British Iorrrnal of Medical Edrrcation, 1975, 9, 70-77
Career attainment - chance or choice Survey of career experience of doctors graduating in Scottish medical schools in 1962
A. D. MclNTYRE and K. M. PARRY’ Scottish Council for Postgraduate Medical Education
K e y words ‘EDUCATION, MEDICAL GRADUATE GENERAL PRACTICE/ *mall ‘HOSPITAL MEDICAL STAFF SPECIALTIES, MEDICAL CONSULTATION TIMEFACTORS DECISION MAKING GENERAL PRACTICE/edUC PHYSICIANS, WOMEN EMIGRATION AND IMMIGRATION VOCATIONAL GUIDANCE SCOTLAND
GREATBRITAIN NORTHAMERICA
The Royal Commission on Medical Education (1968) expressed the view that the years of postgraduate medical education and training following the preregistration year presente4 the most urgent problems ‘both because of the number of trainees involved and because of the present disorganised state of training during these years’ (para 74). ‘Because many registrar posts meet service rather than training needs the availability of a post in which suitable training will be received has become haphazard. Thus, senior house officer and registrar appointments do not at present usually comprise a planned postgraduate education following the preregistration year’. (Royal Commission, para 71). I n considering this problem, the Scottish Council for Postgraduate Medical Education came to the conclusion that further information was needed, and decided to conduct a retrospective questionnaire survey of the training and career experience of the doctors who had qualified in Scotland in 1962.
Method Three hundred and sixty-two medical students graduated in Scottish medical schools in 1962 and a simple questionnaire was sent to the 338 whose names were on the Medical Register at the end of August 1973; 254 (75%) were living in the United Kingdom and 84 (25%), including ‘Requests for reprints to Dr K . M. Parry. Scottish Council for Postgraduate Medical Education. 8 Queen Street, Edinburgh EH2 IJE. 70
those non-British nationals who had returned home, were living overseas. There was an 89% response from those resident in the United Kingdom and a 59% response from those overseas. Each doctor was asked to provide information about date of birth, sex, marital status, country of birth, nationality, medical school. qualifications held, stage when decision made to enter present field of work, whether this decision was influenced by difficulty in obtaining a post in a preferred specialty, the adequacy of the career advice given, and a curriculum vitae of all jobs held since graduation showing the grade of appointment, the specialty, and the place of work.
Results The posts held by the 221 doctors working in the UK are shown in Tab!e 1 . Of the 182 doctors working full time, 78 (43%) were in general practice, 86 (47%) in the hospital and specialist services, and 18 (10%) in other fields of work. All but 1 of the 39 in part-time employment or unemployed were women. Hospital and specialist services Of the 86 doctors working full time in the hospital services in the UK, 11 were women, of whom 3 were married; 46 (53%) had achieved consultant/senior lecturer status, 34 (40%) were senior registrars/!ecturers, and 6
Career attainment - chance or choice
71
Tahle 1. Posts h e f d by doctors working in the United Kingdom M General practice Hospital appointments (NHS, University and Joint) Academic non-clinical Industrial medicine Royal Navy Local authority Family planning Other Unemployed Total
Fir11 rime
Part time
F
F
M
Total
68
87
15
97 7 2 2 9
4
2 2 1
1 -
4 4
9
153
29
were in registrar/other grades. The doctors in the survey were 34 years of age or o!der and all had been graduated for 11 years and fully registered for 10 years: a detailed study was made, therefore, of some of the factors which might have influenced their career experience.
1
38
22 1
and surgical fields being 30% longer than in anaesthetics, ophthalmology, and radiology, The average time taken to reach consultant grade was 8.38 years from full registration, and of this, 7.76 years (93%) were spent in the specialty. The majority spent less than 4 years training as senior registrars, and the average period of postregistration experience before appointment to the senior registrar grade was approximately 5 years. These mean values, however, conceal considerable variations within individual specialties and must be related to the proportion of the sample who had reached consultant status.
The specialty-Table 2 shows that a higher proportion of the doctors had become consultants in the specialties of general medicine, the medical subspecialties, psychiatry, anaesthetics, and the surgical subspecialties, such as ENT, orthopaedics, uro!ogy, accident and emergency, than in the others. The career pattern of those who were consultants varied considerably between the specialties (Table 3), the mean period before appointment as consultant in the medical
Time spent in the specialty - The length of time spent in the specialty did not appear to relate
Table 2. Posts held b y doctors in U.K. hospifal service Consliltants /
Anaesthetics General medicine Other medical specialties1 Psychiatry General surgery Other surgical specialties2 Ophthalmology Obstetrics and gynaecology Laboratory medicine Radiology Other Toial
senior lectiirers
Senior regisrrnrsl lecrrirers
Registrars
Other
Total
5 8
3 1
-1
2
11
-
-
1 10
1 -
-
6 6 2
-
3 2 4 8 2
-
1 -
46
34
4
8 2. 3 3 3
1
9 6
a
-
12
-
12 4 8 11 5
-
-
2
86
'Other medical specialties include one each oE cardiology, chest medicine, dermatology, rheurnatology, medical paediatrics, paediatric cardiology. 'Other surgical specialties include accident and emergency ( I ) , cardiac surgery ( 1 ) . ENT (3), neurosurgery (l), orthopaedics 13). paediatric surgery (3). urology (I).
