Reasons for considering leaving UK medicine: questionnaire study of junior doctors' comments

Introduction

An increase in the number of doctors working in the NHS in England is a major policy initiative in the NHS Plan.1 The “improving working lives” programme aims to ensure that everything is done to encourage doctors, once recruited, to remain in the NHS.2 3 Although loss of junior doctors from the NHS has been a longstanding concern of policy makers, the loss of young home trained doctors from the UK medical workforce does not seem to have increased during the 1980s and 1990s.4 However, in our regular surveys, the proportion of pre-registration house officers who have reported their intention to “continue practising medicine in the United Kingdom for the foreseeable future” declined from around 90% in the 1980s to 75% in the 1990s.5 In the past, early expressed intentions have been shown to be a reasonable predictor of subsequent career pathways. Whether or not early indications are followed, it is important to understand why some doctors say that they may want to leave. We report a systematic qualitative study, in which we explored the distinction between the factors that would be amenable to policy initiatives to encourage doctors to stay in UK medicine and other factors that are largely beyond the influence of policy.

Methods

We regularly survey junior doctors' career intentions. In selected years, we send postal questionnaires to the new graduates of all UK medical schools. For the study reported here, we used information from our survey of graduates of 1999 from all UK medical schools towards the end of their first postgraduate year. Our methods are described in detail elsewhere.6 Among other questions, respondents were asked, “Apart from temporary visits abroad, do you intend to practise medicine in the United Kingdom for the foreseeable future?” They were given a choice of five answers: yes, definitely; yes, probably; undecided; no, probably not; and no, definitely not. Respondents who did not answer “yes, definitely” were asked if they were considering one of three possible options: considering practising medicine abroad; considering leaving medicine but remaining in the United Kingdom; or considering leaving medicine and the United Kingdom. They were then asked to specify, if they wished, in their own words in a designated text box, their main reason for considering leaving. In the analysis, we grouped the respondents into “doctors who were considering leaving the United Kingdom” (first response, above) and “doctors who were considering leaving medicine” (second or third response) (fig).

Fig 1

Derivation of data for analysis. *Includes 80 doctors who were considering leaving medicine and leaving the United Kingdom

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We imported the relevant free text replies into the “N6” qualitative data analysis software package (QSR International Pty, Melbourne, Australia). Some doctors gave a single comment, and others provided several. We coded all comments by each individual doctor. We developed the coding scheme as we read and coded each response. We coded the two groups separately (those who might leave the United Kingdom and those who might leave medicine), to ensure that for each group we developed a set of subcategories (“nodes” in the terminology of N6) that fully reflected the variety of comments of the group members. One of us (PJM) did the coding.

We used the summary terms “working conditions” and “lifestyle choices” to reflect the main reasons for leaving given by the doctors. Working conditions refers to all aspects of their day to day work as doctors, such as pay, working hours, and job satisfaction. Lifestyle choices concerns other aspects of doctors' lives unrelated to work, such as domestic, family, and personal considerations; travel aspirations; or the desire to live in a location with a better climate or a higher standard of living. This distinction, as reported by the doctors themselves, was clear in most responses. Some doctors made a connection between the two, particularly in comments about long working hours and their impact on social and domestic life. We defined a third broad category, “work related purpose.” For doctors considering leaving the United Kingdom, this refers to those who indicated a positive decision to seek specific work experience by working abroad. For doctors considering leaving medicine, it refers to a positive choice to explore other career options and interests. The subcategory “overseas relief/voluntary work” has been included within the main category “lifestyle choices,” because the comments made suggested that the motivation for this choice was related more to lifestyle choice than to working conditions in UK medicine.

We used the search facilities of the N6 software to select responses from those doctors who would probably or definitely not continue practising in the United Kingdom or in medicine. We also extracted the comments of those who commented only on working conditions or only on lifestyle choices, in order to help in assessing the degree to which policy initiatives (which would mainly impact working conditions) could encourage doctors to remain in UK medicine.

