Progression of junior doctors into higher specialist training

OBJECTIVES: To report on the transition of junior doctors into higher specialist training in the UK, following the Calman reforms and recent initiatives to promote training in general practice. Design and setting Postal questionnaire survey carried out in the UK. PARTICIPANTS: All graduates of 1996 from UK medical schools were surveyed in 2002. MAIN OUTCOME MEASURES: Outcome measures were considered to be details of applications, outcomes of applications, intentions to apply for specialist training, and career plans with regard to such issues as flexible training and work. RESULTS: Of 2312 responders, 39% had applied for specialist registrar (SpR) training and 35% for general practice (GP) training. Of applicants for SpR training, 68% were successful; 24% failed, almost all of whom intended to reapply, many after gaining research experience; 4% awaited a decision, and 4% had had another outcome (e.g. they withdrew their application). A sixth of responders intended to apply but had not yet done so. Of applicants for GP training, 95% had been successful. A further 2% intended to apply but had not yet done so. Responders viewed flexible and part-time training and work opportunities, and information about available posts, as being more widely available in general practice than in hospital practice. Half of the responders did not agree that their postgraduate training had been of a high standard. CONCLUSIONS: Progression into GP training seemed to have been a smoother and less protracted process than that into SpR training. Delayed applications for SpR training were common, and many of those who had applied had not been accepted. The use of research experience to strengthen a re-application was common.     

Views of doctors in training on the importance and availability of career advice in UK medicine

OBJECTIVES: To determine whether doctors in their first year after qualification wanted career advice, and, if so, whether they thought they had been able to obtain useful advice, and whether older doctors thought that adequate career advice had been available to them. METHODS: We carried out a postal questionnaire survey of all UK medical graduates of 1988, 1993, 1996, 1999 and 2002, and a 25% random sample of the graduates of 2000. RESULTS: The response rate was 67.4% (24 261/35 976 mailed questionnaires). Of doctors in the first postgraduate year, 95% agreed that: 'It is important to be given career advice at this stage of training.' A total of 38% disagreed with the statement: 'I have been able to obtain useful career advice since graduation.' Of more experienced doctors surveyed between 3 and 11 years after graduation, 34% agreed that: 'Making career choices has been made more difficult by inadequate career advice.' CONCLUSIONS: The great majority of junior doctors want career advice after qualification. It cannot be assumed that they are able to seek it out for themselves satisfactorily. Career advice needs to be planned into postgraduate work and training.     

Variation by medical school in career choices of UK graduates of 1999 and 2000

OBJECTIVE: To report on how newly qualified doctors' specialty choices, and factors that influenced them, varied by medical school. DESIGN: Postal questionnaires. SETTING: United Kingdom. SUBJECTS: All doctors who graduated in the UK in 1999 and 2000. MAIN OUTCOME MEASURES: Choices of eventual career expressed 1 year after graduating, and factors influencing their choices. RESULTS: There were some significant differences between medical schools in the career choices made by their graduates. For example, the percentage of respondents who expressed the choice of general practice was significantly low among graduates of Oxford and Cambridge and high among graduates of Birmingham and Leicester. There was also significant variation between medical schools in choices for hospital medical and surgical specialties. There were significant differences, too, between medical schools in the extent to which career choices had been strongly influenced by graduates' inclinations before starting medical school and by their experience of their chosen specialty, particular teachers and departments at medical school. As well as the differences, however, there were also many similarities between the schools in graduates' career choices. DISCUSSION: Medical schools currently provide students with a broad training suited to any subsequent choice of specialty. We suggest that the similarities between schools in the career choices made by graduates are generally more striking than the differences. We raise the question of whether there should be any specialisation by individual schools to train students for careers in particular branches of medical practice.     

