career choices at the end of the pre-registration year of doctors who qualified in the united...

Career choices at the end of the pre-registration yearof doctors who quali®ed in the United Kingdom in 1996

Michael J Goldacre,1 Jean M Davidson2 & Trevor W Lambert3

Objective To report the career intentions one year after

quali®cation of doctors who quali®ed in the United

Kingdom (UK) in 1996, and to compare their inten-

tions with those of 1993 quali®ers at the same stage.

Design Postal questionnaires.

Setting United Kingdom.

Subjects All doctors who quali®ed 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 respon-

dents chose general practice compared with 25á8% of

1993 respondents. The percentage choosing general

practice fell more sharply among women, from 34á0%

to 25á2%, than among men, from 17á5% to 14á1%.

Choices for surgical specialties rose from 16á9% of

1993 respondents to 21á4% of 1996 respondents. The

percentage choosing the surgical specialties rose among

women, from 7á8% to 11á6%, compared with a rise

among men from 26á1% to 32á2%. The percentage of

respondents who de®nitely or probably intended to

pursue a long-term career in the UK was 77á7%

compared with 75á7% of 1993 respondents. Most of the

home-based respondents who had doubts about prac-

tising in the United Kingdom were considering prac-

tising abroad. Only 1% made an explicit ®rst choice for

a non-medical career. However, in all, 9á4% said that

there was a possibility that they might leave medicine.

Conclusion The substantial decline in intentions to

enter general practice among newly quali®ed doctors,

seen in the 1993 quali®ers, is continued in the 1996

quali®ers. 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 hos-

pital 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.

Keywords *Attitude of health personnel; career choice;

*education, medical, graduate; Great Britain; hospital

medical staff, *psychology; job satisfaction.

Medical Education 1999;33:882±889

Introduction

National surveys have been undertaken in the United

Kingdom (UK) of the long-term career plans of doc-

tors who quali®ed in 1974, 1977, 1980, 1983 and

1993, as expressed at the end of their ®rst year after

qualifying.1 We have now studied career intentions of

the 1996 quali®ers. We were interested in the whole

range of career choices of future specialty. We were

also interested speci®cally in the choice of general

practice as a long-term career because it had declined

in the quali®ers of 1993 compared with those of the

1980s;1 in whether the historically small percentage of

women who chose surgical specialties was increasing;

in whether choices by medical school were similar in

the 1996 cohort to those expressed by the 1993

cohort; and in whether the decline in intentions to

practice medicine long-term in the United Kingdom,

seen in the intentions of the 1993 cohort when com-

pared with earlier cohorts,2 was sustained in the

quali®ers of 1996.

Method

Information about career intentions was ascertained, as

in our previous surveys,1 by sending questionnaires to

1 Director, 2 Research Of®cer, 3 Statistician, UK Medical Careers

Research Group, Unit of Health-Care Epidemiology, Department of

Public Health, University of Oxford, Old Road, Oxford OX3 7LF,

UK

Correspondence: Dr Michael J Goldacre, Unit of Health-Care Epide-

miology, Old Road, Oxford OX3 7LF, UK

Research papers

882 Ó Blackwell Science Ltd MEDICAL EDUCATION 1999;33:882±889

all doctors who quali®ed in the UK, at the end of their

pre-registration year, with a maximum of three

reminders sent to non-respondents. Doctors were asked

to state up to three long-term choices of career in order

of preference, being `as speci®c or as general as you

wish'. Where respondents gave tied ®rst choices, each

choice was given a weight of one-half (or one-third in

the occasional case of three tied choices). Adjusted

standardized residuals3 were used to compare ®rst

choices of 1996 and 1993 quali®ers.

In this survey we asked our usual question: Apart

from temporary visits abroad, do you intend to practise

medicine in the United Kingdom for the foreseeable future?

This question incorporates both the possibility of

practising abroad and of leaving medicine. In the

present survey, in an attempt to distinguish these, we

also asked:

If you did not answer `Yes ± de®nitely', are you:

(a) considering practising medicine abroad?

(b) considering leaving medicine but remaining in the

United Kingdom?

(c) considering leaving medicine and leaving the United

Kingdom?