it1 group
Total training in specialty
8 6 6 2 8 2 3 3 3
-
Mean all specialties
5
6.5
8.2 7.5 5.5
* L
4 8 2 7.76
8.25 8.56
10 3
-
8.5
7.75
1
8.7
8.1 5.8
9.2
9.4 9.5 4.5 9.5 10.0
6.6 8.3 1 8.25
3 1 0
Senior Senior Consiil/ants registrars Consrrl/ants registrars
Anaesthetics General medicine Other medical specialties Psychiatry General surgery Other surgical specialties Ophthalmology Obstetrics and gynaecology Laboratory medicine Radiology
-
Number
3.14
3.56 3.42 3.42 3.1 3 2.63 3.25 2.50 4.50 2.50
2.5
Consultants
3.1
3.0 3.0 3.0 2.6 4.0 2.8
1.o
2.7 2.5 -
Senior registrars
registrar
A s senior
Table 3. Training experience of consultantslsenior lecturers and seni or regislrarsllecturers
4.62
3.0 3.0
5.67
4. I 4.75 4.83 4.33 5.13 5.94 3.25
5.6
3.5 6.5 7.0 5.5 6.6 4.1 3.0
-
7.0
6.7
Senior Consultants registrars
A s liorise oficerl senior house oficerl registrar same specialty
0.62
1.0 0.13 0.0 0,83 0.5 0.06 1.5 I .67 0.33 2.33
Consriltanls
-
1.4
1.1
0.9 I .9 4,3
0.0
6.0 0.5
0.7 0.5
Senior registrars
A s lioiise oficerl senior liorise oficrrl registrar other specialty
L
b
3 %
p.
n
3
3
P
Career attainment
- chance or choice
13
general surgery to accident and emergency surgery, and both had become consultants. The other four, who were still senior registrars, changed from general surgery to orthopaedic surgery, paediatric surgery (2), and from pathology to haematology. A further 6 changed specialty at an early stage in their career and became consultants in bacteriology, patho:ogy, radiology, ophthalmology, gynaecology, and psychiatry. The remaining 3 changed considerably later and were either registrars or senior registrars in bacteriology, psychiatry, anaesthetics.
to the chance of becoming ;I consultant within a given period. All 34 senior registrars (except the one in psychiatry) had already spent, on average, one year longer in their specialty than those who had become consultants in these specialties. In most instances the additional time was spent in junior grades in the specialty, frequently for as long as 6 years, and not as senior registrars. Few, either consultants or senior registrars, had experience outside their own specialty. Stage of decision to enter field of work - Fortyfour (51 %) stated that they had decided on their specialty by the end of the preregistration period and 77% within 2 years of registration. This figure rises to 83% if account is taken of those whose late decision was to enter a subspecialty from the parent specialty (Table 4). Apart from the few who decided more than 4 years after registration, the stage of decision did not seem to influence the chance of becoming a consultant within a given period. The stated times of decision correspond very closely with the subsequent career patterns and the timing suggests that many made their decision to follow a specialty while already holding a junior post in the specialty.
Stage of obtaining specialist diplomas - Table 5 suggests that, in general, the earlier qualifications such as the MRCP and FRCS were obtained, the sooner an appointment was made in the senior registrar and consultant grades. (In the case of psychiatry the DPM was a more useful guide for this cohort than the recent MRC Psych. diploma.) The time obtaining such additional qualifications is, of course, influenced by opportunities for study, the service load of the post, and the ability of the individuaIs concerned. Mobility - Of the 86 in the hospital and specialist services, 49 were working in Scotland and 37 in England and Wales. Of those in Scotland, 22 (45%) were consultants and 24 (47%) senior registrars, whereas 24 (65%) of those who had gone to England and Wales were consultants and 10 (27%) senior registrars - the opportunities for Scots going south and Englishmen returning home seemed to be similar. Of the 24 senior registrars in Scotland, 18 were working in hospitals associated with their medical school
Decision influenced by difficulty in entering preferred specialty - Fifteen doctors were influenced to some extent in their choice of specialty by difficulty in obtaining posts in a preferred specialty, but only 3 of these had spent longer than one year in the preferred specialty. Six changed from the parent specialty to a subspecialty. One changed from general medicine to chest medicine. and another from
Table 4. Post held at time of survey related to time of decision Time of decision
Consultant / senior lecturer
Senior registrar/ lecturer
Registrar
Other
Total
7
8 I1
-
1
1 1
11 21
8l 3
-
-
22
As undergraduate
In preregistration posts Post registration 0-2 years 2-4 years 4-6 years 6 years '1 in parent field from registration. 23 in parent field from registration. 32 in parent field from registration.