The effect of gender on medical students' aspirations: a qualitative study

Objective  This study aimed to explore the effect of gender on medical students' aspirations.
Methods  The study design included purposive sampling and interim data interpretation to guide recruitment of medical students with a wide spectrum of opinions. Data were collected through audio-recorded, semi-structured, in-depth exploratory interviews, which were transcribed verbatim. Qualitative analysis was carried out by a female medical student researcher. Her evolving interpretation was constantly compared against the original data by male (doctor) and female (pharmacist) staff researchers in a systematic search for internal corroboration or disconfirmation. Causal associations consistently present in the data are reported.
Results  Six male and six female medical students in Years 3 and 4 shared a wish to achieve a work−life balance that allowed them to devote time to bringing up children while contributing usefully to society as doctors. However, women were readier to compromise professional attainment within their personal work−life balances. Their readiness derived from gendered stereotypes of women's social and professional roles, a lack of female professional role models, womens' greater awareness of the tensions between career and family, various other informal social influences, and a lack of positive career advice to counterbalance these influences.
Conclusions  Better career advice and more flexible work opportunities are needed if the two-thirds of medical students who are women are to contribute specialist as well as generalist expertise to the medical workforce.     

Attachment theory in health care: the influence of relationship style on medical students' specialty choice

INTRODUCTION: Converging sources suggest that patient-provider relationships in primary care are generally of greater intensity and duration than those in non-primary care specialties. In this study, we hypothesised that Year 2 medical students whose close relationships were characterised by security and flexibility would be more likely than students who were less comfortable in close relationships to plan to pursue primary over non-primary care postgraduate training. METHODS: We determined the relationship styles and demographic characteristics of 144 Year 2 medical students. We also gathered information regarding their predicted choices of postgraduate training, which were clustered into primary or non-primary care categories. We compared student choices with respect to their interpersonal relationship styles based on attachment theory. RESULTS: Prevalences of attachment styles were similar to those found in the general population, with 56% of students rating themselves as having a secure relationship style. Students with a secure style were more likely to choose primary care (61%) over non-primary care compared to those whose styles were characterised by self-reliance, support-seeking or caution (41% chose primary care). Compared to those with a secure relationship style, students with a cautious style [OR = 5.9 (1.9, 18.7)] and students with a self-reliant style [OR = 2.4 (0.96, 5.9)] were more likely to choose non-primary over primary care, after controlling for gender. CONCLUSIONS: Assessing relationship styles using attachment theory is a potentially useful way to understand and counsel medical students about specialty choice.     

Training of Kuwaiti medical doctors and their specialty choices: sociocultural impact

Kuwait has a comprehensive and well-structured health care system. However, to deliver such care the country relies on expatriate medical doctors. This paper attempts to discuss the sociocultural influences on the training of Kuwaiti medical doctors and their specialty choices in order to gauge future requirements of the Kuwaiti Health Services.     

Perceptions of the learning environment in higher specialist training of doctors: implications for recruitment and retention

INTRODUCTION: Career choice, sense of professional identity and career behaviour are influenced, subject to change and capable of development through interaction with the learning environment. In this paper workplace learning discourses are used to frame ongoing concerns associated with higher specialist training. Data from the first stage of a multimethods investigation into recruitment into and retention in specialties in the West Midlands is used to consider some possible effects of the specialist learning environment on recruitment and retention. METHODS: The aim of the study was to identify issues, through interviews with 6 consultants and questionnaires completed by specialist registrars from specialties representing a range of recruitment levels. These would inform subsequent study of attributes and dispositions relevant to specialist practice and recruitment. The data were analysed using NVivo software for qualitative data management. RESULTS: Participants' perceptions are presented as bipolar dimensions, associated with: curriculum structure, learning relationships, assessment of learning, and learning climate. They demonstrate ongoing struggle between different models of workplace learning. CONCLUSION: Changes in the postgraduate education of doctors seem set to continue well into the future. How these are reflected in the balance between workplace learning models, and how they influence doctors' sense of identity as specialists suggests a useful basis for examination of career satisfaction and recruitment to specialties.     

