Today's doctors: What do men and women value in a training post?

The Evolving Landscape of Discrete Choice Experiments in Health Economics: A Systematic Review

INTRODUCTION

Stakeholder preference evaluations are increasingly emphasized in healthcare policy and health technology assessment. Discrete choice experiments (DCEs) are the most common method for quantifying preferences among patients, the public, and healthcare professionals. While prior reviews (1990-2017) have examined DCE trends, no comprehensive synthesis exists for studies published since 2018. This updated review (2018-2023) provides critical insights into evolving methodologies and global trends in health-related DCEs.

METHODS

A systematic search (2018-2023) of Medline, Embase, and Web of Science identified relevant studies. Studies were screened for inclusion and data were extracted, including details on DCE design and analysis. To enable trend comparisons, the search strategy and extraction items aligned with previous reviews.

RESULTS

Of 2663 identified papers, 1279 met the inclusion criteria, reflecting a significant rise in published DCEs over time. DCEs were conducted globally, with a remarkable increase in publications from Asia and Africa compared with previous reviews. Experimental designs and econometric models have advanced, continuing prior trends. Notably, most recent DCEs were administered online.

DISCUSSION

The rapid growth of DCE applications underscores their importance in health research. While the methodology is advancing rapidly, it is crucial that researchers provide full transparency in reporting their methods, particularly in detailing experimental designs and validity tests, which are too often overlooked. Key recommendations include improving reporting of experimental designs, applying validity tests, following good practices for presenting benefit-risk attributes, and adopting open science practices. Ensuring methodological rigor will maximize the impact and reproducibility of DCE research in health economics.

Improving recruitment to occupational health professions through highlighting intrinsic rewards

BACKGROUND

There are currently 2.5 million people economically inactive in the UK due to sickness. The government is considering a range of new initiatives to bring them back into the workforce; however, a lack of occupational health (OH) professionals, who play an important part in the recovery of physical and mental conditions that would otherwise inhibit employees from working, is hindering these efforts.

AIMS

To identify factors that make OH attractive as a source of employment with the aim of assisting those undertaking recruitment to the specialism.

METHODS

We conducted a qualitative study comparing the views of 13 OH nurses and doctors ('insiders') and 45 students and professionals from other medical and nursing fields ('outsiders') across the UK. Both groups provided their perceptions about what makes OH an attractive career. Data collection involved a mix of interviews and focus groups conducted from March to July 2023. Transcripts were thematically analysed using NVivo 14 to manage the data.

RESULTS

Both groups highly valued the work-life balance offered by OH work, which represents a positive point of attraction to employment. In addition, people working in OH talked extensively about more intrinsic rewards-the opportunity to be impactful, to enjoy job variety and to practise preventative approaches.

CONCLUSIONS

The intrinsic rewards that OH work brings need to be advertised more widely to attract potential recruits who are 'a good fit' to OH and will be committed to the field.

The hidden costs of the intercollegiate membership of the Royal College of surgeons examinations: Can trainees afford it?

BACKGROUND

The Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination is a mandatory requirement for higher specialty surgical training in the UK. However, there is a significant economic impact on trainees which raises the question of whether the costs of this exam hinder surgical career progression. This study explores the burden of these exams on trainees.

METHODS

A 37-point questionnaire was distributed to all trainees who were preparing for or have sat MRCS examinations. Univariate analyses included the cost of the preparatory resources, extra hours worked to pay for these and the examinations, and the number of annual leave (AL) days taken to prepare. Pearson correlation coefficients were used to identify possible correlation between monetary expenditure and success rate.

RESULTS

On average, trainees (n ​= ​145) spent £332.54, worked 31.2 ​h in addition to their rostered hours, and used 5.8 AL days to prepare for MRCS Part A. For MRCS Part B/ENT, trainees spent on average £682.92, worked 41.7 extra hours, and used 5 AL days. Overall, the average trainee spent 5-9% of their salary and one-fifth of their AL allowance to prepare for the exams. There was a positive correlation between number of attempts and monetary expenditure on Part A preparation (r(109)=0.536, p ​< ​0.001).

CONCLUSIONS

There is a considerable financial and social toll of the MRCS examination on trainees. Reducing this is crucial to tackle workforce challenges that include trainee retention and burnout. Further studies exploring study habits can help reform study budget policies to ease this pressure on trainees.

