Career choices of junior doctors: is the physician an endangered species?

Future Dreams of Junior and Senior Medical Students at a Public Saudi Medical School

BACKGROUND

Medical education is a challenging profession requiring students to acquire various skills and develop them continuously before and after graduation. The study aimed to assess the students' preference toward specialty and determine their preferred residency program and future ambitions regarding administrative and leadership positions.

METHODOLOGY

This is a cross-sectional self-administered survey that included medical students in 1st year, and 5th year and internship at Imam Mohammad Ibn Saud Islamic University (IMSIU). The questionnaire consisted of demographic information and questions about the student's choices regarding plans.

RESULTS

Four hundred and fifty-eight (458) medical students out of 583 students (55.5% junior and 44.5% senior students) enrolled themselves in the study and completed the survey. Findings revealed that medical students' top five preferred future general medical specialties were surgery (34.5), followed by internal medicine (18.3), family medicine (17.2), dermatology (14.6), and emergency medicine (15.9). The junior students were found to be more inclined toward dermatology, medical genetics, and surgical general specialties. The findings showed that 63% of the students were interested in becoming future leaders, with 52.8% of them wishing to become head of a medical department. When asked about their desired qualifications, 85.8% preferred the Saudi Board.

CONCLUSION

Surgery was the most favorable specialty among medical students, followed by internal medicine, family medicine and dermatology, and emergency medicine. The study showed a significant difference between males and females and seniors and juniors in preference of specialty and medical qualification, the female medical students prefer to specialize in dermatology (p=0.027), neurology (p=0.028), and obstetrics and gynecology (p=0.001) as a general specialty significantly more than male medical students. It shows that students are interested in future leadership goals.

Regional survey of foundation trainee doctors' views on a career in gastroenterology: implications for diversity and inclusion

Objective

We aimed to establish the perception of foundation doctors (FDs) towards gastroenterology, focusing on identifying determinants which make the career desirable or undesirable between genders, and to recognise factors to increase diversity in recruitment.

Method

An electronic survey was circulated to Northwest of England FDs, categorical variables and data were analysed using χ2 test including comparisons by gender and exposure to gastroenterology either as an undergraduate or FD.

Results

133 responses were received (males 55.6%, 37 foundation year 1 (FY1) doctors, 85 FY2 doctors and 11 FY3 doctors). Four (3.0%) FDs were considering a career in gastroenterology. Gastroenterology was perceived positively by 72 (54.1%) of FDs. Significant differences were found between genders in the importance of the following factors influencing specialty selection; patient-centred care (female 52.5% vs male 25.7%, p=0.01), good mentorship (female 67.8% vs male 45.9, p=0.012), income (female 33.9% vs male 59.5%, p=0.003) and length of training (female 27.1% vs male 52.7%, p=0.003). The male predominant existing workforce (female 27.1% vs male 6.8%, p=0.001), and requirement to be a medical registrar (female 74.6% vs male 56.8%, p=0.033) were negatively perceived aspects of gastroenterology among female FDs. Most FDs (female 80.5%, male 70.7%) indicated increased acceptability of less than full time training and greater flexibility may attract more females to gastroenterology.

Conclusion

Increased flexibility in training and greater postfoundation exposure and mentorship may improve diversity within the specialty. The role of general medicine poses significant concern for FDs and may need further evaluation.

General practice is "different": a qualitative study of adaptation experiences of East Staffordshire general practice speciality trainees

BACKGROUND

Undergraduate medical education and foundation training are still largely hospital based. General practice trainees also spend nearly half of their speciality training in hospitals. Aims: To explore adaptation experiences of general practice speciality trainees throughout the training. Method: Semi-structured participant-observer interviews with 18 purposively selected trainees on the East Staffordshire vocational training scheme, observation, stakeholder discussions and concurrent inductive thematic analysis. Results: Undergraduate and early general practice experience during speciality training, general practice trainer role modelling and mastering core general practice skills, facilitated transition. An inclusive and supportive general practice environment, facilitating engagement with a community of practice involving peers, general practice trainers and vocational training programme fostered belongingness. A reduced sense of belongingness during hospital rotations impacted on training and work. Building bridging social connections, personal agency initiatives to bring general practice relevance into hospital training, signposting to general practice relevant duties and mastery of secondary care relevant competencies helped gain belongingness in hospital. While some international graduates required assistance in specific areas; overall, general practice trainees had optimistic views of their future. Conclusion: The main contribution of this study was to relate the adaptation experiences of trainees to learning and practice based on Wenger's communities of practice to enable a better understanding of how they can be influenced to enhance training.Abbreviations: CoP: Community of practice; GP: General practice; GPST: General practice speciality trainee; M: Male; F: Female; ST1: First-year GPST; ST2: Second-year GPST; ST3: Third-year GPST; UKG: UK-based primary medical qualification; IMG: Non-UK primary medical qualification.

