Brit. 3. P@ychiat.(1976), 528, 290-8
Career Intentions of Senior Registrars in General Psychiatry By PETER BROOK
Summary.
A postal
inquiry
of all senior
registrars
in general
psychiatry
United Kingdom gave a nearly go per cent response rate. Between a fifth of the respondents will not be pursuing general psychiatry level in this country, most of these opting for a psychiatric specialty. overseas graduates will probably remain in this country. Slightly than
men
are aiming
for a consultancy
in general
psychiatry,
in the
a quarter and at consultant Nearly all the fewer women the rest of the
women proposing to switch to one of the specialties. Some of the implications of these findings are discussed, including a proposal for a yearly follow-up of the respondents.
Iwri@oDuc'rioN
Am@ As well as inquiring into whether the respondents were aiming for a consultant post in general psychiatry within the United King
At the present time there are something over 200
Senior
chiatry.
registrars
Of these,
working
it is known
in
that
general
a little
psy
less
than a third are overseas born and rather fewer than a quarter are women (D.H.S.S., 1974).
dom, questions were asked as to the type of hospital they hoped to practise in, the part of the country where they would most likely seek
It is generally assumed, even by those con cerned with manpower needs, that all will aspire to become consultants in this country working in the same field and not in child or
an
go abroad psychiatrists
permanently, while regard it as pro
bable or possible that they will return to their own country or go to North America to practise psychiatry more or consultant
consider
consultant
forensic psychiatry or in mental handicap. But there are indications that this assumption may not be correct. Medical emigration for professional reasons is well established (Gish and Wilson, 1970 ; Gish, 1971), and some home graduates will many overseas
appointment,
would
post
what
in general
alternatives
failed
they
to obtain
psychiatry
a
within
what they considered to be a reasonable time. METHOD
A questionnaire was constructed containing these questions and also making an inquiry into personal and professional matters such as sex, age, type of hospital where most of the psychia tric training had hospital, higher country of birth Lists of senior
(Brook, 1973); and some women will, less reluctantly, settle for a non post (Brook, 1973).
and
if they
been received, type of present qualifications, employers and and origin. registrars in psychiatry holding
National Health Service posts, but not including honorary posts, were obtained from each
To test these assumptions and to look further at a number of other questions related to senior registrars, Manpower
the author was commissioned by the Sub-committee of the Educadon
Committee
of the Royal College of Psychiatrists
Regional Kingdom. addressed registrars
to conduct intentions
a nationwide of all senior
should complete it unless they were working in a psychiatric specialty (in which case they
survey of the career registrars in general
psychiatry in the United Kingdom.
were *90
Health Authority in the United The questionnaire, with a stamped envelope, was sent to all senior on the list, with a request that they
asked
to return
it blank
but
with
an
BY PETER BROOK explanatory
note).
A reminder
letter
was sent
a month later, and a month after this a second letter was despatched, with another question naire. In a few cases a third reminder and questionnaire were sent out. RESULTS
A total of 299 questionnaires these,
were sent. Of
five were sent twice to the same name
in
error because of a joint appointment by two authorities, and 73 were returned uncompleted because the respondents were not in general psychiatry. Of the remaining 22 I , 203 were returned
completed—a
response
rate
of
92
per cent.
Of the respondents i 57 were men ; 46 were women. Seven of the latter were in super numerary
posts
who
for married
had
women.
graduated
Kingdom
or the Republic
134;
group
this
qualffied.
The distinction
Department
of
(D.H.S.S.) country
will
in
of Ireland
be referred
Respon
the
United
numbered
to hereafter
as
‘¿homegraduates'. Those who had qualified outside these isles numbered 6g; they will be referred to as ‘¿overseas graduates'. Table I shows in more detail where respon dents had been born and where they had
is made because the
Health
classifies
of qualification
and
Social
doctors
not
Security
by
their
but by their country
country (Brook, 1972 ; Brook, 1974a). The table shows that this discrepancy also exists for senior
registrars, though to a lesser degree. This finding that the countries of birth and qualification are not necessarily the same would seem to under line the need for a change in the way the D.H.S.S.
accepted
classifies
doctors—if,
that
that country of qualification categorization.
is,
it
The very
large contribution made by medical schools in the Indian sub-continent and the Far East is noteworthy. Mean ages Men Women Home graduates Overseas
33 years 36 years 33 years
graduates
All respondents
34 years
34 years. Range
27—56. Median
Ireland
(except
U.S.A.
India and
outside
Africa
Europe
8 6
12 53
and U.K. and EireU.K.
Far East
Canada)OtherAll
Qualified..
6 7
7
..7
4 2
49 47
134TABLE
282
6g121
II
Tjpe ofreceivedPsychiatric hospitalwheremajorityof training Teaching MaudsleyOtherTotalMen
hospitals and and units 67(43%)
33.
Tables II and III show the type of hospital
‘¿Old'
EireBorn
is
is a more
TABII I Cowztries of birth and qual@ficaiion
Republic Common- Canada of wealth and
of
birth. It is known that about half of the senior psychiatrists surveyed in 1970—1974 who had been born overseas had qualified in this
useful and meaningful
Demographic
dents
291
Bethiem
17(11%)
(1%)
Women
..
:7(37%)
3 (@%)
0
All..
26 (56%)
..71(45%)
97(48%)
84(42%)
20(10%)2
2
46 (1%)157
203
292
CAREER
INTENTIONS
OF SENIOR
REGISTRARS
TABI@EIII
IN GENERAL
graduates peripheral
Past trainingexperienceb, cow*trjof qualification hospitalPsychiatric other)MaudsleyOverseasn=6g24(35%)43(62%)2 (and
teaching
(@%)Homen (54%)@@%)18
jobs
which
are solely in
Table V shows present type ofappointment by sex. Women, as would be expected, are over represented in special programmes, but besides this, they are slightly over-represented in
Teaching
= 13471
are holding hospitals.
