Doctors' reasons for rejecting initial choices of specialties as long-term careers

OBJECTIVES: To report on rejected choices of specialty as long-term careers and reasons for rejection. DESIGN: Postal questionnaire survey. SETTING: United Kingdom. PARTICIPANTS: All graduates of 1996 and 1999 from UK medical schools during their first year after qualification. MAIN OUTCOME MEASURES: Any career choice which had been seriously considered and rejected and the reason for its rejection. RESULTS: In all, 33.1% (1871) of respondents named a rejected choice and gave reasons for its rejection. Disproportionately high numbers rejected the surgical specialties, paediatrics and obstetrics and gynaecology (O&G), using the specialty distribution of positive choices as the comparator. Relatively few doctors rejected general practice (GP) after giving it serious consideration. Doctors rejecting the hospital medical and surgical specialties or paediatrics were most likely to specify reasons relating to quality of life. Three-quarters of the graduates of 1999 who rejected O&G did so because of poor career prospects. CONCLUSIONS: Quality of life issues, and concerns about working relationships, are sufficiently influential to persuade many doctors to abandon an initial choice of medical career. It is unlikely that much of the decline in entry to GP is attributable to rejection of GP by doctors who initially chose it. The decline must therefore represent an increase in the number of doctors who had never seriously considered it as a long-term career choice.     

Career satisfaction and professional accomplishments

Medical Education 2010: 44 : 969–976 Context Research on doctor career satisfaction has often focused on factors such as income, specialty, gender, work hours, autonomy, patient load, lifestyle preferences, work environment, and insurance regulations. Other educational, personal and professional factors have not received sufficient empirical attention. Objective This study was designed to test the following five hypotheses that doctors’ career satisfaction is associated with: (i) Higher satisfaction with their undergraduate medical education; (ii) Greater academic and clinical competence; (iii) More involvement in teaching and research activities; (iv) Higher orientation toward lifelong learning; and (v) Increased professional accomplishments. Methods A survey was mailed in 2006 to a national sample of 5349 doctors in the United States who graduated from Jefferson Medical College between 1975 and 2000; 3170 (59%) returned completed surveys. Based on responses to a career satisfaction question, doctors were classified into three groups: Highly satisfied (top third, n = 1078); moderately satisfied (middle third, n = 1031); and least satisfied (bottom third, n = 1061). These groups were compared on a number of variables. Results All five research hypotheses were confirmed. Additionally, no significant association was observed between career satisfaction, age, years in practice, gender, or ethnicity; however, career satisfaction was associated with doctors’ specialties. Conclusions The findings suggest that factors such as satisfaction with medical education, medical school class rank, assessments of clinical competence, teaching, and research activities, orientation toward lifelong learning, and professional accomplishments should be considered for a more comprehensive understanding of doctors’ career satisfaction.     

Participation in the workforce by Australian medical graduates

OBJECTIVE: To investigate workforce participation patterns among Australian medical graduates and the extent of cohort differences in these patterns. DESIGN: We carried out a retrospective longitudinal cohort study, with data collected by postal survey on current occupation, location, absences from the workforce and occupation since graduation. PARTICIPANTS: Graduates who had completed their basic medical training at Monash University, Melbourne, Australia, in 1980, 1985, 1990 and 1995 were invited to participate (n = 546); 368 took part in the study (69%). OUTCOME MEASURES: The proportion of graduates in the Australian medical workforce, the equivalent full-time contribution to the Australian medical workforce, and the proportion taking temporary absences from the workforce were determined. RESULTS: The rate of participation in the Australian medical workforce was 96% 2 years after graduation. It then declined to reach 85% by 10 years and regained slightly to reach 88% by 15 years after graduation. There was no indication that the 1995 cohort made a lower contribution to the Australian medical workforce than the earlier cohorts in their first 7 years after graduation. CONCLUSION: Although there are few indications of differences between these cohorts during the first 7 years after graduation, the main contributing factors to losses from the Australian medical workforce -- medical work overseas and parental leave -- do not exert their maximum influence until a later time point. Longitudinal cohort data are essential for monitoring trends in medical workforce participation and hence for effective workforce planning.     

