Medical graduates’ early career choices of specialty and their eventual specialty destinations: UK prospective cohort studies
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3199 (Published 06 July 2010) Cite this as: BMJ 2010;341:c3199All rapid responses
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I am really glad to see this study being done. It highlights the
importance of choosing one's career and specialty after taking all the
factors into consideration. After all, doctors are choosing their lifetime
career in one specialty. The cohort used in this study have been until
1996 but I feel that we need a prospective cohort study to be done
especially including the doctors from the recent years especially after
the introduction of Modernising medical careers in 2007.
The introduction
of Foundation years 1 and 2 does help the situation to a certain extent,
but it does not allow the doctors to have experience in all the broader
disciplines and specialties before they take an informed choice about the
specialty they want to pursue and be in for the rest of their lives. I
feel there should be more flexibility for doctors to change specialties in
the first two years of specialty training i.e. what we say as beeing a
core trainee (CT1s and CT2s). This will allow doctors to have first hand
experience of working in a particular specialty and to know all the
positives and negatives of that specialty and then decide whether to
continue in the same specialty or change over to the other perceived
better ones.
This also raises the question of membership exams that need
to be attempted in the first or second year of the specialty training and
so there should evolve a mechanism where broader discipline academic
colleges can work in partnership with each other. This study has
especially highlighted about the surgical discipline and how doctors chose
this particular discipline earlier in their career. But we need to
consider the larger picture about the other disciplines such as
Paediatrics, Anaesthesia or Psychiatry where it has been perceived to have
not attracted many medical students and Foundation doctors as a chosen
specialty. So we should be able to give that flexibility to the doctors in
their earlier years of their career so that they can make an informed
choice about the specialty they will ultimately be settling in.
Otherwise, it will be like once in a lifetime career but only one chance
is given to choose when most of us will not be having any knowledge of
working in many disciplines. I hope that more similar studies are done to
enlighten us about potential future specialty options in the earlier years
of our career.
Competing interests:
None declared
Competing interests: No competing interests
I read this paper with great interest as it covers an issue that
affects health care planning and provision especially with the projected
shortage of specialists.
The study which starts with over 15000 young doctors (ending with about
8000 responding) with cohorts starting from 1974 shows us that for
surgeons, there are clear early career preferences, with over 90% of those
who ended up as surgeons knowing that they wanted to be surgeons in their first
year. Therefore it is understandable that those who are surgeons selecting
young doctors for surgery will consider an early career choice obvious.
However this data hides another interpretation as it is apparent from the
data in table 4 that in only two specialties (general practice and
psychiatry) was there over a 60% chance that someone who was PGY1 would
end up in their chosen specialties. Some specialties e.g. surgery appear
to have a less than 60% chance that those who want to do surgery end up as
surgeons. This would suggest that it may be best for training programs to
allow time for young doctors to mature and understand the expectations and
requirements for their chosen specialty and not get swept along in the
race for their “once in a life “ chance at their speciality.
Considering this, colleges should carefully review their selection
criteria and reflect on the advisably of selecting only surgical trainees
in their early PGY years.
*Adapted from Oscar Wilde, Lady Windermere's Fan, 1892, Act III,
Irish dramatist, novelist, & poet (1854 - 1900)
Competing interests:
None declared
Competing interests: No competing interests
We reply to Professor Kaczorowski. Our published sentence, in full,
was: 'Compared with the availability of posts, too many newly qualified
doctors in the UK want careers in hospital specialties and too few in
general practice.' 1 This is clearly the case: the ratio of doctors
wanting a post in general practice in year one to those in a GP post in
year ten was 81% (2981/3689, our table 4). The ratio of those wanting a
post in hospital practice in year one to those in a hospital post in year
ten was 114% (5600/4892, table 4). We have also published on posts as
well as postholders: in that study the percentage of newly qualified
doctors (UK graduates of 2002) who wanted to be a GP was 23%, but GPs
comprised 51% of the career grade workforce.2 It almost goes without
saying that the mismatches between early choice and becoming a postholder
reflect the availability of posts across different specialties. However,
the mismatches are not artefacts of the availability of posts. They are
inevitable consequences of it. Our conclusion, repeated in the second
sentence of this letter, is correct. It is also very important, because
medical students and young doctors need to understand that many of them
will have to be (and hopefully will want to be) GPs.