15 14
82 1 1
-
43
1
2
-
11
2 7
4-6 4 3
6 (1)
2
2
2-2-3-3 2
Getrerd medicitre Other
4
2-2-3' 2 7-2-4-5:
MRCP
6
4 5-32
6? 6 3--5
3
5
3-4-5-6' 2-4 3-9
Oiher. incliidiirg oplrthcrltnology
6
5-6-5
7-5-5
MRCOG
93
9 10-9 8 -9 9
MRC Psycl1
1
Cardiac surgeon MRCP+ FRCS. Pathologists. Also has MRCP. N o t e : Each number represents number of years taken by one person from registration to obtaining diploma.
3
7-1 4-4 5-5-4 2
3
3
Grricrul surgery
FRCS
(9)
103
n
6
7
(2)
5
(4)
MRC Po1I1
(3)-(3) (3)-(5)
DPM
N o . o f years f r o m registratioti till obtoiriirig higher qiralification
( ) Indicates same person with two related diplomas.
1973 1972 1971 1970 I969 1968 Senior registrtrr 1973 1972 1971 1970 1969 1968 1967
C~Jll.Sll/~tltlt
Yaor of obtrrirrirrg F F A DA grtrde
(7)
(8)
FFR
Table 5. T i m e taken f r o m f u l l registration to obtaining appropriate diplotila related t o t i w e of appointment t o present grade
5
9
4
5
6
DMRD DMRT
Career uttninmerit - chance or choice
7s
Stage of decision and subsequent trainingForty-three (55 %) decided before registration to follow a career in general practice (30 as undergraduates and 13 during preregistration General practice year); 32 (74%) of those deciding at this stage Seventy-eight (43 %) of the 182 doctors working became principals within 2 years and 88% full time in the United Kingdom were in general within 3 years of registration. Their postpractice. Ten were women, 5 of whom were registration hospital experience was rather married. All but 2 had become principals, 53% limited: 38 (88%) of the 43 had held a post within 2 years of full registration and 72% in obstetrics, but only 15 (35%) had hospital within 3 years. Details of the time taken to experience in non-obstetric posts, the average reach their present grade are shown in Table 6. duration being 114 months (range 3 months to Post-registration training - The post-registration 4) years - mode 6 months). Their experience in training and experience of the doctors in general general practice before becoming principals is practice varied considerably. Three (4%) had shown in Table 7. Seven (16%) became princino post-registration hospital -experience and 34 pals on entry, 13 (30%) within 12 months, and (44%) had experience in obstetrics only. The re- 33% in between 12 and 15 months; 15 (35%) maining 41 (52%) had some experience in a were trainee assistants. Thirty-five (45 %) decided after registration non-obstetric specialty for periods ranging from 3 months to 7 years (mean 26 months). The to enter general practice and 10 stated that they specialties principally involved were anaesthe- were influenced in making their decision by tics, accident and emergency, chest medicine, difficulty in obtaining a post in a preferred dermatology, ENT, general medicine, general specialty. The specialties involved were obsurgery, geriatrics, and paediatrics; 26 of this stetrics and gynaecology - 4; anaesthetics - 2; ENT - I ; general medicine - 2; geriatrics - 1. 41 also had hospital obstetric experience. None, apart from one Part I FFA, had an The length of time in general practice before appropriate higher qualification for the prebecoming a principal varied from nil to more ferred specialty. than 5 years, but in 85% it was less than 15 The 35 who decided after registration had months. Eighteen (23 %) became principals on entry, 10 (13%) in less than 6 months, and 38 more extensive hospital experience; 22 (63 %) had held obstetric posts and 26 (74%) one or (49%) by between 6 months and 15 months.
9 in surgical specialties and 5 in laboratory specialties.
-
Table 6. Time taken to reach present grade in general practice T i m e taken
No. in group
6m
1 yr
2yr
3yr
4yr
5 yr
6yr
7yr
8yr
9yr
10yr
Total
1
16
24
15
3
7
2
2
3
3
2
78
Table 7. Tirne spent in general practice before becoming principal Stage of decision
Time in genertil pructice
Undergradtiate
3 0 (loo'%)
Preregistru[iori
13 ( I O O O A )
'Indicates number who had been general practitioner trainees.
Post-registration
35 (10096)
Total
78 (100%)
76
A . D.Mclntyre and K. M . Parry
more non-obstetric posts for an average of 3 years (range 3 months to 7 years, 16 for at least 2 years). Their experience in general practice is shown in Table 7. Eleven (31 %) became principals on entry, 10 (28%) within 12 months, and 11 (31%) in between 12 and 15 months; 14 were trainee assistants. Once a firm decision to enter general practice had been made 51% of this group became principals in 1 year and 89% within 2 years of deciding.
anaesthetics, obstetrics, genetics. and general medicine); unemployed 9. Many of those employed part-time were doing only occasional locums or sessions and several indicated they would like to do more but had difficulty in finding work. There was a tendency to choose posts which have office hours or permit maximum flexibility.