PSYCHIATRY
hospitals
and a smaller
proportion
are
in rotating posts. Could the reason be that women find these jobs less attractive because family commitments make it less easy for them tobe mobile?
(:3%)
at which respondents had received the majority of their registrar training. It will be seen that a slightly higher proportion ofwomen had trained in a teaching or university hospital setting, while, on the other hand, overseas graduates were less likely than home graduates to have trained in
Higher qualifications
The degree of M.R.C.PSyCh. was held by ‘¿73 senior registrars. That of M.D. was held by six graduates of teaching and university hospital. Of the 15 holders of the M.R.C.P.,
these types of hospital.
six
This discrepancy between home and over seas graduates persists when the present type of
was to be expected on the basis of previous surveys (Brook, 1972 ; Brook, 1974a).
training
setting
is looked
at.
Two
between
a teaching
supernumerary
and a non-teaching
the
Maudsley
group;
this
finding
Specialty choice The first question asked ofthe senior registrars was, ‘¿At the present time is you aim a consultant
hospital,
special hospital
appointments.
from
additional
types of programmes found at senior registrar level are the joint or rotating appointment held and ‘¿other'which includes
are
More
or
post
in general
psychiatry
(with
or without
special interest) in the United Kingdom?'
overseas
TABi..@IV Present aJ@bointment by country of qualification
Teaching teachingMaudsleyOtherOverseas(n hospitalRotating,
= 6@)8 (i@%)Home(n
Psychiatric
(12%)26
(38%)
= 134)34(25%)20(15%)
@
Women (7%)All
32 (46%)—3 (8%)TABu@V55(41%)14(11%)ii
appointmentTeaching
MaudsleyMen
Psychiatric and
hospital
Present
of
hospital and Rotating onlyPsychiatric unit onlySpedalBethlem
.. (21%) ..33 13(28%)33 ..46(23%)43(21%) * Seven
(21%)
73(47%)
10(22%)
12(26%)7 85(43%)15
of these
were
in S.R.
posts
for married
(6%)
(@%) 8(17%)io (@j%)13
women.
(One respondent failed to complete this question).
3 (6%)
a
BY PETER BROOK
One hundred and fifty-five (76 per cent) said ‘¿yes' to the question. Those replying ‘¿no' were then asked what they intended to do by mdi eating
The figures for home and overseas graduates are almost identical; it would seem quite clear that once a doctor from overseas has obtained a senior registrar post he will almost certainly be wishing to remain in this country.
their first choice to one ofsix alternatives:
(i) Go into a psychiatric specialty (forensic psychiatry, child psychiatry, subnor mality,
psychotherapy,
293
Rather
fewer
women
than
men,
but still in
the order of two-thirds, are staying in general psychiatry, most of the remainder planning to go to one of the specialties. It could be specu
psychogeriatrics)
in this country. Go into another hospital specialty in this country. (iii)@Co into general practice in this country. (iv) Go into an academic or research post in (ii)
lated
that
part-time
jobs
are more
frequently
available in one of the specialties and hence this would make them more attractive to women. It should be noted that as many women as men are planning to leave this country. Some of the senior registrars who are emigrating are likely to be returning to their homelands. There is little difference between the older
this country.
(v) Emigrate. (vi) Other (spedfy which). Table VI gives career intentions cate gorized by country ofqualiflcation, sex and age. For the last, two groupings are made, those aged 36 and over and those under @6.Overall, the majority are seeking a consultant post in general psychiatry in this country, but a sub stantial proportion—a fifth—are not; most of these latter are aiming for the specialties.
and
the younger
age groups
except
of the former are contemplating Contrary to the expectation previous study (Brook, 1973) proportion of senior registrars
that
fewer
emigration. produced by a an insignificant plan to enter
general practice. Few look to an academic career; it is possible that future senior lecturers
TABi@ VI Career intentions by country ofqualzfication, sex and age Percentages
Consultantpost inOtherGeneralAcademicgeneralpsychiatricpracticepostEmigratepsychiatryspecialtyin
U.K.*.Home
U.K.tin
graduates(n=@) .. .. Overseas graduates75i6I27(n=6g) .. .. All men8212——5(n=57) ..8oI,I26All .. women(n=46)
..6726——7Less .. than g6 years of age
Men (n = “¿3). . 8Men(n=@) Women(n=25).. 36 years and over79
6810
24I
66
29
7814
14—
—¿3
—¿7
—¿
—¿
.. Women
(n = 21) . .
All respondents 6—
(n=2o3)..
..84
I—
5
I2
t Includes general psychiatry witha‘¿special interest'. * Other psychogeriatrics.
specialty
includes
forensic
psychiatry,
child
psychiatry,
subnormality
psychotherapy
and
CAREER
294
INTENTIONS
OF SENIOR
REGISTRARS
have already gone on to the academic ladder at the lecturer stage. When career intentions are looked at by the type of hospital in which respondents trained the only striking feature is that 30 per cent of Maudsley graduates are planning to go into a specialty. One explanation of this could be that having had experience in most of the specialties
during
their
training
has made
the
idea of specialization more attractive to them. This same finding holds when career inten
IN GENERAL
PSYCHIATRY
tion is that this is a reflection of the fact that a higher proportion of the former are or have been working in a teaching hospital. By and large, women's aspirations are not noticeably lower than men. It is quite clear that the possession
of a higher
qualification
produces
expectations of a post in a teaching hospital. When responses are broken down first by type of hospital at which psychiatric training was received, and secondly by the present type of post (Table VIII), it will be observed that the
tions are broken down by present appointment; it is noteworthy that i6 per cent of the psychia tric hospital group are planning to emigrate. Those who answered ‘¿yes' to the first question
been at the Bethlem-Maudsley hope for some form of teaching hospital appointment.