Educational supervisors evaluate the preparedness of graduates from a reformed UK curriculum to work as pre-registration house officers (PRHOs): a qualitative study

INTRODUCTION: In 1996 the University of Liverpool introduced an integrated problem-based learning (PBL) medical curriculum incorporating the recommendations of Tomorrow's Doctors. This paper investigates whether the PRHO (pre-registration house officer) educational supervisors who supervise Liverpool graduates believe that the reformed curriculum is producing house officers who have the competencies outlined by the General Medical Council. METHODS: Forty-one interviews were arranged with a sample of educational supervisors in the Mersey Deanery area to ascertain their views on the competencies of Liverpool PRHOs. The interviews were tape-recorded, transcribed and analysed. RESULTS: The supervisors felt that the PRHOs had been well prepared to work as PRHOs, and compared with traditional graduates they were actually better prepared for the job of PRHO. They saw the PRHOs as competent communicators with improved clinical skills, who had good attitudes, were aware of limitations, were team workers, good at history-taking and examination and had different approaches to finding information. There was a very confusing picture regarding basic knowledge, with some consultants expressing concerns, despite saying they had adequate knowledge to work as PRHOs. It emerged that there was little consensus about the knowledge base of the traditional or PBL graduates or what knowledge level was needed at this stage. DISCUSSION: Educational supervisors believe that the reformed curriculum in Liverpool is producing competent PRHOs who have been better prepared for the role of PRHO than previous graduates. It could be that uncertainty over knowledge base may be the price paid for reducing the factual burden and improving preparedness for professional practice.     

Current practice patterns and training status of selected graduates at the King Abdulaziz University College of Medicine, Saudi Arabia

Graduate doctors are the primary output of medical education programmes. It is important for institutions to identify systematically the types of medical activities in which their former students are involved in order to determine the effectiveness of the curriculum, assessing academic standards and reviewing admissions policies. Information was obtained from a survey of men and women graduates from three of the early graduation classes of King Abdulaziz University College of Medicine in Saudi Arabia about postgraduate medical training, certification, practice patterns, and other curriculum issues. Information collected from 151 graduates (90%) indicated that 96% were practising medicine in a variety of medical specialties and subspecialties. Six were not practising at the time of the study. Significant differences were found in the specialties being practised when men and women were compared. Men tended to practise in medicine, surgery, dermatology, urology, ENT, ophthalmology and orthopaedics, while women concentrated in obstetrics and gynaecology and paediatrics. Certification beyond medical school was earned by 49% with no significant difference being found comparing men to women. Men earned the majority of their postgraduate certifications outside Saudi Arabia while most women earned theirs in Saudi Arabia. Graduates indicated that departments in the basic sciences were least helpful in preparing them as doctors, while selected clinical departments were most helpful. It was concluded from the study that the curriculum goals of the College of Medicine, namely a curriculum of international standards producing graduates to take leadership roles in both teaching and medical practice, were realized in part by the graduates surveyed.     

Responding to the implications of the genetics revolution for the education and training of doctors: a medical humanities approach

BACKGROUND: Rapid advances in the field of genetics continue to present medical educators with significant challenges. Whilst there is undoubtedly a pressing need to educate doctors about genetic disorders, research and therapies, there is a parallel need to provide a context for all of these. CONTENT: An interdisciplinary, arts and humanities based approach, responding to this need, is described. This teaching has been successfully delivered both as optional and core undergraduate teaching, and as part of continuing professional development. THE HUMAN PERSPECTIVE: STORIES NOT HISTORIES: Understanding of the patient's perspective can be significantly improved by drawing on both written and oral stories of illness. THE HISTORICAL PERSPECTIVE: LEARNING FROM THE PATIENT: Experiential learning provides insights into the social history of developments in genetics, thereby placing the current concern and debate about the new genetics in context. THE ROLE OF THE MEDIA: THE POWER TO PERSUADE: Critical reading skills can be developed and the power of the popular press to influence the reader acknowledged by analysing and employing the skills of the journalist when reporting developments in biotechnology. LEARNER ASSESSMENT AND EVALUATION: Assessment, both formative and summative, demonstrates sophisticated insights and perspectives into the lived experience of genetic illness. Learner evaluation of the teaching is high. CONCLUSION: Medical humanities offers a powerful way to convey an understanding of how genetic disorders impact on the lives of patients and families, and to set this against the background of a history rich in the uses, and abuses, of knowledge of heredity.     