Gender, flexibility and workforce in the NHS: A qualitative study

Data from the General Medical Council show that the number of female doctors registered to practise in the UK continues to grow at a faster rate than the number of male doctors. Our research critically discusses the impact of this gender-based shift, considering how models of medical training are still ill-suited to supporting equity and inclusivity within the workforce, with particular impacts for women despite this gender shift. Drawing on data from our research project Mapping underdoctored areas: the impact of medical training pathways on NHS workforce distribution and health inequalities, this paper explores the experiences of doctors working in the NHS, considering how policies around workforce and beyond have impacted people's willingness and ability to continue in their chosen career path. There is clear evidence that women are underrepresented in some specialties such as surgery, and at different career stages including in senior leadership roles, and our research focuses on the structural factors that contribute to reinforcing these under-representations. Medical education and training are known to be formative points in doctors' lives, with long-lasting impacts for NHS service provision. By understanding in detail how these pathways inadvertently shape where doctors live and work, we will be able to consider how best to change existing systems to provide patients with timely and appropriate access to healthcare. We take a cross-disciplinary theoretical approach, bringing historical, spatiotemporal and sociological insights to healthcare problems. Here, we draw on our first 50 interviews with practising doctors employed in the NHS in areas that struggle to recruit and retain doctors, and explore the gendered nature of career biographies. We also pay attention to the ways in which doctors carve their own career pathways out of, or despite of, personal and professional disruptions.

What are the concerns of second-degree medical students entering specialty OMFS training?

Oral and maxillofacial surgery (OMFS) applicants are faced with numerous challenges. Previous research has demonstrated that financial burden, length of OMFS training, and impact on personal life are cited as major drawbacks to pursuing the specialty, with trainees having concerns about the Membership of the Royal College of Surgeons (MRCS) examinations. The current study aimed to explore second-degree medical students' concerns about obtaining a specialty training post in OMFS. An online survey was distributed via social media to second-degree students across the United Kingdom and 106 responses were received. A lack of publications and lack of involvement in research (54%) as well as attaining accreditation with the Royal College of Surgeons (27%) were cited as the primary and secondary concerns in relation to securing a higher training post. Seventy-five per cent of respondents had no first-author publications, 93% expressed concerns about passing the MRCS examination, and 73% had more than 40 OMFS procedures within their logbook. Second-degree medical students reported having ample clinical and operative experience in OMFS. Their main concerns were about research and MRCS examinations. To alleviate these concerns, BAOMS could provide educational initiatives and dedicated mentorship programmes for second-degree students, and could adopt a collaborative approach with discussion with major postgraduate training stakeholders.

What do Turkish, Spanish, and Pakistani medical students value in specialty training positions? A discrete choice experiment

BACKGROUND

The aim of this study was to find out specialty training preferences of senior medical students from three medical schools in Turkey, Spain, and Pakistan.

METHODS

A Discrete Choice Experiment was carried out using an electronic form for students in three countries in 2021-2022 term. Each choice set in the form consisted of two hypothetical specialty training positions. The attributes were location, earnings, working conditions, personal perspective, quality of education, probability of malpractice, and prestige. Conditional logit model was used to estimate participants' preferences and "willingness to accept" values.

RESULTS

The most valued attribute was "personal perspective on specialty area" for Turkish and Spanish students, while this attribute was not meaningful for Pakistani students. Turkish students needed a 204% of change in their income for a swap between the specialty that they like and not like. This tradeoff necessitated a 300% change for Spanish students. The most valued attribute for Pakistani students, which was "working conditions", necessitated a 97% increase in income to switch from working in good conditions to working in poor conditions.

CONCLUSION

In this first multinational DCE study in the medical education literature, we found the preferences of medical students in Turkey, Spain, and Pakistan are affected to various extents by several factors.

Who cares where the doctors are? The expectation of mobility and its effect on health outcomes

Doctors are typically portrayed as active agents in their work lives. However, this paper argues that this construction of agency ignores the effects of the healthcare structures that constrain choice, which in turn affects population health outcomes. Medical training pathways, regional boundaries, and rationalisation all have a long-lasting impact on the provision of healthcare. Using a mobilities lens to examine the movement of doctors, this paper examines how the expectation of movement built into training programmes perpetuates unequal access to healthcare. Long waiting times, poor care quality and lack of preventative care all perpetuate health inequalities; as one of the socio-economic determinants, access to healthcare affects health outcomes.