were next asked what sort of post they were
Career alternatives
hoping
Those senior registrars who are aiming for consultant posts in general psychiatry were asked what they might do if they failed to obtain a consultant post within what they considered to be a reasonable time. They were offered ten alternatives as below:
for, and were offered
a psychiatric teaching
the alternatives
unit in a general
or university
hospital;
of:
hospital ; a a psychiatric
hospital; ajoint appointment in both a teaching and a non-teaching horpital; other. The replies are summarized in Table VII and are further sub-divided by country of qualification, sex and the possession of a higher qualification other than the M.R.C.Psych. Home graduates' aspirations are higher than those of overseas
graduates
; an obvious
great
of those
who
are or who
(i) Seek a permanent non-consultant in general psychiatry. (ii) Switch to child psychiatry. (iii)
explana TABLE
majority
Switch
have
post
to subnormality.
V1I
Type ofhospital post hopedfor B, country ofbirth, sex and higher qualifications Percentages
Psychiatric
teaching or and non hospitalCombined University hospitalTeaching hospitalPsychiatric
unit
in a
general
teachingOtherSenior consultantpost registrars aiming for ..n=155 in general psychiatry ..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
Home graduates n=96 5fl=59
..
.
27:3
2032
3219
i64
Overseas graduates32 ..
Men41232242fl124 .. Women3!12312!4n=31 ..
Higher qualification M.R.C.Psych.)39i63563fl21 (other than ..
..
..
..
No higher qualificationI03324295fl134 ..
..
..
..36‘034‘74
—¿
BY PETER BROOK
295
TA&.z VIII Type ofhospitalpost hopedfor
By typeof/zospital wheretrainedand @e ofpresent appointment Percentages
PsychiatricTeachingCombinedunit in a
OtherhospitalhospitalteachingTraining
generalor
and non hospitalteaching UniversityPsychiatric
typeTeachingn=77 hospital ......37i620243Psychiatric ..
other)n=64 (and ..
..
Bethlem-Maudsley....3'25395fl14 ......75°7297Present ..
postTeaching type of ......282828i6Joint n=32 ..
......3373'263Psychiatricfl=34 fl=74 .. ..
..
Other....4'—5063n=6 .. .. Bethlem-Maudsley....‘7‘7‘7‘732fl=9 ..
(iv)
......II56—22II
Switch to forensic psychiatry (not prison service).
(v) (vi)
Switch to prison service. Switch to psychogeriatrics.
(vii)
Switch
(viii)
Switch to another specialty.
(ix)
to psychotherapy.
Go into general
rejection of a permanent non-consultant post and would seem more prepared to emigrate. The first finding is in keeping with a survey on the medical assistant grade made late 1973 and early 1974 by the Manpower Sub-Committee (Bewley, 1974). An identical proportion of senior
registrars
permanent
practice.
then
unhesitatingly
non-consultant
rejected
a
post. This consistency
is of course, to be expected, as many of the senior registrars surveyed would also have For each question respondents were allowed responded to the questionnaire on the medical one of three alternatives, ‘¿probably', ‘¿possibly', assistant grade. Replies were then categorized ‘¿definitely no'. The identical questions were by sex and country of qualification as shown in Table X. asked of the group of newly-appointed con (x)
sultants
Emigrate permanently.
in
a survey
made
in
1973
(Brook,
Taking
first the differences
between
the men
and the women it will be seen that women are 1974b), except that the consultant group (who will be referred to hereafter as the ‘¿I96@more prepared to accept a non-consultant post, and conversely very many fewer are prepared consultants') were not offered the alternatives of a switch to the prison service or psycho to emigrate. Again, and expectedly, this is in therapy.
The responses
of the senior registrars
and of the ig6g consultants are given in Table IX. The two most striking differences are that the senior registrars are more definite in their
keeping with the medical assistant question naire. Other differences are not striking, but it
will be seen that women view the prospect of an alternative career in psychotherapy rather more favourably than men and, surprisingly,
296
CAREER INTENTIONS OF SENIOR REGISTRARS IN GENERAL PSYCHIATRY TABt.a IX Expressedpreferencefor careeralternatives to a Consultant post in general p@yc/ziatry ‘¿1969'Consultants and Senior Registrars
Percentages ‘¿1969' Consultants
n = 125; Senior Registrars n = 153
noConProbably RegistrarsSeek a
sultants
permanent
Switch to child psychiatry . . Switch to subnormality .. to
Definitely
Senior
Con-
Senior
Con-
Registrars
sultants
Registrars
sultants
Senior
non-consultant
post in general psychiati@y Switch
Possibly
forensic
psychiatry
prison service)
i8
7
26
i8
57
75
.. ..
6 4
io 3
41 20
24 10
53 76
66 87
(not
..
..
5
7
29
33
66
60
Switch to prison service* . . Switch to psycho-geriatrics
.. ..
—¿ io
I 5
—¿ 21
7 29
fig
92 66
Switch to psycho-therapy
..
—¿
17
—¿
32
—¿
5!
..
6
2
19
9
75
89
.. 14 . . 29.S 30
7 42
42 35
24 29
45 35
69
Switch
to another
..
..
..
specialty
Go into general practice Emigrate permanently
.. ..