Working Overseas Eighty-four (25%) of the 338 questionnaires Higher qualifications- Fifty-one of the 78 were sent to overseas addresses and 6 were ungeneral practitioners had additional medical traceable by the Post Office; 46 (59%) were qualifications; some had more than one. The completed and returned. qualifications held were D.Obst.RCOG - 42; Thirteen of the replies were from non-British MRCGP - 5 ; DA - 8; DPH - 3, DCH - 8; nationals, 11 of whom had returned to their MD- 1. own countries, and 2 were in North America. Seven had left the United Kingdom by the end of one year-2 immediately on graduationWomen doctors Of the 362 doctors in the sample, 104 (29%) and the other 5 after holding preregistration were women. Questionnaires were sent to the 99 posts for a year. The remainder stayed for on the Medical Register and 5 were untraceable periods varying from 24 to 7f years, the mean by the Post Office; 75 questionnaires were com- being 4 years, and obtained one or more addipleted, giving a response rate of 80%. Eight tional qualifications (DRCOG - 1; MRCOG doctors (7 British citizens and 1 Australian) 1; DCH- 3; MRCP -2; DPH- 1). Of the 7 who were working overseas and are included with went home soon after graduation, 3 returned later for additional training and dip!omas : that group. Of the 67 women doctors presently in the UK, D M R D - 1 ; F R C S - 1 ; D P H - 1 . Thirty-three British nationals, including 7 17 were not married. All 17 worked full-time; married women working overseas, returned 4 were principals in general practice, 4 hospital consultants (anaesthetics 2, general medicine 1, completed questionnaires. The 26 male doctors psychiatry l), 4 senior registrars (anaesthetics were mostly in North America (Canada 19, 1, obstetrics and gynaecology 2, paediatric sur- USA l), and the remainder were in Australia gery I), and 5 were in varied other posts outside (2), Holland (I), Nigeria (I), Zaire (l), Malawi the hospital. This gives a hospital/G.P. ratio (1). Six were in general practice, 18 in hospital of 2: 1 which is higher than the ratio of 1.12: 1 specialties, and 2 worked as missionaries. The for the survey !as a whole. The consultant/ peak periods for leaving the United Kingdom senior registrar ratio is 1 : 1, whereas that for were 3 to 6 years after graduation (with few the survey as a whole is 1.3 : 1, but the career higher qualifications) and 10 to 11 years after pattern of the unmarried women is similar to graduation (having completed higher training). All the women doctors were married, and that of their male colleagues in the same they lived in Canada (2), New Zealand, USA, specialty Switzerland, Rhodesia, and Sardinia. Two Of the 50 married women doctors, 12 worked worked full time, one in microbiology and the full time; 6 were in general practice; 2 were other in renal dialysis; 4 were in part-time work consultants in hospital (anaesthetics and bacteriology), and 1 a clinical assistant in and one was temporarily unemployed. anaesthetics; 2 were nonclinical university lecturers and 1 was a local authority doctor. The Miscellaneous other 38 of the married women were employed Eighteen of the 1962 graduates were working as follows: general practice 9; local authority in other specialties as follows: academic nonand family planning 10; hospital 10 (psychiatry, clinical 7 (3 female): industrial medicine 2; local
Career urtuinment
authority 3 (2 female); Royal Navy 2; other 4 (3 female).
Career guidance The questionnaire included the question, ‘Do you think you had adequate career advice?’ and of the 267 who completed the questionnaire, 173 (65%) said ‘no’. The general practitioners responded with an overwhelming statement that the training received was not suited to general practice; special mention was made of the lack of training in the minor specialties. The principal comment from doctors in the hospital service was concerning the lack of organization in training and, in the case of the surgical specialties, the haphazard nature of training in operating techniques. Several stated that the training period was too long, that the service load was too heavy, that training for a specialty was too narrowly based, and that a period of training in general practice would have been beneficial. The training received in
- chance or choice
17
peripheral hospitals was considered by a number to have been very valuable.
Summary A survey was carried out of the career experience of the doctors who graduated from Scottish medical schools in 1962. Few of those in general practice in the UK had undergone the minimum period of vocational training now considered necessary for new entrants to practice. Of those in the hospital and specialist services, 53 % were consultants. There was a tendency for early career decisions to be made, leading to an increasing number of doctors obtaining postgraduate training almost exclusively in one specialty. Many married women doctors were underemployed. A quarter of the doctors were living overseas, including those of the nonBritish nationals who had returned to their country of origin.
Reference Royal Commission on Medical Education (1968). Cmnd. 3569. HMSO, London.