Making the (Business) Case for Clinical Ethics Support in the UK

This paper provides a series of reflections on making the case to senior leaders for the introduction of clinical ethics support services within a UK hospital Trust at a time when clinical ethics committees are dwindling in the UK. The paper provides key considerations for those building a (business) case for clinical ethics support within hospitals by drawing upon published academic literature, and key reports from governmental and professional bodies. We also include extracts from documents relating to, and annual reports of, existing clinical ethics support within UK hospitals, as well as extracts from our own proposal submitted to the Trust Board. We aim for this paper to support other ethicists and/or health care staff contemplating introducing clinical ethics support into hospitals, to facilitate the process of making the case for clinical ethics support, and to contribute to the key debates in the literature around clinical ethics support. We conclude that there is a real need for investment in clinical ethics in the UK in order to build the evidence base required to support the wider introduction of clinical ethics support into UK hospitals. Furthermore, our perceptions of the purpose of, and perceived needs met through, clinical ethics support needs to shift to one of hospitals investing in their staff. Finally, we raise concerns over the optional nature of clinical ethics support available to practitioners within UK hospitals.

Exploring communities of practice in the NHS: A core medical trainee experience

Objectives

A community of practice was described by Lave and Wenger as a mutual engagement using a shared repertoire of resources to attain a shared goal. This study explored the extent to which NHS workplaces function as communities of practice for core medical trainees.

Methods

All core medical trainees in one region were invited to a semi-structured interview. A framework was produced using communities of practice themes and a hybrid deductive-inductive method used for data analysis.

Results

NHS workplaces function as communities of practice by enabling engagement and by formation of mutual relationships. Joint enterprise was evidenced by multidisciplinary team working. Full participation was limited by service provision and short training rotations.

Conclusions

Trainee attendance in clinic and procedure lists should be facilitated. Trainees should be enabled to 'act up' as registrar. Flexibility is needed in jobs by allowing swaps between trainees and the facilitation of 'taster weeks'.

Exploring the perceived medical ethics and law training needs of UK foundation doctors

Foundation doctors (FDs) encounter a wide range of ethical and legal issues during their first two years of work. Despite ethics being a key part of most modern undergraduate curricula, FDs can struggle with the issues they see. This study is based on results from an on-line survey answered by 479 UK FDs regarding their medical law and ethics learning needs, and their undergraduate training in this area. Over two-thirds stated they would wish to receive MEL training as an FD on self-discharge against medical advice (∼71%), sedating patients (∼70%), decision making in emergency medicine (∼67%), and withholding and withdrawing treatment (∼66%). Over half of all respondents want MEL training during their Foundation Programme on DNACPR orders (∼63%), dealing with patients with suicidal intent (∼59%), Mental Health Act (∼55%), Deprivation of Liberty Safeguards (∼54%), and end of life care (∼53%). We therefore propose a minimum curriculum for ethics and law training for FDs based on these topics, as well as cases brought by the FDs themselves.

Trends in recruitment into core medical training in the UK

The Physician Specialty Recruitment Office of the Royal College of Physicians has overseen recruitment into core medical training since 2009. This has allowed trends in recruitment numbers and the experience of applicants to be followed. Current recruitment into core training is not providing a large enough pool of trainees to sustain adequate filling of higher medical specialty training posts and therefore ultimately bridge the consultant vacancy rates in the UK.

How can we make renal medicine careers more appealing to UK trainees?