Perceived stress during undergraduate medical training: a qualitative study

INTRODUCTION: Medical education is long and emotionally taxing. It can involve levels of stress that lead to disruptions in both physical and mental health. This qualitative study explores the views of Year 5 medical students on the causes of stress throughout their undergraduate medical training. METHOD: Semi-structured interviews were conducted with 21 final year medical students at the University of Birmingham between January and May 2001. RESULTS: Pressure of work, especially in terms of preparing for examinations and acquiring professional knowledge, skills and attitudes were reported as the most stressful aspects of medical training. Transition periods, particularly between school and medical school, preclinical and clinical training, and clinical training to approaching qualification were highlighted as particularly stressful. A perceived lack of support from the medical school authorities also appeared to add to student stress levels. DISCUSSION: Student stress may be alleviated by greater guidance and support from the medical school during crucial transition periods. Aspects of professional socialisation may also need to be addressed to reduce the levels of stress associated with undergraduate training for future generations of medical students.     

Careers in medicine: appointment to specialist training posts in Queensland in 1988

Appointments to accredited specialist training positions in the State of Queensland, Australia in 1988 were analysed to show the success rates of applicants. Women were less likely to apply for training, but gained proportionately more appointments than men. Other factors in success were application from a major teaching hospital, graduation from the State medical school and, for new applicants, an honours degree. The success rates in various specialties differed significantly as did their appeal to women and to honours graduates. It is concluded that new graduates need better information and advice on career choice and that individual disciplines need to look carefully at the image and organization of their training programmes.     

An evaluation of a national scheme for continuing professional development (CPD) for career grade doctors: the Royal College of Paediatrics and Child Health's programme for paediatricians evaluated by focus group methodology

OBJECTIVES: To evaluate a national continuing professional development (CPD) scheme through the views and experiences of its participants. METHODS: A qualitative focus group methodology was used. Forty-nine career grade paediatricians were allocated to nine focus groups according to their work settings, ages and posts. All groups discussed the following: (a) ease or difficulty of achieving CPD requirements; (b) whether a personal professional development plan (PDP) enabled the planning process for CPD; (c) whether CPD participation facilitated changes in practice, and (d) their views on the CPD system in operation at the time of the study. RESULTS: Taking part in CPD had a positive effect on participants' clinical practice and broadened their professional and academic base. The main difficulties in achieving CPD were variable financial support (especially for non-consultant staff) and pressure due to extra work accumulating during study leave. The quality of internal CPD meetings was inconsistent. A professional development plan was useful for planning CPD needs, but there was a conflict between the educational and training needs of the individual and the employing NHS Trusts. The scheme's guidelines were clear but there were reservations about its layout and the system of recording points. CONCLUSION: This study enabled discovery of the views of paediatricians participating in a national CPD scheme operated by the Royal College of Paediatrics and Child Health. Consequently, changes were made to the scheme's presentation (but not content) and process of recording points. Barriers to achieving CPD requirements were identified and are being monitored. Efforts to involve non-consultant career grade paediatricians have been increased.     

Continuing medical education and career choice among graduates of problem-based and traditional curricula

A survey was conducted among graduates of two Canadian medical schools who have been in practice for more than 9 years. The purpose of the study was to test the hypothesis that graduates of a problem-based curriculum differ from graduates of a traditional curriculum in their attitude to and participation in continuing medical education (CME) activities. Differences were noted in the rate of participation in certain CME activities (attendance at national and international conferences and meetings) between specialists and family doctors in both groups of alumni. However, the data indicate that the differences in learning-teaching methods employed in the course of the undergraduate medical curriculum do not exert a decisive influence upon the learning habits of the graduates.     

Allocation of junior hospital doctors to pre-registration posts: does Britain need a national matching scheme?