Career attainment - chance or choice Survey of career experience of doctors graduating in Scottish medical schools in 1962
A. D. MclNTYRE and K. M. PARRY’ Scottish Council for Postgraduate Medical Education
K e y words ‘EDUCATION, MEDICAL GRADUATE GENERAL PRACTICE/ *mall ‘HOSPITAL MEDICAL STAFF SPECIALTIES, MEDICAL CONSULTATION TIMEFACTORS DECISION MAKING GENERAL PRACTICE/edUC PHYSICIANS, WOMEN EMIGRATION AND IMMIGRATION VOCATIONAL GUIDANCE SCOTLAND
GREATBRITAIN NORTHAMERICA
The Royal Commission on Medical Education (1968) expressed the view that the years of postgraduate medical education and training following the preregistration year presente4 the most urgent problems ‘both because of the number of trainees involved and because of the present disorganised state of training during these years’ (para 74). ‘Because many registrar posts meet service rather than training needs the availability of a post in which suitable training will be received has become haphazard. Thus, senior house officer and registrar appointments do not at present usually comprise a planned postgraduate education following the preregistration year’. (Royal Commission, para 71). I n considering this problem, the Scottish Council for Postgraduate Medical Education came to the conclusion that further information was needed, and decided to conduct a retrospective questionnaire survey of the training and career experience of the doctors who had qualified in Scotland in 1962.
Method Three hundred and sixty-two medical students graduated in Scottish medical schools in 1962 and a simple questionnaire was sent to the 338 whose names were on the Medical Register at the end of August 1973; 254 (75%) were living in the United Kingdom and 84 (25%), including ‘Requests for reprints to Dr K . M. Parry. Scottish Council for Postgraduate Medical Education. 8 Queen Street, Edinburgh EH2 IJE. 70
those non-British nationals who had returned home, were living overseas. There was an 89% response from those resident in the United Kingdom and a 59% response from those overseas. Each doctor was asked to provide information about date of birth, sex, marital status, country of birth, nationality, medical school. qualifications held, stage when decision made to enter present field of work, whether this decision was influenced by difficulty in obtaining a post in a preferred specialty, the adequacy of the career advice given, and a curriculum vitae of all jobs held since graduation showing the grade of appointment, the specialty, and the place of work.
Results The posts held by the 221 doctors working in the UK are shown in Tab!e 1 . Of the 182 doctors working full time, 78 (43%) were in general practice, 86 (47%) in the hospital and specialist services, and 18 (10%) in other fields of work. All but 1 of the 39 in part-time employment or unemployed were women. Hospital and specialist services Of the 86 doctors working full time in the hospital services in the UK, 11 were women, of whom 3 were married; 46 (53%) had achieved consultant/senior lecturer status, 34 (40%) were senior registrars/!ecturers, and 6
Career attainment - chance or choice
71
Tahle 1. Posts h e f d by doctors working in the United Kingdom M General practice Hospital appointments (NHS, University and Joint) Academic non-clinical Industrial medicine Royal Navy Local authority Family planning Other Unemployed Total
Fir11 rime
Part time
F
F
M
Total
68
87
15
97 7 2 2 9
4
2 2 1
1 -
4 4
9
153
29
were in registrar/other grades. The doctors in the survey were 34 years of age or o!der and all had been graduated for 11 years and fully registered for 10 years: a detailed study was made, therefore, of some of the factors which might have influenced their career experience.
1
38
22 1
and surgical fields being 30% longer than in anaesthetics, ophthalmology, and radiology, The average time taken to reach consultant grade was 8.38 years from full registration, and of this, 7.76 years (93%) were spent in the specialty. The majority spent less than 4 years training as senior registrars, and the average period of postregistration experience before appointment to the senior registrar grade was approximately 5 years. These mean values, however, conceal considerable variations within individual specialties and must be related to the proportion of the sample who had reached consultant status.
The specialty-Table 2 shows that a higher proportion of the doctors had become consultants in the specialties of general medicine, the medical subspecialties, psychiatry, anaesthetics, and the surgical subspecialties, such as ENT, orthopaedics, uro!ogy, accident and emergency, than in the others. The career pattern of those who were consultants varied considerably between the specialties (Table 3), the mean period before appointment as consultant in the medical
Time spent in the specialty - The length of time spent in the specialty did not appear to relate
Table 2. Posts held b y doctors in U.K. hospifal service Consliltants /
Anaesthetics General medicine Other medical specialties1 Psychiatry General surgery Other surgical specialties2 Ophthalmology Obstetrics and gynaecology Laboratory medicine Radiology Other Toial
senior lectiirers
Senior regisrrnrsl lecrrirers
Registrars
Other
Total
5 8
3 1
-1
2
11
-
-
1 10
1 -
-
6 6 2
-
3 2 4 8 2
-
1 -
46
34
4
8 2. 3 3 3
1
9 6
a
-
12
-
12 4 8 11 5
-
-
2
86
'Other medical specialties include one each oE cardiology, chest medicine, dermatology, rheurnatology, medical paediatrics, paediatric cardiology. 'Other surgical specialties include accident and emergency ( I ) , cardiac surgery ( 1 ) . ENT (3), neurosurgery (l), orthopaedics 13). paediatric surgery (3). urology (I).