Results

There were 3868 quali®ers in the 1996 cohort. No

current address could be found for 55 doctors, 16 of

whom were known to be abroad. One doctor was

known to have died and 3 answered that they did not

wish to participate in the survey. Of the remaining 3809

(1953 men, 1856 women), 2926 replied (76á8%,

comprising 71á4% of the men and 82á5% of the wom-

en).

Choice of specialty1

The choices of long-term specialty are shown in

Table 1 in which we reproduce, as far as practicable,

the choices in the terms used by the respondents. We

also grouped choices into 14 mainstream specialties as

in our previous studies.1 The 1996 respondents differed

overall in their ®rst choices of mainstream specialty

compared with the 1993 respondents (v213 � 56á1,

P < 0á001). First choices for the surgical specialties rose

from 16á9% to 21á4%; in the medical specialties there

was a smaller increase from 22á1% to 24á9%. The large

increase in ®rst choices for the surgical specialties was

mainly due to a much larger number of respondents

specifying `surgery' or `a surgical specialty' without

further detail (Table 1). This accounted for 29% (128/

449) of men's surgical choices and 34% (61/178) of

women's. Many doctors who chose medical specialties

also signi®ed this choice without further speci®cation

(Table 1). Of individual medical specialties, those most

commonly speci®ed were cardiology and gastroenter-

ology. Of individual surgical specialties, orthopaedics

was speci®ed most commonly followed by ophthal-

mology, ear nose and throat, and plastic surgery.

The percentage of women choosing the surgical

specialties rose by almost half, although it remains

small compared to the percentage of men. First choices

by women for the medical specialties and paediatrics

rose signi®cantly; these specialties showed no signi®-

cant change for men (Table 2).

First choices for general practice fell from 25á8% of

the 1993 respondents (95% con®dence interval: 24á2%

± 27á5%) to 20á0% of the 1996 respondents (18á5% ±

21á4%). Second or third choices for general practice

were expressed by 22á1% of respondents in 1993 and by

20á5% of respondents in 1996. In all other specialties

the percentages of ®rst choices were not signi®cantly

different in the two cohorts.

The decline in ®rst choices for general practice was

greater in percentage terms among women than among

men (Table 2). However, the continuing increase in

the proportion of quali®ers who are women meant

that, as in the 1993 cohort, the number of women

respondents from the 1996 cohort choosing general

practice was approximately double the number of men

doing so.

In Table 1, the doctors tabulated as expressing `non-

medical' choices are those who speci®ed a named non-

medical career (e.g. lawyer, accountant). First choices

for a speci®ed non-medical career were almost

unchanged at about 1%.

Specialty choice of graduates from different

medical schools

First choices of the 1996 responders, by medical school

attended, are shown in Table 3 together with the ®rst

choices of the 1993 responders during their pre-regis-

tration year. For general practice, some medical schools

showed similar ®ndings, comparing the two years, and

others were less consistent. For example, the percent-

age of graduates from Oxford and Cambridge who

chose general practice was consistently low. There were

signi®cant declines (P < 0á05) in the percentage of

responders who chose general practice between 1993

and 1996 among the graduates of Birmingham, Man-

chester, Charing Cross and Westminster, and Belfast.

Signi®cant increases (P < 0á05) in the percentage

choosing the surgical specialties were seen among the

graduates of Bristol, Leeds, Manchester and Belfast.

Career choices of doctors at the end of the pre-registration year · M J Goldacre et al. 883

Ó Blackwell Science Ltd MEDICAL EDUCATION 1999;33:882±889

Table 1 First, second and third choices of eventual career (corrected for ties) among 1996 quali®ers from United Kingdom medical

schools during their pre-registration year, compared with the ®rst choices of quali®ers in 1993 at the same stage