The attitudes of British postgraduate deans and senior medical students to the introduction of a national pre-registration house officer allocation scheme were investigated by postal questionnaire. Several postgraduate deans expressed interest, but most were not in favour of the proposal. Students held similar views. The advantages and disadvantages of a national scheme are discussed.     

Education and training in the senior house officer grade: results from a cohort study of United Kingdom medical graduates

INTRODUCTION: This paper shows the findings from a survey of 439 senior house officers undertaken as part of the British Medical Association cohort study of 1995 medical graduates. The aim of the study was to assess the quality of senior house officer training in the United Kingdom. METHOD: In July 1997 a postal questionnaire was sent to a sample of 545 doctors who graduated from medical school in 1995. Responses were received from 515 (95%). Only those doctors who had worked as a senior house officer in the previous 12 months were included in the analysis (n = 439). RESULTS: Encouraging results are that 69% of the senior house officers surveyed had discussed their progress directly with their consultant, and 24% rated their supervision by their consultant as 'excellent'. Of concern are the findings that 47% of respondents did not receive protected teaching time and 16% were unable to take study leave. DISCUSSION: The study revealed wide variability in the quality of training received by senior house officers in the United Kingdom. Whilst some respondents - notably those in general practice, accident and emergency, paediatrics and psychiatry - had enjoyed a high standard of education and training, it was clear that a minority of posts continue to offer little if any educational value to the post holder. The results point to a need for a more systematic approach to maintaining standards in senior house officer training with greater incentives for under-performing trusts.     

Teaching medical English to foreign-language doctors

Acquisition of an advanced medical degree beyond licensure and specialization is advantageous and encouraged in Swedish medical education. Since a thesis and a number of published works, usually in English are required, there is considerable interest in medical writing by doctors and medical scientists. A voluntary course in 'Biomedical Authorship' which included presentation of oral reports was offered by the Karolinska Institutes' Medical Faculty. This course was intended to prepare participants for their thesis work and for presentations at scientific congresses. The course revealed that the principle difficulty was not in English skills which were rather good, but in the students' inexperience in critically rereading what they had written and making suitable revisions. A case study method was used so that students acquired experience in critically reading and correcting their own work and that of others. An instructor who understood the evolution of academic Swedish was of considerable help in explaining some of the 'Swenglishisms' that arose during the course. The oral presentation portion, which used videotapes of students, showed the students as lacking experience in basic public speaking and as frequently being apprehensive. This was much improved by taped poetry readings, scientific reports and slide shows. This Swedish experience should apply to teaching biomedical writing in the other Scandinavian countries and in Northern Europe.     

Views of junior doctors about their work: survey of qualifiers of 1993 and 1996 from United Kingdom medical schools

OBJECTIVE: To investigate the views of junior doctors about their work. DESIGN: Postal questionnaire surveys. SETTING: United Kingdom. SUBJECTS: Doctors who graduated from medical schools in the United Kingdom in 1996, surveyed at the end of their preregistration year (2926 respondents), and graduates of 1993 surveyed 3 years after qualification (2541 respondents). RESULTS: Almost 70% of the 1996 qualifiers felt that they worked excessive hours and 80% felt that they undertook too many routine non-clinical duties. Only 24% agreed that their postgraduate training was of a high standard and 22% felt they were being asked to perform clinical tasks with inadequate training. A total of 70% were dissatisfied with arrangements for cover for absent doctors. Senior doctors and nurses were regarded as supportive by most respondents, but hospital management was not. Although 65% were satisfied with their future prospects, only 36% had been able to obtain useful careers advice. Job enjoyment was reasonably high, with two-thirds scoring 6 or more on a scale from 1 (not enjoying at all) to 10 (greatly enjoying), but 70% of respondents felt that they had insufficient time for family and social activities. A briefer questionnaire sent to the 1993 qualifiers in 1996 showed similar results. CONCLUSIONS: More needs to be done to ensure that junior doctors are trained appropriately for the tasks they undertake, to ensure that they regard their training highly, to reduce excessive non-clinical work, and to provide reasonable working hours and cover.