it1 group
Total training in specialty
8 6 6 2 8 2 3 3 3
-
Mean all specialties
5
6.5
8.2 7.5 5.5
* L
4 8 2 7.76
8.25 8.56
10 3
-
8.5
7.75
1
8.7
8.1 5.8
9.2
9.4 9.5 4.5 9.5 10.0
6.6 8.3 1 8.25
3 1 0
Senior Senior Consiil/ants registrars Consrrl/ants registrars
Anaesthetics General medicine Other medical specialties Psychiatry General surgery Other surgical specialties Ophthalmology Obstetrics and gynaecology Laboratory medicine Radiology
-
Number
3.14
3.56 3.42 3.42 3.1 3 2.63 3.25 2.50 4.50 2.50
2.5
Consultants
3.1
3.0 3.0 3.0 2.6 4.0 2.8
1.o
2.7 2.5 -
Senior registrars
registrar
A s senior
Table 3. Training experience of consultantslsenior lecturers and seni or regislrarsllecturers
4.62
3.0 3.0
5.67
4. I 4.75 4.83 4.33 5.13 5.94 3.25
5.6
3.5 6.5 7.0 5.5 6.6 4.1 3.0
-
7.0
6.7
Senior Consultants registrars
A s liorise oficerl senior house oficerl registrar same specialty
0.62
1.0 0.13 0.0 0,83 0.5 0.06 1.5 I .67 0.33 2.33
Consriltanls
-
1.4
1.1
0.9 I .9 4,3
0.0
6.0 0.5
0.7 0.5
Senior registrars
A s lioiise oficerl senior liorise oficrrl registrar other specialty
L
b
3 %
p.
n
3
3
P
Career attainment
- chance or choice
13
general surgery to accident and emergency surgery, and both had become consultants. The other four, who were still senior registrars, changed from general surgery to orthopaedic surgery, paediatric surgery (2), and from pathology to haematology. A further 6 changed specialty at an early stage in their career and became consultants in bacteriology, patho:ogy, radiology, ophthalmology, gynaecology, and psychiatry. The remaining 3 changed considerably later and were either registrars or senior registrars in bacteriology, psychiatry, anaesthetics.
to the chance of becoming ;I consultant within a given period. All 34 senior registrars (except the one in psychiatry) had already spent, on average, one year longer in their specialty than those who had become consultants in these specialties. In most instances the additional time was spent in junior grades in the specialty, frequently for as long as 6 years, and not as senior registrars. Few, either consultants or senior registrars, had experience outside their own specialty. Stage of decision to enter field of work - Fortyfour (51 %) stated that they had decided on their specialty by the end of the preregistration period and 77% within 2 years of registration. This figure rises to 83% if account is taken of those whose late decision was to enter a subspecialty from the parent specialty (Table 4). Apart from the few who decided more than 4 years after registration, the stage of decision did not seem to influence the chance of becoming a consultant within a given period. The stated times of decision correspond very closely with the subsequent career patterns and the timing suggests that many made their decision to follow a specialty while already holding a junior post in the specialty.
Stage of obtaining specialist diplomas - Table 5 suggests that, in general, the earlier qualifications such as the MRCP and FRCS were obtained, the sooner an appointment was made in the senior registrar and consultant grades. (In the case of psychiatry the DPM was a more useful guide for this cohort than the recent MRC Psych. diploma.) The time obtaining such additional qualifications is, of course, influenced by opportunities for study, the service load of the post, and the ability of the individuaIs concerned. Mobility - Of the 86 in the hospital and specialist services, 49 were working in Scotland and 37 in England and Wales. Of those in Scotland, 22 (45%) were consultants and 24 (47%) senior registrars, whereas 24 (65%) of those who had gone to England and Wales were consultants and 10 (27%) senior registrars - the opportunities for Scots going south and Englishmen returning home seemed to be similar. Of the 24 senior registrars in Scotland, 18 were working in hospitals associated with their medical school
Decision influenced by difficulty in entering preferred specialty - Fifteen doctors were influenced to some extent in their choice of specialty by difficulty in obtaining posts in a preferred specialty, but only 3 of these had spent longer than one year in the preferred specialty. Six changed from the parent specialty to a subspecialty. One changed from general medicine to chest medicine. and another from
Table 4. Post held at time of survey related to time of decision Time of decision
Consultant / senior lecturer
Senior registrar/ lecturer
Registrar
Other
Total
7
8 I1
-
1
1 1
11 21
8l 3
-
-
22
As undergraduate
In preregistration posts Post registration 0-2 years 2-4 years 4-6 years 6 years '1 in parent field from registration. 23 in parent field from registration. 32 in parent field from registration.