Background

There is a global decline in interest in careers in renal medicine. This is concerning given the increasing global burden of kidney disease. Previous studies in the USA and Australia have identified factors such as a poor work-life balance, lack of role models and the challenging nature of the speciality as possible reasons behind recruitment struggles. This study aimed to identify factors associated with declining interest among trainees in the UK.

Methods

We conducted a survey of 150 National Health Service Foundation trainees (interns) and Core Medical Trainees in Health Education West Midlands. Participants completed a 14-part paper-based questionnaire capturing data on trainee demographics, medical school and postgraduate exposure to renal medicine and perceptions of a career in renal medicine.

Results

There was limited early clinical exposure to renal medicine both in terms of time spent in the speciality and perceived exposure to the range of domains of the speciality. Trainees perceived the speciality as complex with a heavy workload. Very few trainees considered the speciality to be lifestyle oriented. There was also disinterest in taking on the associated general medicine commitments of the training programme. Job experience and identification of role models increased the likelihood of consideration of the speciality.

Conclusion

This survey has identified key areas to drive interest in the speciality, including early engagement, enthusiastic supervision and increased training flexibility. Urgent attention is required to address these areas and make renal medicine careers more appealing.

How do workplaces, working practices and colleagues affect UK doctors' career decisions? A qualitative study of junior doctors' career decision making in the UK

OBJECTIVES

This study draws on an in-depth investigation of factors that influenced the career decisions of junior doctors.

SETTING

Junior doctors in the UK can choose to enter specialty training (ST) programmes within 2 years of becoming doctors. Their specialty choices contribute to shaping the balance of the future medical workforce, with views on general practice (GP) careers of particular interest because of current recruitment difficulties. This paper examines how experiences of medical work and perceptions about specialty training shape junior doctors' career decisions.

PARTICIPANTS

Twenty doctors in the second year of a Foundation Training Programme in England were recruited. Purposive sampling was used to achieve a diverse sample from respondents to an online survey.

RESULTS

Narrative interviewing techniques encouraged doctors to reflect on how experiences during medical school and in medical workplaces had influenced their preferences and perceptions of different specialties. They also spoke about personal aspirations, work priorities and their wider future.Junior doctors' decisions were informed by knowledge about the requirements of ST programmes and direct observation of the pressures under which ST doctors worked. When they encountered negative attitudes towards a specialty they had intended to choose, some became defensive while others kept silent. Achievement of an acceptable work-life balance was a central objective that could override other preferences.Events linked with specific specialties influenced doctors' attitudes towards them. For example, findings confirmed that while early, positive experiences of GP work could increase its attractiveness, negative experiences in GP settings had the opposite effect.

CONCLUSIONS

Junior doctors' preferences and perceptions about medical work are influenced by multiple intrinsic and extrinsic factors and experiences. This paper highlights the importance of understanding how perceptions are formed and preferences are developed, as a basis for generating learning and working environments that nurture students and motivate their professional careers.

12 tips for developing trainee-led initiatives to promote recruitment to training in shortage specialties

This article was migrated. The article was marked as recommended. The healthcare needs of the global population are changing, leaving many medical specialties facing ballooning demand in the context of under-filled specialty training programmes. In this paper we draw on a synthesis of existing literature and our experiences of developing a series of initiatives to tackle the challenge of recruitment to specialty training in geriatric medicine in the UK. We propose a set of strategies that can contribute to the development and success of such initiatives and commend these to healthcare professionals, both junior and senior, who are working in so-called 'shortage' specialities facing recruitment challenges. A common theme throughout the twelve tips is the need to empower trainees to deliver such initiatives. Trainees' unique insight into training programmes, coupled with their burgeoning enthusiasm for their chosen specialty, ought to be harnessed, as it offers a ripe source of potential ideas and solutions to tackle recruitment problems.

Why geriatric medicine? A survey of UK specialist trainees in geriatric medicine

Background

there is concern that there are insufficient numbers of geriatricians to meet the needs of the ageing population. A 2005 survey described factors that influenced why UK geriatricians had chosen to specialise in the field-in the decade since, UK postgraduate training has undergone a fundamental restructure.

Objective

to explore whether the reasons for choosing a career in geriatric medicine in the UK had changed over time, with the goal of using this knowledge to inform recruitment and training initiatives.

Design

an online survey was sent to all UK higher medical trainees in geriatric medicine.