What do Iranian physicians value most when choosing a specialty? Evidence from a discrete choice experiment

BACKGROUND

Choosing a specialty by physicians is fundamentally linked to the performance of health systems and public health outcomes. Identifying the determinants of specialty selection is important to health policy for targeting resources and planning the development of services. This study examined preferences of Iranian physicians for medical specialty using a discrete choice experiment (DCE) method.

METHODS

In this study, the attributes of the DCE were determined using rigorous qualitative approach. Then we applied D-efficiency criteria to design the DCE and validated it at a pilot study. In the final survey, we recruited participants from six Iranian provinces and analyzed data using conditional logit model. We estimated willingness to pay (WTP) for non-monetary attributes.

RESULTS

The WTP analysis revealed that the most important non-monetary attributes in the selection of a specialty were job burnout, opportunity for procedural activities, and job prestige. The results imply that the attributes that were related to the quality of personal life was more important only for physicians who preferred to choose non-surgical specialties.

CONCLUSIONS

The findings demonstrate that traditional gender patterns of specialty selection are changing and quality of personal life characteristics might be the most important factor when developing policies to recruit physicians into non-surgical specialties.

A cross-sectional study examining MRCS performance by core surgical training location

BACKGROUND

In the UK, core surgical training (CST) is the first specialty experience that early-career surgeons receive but training differs significantly across CST deaneries. To identify the impact these differences have on trainee performance, we assessed whether success at the Membership of the Royal College of Surgeons (MRCS) examinations is associated with CST deanery.

METHODS

A retrospective cohort study of UK trainees in CST who attempted MRCS between 2014 and 2020 (n = 1104). Chi-squared tests examined associations between locality and first-attempt MRCS performance. Multivariate logistic regression models identified the likelihood of MRCS success depending on CST deanery.

RESULTS

MRCS Part A and Part B pass rates were associated with CST deanery (p < 0.001 and p = 0.013, respectively). Candidates that trained in Thames Valley (Odds Ratio [OR] 2.52 (95% Confidence Interval [CI] 1.00-6.42), North Central and East London (OR 2.37 [95% CI 1.04-5.40]) or South London (OR 2.36 [95% CI 1.09-5.10]) were each more than twice as likely to pass MRCS Part A at first attempt. Trainees from North Central and East London were more than ten times more likely to pass MRCS Part B at first attempt (OR 10.59 [95% CI 1.23-51.00]). However, 68% of candidates attempted Part A prior to CST and 48% attempted Part B before or during the first year of CST.

CONCLUSION

MRCS performance is associated with CST deanery; however, many candidates passed the exam with little or any CST experience suggesting that some deaneries attract high academic performers. MRCS performance is therefore not a suitable marker of CST training quality.

Factors affecting the UK junior doctor workforce retention crisis: an integrative review

OBJECTIVES

To determine the factors contributing to the junior doctor workforce retention crisis in the UK using evidence collected directly from junior doctors, and to develop recommendations for changes to address the issue.

DESIGN

Integrative review.

DATA SOURCES

Searches were conducted on Ovid Medline and HMIC to locate evidence published between January 2016 and April 2021. This was supplemented by publications from relevant national organisations.

ELIGIBILITY CRITERIA

English-language papers relating to UK junior doctor retention, well-being or satisfaction which contained data collected directly from junior doctors were included. Papers focusing solely on the pandemic, factors specific to one medical specialty, evaluation of interventions, or numerical data with no evidence relating to causation were excluded. Review papers were excluded.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and coded on NVivo by FKL, then thematic analysis was conducted.

RESULTS

47 papers were included, consisting of academic (qualitative, quantitative, mixed and commentary) and grey literature. Key themes identified were working conditions, support and relationships, and learning and development, with an overarching theme of lack of flexibility. The outcomes of these factors are doctors not feeling valued, lacking autonomy, having a poor work-life balance, and providing compromised patient care. This results in need for a break from medical training.

CONCLUSION

This review builds on findings of related literature regarding working environments, isolation, stigma, and desire for autonomy, and highlights additional issues around learning and training, flexibility, feeling valued, and patient care. It goes on to present recommendations for tackling poor retention of UK junior doctors, highlighting that the complex problem requires evidence-based solutions and a bottom-up approach in which junior doctors are regarded as core stakeholders during the planning of interventions.