A comparison of practice outcomes of graduates from traditional and non-traditional medical schools in Australia

AIM: The primary aim of the study was to compare the practice outcomes of doctors who graduated from a non-traditional, problem-based medical school (University of Newcastle) with those of graduates from a traditional programme (University of Sydney), matched randomly on the background characteristics of graduation year, age, gender, and rural primary and secondary school education. Our secondary aim was to differentiate admission from curricular influences by comparing the outcomes of Newcastle and Sydney graduates who entered medical school under similar admission criteria ('traditional academic' entry). DESIGN: Nested case-control analysis in a retrospective cohort study. METHODS: A validated mail-out survey was distributed to all Newcastle and Sydney graduates registered to practise in the state of New South Wales, Australia. OUTCOME MEASURES: Current main occupation (clinician or other), clinical career choice (family medicine and psychiatry or other specialties), practice location (urban or rural) and employment sector (public or private). RESULTS: A total of 513 Newcastle respondents (68% of the original, eligible Newcastle sample) were each matched randomly with a Sydney respondent according to the four background characteristics. Medical school background was not related to main occupation; over 90% of all graduates were employed in clinician positions. A greater proportion of Newcastle than Sydney graduates were either training or qualified in family medicine or psychiatry rather than in other specialties. The school of graduation was not related to practice environment; fewer than 20% of all graduates were working in rural locations and around 25% were employed in the public sector. There were no differences in outcome between Newcastle and Sydney graduates who had entered medical school under similar academic criteria. CONCLUSION: Our study suggests that initial selection procedures of medical school candidates with particular background characteristics and attributes may influence practice outcomes. Further research is required to confirm these findings.     

The effect of a psychiatric attachment on students' attitudes to and intention to pursue psychiatry as a career

OBJECTIVES: This study examined determinants of students' attitudes to psychiatry and intentions to pursue psychiatry as a career, considering: (1) experiences during the clinical attachment; (2) type of curriculum (traditional or problem-based), and (3) student characteristics (age and gender). The relationships between attitudes, career intentions and academic performance were examined. METHOD: Fourth year medical students (n = 379) completed questionnaires at the beginning and end of an 8-week psychiatry attachment to assess their attitudes to psychiatry, career intentions and experiences during the attachment. Students completed two assessments consisting of a multiple choice paper and a clinical viva. Consecutive cohorts of students receiving a traditional curriculum (n = 188) and a problem-based curriculum (n = 191) were compared. RESULTS: Students' attitudes to psychiatry improved and intentions to pursue psychiatry as a career increased during the attachment. These changes were predicted by specific experiences during the attachment, such as receiving encouragement from consultants, seeing patients respond well to treatment and having direct involvement in patient care. There was no difference in change in attitudes or career intentions between the two cohorts. Students with more favourable attitudes or career intentions at the outset did not report more favourable experiences during the attachment. Attitudes and career intentions were unrelated to performance in psychiatry assessments. Improvement in attitudes was related to an increased intention to pursue psychiatry as a career. CONCLUSIONS: Change in attitudes and career intentions was dependent on the actions of the clinical teachers. Undergraduate teachers may have an important influence on the numbers of doctors who choose this specialty as a career.     

A survey of clinical teaching fellowships in UK medical schools

CONTEXT: Undergraduate medical education in the UK has changed considerably over the last decade. One development has involved the creation of teaching-specific posts for junior doctors by medical schools. These posts are generally termed 'clinical teaching fellowships', but it is not known how many of them exist, or whether they are similar in terms of educational activities, professional development, and research and clinical experience opportunities. METHODS: Teaching deans in all UK medical schools were sent a questionnaire relating to clinical teaching fellowships, and were asked to distribute a second set of different questionnaires to their clinical teaching fellows, which were to be returned to the authors separately. RESULTS: A total of 28 deans and 46 fellows responded. Fifteen medical schools had clinical teaching fellows and there appeared to be a total of 77 such posts in the UK. There was little uniformity in the activities undertaken within the posts. Deans who employed clinical teaching fellows were unanimously positive regarding the posts. Fellows were generally positive but expressed reservations relating to approval for postgraduate training, career development, deterioration in clinical skills, financial disincentives, credibility within one's own specialty, and provision of training and support. CONCLUSIONS: Clinical teaching fellow posts are generally enjoyed by fellows and valued by deans. Fellows carry out differing duties and their training in medical education is variable. The posts can be unstructured and may lack credibility to doctors outside medical education. Providing specific structured training in medical education, recognised at a national level, would help deal with these concerns.     