1996 Cohort choices 1993 Cohort

First choices Second choices Third choices First choices

Specialty No. % No. % No. % No. %

General practice 584 20.0 322 11.0 278 9.5 677 25.8

Medical specialties 728 24.9 575 19.7 261 8.9 580 22.1

General medicine1 435 14.9 277 9.5 117 4.0 336 12.8

Cardiology 74 2.5 46 1.6 25 0.9 58 2.2

Dermatology 17 0.6 17 0.6 17 0.6 24 0.9

Diabetes & endocrinology 13 0.4 13 0.4 5 0.2 4 0.1

Geriatric medicine 16 0.5 19 0.6 8 0.3 25 0.9

Nephrology 9 0.3 16 0.5 9 0.3 9 0.3

Neurology 25 0.9 22 0.8 11 0.4 25 1.0

Palliative medicine2 19 0.6 37 1.3 11 0.4 16 0.6

Thoracic medicine 28 1.0 36 1.2 9 0.3 15 0.6

Rheumatology/Rehabilitation 7 0.2 15 0.5 5 0.2 7 0.3

Genito-urinary medicine 3 0.1 4 0.1 6 0.2 1 0.1

Clinical genetics 4 0.1 5 0.2 1 <0.1 4 0.2

Gastroenterology 43 1.5 32 1.1 12 0.4 25 1.0

Tropical medicine 8 0.3 9 0.3 3 0.1 7 0.3

Clinical pharmacology 3 0.1 5 0.2 1 <0.1 2 0.1

Infectious diseases 16 0.5 11 0.4 11 0.4 12 0.5

Occupational health 2 0.1 3 0.1 5 0.2 1 0.0

Other medical specialties 6 0.2 8 0.3 5 0.2 9 0.3

Paediatrics 223 7.6 121 4.1 61 2.1 164 6.3

Accident and emergency 82 2.8 143 4.9 80 2.7 69 2.6

Surgical specialties 627 21.4 339 11.6 183 6.3 442 16.9

General surgery3 90 3.1 76 2.6 35 1.2 78 3.0

Surgery (not further speci®ed)4 189 6.5 48 1.6 24 0.8 73 2.8

Ear nose and throat 40 1.4 24 0.8 17 0.6 33 1.3

Neurosurgery 13 0.4 6 0.2 3 0.1 12 0.4

Ophthalmology 47 1.6 18 0.6 16 0.5 70 2.7

Orthopaedics/trauma 104 3.6 58 2.0 32 1.1 86 3.3

Paediatric surgery 15 0.5 9 0.3 4 0.1 12 0.5

Plastic surgery 31 1.1 34 1.2 16 0.5 30 1.1

Cardiac surgery 15 0.5 16 0.5 9 0.3 17 0.6

Urology 19 0.6 12 0.4 9 0.3 7 0.3

Vascular surgery 14 0.5 11 0.4 6 0.2 2 0.1

Dental surgery 28 1.0 13 0.4 4 0.1 16 0.6

Other surgical specialties 22 0.8 14 0.5 8 0.3 6 0.2

Obstetrics and gynaecology 115 3.9 67 2.3 37 1.3 127 4.8

Anaesthetics2,5 207 7.1 151 5.2 94 3.2 184 7.0

Radiology 50 1.7 73 2.5 37 1.3 55 2.1

Clinical oncology 39 1.3 27 0.9 16 0.5 31 1.2

Pathology 41 1.4 36 1.1 29 1.0 42 1.6

Pathology (not further speci®ed) 5 0.2 7 0.2 7 0.2 7 0.3

Microbiology 7 0.2 4 0.1 6 0.2 5 0.2

Histopathology 6 0.2 4 0.1 2 <0.1 7 0.3

Chemical pathology 0 ± 0 ± 0 ± 2 0.1

Haematology 18 0.6 18 0.6 11 0.4 15 0.6

Blood transfusion 0 ± 1 <0.1 0 ± 0 ±

Clinical immunology 1 <0.1 0 0.0 1 <0.1 2 0.1

Forensic medicine 4 0.1 2 0.1 2 <0.1 4 0.2


Career choices of doctors at the end of the pre-registration year · M J Goldacre et al.884

Intentions to practise medicine

in the United Kingdom

The 1996 quali®ers were asked Apart from temporary

visits abroad, do you intend to practise medicine in the

United Kingdom for the foreseeable future? Of 2912

respondents to this question those specifying Yes±de®-

nitely or Yes-probably, Undecided, and No-probably not or

No-de®nitely not, respectively, comprised 77á7% (2264),

13á2% (385) and 9á0% (263). This compares with

75á7%, 14á6% and 9á7%, respectively, among 1993

quali®ers. Responses of the 1996 quali®ers are shown in

detail in Table 4. The table shows that, of the UK-based

quali®ers who had any doubts about practising medicine

in the UK, most considered the possibility of practising

abroad rather than leaving medicine. In all, 9á4% of the

UK-based quali®ers expressed the possibility that they

might leave medicine; almost half expressed the possi-

bility that they might wish to practise abroad.