Professor Kaczorowski is addressing a different question from that
implied in his conclusion (and letter title). He addresses whether the
mismatch between early choice and later destination is unique to general
practice. It is not. Table 4 can be used to show that the ratio of those
in post as GPs, to those who originally specified general practice as
their career choice, was 1.24 to 1. The other specialties in our table 4
where there are more ‘doers’ than ‘choosers’ are accident and emergency
medicine, where the ratio of eventual doers to early choosers is 1.52,
anaesthetics 1.23, radiology 1.77, clinical oncology 1.86, pathology 1.31,
psychiatry 1.34 and public health 2.98 (these, we think, are the data that
Professor Kaczorowski has plotted on the horizontal axis of his graph).
Those with fewer doers than choosers are the hospital medical specialties
where the ratio of doers to choosers is 0.61, paediatrics 0.72, surgery
0.64 and obstetrics and gynaecology 0.70. The points about general
practice as a career choice, worthy of particular comment, are that it is
numerically a very large specialty and that, at least in the UK, policies
encourage the care of patients in general practice rather than hospital
wherever possible.
1. Goldacre MJ, Laxton L, Lambert TW. Medical graduates’ early
career choices of specialty and their eventual specialty destinations: UK
prospective cohort studies. BMJ 2010 Jul 6; 341:c3199. doi:
10.1136/bmj.c3199
2. Lambert TW, Goldacre MJ, Turner G. Career choices of the United Kingdom
medical graduates of 2002: questionnaire survey. Medical Education 2006;
40: 514-521.
Competing interests:
None declared
Competing interests: No competing interests
To the Editor:
The study by Goldacre and colleagues<_1/> reported the results of
medical graduates’ early career choices and their specialty destinations
10 years after graduation using large prospective cohort of all UK medical
school graduates going back to 1974. They concluded that 10 years after
qualification approximately 25% of doctors were working in a specialty
that was different from the one chosen in their third year after
graduation. However, I disagree with the authors’ conclusion that too many
newly qualified doctors in the United Kingdom want careers in hospital
specialties and too few in general practice. In my opinion, this
conclusion is an artifact of asymmetry due to disproportionate
availability of posts across different specialties.
Applying a somewhat modified supply and demand model and using the
data for untied first choice of career one year after graduation and
eventual destination 10 years after graduation across all cohorts (Table
4), it is possible to fit the supply/demand ratio (using marginal rows of
first choice of career one year after graduation / marginal columns of
eventual career 10 years after graduation) for each specialty against the
ratio of actual matches between early choice and later destinations for
each specialty (untied first choice of career one year after graduation/
later career destinations), and show that the two are significantly and
inversely correlated. More specifically, there is a statistically
significant inverse correlation across all career choices and cohorts
between these two ratios as shown in Figure 1, with little indication to
support the conclusion that general practice is an outlier (General
Practice = black dot).
References:
1. Goldacre MJ, Laxton L, Lambert TW. Medical graduates’ early career
choices of specialty and their eventual specialty destinations: UK
prospective cohort studies. BMJ 2010;340:c3199 doi:10.1136/bmj.c3199
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
Goldacre et al’s cohort study investigating the early career choices
of specialty by UK graduates raises some interesting points(1). The most
obvious point lies in the importance of providing early and solid career
guidance, together with a clear review of the medical workforce. This
should be done at both undergraduate and post-graduate level, by medical
schools, Deaneries and Colleges. Whilst this in place in some areas, the
quality of guidance remains variable at best. The recently set up Centre
for Workforce Intelligence will be analysing the UK population’s need for
doctors which could help to guide the expansion or retraction of certain
specialties, but the results of their analysis must be available to all to
allow people to draw their own conclusions.
In addition, the findings of Goldacre’s study suggest that nearly
half of medical graduates were in a different specialty from their choice
at the end of their first professional practice, ten years later. This
consolidates the need for a broad-based foundation, as is currently
provided by the two-year Foundation Programme undertaken by all new UK
graduates. This provides junior doctors with a core grounding in key
clinical skills, as well as affording an insight into specialties which
they may otherwise not have worked in.
One potential solution to allow doctors to change specialties may lie
in developing transferable competencies, which will acknowledge the skills
and experience picked up in previous posts that are relevant to posts in a
different specialty. The Government’s recently published White Paper(2)
promises a period of review for post-graduate training where perhaps such
solutions can be considered in greater detail.