Training immigrant doctors: issues and responses

Summary. An unprecedented wave of immigration of doctors to Israel, mainly from the former Soviet Union, posed for Israeli health leaders the problem of bringing them to a common and accepted Western level of performance. Stemming from the deep commitment which Israel has towards the immigrants, the state offers them a training opportunity to enhance their chances of being licensed and finding jobs in their profession. A 6-month programme was launched by Ben-Gurion University, later adopted by other medical schools and supported by the Government of Israel. The programme was designed to provide effective responses to the specific problems of the immigrant population, which are: lack of knowledge of local language, both everyday and professional; overspecialization in too narrow specialties; possession of clinical specialties which do not exist in the new country; insufficient updating in medical sciences and technology; unawareness of economic implications of health care; difficulty in originating new solutions to clinical problems, and lack of skill in answering objective test items. The programme is characterized by a protective environment, problem-oriented learning, small-group activities and emphasis on learning languages. The clinical problems are designed to emphasize the general practitioner's point of view of both common and emergency situations. The programme has achieved its goals, as judged by the success rate of its graduates in the National Licensing Examination as compared with the success of immigrant doctors who chose not to participate in the training. This success proves that training of immigrant doctors can be attained by a short programme if the learners’ needs are carefully analysed, the programme appropriately designed, and the staff is enthusiastic, devoted and determined.     

Why do doctors attend traditional CME events if they don't change what they do in their surgeries? Evaluation of doctors' reasons for attending a traditional CME programme

OBJECTIVE: This study aimed to discover what the family doctors who attended an annual refresher course wished to obtain from participating in the event and what their response was to evidence that doctor behaviour is not changed by such programmes. DESIGN: The study used the qualitative method of in-depth interviews. SETTING: Ottawa, Ontario, Canada and the surrounding area. PARTICIPANTS: The informants for the study were a sample of 6 family doctors who attended the 50th Annual Refresher Course for Family Physicians, held in April 2001 in Ottawa, Ontario, Canada. METHOD: In-depth interviews with the participants were conducted before and after they attended the annual refresher course. The doctors had pre-registered for the 3-day course. They were purposely selected to obtain diversity of gender, year of graduation from medical school and practice location. RESULTS: The doctors interviewed had 3 main reasons for attending the refresher course: to obtain information or to be updated; to be reassured that their practice behaviour was within accepted guidelines, and to hear from and interact with the specialists who gave presentations. All the participants in the study were able to name changes they had made as the result of attending a similar type of programme in the past and were sceptical of findings that practice behaviour did not change as a result of traditional continuing medical education (CME). CONCLUSIONS: Despite current support for interactive and practice-linked educational activities, the doctors in this study valued the input of the experts who lectured at the course. These doctors were not prepared to accept the currently held precept that their behaviour did not change as a result of attendance at traditional CME programmes.     