Most overseas-based quali®ers did not intend to

practise in the United Kingdom. Of the 61% (91/148)

who were undecided or probably or de®nitely did not

intend to do so, 82% (75/91) intended to practise abroad.

Discussion

The percentage of respondents who, at the end of their

®rst year after quali®cation, speci®ed general practice as

their ®rst choice of long-term career was 46% in the

survey of the 1983 quali®ers, 26% in the 1993 quali®ers

and 20% in the present study. These results con®rm

that the substantial decline in the 1993 cohort was not

an isolated result and they show yet further decline.

Studies of previous cohorts suggest that there is a good

relationship between choice of general practice in the

year after quali®cation and pursuit of an eventual career

in it.4 As an indication of relative needs for general

practitioners, currently over half of all NHS career

grade doctors are principals in general practice: in 1997

there were 32 480 general practitioners and 24 090

hospital consultants in the NHS in Great Britain.5

Current intentions of the present generation of junior

Table 1 (Contd.)

1996 Cohort choices 1993 Cohort

First choices Second choices Third choices First choices

Specialty No. % No. % No. % No. %

Psychiatry 112 3.8 62 2.1 35 1.2 109 4.2

Community health7 3 0.1 5 0.2 2 <0.1 20 0.8

Public health medicine 9 0.3 16 0.5 11 0.4 5 0.2

Other medical choices 36 1.2 41 1.4 31 1.1 46 1.8

Other medical8 16 0.5 22 0.8 13 0.4 17 0.6

Academic/research work 6 0.2 10 0.3 6 0.2 9 0.3

Third world medicine 14 0.5 9 0.3 12 0.4 20 0.8

Specialty not stated 41 1.4 920 31.4 1728 59.1 34 1.3

Non-medical choice9 29 1.0 28 1.0 43 1.5 36 1.4

Total 2926 100.0 2926 100.0 2926 100.0 2621 100.0

Percentages may not add up exactly due to rounding.1 Includes medicine without further speci®cation, general medicine with a special interest, academic medicine and those who speci®ed

two or more of the medical specialties.2 Respondents who speci®ed palliative medicine or palliative care were previously included in anaesthetics2 and have been reassigned to

palliative medicine.3 Includes general surgery with a special interest.4 Includes academic surgery.5 Includes intensive care and pain therapy.6 Includes psychotherapy.7 Includes family planning.8 Includes clinical anatomy, clinical neurophysiology, physiology and those who speci®ed hospital work or work in HM Forces without

giving details of their chosen specialty.9 Comprises those who gave a speci®c non-medical choice.



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1995.



doctors, if translated into subsequent employment,

con®rm a likely substantial shortfall in recruitment of

UK-trained doctors to general practice. Between 1983

and 1993, the fall in choice of general practice had been

greater among men than women.1 Between 1993 and

1996, the fall in choice of general practice was greater

among women than men: it seems as if, in this respect,

the women are starting to catch up with the men.

Interestingly, the main shift towards hospital spe-

cialties, paralleling the decline in general practice, was

an increase in choice for the surgical specialties, rather

than the hospital medical specialties, although choices

for the latter also rose. There has been a large increase

in the percentage of women intending to enter surgery:

the percentage in the 1996 survey is the highest since

these surveys began in 1974. Much of their increased

popularity was accounted for by larger numbers de-

scribing their choice as `surgery' or `general medicine'

without further speci®cation. This appears to re¯ect a

general increase in desire to work in these hospital

specialties rather than in general practice, and not a

wish to work in a speci®c surgical or medical specialty,

for which the percentage changes in choices were

mostly small.