Methods

survey questions that produced categorical data were analysed with simple descriptive statistics. For the survey questions that produced free-text responses, an inductive, iterative approach to analysis, in keeping with the principles of framework analysis, was employed.

Results

two hundred and sixty-nine responses were received out of 641 eligible respondents. Compared with the previous survey, a substantially larger number of respondents regarded geriatric medicine to be their first-choice specialty and a smaller number regretted their career decision. A greater number chose geriatric medicine early in their medical careers. Commitments to the general medical rota and the burden of service provision were considered important downsides to the specialty.

Conclusions

there are reasons to be optimistic about recruitment to geriatric medicine. Future attempts to drive up recruitment might legitimately focus on the role of the medical registrar and perceptions that geriatricians shoulder a disproportionate burden of service commitments and obligations to the acute medical take.

Being the 'med reg': an exploration of junior doctors' perceptions of the medical registrar role

The role of the medical registrar is challenging and acknowledged as being a disincentive to a career in medicine for some junior doctors. We set out to build a broader understanding of the role through exploration of Foundation Doctors' and Core Medical Trainees' perceptions of the role. Data, gathered from focus groups, were analysed using a framework approach. Six key themes were identified, which were grouped under the headings 'perceptions of the medical registrar role' and 'transition into the role'. Our work builds on existing literature to inform a deeper understanding of how junior doctors perceive the medical registrar role. In light of our findings we offer suggestions on possible training initiatives to tackle the issues identified. We also highlight positive perceptions of the role and emphasise the key ambassadorial role that current medical registrars have in relation to attracting tomorrow's medical registrars to the specialty.

Internists' career choice towards primary care: a cross-sectional survey

Background

Swiss primary care (PC) is facing workforce shortage. Up to 2011 this workforce was supplied by two board certifications: general medicine and internal medicine. To strengthen them against subspecialties, they were unified into one: general internal medicine. However, since unification general practitioners’ career options are no longer restrained by early commitment to PC. This may lead to a decrease of future primary care physicians (PCPs).

Methods

To gain insights in timing and factors influencing career choice of internists, we addressed a cross sectional survey to all board certified internists in the years 2000–2010 (n = 1462). Main measures were: final career choice (PCPs, hospital internists or subspecialists), timing and factors influencing career choice, and attractiveness of PCP career during medical school and residency.

Results

Response rate was 53.2%, 44.8% were female and median age was 45 years old. Final career choice was PCP for 39.1% of participants, 15.0% chose to become hospital internists, 41.8% became subspecialists and 4.0% other. Timing of career choice significantly differed between groups. Most of the subspecialists have chosen their career during residency (65.3%), while only 21.9% of the PCPs chose during residency. Work experience in an academic hospital was negatively associated with becoming PCP (P < 0.001). Family influence on career choice was more frequently reported among PCPs and chiefs’ influence more reported among non-PCPs (P < 0.001). Fifty-nine percent of the participants considered a career as PCP to be attractive during medical school, this proportion decreased over time.

Conclusions

Timing of career choice of PCPs and subspecialists strongly differed. PCPs opted late for their career and potentially modifiable external factors seem to contribute to their decision. This stresses the importance of fostering attractiveness of PC during medical school as well as during and after residency and of tailored residency positions for future PCPs in the hospital-dominated new general internal medicine training.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0624-2) contains supplementary material, which is available to authorized users.

Leadership and the medical registrar: how can organisations support these unsung heroes?

Medical registrars have been described as the 'workhorses' of National Health Service hospitals, being at the interface of acute and chronic health services. They are expected to demonstrate effective leadership skills. There are concerns from the Royal College of Physicians that medical registrars are being overwhelmed and unsupported by organisations, and are struggling in their ability to provide safe, high-quality patient care. Junior colleagues are also being deterred by general medical specialties by the prospect of becoming the 'Med Reg'. There is a growing need to support medical registrars in several key aspects of training, not least medical leadership. Thus far, there has been a distinct disparity in the provision of medical leadership training for junior doctors in the UK that has adversely affected the standard of care given to patients. Recent landmark reviews and initiatives, principally the Medical Leadership Competency Framework, have raised awareness of leadership competencies for all doctors and the need for their incorporation into undergraduate and postgraduate curricula. It is hoped that interactive strategies to engage medical registrars in leadership training will lead to positive results including improvements in interdisciplinary communication, patient outcomes and fulfilment of curriculum competencies. Organisations have a duty to improve the quality of medical leadership training so that doctors feel equipped to influence change throughout their careers and be tomorrow's leaders. This review outlines the deficiencies in training, the importance of developing leadership skills in medical registrars and educational strategies that could be implemented by organisations in a cost-effective manner.