Early identification of 'at-risk' students by the parents of paediatric patients

INTRODUCTION: Assessment of medical student clinical skills is best carried out using multiple assessment methods. A programme was developed to obtain parent evaluations of medical student paediatric interview skills for feedback and to identify students at risk of poor performance in summative assessments. METHOD: A total of 130 parent evaluations were obtained for 67 students (parent participation 72%, student participation 58%). Parents completed a 13-item questionnaire [Interpersonal Skills Rating Scale (IPS) maximum score 91, higher scores = higher student skill level]. Students received their individual parent scores and de-identified class mean scores as feedback, and participants were surveyed regarding the programme. Parent evaluation scores were compared with student performance in formative and summative faculty assessments of clinical interview skills. RESULTS: Parents supported the programme and participating students valued parent feedback. Students with a parent score that was less than 1 standard deviation (SD) below the class mean (low IPS score students) obtained lower faculty summative assessment scores than did other students (mean +/- SD, 59% +/- 5 versus 64% +/- 7; P < 0.05). Obtaining 1 low IPS score was associated with a subsequent faculty summative assessment score below the class mean (sensitivity 0.38, specificity 0.88). Parent evaluations combined with faculty formative assessments identified 50% of students who subsequently performed below the class mean in summative assessments. CONCLUSIONS: Parent evaluations provided useful feedback to students and identified 1 group of students at increased risk of weaker performance in summative assessments. They could be combined with other methods of formative assessment to enhance screening procedures for clinically weak students.     

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.     

Volunteer bias in medical education research: an empirical study of over three decades of longitudinal data

CONTEXT: The issue of whether medical education research outcomes can be biased by students' refusal to allow their data to be used in outcomes research should be empirically addressed to assure the validity of research findings. Given that institutions are expected to document the outcomes of their educational programmes, evaluations of clinical performance subsequent to medical school are crucial, but are often incomplete when graduates decline to permit data collection. OBJECTIVES: This study aimed to examine the demographic and performance differences between research volunteers and others. METHODS: A total of 7415 doctors graduated from Jefferson Medical College between 1970 and 2004; 75% (n = 5575) agreed to participate in medical education research by granting written permission for the collection of data from their postgraduate training directors on their behalf (research volunteers); 20% (n = 1489) refused to grant such permission (non-volunteers), and 5% (n = 351) did not return the permission form (non-respondents). This prospective longitudinal study compared research volunteers, non-volunteers and non-respondents on gender, ethnicity, performance measures prior to, during and after medical school, scores on medical licensing examinations, and board certification status. RESULTS: Doctors who granted permission (volunteers) generally performed better during and after medical school. In addition, they scored higher on medical licensing examinations and had a higher certification rate. Women and members of ethnic minority groups were less likely to grant permission. CONCLUSIONS: The study raises questions about the validity of research findings as a result of volunteerism in medical education research. The implications for guidelines regarding the protection of human subjects in medical education research, and for educational outcomes, are discussed.     

Attending doctors' perspectives on how residents learn

CONTEXT: Graduate medical education is currently facing major educational reforms. There is a lack of empirical evidence in the literature about the learning processes of residents in the clinical workplace. This qualitative study uses a 'grounded theory' approach to continue the development of a theoretical framework of learning in the clinical workplace by adding the perspective of attending doctors. METHODS: A total of 21 Dutch attending doctors involved in the training of residents in obstetrics and gynaecology participated in 1 of 3 focus group sessions. They discussed their perceptions of how residents learn and what factors influence residents' learning. A grounded theory approach was used to analyse the transcribed discussions. RESULTS: Three related themes emerged. The first concerned the central role of participation in work-related activities: according to attending doctors, residents learn by tackling the everyday challenges of clinical work. The second involved the ways in which attending doctors influence what residents learn from work-related activities. The final theme focused on attending doctors' views of the essential characteristics of residents and their development during residency. CONCLUSIONS: Attending doctors' perspectives complement current insights derived from similar research among residents and from related literature. As part of an ongoing effort to further develop understanding of how residents learn, this study adds several ways in which attending doctors strive to combine guidance in both patient care and resident training. Furthermore, attending doctors' perspectives draw attention to other aspects of learning in the clinical workplace, such as the role of confidence and the balance between supervision and independence.     