15 14
82 1 1
-
43
1
2
-
11
2 7
4-6 4 3
6 (1)
2
2
2-2-3-3 2
Getrerd medicitre Other
4
2-2-3' 2 7-2-4-5:
MRCP
6
4 5-32
6? 6 3--5
3
5
3-4-5-6' 2-4 3-9
Oiher. incliidiirg oplrthcrltnology
6
5-6-5
7-5-5
MRCOG
93
9 10-9 8 -9 9
MRC Psycl1
1
Cardiac surgeon MRCP+ FRCS. Pathologists. Also has MRCP. N o t e : Each number represents number of years taken by one person from registration to obtaining diploma.
3
7-1 4-4 5-5-4 2
3
3
Grricrul surgery
FRCS
(9)
103
n
6
7
(2)
5
(4)
MRC Po1I1
(3)-(3) (3)-(5)
DPM
N o . o f years f r o m registratioti till obtoiriirig higher qiralification
( ) Indicates same person with two related diplomas.
1973 1972 1971 1970 I969 1968 Senior registrtrr 1973 1972 1971 1970 1969 1968 1967
C~Jll.Sll/~tltlt
Yaor of obtrrirrirrg F F A DA grtrde
(7)
(8)
FFR
Table 5. T i m e taken f r o m f u l l registration to obtaining appropriate diplotila related t o t i w e of appointment t o present grade
5
9
4
5
6
DMRD DMRT
Career uttninmerit - chance or choice
7s
Stage of decision and subsequent trainingForty-three (55 %) decided before registration to follow a career in general practice (30 as undergraduates and 13 during preregistration General practice year); 32 (74%) of those deciding at this stage Seventy-eight (43 %) of the 182 doctors working became principals within 2 years and 88% full time in the United Kingdom were in general within 3 years of registration. Their postpractice. Ten were women, 5 of whom were registration hospital experience was rather married. All but 2 had become principals, 53% limited: 38 (88%) of the 43 had held a post within 2 years of full registration and 72% in obstetrics, but only 15 (35%) had hospital within 3 years. Details of the time taken to experience in non-obstetric posts, the average reach their present grade are shown in Table 6. duration being 114 months (range 3 months to Post-registration training - The post-registration 4) years - mode 6 months). Their experience in training and experience of the doctors in general general practice before becoming principals is practice varied considerably. Three (4%) had shown in Table 7. Seven (16%) became princino post-registration hospital -experience and 34 pals on entry, 13 (30%) within 12 months, and (44%) had experience in obstetrics only. The re- 33% in between 12 and 15 months; 15 (35%) maining 41 (52%) had some experience in a were trainee assistants. Thirty-five (45 %) decided after registration non-obstetric specialty for periods ranging from 3 months to 7 years (mean 26 months). The to enter general practice and 10 stated that they specialties principally involved were anaesthe- were influenced in making their decision by tics, accident and emergency, chest medicine, difficulty in obtaining a post in a preferred dermatology, ENT, general medicine, general specialty. The specialties involved were obsurgery, geriatrics, and paediatrics; 26 of this stetrics and gynaecology - 4; anaesthetics - 2; ENT - I ; general medicine - 2; geriatrics - 1. 41 also had hospital obstetric experience. None, apart from one Part I FFA, had an The length of time in general practice before appropriate higher qualification for the prebecoming a principal varied from nil to more ferred specialty. than 5 years, but in 85% it was less than 15 The 35 who decided after registration had months. Eighteen (23 %) became principals on entry, 10 (13%) in less than 6 months, and 38 more extensive hospital experience; 22 (63 %) had held obstetric posts and 26 (74%) one or (49%) by between 6 months and 15 months.
9 in surgical specialties and 5 in laboratory specialties.
-
Table 6. Time taken to reach present grade in general practice T i m e taken
No. in group
6m
1 yr
2yr
3yr
4yr
5 yr
6yr
7yr
8yr
9yr
10yr
Total
1
16
24
15
3
7
2
2
3
3
2
78
Table 7. Tirne spent in general practice before becoming principal Stage of decision
Time in genertil pructice
Undergradtiate
3 0 (loo'%)
Preregistru[iori
13 ( I O O O A )
'Indicates number who had been general practitioner trainees.
Post-registration
35 (10096)
Total
78 (100%)
76
A . D.Mclntyre and K. M . Parry
more non-obstetric posts for an average of 3 years (range 3 months to 7 years, 16 for at least 2 years). Their experience in general practice is shown in Table 7. Eleven (31 %) became principals on entry, 10 (28%) within 12 months, and 11 (31%) in between 12 and 15 months; 14 were trainee assistants. Once a firm decision to enter general practice had been made 51% of this group became principals in 1 year and 89% within 2 years of deciding.
anaesthetics, obstetrics, genetics. and general medicine); unemployed 9. Many of those employed part-time were doing only occasional locums or sessions and several indicated they would like to do more but had difficulty in finding work. There was a tendency to choose posts which have office hours or permit maximum flexibility.
