accident and emergency medicine, psychiatry, anaesthetics, paediatrics, and orthopaedics. Of trusts responding to the survey; 79% reported poor response, and sometimes no response, to advertisements for consultants.

The most recent Health Treads article was published in late 1994. The Department of Health does not intend to continue the series in its present form and suggests that its Specialist Workforce Advisory Group will in future produce equivalent data. One hopes this will be the case; in the trust era there are relatively few sources of collated national information on employment opportunities in the NHS.


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