Results

Overall, 2727 (64.6%) of 4221 doctors replied to our questionnaire. Of these, 1777 (65.2%) did not definitely intend to practise medicine in the United Kingdom (fig). The data for analysis comprised comments from 1326 of these doctors (the rest did not provide comments or provided comments that we were unable to code), of whom 1047 indicated that they were considering leaving the United Kingdom and 279 were considering leaving medicine. Overall, 16.0% (212/1326) reported that they were probably not or definitely not going to continue to practise in the United Kingdom, practise medicine, or both. Table 1 summarises the main reasons given for considering leaving the United Kingdom, medicine, or both. Table 2 and table 3 provide a more detailed breakdown of the most common reasons. The box contains exemplar text extracts of reasons given by doctors for leaving medicine, the United Kingdom, or both.

Our response rate of 64.6%, although high for a postal questionnaire survey, might lead to concerns about non-responder bias. As this was the first occasion on which we had surveyed these doctors, our only information about non-responders was their sex and (clinical) medical school attended. In line with our previous surveys,7 and the general experience of survey researchers, we had a higher response from women than from men—71.4% (1568/2195) of women in the cohort and 57.8% (1171/2026) of men responded (χ² = 85.4, df = 1, P < 0.001). The response rate showed some variation by medical school in (χ² = 80.2, df = 22, P < 0.001); the only significant outliers (based on analysis of adjusted residuals), both significantly high, were Oxford medical school with 81% response and Birmingham with 79% response.

Discussion

The number of doctors who were considering leaving the United Kingdom, but staying in medicine, was considerably greater than the number considering leaving medicine. This accords with our evidence on what doctors actually do if they leave UK medicine: many more work abroad, but stay in medicine, than leave medicine.4 8 9 For those doctors who were considering leaving the United Kingdom, lifestyle choices were important to a larger number of doctors than were working conditions, although working conditions were cited as important by about 40%. In contrast, those doctors considering leaving medicine were much more likely to cite working conditions as a reason and were less concerned about lifestyle choices. Overall, nearly one third of the respondents who were considering leaving the United Kingdom, medicine, or both gave reasons solely related to working conditions. This suggests that these doctors might be persuaded to commit themselves to working in UK medicine if working conditions in the NHS improved. The analysis of the detailed breakdown of reasons given by doctors indicates that policy initiatives would be most effective if targeted at pay and at long and unsocial working hours.

Men and women gave broadly similar reasons for intending to work in medicine abroad. Women were a little more likely than men to refer to lifestyle choices associated with doing overseas relief or voluntary work, the desire to work abroad to broaden their experience, or a wish to travel for its own sake. Women who were considering leaving medicine were motivated to do so by their lifestyle choices, especially those related to domestic and social factors. Men tended to give reasons that were largely associated with direct, day to day work activities: poor working conditions, underfunding and poor facilities, low levels of job satisfaction, and poor job and career prospects. This was the case whether male respondents were considering leaving the United Kingdom or leaving medicine. This suggests that young women doctors continue to find it difficult to balance the demands of work and their domestic and social responsibilities and needs, whereas young male doctors largely focus on factors that are directly related to work and career.

The study's main focus was on reasons that led some young doctors to feel disaffection with UK medicine. However, we can also say a little about the motivating factors for those who said they definitely intended a UK medical career. They showed greater satisfaction with their career prospects, had enjoyed the pre-registration house officer year more, and had been more satisfied with the leisure time available to them than had their colleagues who wished to leave. They were also considerably more definite about their long term career choices. Interpreting these results is difficult, but they hint that those doctors who definitely intend to remain in UK medicine may have a more realistic attitude to the practicality of a medical career than others.

Working hours have been subject to recent government policy initiatives. The reduction of working hours, and changes in working patterns to accommodate this reduction, have been progressing as a result of the “new deal” and the European Working Time Directive.10 11 Compliance with targets on reduced working hours has improved nationally: from 61.6% in 2000 to 79.0% in 2003.12 13 This suggests that very long and unsocial working hours should soon no longer be a fundamental feature of UK postgraduate medical training. However, problems remain in fully complying with working hours regulations within the timeframe required. In addition, the reforms to training at senior house officer level, and the need to ensure that there are enough doctors at all grades to provide 24 hour cover,14 probably means that problems related to working hours and their unsocial effect will continue for some time. Concern also exists about whether the reduction in working hours will reduce doctors' opportunities to gain enough experience to become adequately trained.14 Current policy documents make it clear that the Department of Health and the NHS are attempting to tackle adverse working conditions.2 3 11 If the benefits of the recent large increase in the numbers of UK medical students are to be fully realised in the NHS, measures must be taken to minimise avoidable attrition.