Consultants.TABi@zX&pressedpreferencefor Not offered
to ‘¿,@6g'
careeralternatives to a Consultant post in general p.@yc/iiatry
By sexandcowlkyof qualification Percentages Menn=122;Womenn=31;Hgsn=g8;Ogsn=55Probably
noMen
Possibly
Women Hgs Seek a permanent
child
chiatry
..
to forensic
.. in ..
to prisonservice
SWitCh to psychogeria tries .. .. Switch
to to
7
II
39
23
7
83
io
‘¿3
6
i8
3
—¿
I
5
26
19
—¿ 26
64
68
70
56
8
i6
‘¿5
—¿
89
84
84
95
8
34
33
37
29
60
6i
58
63
3
4
i6
‘¿0 —¿
94
84
90
97
45
71
86
6
6
5
2
—¿
—¿
6
3
5
5
30
29
28
33
64
68
67
62
..
i9
13
33
29
33
3!
52
45
48
56
2
I
ii
—¿
ii
5
87
97
87
94
3
4
12
24
26
33
8
70
7!
63
8o
io
3!
30
29
33
24
2!
6i
36
i8
‘¿5a6
another
specialty .. Go into general prac tice
6
psycho
therapy.. Switch
i6
psy
chiatry (not prison service) Switch
6
psy
Switch tosubnormality Switch
Ogs
post in
general psychiatry to
Ogs Men Women Hgs
non
consultant Switch
Ogs Men Women Hgs
Definitely
..
Emigratepermanently
..
2 6
@g
3
@8
BY PETER BROOK rather
fewer
women
are prepared
to consider
the possibility of a switch to child psychiatry. When home and overseas graduates are compared it will be seen that the overseas graduates
are
changing emigrate turning
more
prepared
to
consider
to child psychiatry, and more would permanently, presumably many re to their own countries. DISCUSSION
Perhaps the most important finding from the survey is that between a quarter and one-fifth of the senior registrars surveyed will not be seeking a consultant post in general psychiatry in this country, but instead will for the most part
be
going
into
one
of
the
psychiatric
specialties. An important implication from this finding is that an appropriate allowance will need to be made in the senior registrar establish ment in order to fill consultant vacancies caused by death, retirement and the creation of new posts.
It seems
unlikely
that
senior
registrars
established in one of the specialties will switch back to general psychiatry, but some allowance will need
to be made
for those
doctors
in the
lecturer grade who will choose to move off the academic
ladder and seek a N.H.S.
consultancy.
297
seems to be no difference between the older and younger age groups in this respect.
The senior registrars' expressed preference for a number of career alternatives if they failed to obtain a consultant post in a reasonable time carries
a clear
message.
The
men's
first alter
native is emigration, and a switch to other specialties is much less popular. Women, on the other hand, would put a change to psycho therapy, child psychiatry or a permanent non consultant post before emigration, a finding
which is understandable for married women who would be less able to uproot their spouses than would
their male colleagues.
What will be of great interest is to see what does happen
to this group
of senior
registrars;
how many will in fact remain in general pay chiatry, how many will leave this country to emigrate or in the case of overseas graduates return
to their
own countries,
and
how many
and which ones will get the most highly re garded jobs. The high response rate gives a satisfactory sampling frame for follow-up pur poses and further
(and briefer)
inquiries
will be
made at yearly intervals for the next four years, by which time most of the senior registrars will have found permanent consultant posts.
The numbers of these will be in the order of 6—7a year
(Brook,
1974b).
There would in the past seem to have been a tacit assumption on the part of the D.H.S.S. that all senior registrars, whatever their country of origin, will be seeking a consultant post in this country, and the soundness of this assump tion is borne out by the insignificant proportion tion of overseas graduates who wish to leave. Previous surveys (Brook, 1973 ; Bewley, 1974) have suggested that many women trainees would more or less reluctantly settle for a permanent non-consultant post, but a recent inquiry in the South West Region (Ashurst, 1975) has contra dicted these findings. The present survey shows that two-thirds of the women senior registrars are aiming for a consultancy in general psy chiatry thus supporting Ashurst's findings. Most ofthe rest will be going into one ofthe specialties, and although the questionnaire referred to a ‘¿post' and not specifically a consultant one, it would be reasonable to assume that this is the level they are aiming for. Interestingly, there
Acwowi.@noua@im I am grateful to all those who completed the question noire. I am indebted to Miss Jane Boyce, whose administrative
skills played
a large part
in securing
the
exceptionally high return rate. REFERENcEs
ASHTJP.ST, P. (ig@@)The changing face of the psychiatrist in training. Xews and Xotes, Supplement to the British Journal ofPqchiat,y, April 1975. BEWLEY, T. (ig@@) Survey
of opinions
on the medical
assistant grade. News and Xotes, Supplement to the British Journal ofP@ychiatty,November 1974. BROOK, P. (1972) Consultant
psychiatrists.
British Journal
ofMedical Education,6, 190—5. —¿
(‘973)
Piatrists
in
Training.
Psychiatry Special Publication Royal Coflege of Psychiatrists. —¿
(19744)
The
post-graduate
education
British
Journal
of
No. 7. London: and
training
of
consultant psychiatrists. British Journal of [email protected], 124, 109-24. —¿
(1974b)
Psychiatrists:
background,
career
and
career
alternatives of a group of recently appointed con sultants. British Journal ofPsychiatrj, i@, 1-9.
298
CAREER INTENTIONSOF SENIOR REGISTRARSIN GENERAL PSYCHIATRY
DEPARTMENT OF HEALTh AND SOOIAL SECURITY (i97i,)
Hospital Met&al Skif—England and Walss. National Tables 30 September 1973. Statistics and Research Division. D.HSS.
Gissi,
0.
& WuaoN,
J.
D. (ig@io) Emigrating
London: G. Bell.
Peter Brook,
M.D., P.LO.P*yCb., Wade,
(Received 24 Februarj 1975)
Hospital,
British
Physicians. SocialScienceand Medicine, @, 495-511. Gisx, 0. (ig7i) DoctorM@ation and WorldHealth. Occa sional Papers on Social Administration. No. 43.