Career choices at the end of the pre-registration year of doctors who qualified in the united kingdom in 1996

OBJECTIVE: To report the career intentions one year after qualification of doctors who qualified in the United Kingdom (UK) in 1996, and to compare their intentions with those of 1993 qualifiers at the same stage. DESIGN: Postal questionnaires. SETTING: United Kingdom. SUBJECTS: All doctors who qualified in the UK in 1996. MAIN OUTCOME MEASURES: Choices of eventual career expressed one year after qualifying. RESULTS: We report on detailed choices of long-term careers for all specialties. Only 20% of 1996 respondents chose general practice compared with 25.8% of 1993 respondents. The percentage choosing general practice fell more sharply among women, from 34.0% to 25.2%, than among men, from 17.5% to 14.1%. Choices for surgical specialties rose from 16.9% of 1993 respondents to 21. 4% of 1996 respondents. The percentage choosing the surgical specialties rose among women, from 7.8% to 11.6%, compared with a rise among men from 26.1% to 32.2%. The percentage of respondents who definitely or probably intended to pursue a long-term career in the UK was 77.7% compared with 75.7% of 1993 respondents. Most of the home-based respondents who had doubts about practising in the United Kingdom were considering practising abroad. Only 1% made an explicit first choice for a non-medical career. However, in all, 9. 4% said that there was a possibility that they might leave medicine. CONCLUSION: The substantial decline in intentions to enter general practice among newly qualified doctors, seen in the 1993 qualifiers, is continued in the 1996 qualifiers. A shortfall in recruitment of UK-trained doctors to general practice is the likely outcome. The rise in choices for the surgical specialties, particularly among women, may herald a renewed interest in hospital specialist training following the Calman changes. It is worrying that almost a quarter of respondents indicated some doubts about pursuing a medical career in the UK.     

Education and the working patterns of junior doctors in the UK: a review of the literature

OBJECTIVE: To identify and review UK research relating to the effects of patterns of work on the education of junior doctors, describe the trends in the research, contextualise the progress of the UK in reducing the number of hours worked by junior doctors alongside that of other countries and identify areas for future research. METHOD: A total of 77 research studies, mostly written after 1995, were identified as relevant from approximately 900 references generated by searching Medline and using a 'snowball' technique. The articles identified were qualitatively reviewed to identify their key research conclusions and/or the main points of argument. These were collated and presented in a qualitative review. RESULTS: Research in the UK is contradictory regarding the effects of working patterns and the views of doctors towards them. Further research is needed to examine in depth the differences in the effects of working patterns on education between hard-pressed and non hard-pressed specialties, hospitals and regions. When viewed in an international context, the UK ranks among a number of countries with similar medical systems that are moving towards reducing the hours worked by doctors in training, all of which are at different points in the process. CONCLUSION: The literature review has helped to identify the popular wisdom surrounding the debate on junior doctors' hours, the progress of the UK when compared to that of other countries and gaps in research. Further research is needed to refine understanding of this area.     

Women in the UK academic medicine workforce

OBJECTIVES: This study aimed to compare data on the employment profiles (such as grade, place of work, etc.) of male and female clinical academics. METHODS: We carried out a comparative review of workforce data within academic medicine for 2004 and 2005, pertaining to the workforce in all specialties in UK medical schools. RESULTS: We identified 3255 and 3365 lecturers, senior lecturers, readers and professors in 2004 and 2005, respectively, of whom 21% were women. In 2004 and 2005, 12% and 11%, respectively, of 1157 and 1364 UK medical professors were women. The number of women filling such positions in individual schools ranged from 0% to 33% across schools. The total numbers of women post-holders and their full-time equivalents were similar, indicating that the majority of posts were full-time. CONCLUSIONS: In England only 1 in 10 medical clinical professors are women. At the onset of the study period, 6 medical schools employed no female professors, with a consequent lack of female role models at these institutions. Large variations between schools suggest that some workforce practices may be detrimental to women's academic careers.     