A National Survey on the characteristics of Iranian General Practitioners and Their Preferred Specialty: A Need to Transition toward Preventive Medicine

Background:

The shortage and unbalanced distribution of physicians has adverse effects on the provision of equitable services at all levels of health care and especially at the prevention and primary care levels. The choice of specialty can seriously change the structure and composition of the physician workforce. Therefore, this study aimed to investigate the relationship between background characteristics of Iranian general practitioners' (GPs) and their preferred specialty fields.

Methods:

In this mixed-method study, first, 12 medical doctors participated in a nominal group technique to determine the most important background characteristics that affect GPs' preferences for specialty selection. In the second phase, we conducted a survey among 680 GPs in six provinces from different geographic regions. We gathered data using a researcher-made checklist and analyzed them using an adjusted multivariate regression.

Results:

The adjusted analysis showed that being female, being married, being in an older age group, having children, graduation from universities located in the provincial centers, and decision for living and practicing in the less-populated areas were significantly associated with the Iranian GPs' preferences for non-surgical specialties.

Conclusions:

This study provided evidence that could inform national health workforce policy-makers to avoid unbalanced distribution of physicians and accordingly to ensure the provision of equitable services at all levels of healthcare and especially at the primary care level. Other effective factors on the selection of specialty should be evaluated at the national level using specific surveys and econometrics studies such as discrete selection experiment to move toward preventive medicine.

Performance at medical school selection correlates with success in Part A of the intercollegiate Membership of the Royal College of Surgeons (MRCS) examination

Medical schools in the UK typically use prior academic attainment and an admissions test (University Clinical Aptitude Test (UCAT), Biomedical Admissions Test (BMAT) or the Graduate Medical School Admissions Test (GAMSAT)) to help select applicants for interview. To justify their use, more information is needed about the predictive validity of these tests. Thus, we investigated the relationship between performance in admissions tests and the Membership of the Royal College of Surgeons (MRCS) examination.The UKMED database (https://www.ukmed.ac.uk) was used to access medical school selection data for all UK graduates who attempted MRCS Part A (n=11 570) and Part B (n=5690) between 2007 and 2019. Univariate and multivariate logistic regression models identified independent predictors of MRCS success. Pearson correlation coefficients examined the linear relationship between test scores and MRCS performance.Successful MRCS Part A candidates scored higher in A-Levels, UCAT, BMAT and GAMSAT (p<0.05). No significant differences were observed for MRCS Part B. All admissions tests were found to independently predict MRCS Part A performance after adjusting for prior academic attainment (A-Level performance) (p<0.05). Admission test scores demonstrated statistically significant correlations with MRCS Part A performance (p<0.001).The utility of admissions tests is clear with respect to helping medical schools select from large numbers of applicants for a limited number of places. Additionally, these tests appear to offer incremental value above A-Level performance alone. We expect this data to guide medical schools' use of admissions test scores in their selection process.

Career aspirations among specialty residents in France: a cross-sectional gender-based comparison

BACKGROUND

Most studies evaluating career aspirations among gender are performed in Anglo-Saxon countries. Two recent French studies looked at the career choice of residents in obstetrics & gynecology. It seemed useful to us to broaden this questioning to other specialties, by proposing a study to all residents in the same Faculty. The objective of our study was to describe residents' career aspirations and possible barriers according to gender.

METHODS

Declarative cross-sectional survey, using questionnaires sent by email to the specialty residents of the Faculty of Medicine of Lille (France). An analysis by specialty group (i.e., medicine, surgery, obstetrics & gynecology, and anesthesia & resuscitation) and a comparison of the results according to gender were performed.

RESULTS

Of the 1384 specialty residents currently in training, 462 answered the questionnaire (33.38%), among whom 289 women and 173 men (average age = 27.08 ± 0.091 years). Seventeen women (5.9%) were currently considering a university hospital career versus 37 men (21.4%) (p = 0.001). Gender analysis made it possible to identify obstacles to engaging in a university career: lacking a female model, more frequent doubting the ability to undertake this type of career among women (61.6%) than men (35.3%) (p < 0.001), and gender discrimination felt in the workplace for 51.6% of women (versus 7.5% of men, p < 0.001). Subgroup analysis showed specificities related to each specialty.

CONCLUSIONS

Few residents plan to embark upon a university hospital career, let alone female residents. There are considerations specific to each specialty and marked gender differences regarding career aspirations. Many features have been identified as obstacles to access to university hospital positions for women. It is important to develop strategies to remove these barriers and enable women to pursue such university careers.

TRIAL REGISTRATION

Not applicable (no intervention).