Breniwood, Ersex, CMi4
5HQ
Career Intentions of Senior Registrars in General Psychiatry By PETER BROOK
Summary.
A postal
inquiry
of all senior
registrars
in general
psychiatry
United Kingdom gave a nearly go per cent response rate. Between a fifth of the respondents will not be pursuing general psychiatry level in this country, most of these opting for a psychiatric specialty. overseas graduates will probably remain in this country. Slightly than
men
are aiming
for a consultancy
in general
psychiatry,
in the
a quarter and at consultant Nearly all the fewer women the rest of the
women proposing to switch to one of the specialties. Some of the implications of these findings are discussed, including a proposal for a yearly follow-up of the respondents.
Iwri@oDuc'rioN
Am@ As well as inquiring into whether the respondents were aiming for a consultant post in general psychiatry within the United King
At the present time there are something over 200
Senior
chiatry.
registrars
Of these,
working
it is known
in
that
general
a little
psy
less
than a third are overseas born and rather fewer than a quarter are women (D.H.S.S., 1974).
dom, questions were asked as to the type of hospital they hoped to practise in, the part of the country where they would most likely seek
It is generally assumed, even by those con cerned with manpower needs, that all will aspire to become consultants in this country working in the same field and not in child or
an
go abroad psychiatrists
permanently, while regard it as pro
bable or possible that they will return to their own country or go to North America to practise psychiatry more or consultant
consider
consultant
forensic psychiatry or in mental handicap. But there are indications that this assumption may not be correct. Medical emigration for professional reasons is well established (Gish and Wilson, 1970 ; Gish, 1971), and some home graduates will many overseas
appointment,
would
post
what
in general
alternatives
failed
they
to obtain
psychiatry
a
within
what they considered to be a reasonable time. METHOD
A questionnaire was constructed containing these questions and also making an inquiry into personal and professional matters such as sex, age, type of hospital where most of the psychia tric training had hospital, higher country of birth Lists of senior
(Brook, 1973); and some women will, less reluctantly, settle for a non post (Brook, 1973).
and
if they
been received, type of present qualifications, employers and and origin. registrars in psychiatry holding
National Health Service posts, but not including honorary posts, were obtained from each
To test these assumptions and to look further at a number of other questions related to senior registrars, Manpower
the author was commissioned by the Sub-committee of the Educadon
Committee
of the Royal College of Psychiatrists
Regional Kingdom. addressed registrars
to conduct intentions
a nationwide of all senior
should complete it unless they were working in a psychiatric specialty (in which case they
survey of the career registrars in general
psychiatry in the United Kingdom.
were *90
Health Authority in the United The questionnaire, with a stamped envelope, was sent to all senior on the list, with a request that they
asked
to return
it blank
but
with
an
BY PETER BROOK explanatory
note).
A reminder
letter
was sent
a month later, and a month after this a second letter was despatched, with another question naire. In a few cases a third reminder and questionnaire were sent out. RESULTS
A total of 299 questionnaires these,
were sent. Of
five were sent twice to the same name
in
error because of a joint appointment by two authorities, and 73 were returned uncompleted because the respondents were not in general psychiatry. Of the remaining 22 I , 203 were returned
completed—a
response
rate
of
92
per cent.
Of the respondents i 57 were men ; 46 were women. Seven of the latter were in super numerary
posts
who
for married
had
women.
graduated
Kingdom
or the Republic
134;
group
this
qualffied.
The distinction
Department
of
(D.H.S.S.) country
will
in
of Ireland
be referred
Respon
the
United
numbered
to hereafter
as
‘¿homegraduates'. Those who had qualified outside these isles numbered 6g; they will be referred to as ‘¿overseas graduates'. Table I shows in more detail where respon dents had been born and where they had
is made because the
Health
classifies
of qualification
and
Social
doctors
not
Security
by
their
but by their country
country (Brook, 1972 ; Brook, 1974a). The table shows that this discrepancy also exists for senior
registrars, though to a lesser degree. This finding that the countries of birth and qualification are not necessarily the same would seem to under line the need for a change in the way the D.H.S.S.
accepted
classifies
doctors—if,
that
that country of qualification categorization.
is,
it
The very
large contribution made by medical schools in the Indian sub-continent and the Far East is noteworthy. Mean ages Men Women Home graduates Overseas
33 years 36 years 33 years
graduates
All respondents
34 years
34 years. Range
27—56. Median
Ireland
(except
U.S.A.
India and
outside
Africa
Europe
8 6
12 53
and U.K. and EireU.K.
Far East
Canada)OtherAll
Qualified..
6 7
7
..7
4 2
49 47
134TABLE
282
6g121
II
Tjpe ofreceivedPsychiatric hospitalwheremajorityof training Teaching MaudsleyOtherTotalMen
hospitals and and units 67(43%)
33.
Tables II and III show the type of hospital
‘¿Old'
EireBorn
is
is a more
TABII I Cowztries of birth and qual@ficaiion
Republic Common- Canada of wealth and
of
birth. It is known that about half of the senior psychiatrists surveyed in 1970—1974 who had been born overseas had qualified in this
useful and meaningful
Demographic
dents
291
Bethiem
17(11%)
(1%)
Women
..
:7(37%)
3 (@%)
0
All..
26 (56%)
..71(45%)
97(48%)
84(42%)
20(10%)2
2
46 (1%)157
203
292
CAREER
INTENTIONS
OF SENIOR
REGISTRARS
TABI@EIII
IN GENERAL
graduates peripheral
Past trainingexperienceb, cow*trjof qualification hospitalPsychiatric other)MaudsleyOverseasn=6g24(35%)43(62%)2 (and
teaching
(@%)Homen (54%)@@%)18
jobs
which
are solely in
Table V shows present type ofappointment by sex. Women, as would be expected, are over represented in special programmes, but besides this, they are slightly over-represented in
Teaching
= 13471
are holding hospitals.
