Medical Education, 1976, 10, 463-473

Doctors’ career choice: previous research and its relevance for policy-making ROSEMARY HUTT Institute of Manpower Studies

Summary During the last 10 years, a good deal of interest has been shown by both researchers and policy-makers in the factors which determine doctors’ choice of specialty. In this sense ‘specialty’ includes not only the hospital specialties but general practice and occupational and community health. This interest has arisen in part from the problems of geographical and inter-specialty maldistribution which have persisted since the inception of the Health Service. As plans for increasing the total numbers of British doctors begin to be put into effect, the attention of medical manpower planners may well be more sharply focused on ways of ensuring that this increased supply is used in the best possible way. Key words : *CAREER CHOICE ; SPECIALTIES, MEDICAL/ *man; RESEARCH; HEALTH AND WELFARE PLANNING; SOCIOECONOMIC FACTORS ;PERSONALITY ;EDUCATION, MEDICAL; MOTIVATION; INCOME; GREAT BRITAIN

Introduction The purpose of this article is to review the research on the determinants of doctors’ career choice in the U.K., to underline the areas in which more research is needed and to provide an extensive, though not exhaustive, list of references from which other researchers can start. Interest in the problem has not been confined to this country, but in the present review, in order to reduce the problem to more manageable proportions, Correspondence: Mrs Rosemary Hutt, Institute of Manpower Studies, University of Sussex, Mantell Building, Falrnar, Brighton BNl 9RF.

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only the work which has relevance to the British situation will be discussed. The paper is focused on career choice in the United Kingdom, and U.S. publications and occasionally those in other countries are referred to only when they appear to throw light on the British problem by discussing factors which may operate in similar ways even in the different environments of other health care systems. The question of how doctors make their career choice has been approached by doctors themselves by economists, sociologists, educationalists, psychologists, psychiatrists and policy-makers. Sometimes interest in the problem has arisen because of a concern that career advisers should have better information to enable them to help young doctors choose jobs to which they will be well suited. Sometimes it has arisen because of the policy-makers’ and planners’ dissatisfaction with a situation in which there are unfilled vacancies in some specialties and a surplus of candidates for others. Of the hospital specialties, geriatrics, venereology, rheumatology, anaesthetics, radiology and the psychiatry and pathology groups have been short of applicants, while the opposite has been true of general medicine and the surgery group (Health Trends, passim). Last (1967b), Shore (1970, 1974) and Clayden & Parkhouse (1972) have explored the failure of studen preferences and career choices to match vacancies in particular specialties. Misallocation of resources is made worse by the variations in attractiveness between jobs in different regions and in differen hospitals (Maynard, 1972; Freeman, 1974). The interest of economists has been aroused in a situation in which economic forces, instead of working to correct the imbalance, are, at least as regards the

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hospital specialties, actually working to maintain and reinforce it. Salaries are not differentiated; merit awards tend to be concentrated in the ‘popular’ specialties and in the popular areas (Lavers & Rees, 1972), as also do opportunities for private practice, while those who fail to find the rewards they hoped for can, and do, emigrate. Educationalists have been interested in the effects of the selection system and in the effects of medical training itself in contributing to the maldistribution of doctors. Sociologists have concentrated on the part played by the cultural environment in the medical schools, by faculty influence and by the relative prestige and status inside and outside the profession of certain specialties, whereas psychiatrists and psychologists have been more concerned to find out the different personality types who enter the specialties. Because the approaches to the problem have been so diverse, this article will not summarize chronologically the research that has been done, but will consider together books and articles which share a common approach or which have studied similar kinds of factors. The main factors which interact to determine a doctor’s choice of specialty can be grouped so that we can discuss them more clearly.

1. Background factors. These include sex, parental occupation, school, family and social background, nationality and marital status. 2. Personality and attitude factors. This group could clearly be extensive but some of the important aspects of personality for this purpose are the doctor’s attitudes towards patients, death, problemsolving, team-work, decision-making and the exercise of authority. 3. Factors relating to the educational system. This is a complex group of factors covering the various ‘filters’ which influence the kinds of people entering and going through the medical schools : secondary school record, careers advice, the selection system, examination performance, the medical training system, and the student’s ‘image’ of the various specialties. 4. Career factors. Pay and the chance of distinction awards, income relativities, promotion prospects, the possibilities of emigrating, opportunities for private practice, and prestige. 5 . Working conditions. For example: area of residence, type of hospital, equipment and facilities available, length of working day, regularity of hours, and effects on family life.