Yours sincerely,
Miss Shreelata Datta
1. Goldacre MJ, Laxton L, Lambert TW. Medical graduates’ early career
choices of specialty and their eventual specialty destinations: UK
prospective cohort studies. BMJ 2010; 341:c3199
2. Secretary of State for Health. Equity and excellence: liberating
the NHS. Department of Health, 2010.
www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspoli...
Competing interests:
STD is currently Chair of the UK Junior Doctors' Committee
Competing interests: No competing interests
The findings of the article are interesting and give an insight and
predication of future trends in careers choices. The cohorts studied were
starting out in their careers during a more flexible and generic training
era. Today, it feels that trainees have to make a choice on career pathway
from day 1 of training and within 18 months of qualification, by
definition have to choose on the major pathway they want to, or most want
to pursue. I am currently working as an F2 in Trauma and Orthopaedics but
by the time I had started this post I had already applied and been
allocated a post in Core Medical Training. Fortunately this is the path I
wish to pursue but I have enjoyed the Trauma experience, far more than I
thought and who knows how I would have applied if I had been given more
time to experience different working environments and specialities.
I support the call that the authors make to "streamline" training and
career progression for those who know what they want and maybe Royal
Colleges should even consider creating "themed" rotations for Core years
for those who already know they want to become cardiologists, oncologists
et al. However, I feel this also highlights the importance of career
advice for young doctors who are unsure of career ambitions. It seems the
only option doctors perceive open to them at present is to up sticks and
work in Australia and that is something that neither the UK medical
workforce or our patients can afford to happen.
Competing interests:
None declared
Competing interests: No competing interests
Re: Medical graduates’ early career choices of specialty and their eventual specialty destinations: UK prospective cohort studies
Orthopaedic Sports Medicine
Orthopaedics is broadly considered to be a surgical speciality concerned with disorders of the musculoskeletal system and there has always historically been a shared interest between Orthopaedic surgery and Sports medicine. In the UK, Sports medicine has traditionally been an unrecognised side interest for Orthopaedic surgeons, physicians and general practitioners until recently. In 2005 Sports and Exercise medicine (SEM) was officially made a GMC-approved postgraduate speciality training pathway in the UK.
The current requirements for entry into ST3 for SEM are as follows: completion of core medical training (CMT), acute care common stem (ACCS) or general practice speciality training (GPVTS).
For a junior doctor who may have an interest in both Orthopaedics and Sports medicine this can lead to tough choices in the present system. Although there remains little crossover in the UK it is interesting to note that this is not the case in other countries.
In America, the American Orthopaedic Society for Sports Medicine is a world leader in sports medicine research and education. Founded in 1972 it still remains largely made up of orthopaedic surgeons with an interest in Sports medicine. Sports medicine is recognised in the States as a sub speciality of Orthopaedic surgery.
In Australia, the Australasian College of Sports Physicians is the recognised body and eligibility is open to any fully qualified Australian resident Doctor who has completed their foundation years in Australia. This means no previous speciality training is required.
The current GMC recognised speciality pathway could learn a lot from either of these two different foreign pathways. One of the many criticisms surrounding the change to MMC career pathways has been the rigidity of the new career pathways and lack of crossover between specialities.
MMC (modernising medical careers) was introduced in 2005 to replace the traditional postgraduate career pathway in medicine and improve patient care by “Improving medical education with a transparent and efficient career path for doctors”
The difficulty is that Doctors are being forced to enter a speciality pathway earlier than ever before and there is little room to manoeuvre yourself sideways to another speciality without returning to the bottom rung of the ladder (CT or ST1). In the case of Sports medicine that is a minimum of three years in the recognised pathways just to be eligible and enter fierce open competition for limited places.
Many current trainees in Orthopaedics are completing postgraduate Masters and Diplomas in Sports and Exercise medicine because they naturally have an interest in this area (admittedly also to stay abreast of the considerable competition in this speciality). It is worth noting that in the current system up to half of core surgical trainees are unsuccessful at gaining a registrar (ST3) post at CT2. In the future, perhaps the eligibility criteria for Sports and exercise medicine could be reviewed. This would surely offer greater career mobility in this particular area. There are countless other areas of medicine that have considerable crossover and could also benefit from similar attention such as neurology and neurosurgery. If the eligibility criteria for other specialities was also reviewed throughout the whole system to allow greater access from other specialities and at least acknowledge other forms of medical training it would lead to a more satisfied Doctor workforce and ultimately better patient outcomes.
Competing interests: No competing interests