PSYCHIATRY
hospitals
and a smaller
proportion
are
in rotating posts. Could the reason be that women find these jobs less attractive because family commitments make it less easy for them tobe mobile?
(:3%)
at which respondents had received the majority of their registrar training. It will be seen that a slightly higher proportion ofwomen had trained in a teaching or university hospital setting, while, on the other hand, overseas graduates were less likely than home graduates to have trained in
Higher qualifications
The degree of M.R.C.PSyCh. was held by ‘¿73 senior registrars. That of M.D. was held by six graduates of teaching and university hospital. Of the 15 holders of the M.R.C.P.,
these types of hospital.
six
This discrepancy between home and over seas graduates persists when the present type of
was to be expected on the basis of previous surveys (Brook, 1972 ; Brook, 1974a).
training
setting
is looked
at.
Two
between
a teaching
supernumerary
and a non-teaching
the
Maudsley
group;
this
finding
Specialty choice The first question asked ofthe senior registrars was, ‘¿At the present time is you aim a consultant
hospital,
special hospital
appointments.
from
additional
types of programmes found at senior registrar level are the joint or rotating appointment held and ‘¿other'which includes
are
More
or
post
in general
psychiatry
(with
or without
special interest) in the United Kingdom?'
overseas
TABi..@IV Present aJ@bointment by country of qualification
Teaching teachingMaudsleyOtherOverseas(n hospitalRotating,
= 6@)8 (i@%)Home(n
Psychiatric
(12%)26
(38%)
= 134)34(25%)20(15%)
@
Women (7%)All
32 (46%)—3 (8%)TABu@V55(41%)14(11%)ii
appointmentTeaching
MaudsleyMen
Psychiatric and
hospital
Present
of
hospital and Rotating onlyPsychiatric unit onlySpedalBethlem
.. (21%) ..33 13(28%)33 ..46(23%)43(21%) * Seven
(21%)
73(47%)
10(22%)
12(26%)7 85(43%)15
of these
were
in S.R.
posts
for married
(6%)
(@%) 8(17%)io (@j%)13
women.
(One respondent failed to complete this question).
3 (6%)
a
BY PETER BROOK
One hundred and fifty-five (76 per cent) said ‘¿yes' to the question. Those replying ‘¿no' were then asked what they intended to do by mdi eating
The figures for home and overseas graduates are almost identical; it would seem quite clear that once a doctor from overseas has obtained a senior registrar post he will almost certainly be wishing to remain in this country.
their first choice to one ofsix alternatives:
(i) Go into a psychiatric specialty (forensic psychiatry, child psychiatry, subnor mality,
psychotherapy,
293
Rather
fewer
women
than
men,
but still in
the order of two-thirds, are staying in general psychiatry, most of the remainder planning to go to one of the specialties. It could be specu
psychogeriatrics)
in this country. Go into another hospital specialty in this country. (iii)@Co into general practice in this country. (iv) Go into an academic or research post in (ii)
lated
that
part-time
jobs
are more
frequently
available in one of the specialties and hence this would make them more attractive to women. It should be noted that as many women as men are planning to leave this country. Some of the senior registrars who are emigrating are likely to be returning to their homelands. There is little difference between the older
this country.
(v) Emigrate. (vi) Other (spedfy which). Table VI gives career intentions cate gorized by country ofqualiflcation, sex and age. For the last, two groupings are made, those aged 36 and over and those under @6.Overall, the majority are seeking a consultant post in general psychiatry in this country, but a sub stantial proportion—a fifth—are not; most of these latter are aiming for the specialties.
and
the younger
age groups
except
of the former are contemplating Contrary to the expectation previous study (Brook, 1973) proportion of senior registrars
that
fewer
emigration. produced by a an insignificant plan to enter
general practice. Few look to an academic career; it is possible that future senior lecturers
TABi@ VI Career intentions by country ofqualzfication, sex and age Percentages
Consultantpost inOtherGeneralAcademicgeneralpsychiatricpracticepostEmigratepsychiatryspecialtyin
U.K.*.Home
U.K.tin
graduates(n=@) .. .. Overseas graduates75i6I27(n=6g) .. .. All men8212——5(n=57) ..8oI,I26All .. women(n=46)
..6726——7Less .. than g6 years of age
Men (n = “¿3). . 8Men(n=@) Women(n=25).. 36 years and over79
6810
24I
66
29
7814
14—
—¿3
—¿7
—¿
—¿
.. Women
(n = 21) . .
All respondents 6—
(n=2o3)..
..84
I—
5
I2
t Includes general psychiatry witha‘¿special interest'. * Other psychogeriatrics.
specialty
includes
forensic
psychiatry,
child
psychiatry,
subnormality
psychotherapy
and
CAREER
294
INTENTIONS
OF SENIOR
REGISTRARS
have already gone on to the academic ladder at the lecturer stage. When career intentions are looked at by the type of hospital in which respondents trained the only striking feature is that 30 per cent of Maudsley graduates are planning to go into a specialty. One explanation of this could be that having had experience in most of the specialties
during
their
training
has made
the
idea of specialization more attractive to them. This same finding holds when career inten
IN GENERAL
PSYCHIATRY
tion is that this is a reflection of the fact that a higher proportion of the former are or have been working in a teaching hospital. By and large, women's aspirations are not noticeably lower than men. It is quite clear that the possession
of a higher
qualification
produces
expectations of a post in a teaching hospital. When responses are broken down first by type of hospital at which psychiatric training was received, and secondly by the present type of post (Table VIII), it will be observed that the
tions are broken down by present appointment; it is noteworthy that i6 per cent of the psychia tric hospital group are planning to emigrate. Those who answered ‘¿yes' to the first question
been at the Bethlem-Maudsley hope for some form of teaching hospital appointment.