The main differences between medical schools were

seen in the choices for general practice, surgical spe-

cialties and hospital medical specialties. We present

these ®gures (Table 3), and those on the detailed

choices of specialty (Table 1), as a matter of record

without further comment.

The decline in intentions `de®nitely or probably' to

practice medicine long-term in the United Kingdom,2

although it steadied in the quali®ers of 1996, is a con-

tinuing cause for concern. The majority of respondents

who were uncertain about practising medicine in the

UK were considering a medical career abroad, rather

than leaving medicine. However, it is noteworthy that

9á4% of respondents from UK homes and 6á8% of

overseas-based respondents indicated the possibility

that they might leave medicine.

Acknowledgements

We thank all the doctors who participated, Janet Justice

and Alison Stockford for coding data, and Karen Hol-

lick for administration.

MJG and TWL designed the survey. TWL co-ordi-

nated the survey and provided statistical advice. JMD

analysed the data. MJG wrote the ®rst draft, all authors

contributed to further drafts and all are guarantors.

The UK Medical Careers Research Group is funded

by the Department of Health. The Unit of Health-Care

Epidemiology is funded by the Anglia and Oxford

Regional Of®ce of the NHS Executive.

Table 4 Intentions to practise medicine in the United Kingdom among 1996 quali®ers, by residence prior to entering medical school and

reasons for uncertainty. Percentages (in parentheses) are those in each group expressed as a percentage of all the United Kingdom-based

or overseas-based respondents

Reason for uncertainty about practising in UK

Intention to practise medicine in UK

Intend

practising in UK

Considering

leaving medicine

Considering

medicine abroad Unspeci®ed Total

United Kingdom-based quali®ers

Yes±de®nitely 1093 (39.5) ± ± ± 1093 (39.5)

Yes±probably ± 156 (5.6) 918 (33.2) 40 (1.4) 1114 (40.3)

Uncertain ± 71 (2.6) 262 (9.5) 9 (0.3) 342 (12.4)

No±probably not ± 22 (0.8) 118 (4.3) 16 (0.6) 156 (5.6)

No±de®nitely not ± 11 (0.4) 42 (1.5) 6 (0.2) 59 (2.1)

Total 1093 (39.5) 260 (9.4) 1340 (48.5) 71 (2.6) 2764 (100)

Overseas-based quali®ers

Yes±de®nitely 17 (11.5) ± ± ± 17 (11.5)

Yes±probably ± 2 (1.4) 35 (23.6) 3 (2.0) 40 (27.0)

Uncertain ± 1 (0.7) 37 (25.0) 5 (3.4) 43 (29.1)

No±probably not ± 5 (3.4) 24 (16.2) 1 (0.7) 30 (20.3)

No±de®nitely not ± 2 (1.4) 14 (9.5) 2 (1.4) 18 (12.2)

Total 17 (11.5) 10 (6.8) 110 (74.3) 11 (7.5) 148 (100)

Percentages may not add up exactly due to rounding.



References

1 Lambert TW, Goldacre MJ, Edwards C, Parkhouse J. Career

preferences of doctors who quali®ed in the United Kingdom in

1993, compared with those of doctors qualifying in 1974, 1977,

1980 and 1983. BMJ 1996;313:19±24.

2 Lambert TW, Goldacre MJ, Parkhouse J. Intentions of newly

quali®ed doctors to practise in the United Kingdom. BMJ

1997;314:1591±2.

3 Everett BS. The Analysis of Contingency Tables. 2nd edn.

Chapter 3. London: Chapman & Hall; 1994.2

4 Edwards C, Lambert TW, Goldacre MJ, Parkhouse J. Early

medical career choices and eventual careers. Med Educ

1997;31:237±42.

5 Department of Health. Statistical Bulletin. (1998/35 and 1998/

16). Leeds: Government Statistical Service; 1998.

6 Lambert TW, Goldacre MJ, Parkhouse J. Career preferences

and their variation by medical school among newly quali®ed

doctors. Health Trends 1996;28:135±44.

Received 14 July 1999; accepted for publication 22 July 19993



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