Training the generals of the future

The Future Hospital Commission acknowledges that the principal challenge for healthcare organisations and professionals is to accept the fundamental requirement that patients must be treated with compassion, kindness and respect while having their physical and emotional needs met at all times. The recognition that clinical outcomes alone are an insufficient guide to the adequacy of health service provision demands cultural, organisational and individual change. In the Future Hospital Forum we scan the world literature for papers on systems of care that might best ensure these principles are delivered, and to critically evaluate their potential impact. The theme in this edition is generalism.

Doctors' enjoyment of their work and satisfaction with time available for leisure: UK time trend questionnaire-based study

Introduction

Doctors’ job satisfaction is important to the health service to ensure commitment, effective training, service provision and retention. Job satisfaction matters to doctors for their personal happiness, fulfilment, service to patients and duty to employers. Monitoring job satisfaction trends informs workforce planning.

Materials and methods

We surveyed UK-trained doctors up to 5 years after graduation for six graduation year cohorts: 1996, 1999, 2002, 2005, 2008, 2012. Doctors scored their job enjoyment (Enjoyment) and satisfaction with time outside work (Leisure) on a scale from 1 (lowest enjoyment/satisfaction) to 10 (highest).

Results

Overall, 47% had a high level of Enjoyment (scores 8–10) 1 year after graduation and 56% after 5 years. For Leisure, the corresponding figures were 19% and 37% at 1 and 5 years, respectively. For Leisure at 1 year, high scores were given by about 10% in the 1990s, rising to about 25% in the mid-2000s. Low scores (1–3) for Enjoyment were given by 15% of qualifiers of 1996, falling to 5% by 2008; corresponding figures for Leisure were 42% and 19%. At 5 years, the corresponding figures were 6% and 4%, and 23% and 17%. Enjoyment and Leisure were scored higher by general practitioners than doctors in other specialties. Both measures varied little by sex, ethnicity or medical school attended.

Conclusions

Scores for Enjoyment were generally high; those for Leisure were lower. Policy initiatives should address why this aspect of satisfaction is low, particularly in the first year after graduation but also among hospital doctors 5 years after graduation.

General medical training in gastroenterology: views from specialist trainees on the challenges of dual accreditation

Higher specialist training in general internal medicine (GIM) and the medical specialties has been subject to many changes and increasing subspecialisation in recent years. The 'Shape of Training' review proposes 'broad-based specialty training', shortening of training by one year, and subspecialisation to be undertaken after the certificate of specialty training is obtained. All higher level gastroenterology trainees based in the UK were invited to complete an online survey between July and September 2012 to assess their experience of gastroenterology and GIM training. Overall, 72.7% of trainees expressed satisfaction with their training in gastroenterology but significantly fewer (43.5%) expressed satisfaction with their training in GIM. Satisfaction with gastroenterology training thus is good, but satisfaction with GIM training is lower and levels of dissatisfaction have increased significantly since 2008. Up to 50% of trainees are not achieving the minimum recommended number of colonoscopy procedures for their stage of training. Experience in GIM is seen as service orientated, with a lack of training opportunities. There is a worrying difficulty in gaining the minimum required experience in endoscopy. If the length of specialist training is shortened and generalised, training in key core specialist skills such as endoscopy may be compromised further.

Improving core medical training--innovative and feasible ideas to better training

A recent survey of UK core medical training (CMT) training conducted jointly by the Royal College of Physicians (RCP) and Joint Royal College of Physicians Training Board (JRCPTB) identified that trainees perceived major problems with their training. Service work dominated and compromised training opportunities, and of great concern, almost half the respondents felt that they had not been adequately prepared to take on the role of medical registrar. Importantly, the survey not only gathered CMT trainees' views of their current training, it also asked them for their 'innovative and feasible ways to improve CMT'. This article draws together some of these excellent ideas on how the quality of training and the experience of trainees could be improved. It presents a vision for how CMT trainees, consultant supervisors, training programme directors, clinical directors and managers can work together to implement relevant, feasible and affordable ways to improve training for doctors and deliver the best possible care for patients.