were next asked what sort of post they were
Career alternatives
hoping
Those senior registrars who are aiming for consultant posts in general psychiatry were asked what they might do if they failed to obtain a consultant post within what they considered to be a reasonable time. They were offered ten alternatives as below:
for, and were offered
a psychiatric teaching
the alternatives
unit in a general
or university
hospital;
of:
hospital ; a a psychiatric
hospital; ajoint appointment in both a teaching and a non-teaching horpital; other. The replies are summarized in Table VII and are further sub-divided by country of qualification, sex and the possession of a higher qualification other than the M.R.C.Psych. Home graduates' aspirations are higher than those of overseas
graduates
; an obvious
great
of those
who
are or who
(i) Seek a permanent non-consultant in general psychiatry. (ii) Switch to child psychiatry. (iii)
explana TABLE
majority
Switch
have
post
to subnormality.
V1I
Type ofhospital post hopedfor B, country ofbirth, sex and higher qualifications Percentages
Psychiatric
teaching or and non hospitalCombined University hospitalTeaching hospitalPsychiatric
unit
in a
general
teachingOtherSenior consultantpost registrars aiming for ..n=155 in general psychiatry ..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
Home graduates n=96 5fl=59
..
.
27:3
2032
3219
i64
Overseas graduates32 ..
Men41232242fl124 .. Women3!12312!4n=31 ..
Higher qualification M.R.C.Psych.)39i63563fl21 (other than ..
..
..
..
No higher qualificationI03324295fl134 ..
..
..
..36‘034‘74
—¿
BY PETER BROOK
295
TA&.z VIII Type ofhospitalpost hopedfor
By typeof/zospital wheretrainedand @e ofpresent appointment Percentages
PsychiatricTeachingCombinedunit in a
OtherhospitalhospitalteachingTraining
generalor
and non hospitalteaching UniversityPsychiatric
typeTeachingn=77 hospital ......37i620243Psychiatric ..
other)n=64 (and ..
..
Bethlem-Maudsley....3'25395fl14 ......75°7297Present ..
postTeaching type of ......282828i6Joint n=32 ..
......3373'263Psychiatricfl=34 fl=74 .. ..
..
Other....4'—5063n=6 .. .. Bethlem-Maudsley....‘7‘7‘7‘732fl=9 ..
(iv)
......II56—22II
Switch to forensic psychiatry (not prison service).
(v) (vi)
Switch to prison service. Switch to psychogeriatrics.
(vii)
Switch
(viii)
Switch to another specialty.
(ix)
to psychotherapy.
Go into general
rejection of a permanent non-consultant post and would seem more prepared to emigrate. The first finding is in keeping with a survey on the medical assistant grade made late 1973 and early 1974 by the Manpower Sub-Committee (Bewley, 1974). An identical proportion of senior
registrars
permanent
practice.
then
unhesitatingly
non-consultant
rejected
a
post. This consistency
is of course, to be expected, as many of the senior registrars surveyed would also have For each question respondents were allowed responded to the questionnaire on the medical one of three alternatives, ‘¿probably', ‘¿possibly', assistant grade. Replies were then categorized ‘¿definitely no'. The identical questions were by sex and country of qualification as shown in Table X. asked of the group of newly-appointed con (x)
sultants
Emigrate permanently.
in
a survey
made
in
1973
(Brook,
Taking
first the differences
between
the men
and the women it will be seen that women are 1974b), except that the consultant group (who will be referred to hereafter as the ‘¿I96@more prepared to accept a non-consultant post, and conversely very many fewer are prepared consultants') were not offered the alternatives of a switch to the prison service or psycho to emigrate. Again, and expectedly, this is in therapy.
The responses
of the senior registrars
and of the ig6g consultants are given in Table IX. The two most striking differences are that the senior registrars are more definite in their
keeping with the medical assistant question naire. Other differences are not striking, but it
will be seen that women view the prospect of an alternative career in psychotherapy rather more favourably than men and, surprisingly,
296
CAREER INTENTIONS OF SENIOR REGISTRARS IN GENERAL PSYCHIATRY TABt.a IX Expressedpreferencefor careeralternatives to a Consultant post in general p@yc/ziatry ‘¿1969'Consultants and Senior Registrars
Percentages ‘¿1969' Consultants
n = 125; Senior Registrars n = 153
noConProbably RegistrarsSeek a
sultants
permanent
Switch to child psychiatry . . Switch to subnormality .. to
Definitely
Senior
Con-
Senior
Con-
Registrars
sultants
Registrars
sultants
Senior
non-consultant
post in general psychiati@y Switch
Possibly
forensic
psychiatry
prison service)
i8
7
26
i8
57
75
.. ..
6 4
io 3
41 20
24 10
53 76
66 87
(not
..
..
5
7
29
33
66
60
Switch to prison service* . . Switch to psycho-geriatrics
.. ..
—¿ io
I 5
—¿ 21
7 29
fig
92 66
Switch to psycho-therapy
..
—¿
17
—¿
32
—¿
5!
..
6
2
19
9
75
89
.. 14 . . 29.S 30
7 42
42 35
24 29
45 35
69
Switch
to another
..
..
..
specialty
Go into general practice Emigrate permanently
.. ..