Assessment of patient management skills and clinical skills of practising doctors using computer-based case simulations and standardised patients

CONTEXT: Standardised assessments of practising doctors are receiving growing support, but theoretical and logistical issues pose serious obstacles. OBJECTIVES: To obtain reference performance levels from experienced doctors on computer-based case simulation (CCS) and standardised patient-based (SP) methods, and to evaluate the utility of these methods in diagnostic assessment. SETTING AND PARTICIPANTS: The study was carried out at a military tertiary care facility and involved 54 residents and credentialed staff from the emergency medicine, general surgery and internal medicine departments. MAIN OUTCOME MEASURES: Doctors completed 8 CCS and 8 SP cases targeted at doctors entering the profession. Standardised patient performances were compared to archived Year 4 medical student data. RESULTS: While staff doctors and residents performed well on both CCS and SP cases, a wide range of scores was exhibited on all cases. There were no significant differences between the scores of participants from differing specialties or of varying experience. Among participants who completed both CCS and SP testing (n = 44), a moderate positive correlation between CCS and SP checklist scores was observed. There was a negative correlation between doctor experience and SP checklist scores. Whereas the time students spent with SPs varied little with clinical task, doctors appeared to spend more time on communication/counselling cases than on cases involving acute/chronic medical problems. CONCLUSION: Computer-based case simulations and standardised patient-based assessments may be useful as part of a multimodal programme to evaluate practising doctors. Additional study is needed on SP standard setting and scoring methods. Establishing empirical likelihoods for a range of performances on assessments of this character should receive priority.     

Medical student attitudes to risk taking and self-perceived influence on medical practice

CONTEXT: Little has been published on medical student risk-taking attitudes and behaviours and whether students think these attributes will affect how they treat patients. OBJECTIVES: Our aims were to assess for an association between risk-taking attitudes and behaviours, such as problematic substance use, self-reported risky behaviours, and self-reported accidents, and to test for an association between risk-taking attitudes and student perceptions of the influence of these attitudes on future clinical practice. METHODS: Three consecutive classes of Year 2 medical students (n=315) completed a self-administered, 29-item questionnaire. Risk-taking attitudes were evaluated using a 6-question, risk-taking scale adapted from the Jackson Personality Inventory (JPI). RESULTS: A significant positive correlation was demonstrated between risk-taking attitudes (JPI) and problematic substance use (r=0.34; P<0.01), self-reported risky behaviours (r=0.47; P<0.01), and self-reported accidents (r=0.33; P<0.01). Students who did not think their attitudes toward risk would affect their clinical decision making scored significantly higher on our measure of risk-taking attitudes (t306=-4.60; P<0.01). Students who did not think that their drinking, drug taking or sexual behaviour would affect how they counselled patients on these matters scored significantly higher on our measure of problematic substance use (t307=-2.51; P=0.01). CONCLUSIONS: Although risk-taking attitudes have been associated with significant differences in clinical decision making among doctors, in our sample students with high risk-taking attitudes and behaviours were significantly less likely than their colleagues to think their attitudes would affect their clinical practice. Implications for medical education are discussed.     

Are some of the challenging aspects of the CanMEDS roles valid outside Canada?

CONTEXT: Many countries have adopted the CanMEDS roles. However, there is limited information on how these apply in an international context and in different specialties. OBJECTIVES: To survey trainee and specialist ratings of the importance of the CanMEDS roles and perceived ability to perform tasks within the roles. METHODS: We surveyed 8749 doctors within a defined region (eastern Denmark) via a single-issue, mailed questionnaire. Each of the 7 roles was represented by 3 questionnaire items to be rated for perceived importance and confidence in ability to perform the role. RESULTS: Responses were received from 3476 doctors (42.8%), including 190 interns, 201 doctors in the introductory year of specialist training, 529 residents and 2152 specialists. The overall mean rating of importance (on a scale of 1-5) of the aspects of competence described in the CanMEDS roles was 4.2 (standard deviation 0.6) and did not differ between trainee groups and specialists. Mean ratings of confidence were lower than ratings of importance and increased across the groups from interns to specialists. Differences between specialty groups were evident in both importance and confidence for many of the roles. For laboratory, technical and, to a lesser extent, cognitive specialties, the role of Health Advocate scored the lowest in importance. For general medicine specialties, the roles of Medical Expert, Collaborator, Manager and Scholar all scored lower for importance and confidence. CONCLUSIONS: This study provides a sketch of the content and construct validity of the CanMEDS roles in a non-Canadian setting. More research is needed in how these aspects of competence can be best taught and applied across specialties in different jurisdictions.