6. Intrinsic differences between the specialties themselves. These include the amount of patient contact, the extent to which they are research or science-oriented, their relative ‘success’ rates in terms of curing, the skills they require, and the kinds of satisfaction, social or intellectual, to be derived from them. All these factors and more interact together to determine in which specialty a doctor finally takes up an appointment and whether or not he stays in it. It is worth noting that while the first three groups affect what kind of doctors emerge from the medical schools, the last three are concerned with the kinds of factors in the external situation which the doctors have to weigh up when making their career choices 1. The background factors

These have received a good deal of attention for doctors in general but not, in Britain, very much in relation to specialty choice. The A.S.M.E. survey (Royal Commission on Medical Education, 1968 which was done for the Todd Commission in 1966 studied students’ career preferences. Among their findings were that those from rural areas tended more often to prefer general practice. More women students ‘preferred’ general practice and also paediatrics and public health and fewer chose surgery though this ‘preference’ may be in part a reflection of the necessity of fitting family responsibilities in with professional life. Married students showed a greater preference than single ones for medica science and research and less for internal medicine paediatrics, psychiatry and surgery. There was no association found between final year students specialty preference and type of secondary schoo or social class. But the children of medically qualified parents less often favoured medical science o obstetrics as their intended career and more often chose anaesthetics, radiology and surgery. Studen preferences have also been studied at Edinburgh by Martin & Boddy (1962), by the Ogstons at Aberdeen (1970, 1971), and in the United States by Geertsma & Grinols (1972) and by Oates & Feldman (1971 and others. The usefulness of these findings to the study o actual career choice is limited, however, by the extreme instability of students’ preferences even in their final year. Last & Stanley (1968) found there was almost no relationship between student caree preferences and the type of work being done 5 year

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later, and that only one third of the students expressed the same preference after the 5 year interval as before. Those preferring surgery and general practice were, however, less unstable in their decisions than the rest. The main direction of change was a greater diffusion of choice among the specialties and a move towards those with better career opportunities. Undergraduate preferences do not appear to have much predictive value. McLaughlin & Parkhouse (1972) questioned Sheffield and Manchester medical graduates in their pre-registration year and followed this up with two further surveys of the graduates of the succeeding 2 years (McLaughlin & Parkhouse, 1974; Parkhouse & McLaughlin, 1975). Only 26% of these young doctors had made their minds up ‘definitely’ about their career choice. The study of Scottish medical school graduates of 1962 done by McIntyre & Parry (1975) in 1973 showed that 17% of hospital doctors and 13% of general practitioners were influenced in their career choice by the problems of getting a consultant post. The lateness of career decisions and the apparent willingness to adapt to the practical prospects of obtaining posts in various specialties means that it is quite possible that faculties could encourage or discourage students and young doctors entering specialties before a final choice is made. Sex and marital status have received more attention than other background factors. Stanley & Last (1968) found that women took up careers outside the hospitals, or, if inside, towards those not involving continuous clinical responsibility. Flynn & Gardner (1969) found that of women graduates from the Royal Free Hospital School of Medicine 25% of the single and 29% of the married were working in general practice, 9 % and 25 % respectively in public health, whereas 60% and 39% had hospital appointments. For graduates of both sexes marriage has a precipitating influence on career decisions, and Stanley & Last (1968) found that whereas 69% of unmarried men intended to follow a career in hospitals with continuing clinical responsibility, only 46 % of married men did so. Twice as many married as single men opted for careers in general practice or in para-clinical or non-clinical fields. Both here and in the United States the most significant and consistent findings relating to background factors are those relating to sex. The conclusions of Stanley & Last (1968) were that women