Consultants.TABi@zX&pressedpreferencefor Not offered
to ‘¿,@6g'
careeralternatives to a Consultant post in general p.@yc/iiatry
By sexandcowlkyof qualification Percentages Menn=122;Womenn=31;Hgsn=g8;Ogsn=55Probably
noMen
Possibly
Women Hgs Seek a permanent
child
chiatry
..
to forensic
.. in ..
to prisonservice
SWitCh to psychogeria tries .. .. Switch
to to
7
II
39
23
7
83
io
‘¿3
6
i8
3
—¿
I
5
26
19
—¿ 26
64
68
70
56
8
i6
‘¿5
—¿
89
84
84
95
8
34
33
37
29
60
6i
58
63
3
4
i6
‘¿0 —¿
94
84
90
97
45
71
86
6
6
5
2
—¿
—¿
6
3
5
5
30
29
28
33
64
68
67
62
..
i9
13
33
29
33
3!
52
45
48
56
2
I
ii
—¿
ii
5
87
97
87
94
3
4
12
24
26
33
8
70
7!
63
8o
io
3!
30
29
33
24
2!
6i
36
i8
‘¿5a6
another
specialty .. Go into general prac tice
6
psycho
therapy.. Switch
i6
psy
chiatry (not prison service) Switch
6
psy
Switch tosubnormality Switch
Ogs
post in
general psychiatry to
Ogs Men Women Hgs
non
consultant Switch
Ogs Men Women Hgs
Definitely
..
Emigratepermanently
..
2 6
@g
3
@8
BY PETER BROOK rather
fewer
women
are prepared
to consider
the possibility of a switch to child psychiatry. When home and overseas graduates are compared it will be seen that the overseas graduates
are
changing emigrate turning
more
prepared
to
consider
to child psychiatry, and more would permanently, presumably many re to their own countries. DISCUSSION
Perhaps the most important finding from the survey is that between a quarter and one-fifth of the senior registrars surveyed will not be seeking a consultant post in general psychiatry in this country, but instead will for the most part
be
going
into
one
of
the
psychiatric
specialties. An important implication from this finding is that an appropriate allowance will need to be made in the senior registrar establish ment in order to fill consultant vacancies caused by death, retirement and the creation of new posts.
It seems
unlikely
that
senior
registrars
established in one of the specialties will switch back to general psychiatry, but some allowance will need
to be made
for those
doctors
in the
lecturer grade who will choose to move off the academic
ladder and seek a N.H.S.
consultancy.
297
seems to be no difference between the older and younger age groups in this respect.
The senior registrars' expressed preference for a number of career alternatives if they failed to obtain a consultant post in a reasonable time carries
a clear
message.
The
men's
first alter
native is emigration, and a switch to other specialties is much less popular. Women, on the other hand, would put a change to psycho therapy, child psychiatry or a permanent non consultant post before emigration, a finding
which is understandable for married women who would be less able to uproot their spouses than would
their male colleagues.
What will be of great interest is to see what does happen
to this group
of senior
registrars;
how many will in fact remain in general pay chiatry, how many will leave this country to emigrate or in the case of overseas graduates return
to their
own countries,
and
how many
and which ones will get the most highly re garded jobs. The high response rate gives a satisfactory sampling frame for follow-up pur poses and further
(and briefer)
inquiries
will be
made at yearly intervals for the next four years, by which time most of the senior registrars will have found permanent consultant posts.
The numbers of these will be in the order of 6—7a year
(Brook,
1974b).
There would in the past seem to have been a tacit assumption on the part of the D.H.S.S. that all senior registrars, whatever their country of origin, will be seeking a consultant post in this country, and the soundness of this assump tion is borne out by the insignificant proportion tion of overseas graduates who wish to leave. Previous surveys (Brook, 1973 ; Bewley, 1974) have suggested that many women trainees would more or less reluctantly settle for a permanent non-consultant post, but a recent inquiry in the South West Region (Ashurst, 1975) has contra dicted these findings. The present survey shows that two-thirds of the women senior registrars are aiming for a consultancy in general psy chiatry thus supporting Ashurst's findings. Most ofthe rest will be going into one ofthe specialties, and although the questionnaire referred to a ‘¿post' and not specifically a consultant one, it would be reasonable to assume that this is the level they are aiming for. Interestingly, there
Acwowi.@noua@im I am grateful to all those who completed the question noire. I am indebted to Miss Jane Boyce, whose administrative
skills played
a large part
in securing
the
exceptionally high return rate. REFERENcEs
ASHTJP.ST, P. (ig@@)The changing face of the psychiatrist in training. Xews and Xotes, Supplement to the British Journal ofPqchiat,y, April 1975. BEWLEY, T. (ig@@) Survey
of opinions
on the medical
assistant grade. News and Xotes, Supplement to the British Journal ofP@ychiatty,November 1974. BROOK, P. (1972) Consultant
psychiatrists.
British Journal
ofMedical Education,6, 190—5. —¿
(‘973)
Piatrists
in
Training.
Psychiatry Special Publication Royal Coflege of Psychiatrists. —¿
(19744)
The
post-graduate
education
British
Journal
of
No. 7. London: and
training
of
consultant psychiatrists. British Journal of [email protected], 124, 109-24. —¿
(1974b)
Psychiatrists:
background,
career
and
career
alternatives of a group of recently appointed con sultants. British Journal ofPsychiatrj, i@, 1-9.
298
CAREER INTENTIONSOF SENIOR REGISTRARSIN GENERAL PSYCHIATRY
DEPARTMENT OF HEALTh AND SOOIAL SECURITY (i97i,)
Hospital Met&al Skif—England and Walss. National Tables 30 September 1973. Statistics and Research Division. D.HSS.
Gissi,
0.
& WuaoN,
J.
D. (ig@io) Emigrating
London: G. Bell.
Peter Brook,
M.D., P.LO.P*yCb., Wade,
(Received 24 Februarj 1975)
Hospital,
British
Physicians. SocialScienceand Medicine, @, 495-511. Gisx, 0. (ig7i) DoctorM@ation and WorldHealth. Occa sional Papers on Social Administration. No. 43.
Breniwood, Ersex, CMi4
5HQ