Working Overseas Eighty-four (25%) of the 338 questionnaires Higher qualifications- Fifty-one of the 78 were sent to overseas addresses and 6 were ungeneral practitioners had additional medical traceable by the Post Office; 46 (59%) were qualifications; some had more than one. The completed and returned. qualifications held were D.Obst.RCOG - 42; Thirteen of the replies were from non-British MRCGP - 5 ; DA - 8; DPH - 3, DCH - 8; nationals, 11 of whom had returned to their MD- 1. own countries, and 2 were in North America. Seven had left the United Kingdom by the end of one year-2 immediately on graduationWomen doctors Of the 362 doctors in the sample, 104 (29%) and the other 5 after holding preregistration were women. Questionnaires were sent to the 99 posts for a year. The remainder stayed for on the Medical Register and 5 were untraceable periods varying from 24 to 7f years, the mean by the Post Office; 75 questionnaires were com- being 4 years, and obtained one or more addipleted, giving a response rate of 80%. Eight tional qualifications (DRCOG - 1; MRCOG doctors (7 British citizens and 1 Australian) 1; DCH- 3; MRCP -2; DPH- 1). Of the 7 who were working overseas and are included with went home soon after graduation, 3 returned later for additional training and dip!omas : that group. Of the 67 women doctors presently in the UK, D M R D - 1 ; F R C S - 1 ; D P H - 1 . Thirty-three British nationals, including 7 17 were not married. All 17 worked full-time; married women working overseas, returned 4 were principals in general practice, 4 hospital consultants (anaesthetics 2, general medicine 1, completed questionnaires. The 26 male doctors psychiatry l), 4 senior registrars (anaesthetics were mostly in North America (Canada 19, 1, obstetrics and gynaecology 2, paediatric sur- USA l), and the remainder were in Australia gery I), and 5 were in varied other posts outside (2), Holland (I), Nigeria (I), Zaire (l), Malawi the hospital. This gives a hospital/G.P. ratio (1). Six were in general practice, 18 in hospital of 2: 1 which is higher than the ratio of 1.12: 1 specialties, and 2 worked as missionaries. The for the survey !as a whole. The consultant/ peak periods for leaving the United Kingdom senior registrar ratio is 1 : 1, whereas that for were 3 to 6 years after graduation (with few the survey as a whole is 1.3 : 1, but the career higher qualifications) and 10 to 11 years after pattern of the unmarried women is similar to graduation (having completed higher training). All the women doctors were married, and that of their male colleagues in the same they lived in Canada (2), New Zealand, USA, specialty Switzerland, Rhodesia, and Sardinia. Two Of the 50 married women doctors, 12 worked worked full time, one in microbiology and the full time; 6 were in general practice; 2 were other in renal dialysis; 4 were in part-time work consultants in hospital (anaesthetics and bacteriology), and 1 a clinical assistant in and one was temporarily unemployed. anaesthetics; 2 were nonclinical university lecturers and 1 was a local authority doctor. The Miscellaneous other 38 of the married women were employed Eighteen of the 1962 graduates were working as follows: general practice 9; local authority in other specialties as follows: academic nonand family planning 10; hospital 10 (psychiatry, clinical 7 (3 female): industrial medicine 2; local
Career urtuinment
authority 3 (2 female); Royal Navy 2; other 4 (3 female).
Career guidance The questionnaire included the question, ‘Do you think you had adequate career advice?’ and of the 267 who completed the questionnaire, 173 (65%) said ‘no’. The general practitioners responded with an overwhelming statement that the training received was not suited to general practice; special mention was made of the lack of training in the minor specialties. The principal comment from doctors in the hospital service was concerning the lack of organization in training and, in the case of the surgical specialties, the haphazard nature of training in operating techniques. Several stated that the training period was too long, that the service load was too heavy, that training for a specialty was too narrowly based, and that a period of training in general practice would have been beneficial. The training received in
- chance or choice
17
peripheral hospitals was considered by a number to have been very valuable.
Summary A survey was carried out of the career experience of the doctors who graduated from Scottish medical schools in 1962. Few of those in general practice in the UK had undergone the minimum period of vocational training now considered necessary for new entrants to practice. Of those in the hospital and specialist services, 53 % were consultants. There was a tendency for early career decisions to be made, leading to an increasing number of doctors obtaining postgraduate training almost exclusively in one specialty. Many married women doctors were underemployed. A quarter of the doctors were living overseas, including those of the nonBritish nationals who had returned to their country of origin.
Reference Royal Commission on Medical Education (1968). Cmnd. 3569. HMSO, London.