Survival as medical registrar on call: remember the doughnut

Life as a medical registrar presents many challenges and concern is growing that a downwards trend in recruitment to General Medicine is the direct result of a perception by junior doctors that the role of the medical registrar is excessively demanding and results in poor work-life balance. A solution-focused approach (SFA) can be used successfully to find a satisfying outcome for both registrar and patient in many of the situations encountered during an on-call, as well as carrying over benefits into life outside of work. We explore the origins of SFA and the ways in which it can be successfully applied to clinical medicine, providing case studies from the author's own experience to illustrate the principles of this way of thinking.

The future of general medicine

It is a truth universally acknowledged that there is a problem with general medicine. Physicians have become increasingly specialised over the past 30 years or so, and specialist care has produced increasingly better outcomes for some patients. The patients left behind are looked after by general medicine, where demand is increasing, operational priority within hospitals is low, there is little professional kudos and recruitment is suffering. Three recent reports - Hospitals on the Edge?, the Future Hospital Commission report, and the Shape of Training report - have described the problems, but not articulated compelling solutions. Here, I discuss what is good about general medicine, what is bad and make suggestions for improvement. These involve getting specialities to take responsibility for care of appropriate admissions automatically and without delay, giving general physicians control over the service that they provide, and using well-chosen financial drivers to support movement in the right direction.

Postgraduate medical education - A time of change for physicians

Increasing hospital admissions and staffing pressures mean that most medical registrars find their workload is now heavy or unmanageable. Core medical trainees increasingly think the role of medical registrar is too unattractive or difficult, resulting in less competition for such posts. In autumn 2013, the Future Hospital Commission and Shape of Training outlined their vision to reform postgraduate medical training to better meet the needs of older patients with multiple comorbidities. The Future Hospital Commission proposes that there is a greater emphasis on internal medicine from medical school, with expansion of training opportunities and service provision. Shape of Training recommends a six-year training programme culminating in a Certificate of Specialty Training. New initiatives, such as broad-based training, credentialing and rotas with more continuity, are potential ways to increase training in internal medicine. It is clear that training to achieve generalist expertise is as important as training to achieve specialist expertise.

Survey of core medical trainees in the United Kingdom 2013 - inconsistencies in training experience and competing with service demands

There is currently considerable concern about the attractiveness of hospital medicine as a career and experiences in core medical training (CMT) are a key determinant of whether trainees continue in the medical specialties. Little is understood about the quality and impact of the current CMT programme and this survey was designed to assess this. Three key themes emerged. Firstly, the demands of providing service have led to considerable loss of training opportunities, particularly in outpatients and formal teaching sessions. Trainees spend a lot of this service time doing menial tasks and over 90% report that service takes up 80-100% of their time. Secondly, clinical and educational supervision is variable, with trainees sometimes getting little consultant feedback on their clinical performance. Finally, 44% of trainees report that CMT has not prepared them to be a medical registrar and many trainees are put off acute medical specialties by their experiences in CMT.

Geriatric medicine workforce planning: a giant geriatric problem or has the tide turned?

The UK's population is ageing and an adequately staffed geriatric medicine workforce is essential for high quality care. We evaluated the current and future geriatric medicine workforce, drawing on data relating to the UK population, current geriatric medicine consultants and trainees, recruitment into the specialty and trainee career progression. Data were derived from various sources, including the British Geriatrics Society Education and Training Committee biannual survey of training posts. The demographic of consultant geriatricians is changing and so too are their job plans, with more opting to work less than full time. The number of applicants to geriatric medicine training is increasing, yet increasing numbers of posts remain unfilled (4.7% in November 2010 and 14.1% in May 2013). The majority of geriatric medicine trainees secure a substantive consultant post within 6 months of obtaining their certificate of completion of training This work highlights challenges for the future: potential barriers to trainee recruitment, unfilled training posts and an ageing population and workforce.