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chose careers outside the hospitals, or if inside those with less demanding hours and not involving continuing clinical responsibility: paediatrics, public health and general practice. Aird & Silver’s (1971) findings support this. In the United States too it has been found that women choose specialties with fixed salaries and regular hours in medical settings with non-competitive structures (Kosa & Coker, 1965; Phelps, 1968; Westling-Wikstrand et al., 1970; Shapiro et al., 1968; Powers et al., 1969). This is, no doubt in both countries, the outcome not merely of ‘roletaking’ but of the fact that there is a resistance in hospitals to the flexible structuring of hours and little or no provision for child care (Lopate, 1963; Kaplan, 1971 ; Wilson, 1972; Eisenberg, 1971). The encouragement of women doctors to enter a wider range of specialties by more flexible and positive arrangements for them, is undoubtedly one way in which a determined policy could mitigate the doctor shortage in particular fields. In Britain, Lawrie et a]. (1966) reported that 50% of the respondents in a survey of women doctors were in full-time work and 30% in part-time work. But the loss to medicine through women doctors being unemployed has been compared in the 1960s to the loss through emigration (Stanley & Last, 1968). Schemes for encouraging women doctors to return to work have met varying responses (Whitfield, 1969; Timbury & Ratzer, 1964; Eskin, 1972; Essex-Lopresti, 1970) and they have not always worked as well as was expected. To be effective a policy to stop the waste of medical training given to women who do not use it may have to operate at the selection stage. Ulyat & Ulyat (1971, 1973) have worked successfully on tests which discriminate between women medical students who are likely to continue practising and those who are not. In the United States other background factors have been more widely studied but the results of studies of fathers’ occupation, education and of the geographical and college origin of different types of specialist do not help to explain the career choice of British doctors in a different environment and in a different system of health care.

2. Personality factors

Psychoiogists have been interested in whether there were measurable personality differences between

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doctors entering different specialties and whether this could be used for prediction and career counselling. The results of this kind of study are more easily transferable between one country and another than are studies of background factors, but there are still problems in comparing the personalities of doctors choosing different specialties in different health care systems, where the jobs they are choosing between may not be comparable. In the U.S.A. Strong & Tucker (1952) had developed Standard Vocational Interest Blank (SVIB) scales for surgeons, internists, pathologists and psychiatrists. The criterion group was 1500 established medical specialists, and the SVIBs of 783 students were gathered for the purpose of following up when they later specialized. Eleven years later, the SVIB scores failed completely to predict the specialties they had chosen. This may have been because the patterns of interest associated with a choice of specialty had changed since the criterion group made its decisions. Or it may have been that measurable specialty interests did not appear until after some experience of specialized practice. The most recent attempt at using SVIBs was made in 1971 by Athelstan & Paul (1971), who used the responses of students who later specialized, rather than those of established specialists. These scales had only slightly better predictive success than the first attempt. Nevertheless, personality differences have been found. Menninger (1957) discussed subconscious motives for choosing different specialties. Schumacher (1963, 1964) compared five different career groups. Differences in ability, personality, leadership qualities, and background were analysed and shown to be measurably different for students entering medical school who later chose these five career paths. Livingston & Zimet (1965) compared students opting for surgery, psychiatry, paediatrics and internal medicine and found that intending psychiatrists were the least authoritarian, and the future surgeons the least anxious about death. Yufit et al. (1969), while finding little correlation between particular personality attributes and individual specialties, found a strong relationship between some of these attributes and clusters of similar specialties. The ‘peopleoriented’ specialties and the ‘technique-oriented’ attracted different personality types in terms of an intimacy/isolation construct. The work of Alexander et al. (1972) supports this. Among others in the United States who contributed to the work on

personality differences were Donovan et al. (1972), Otis & Weiss (1972) and Paiva & Haley (1971). In Edinburgh, Walton (1963, 1966, 1967, 1969) showed that students attracted towards psychiatry as a career, tended to be reflective (to favour abstract ideas) and to have the capacity to tolerate ambiguities. Walton & Last (1969) explored other specialty preferences in relation to personality. Potential surgeons were the least anxious group and the most socially outgoing. They were firmer in their decisionmaking. Those opting for hospital specialties were mostly less sociable and impulsive but more tolerant of uncertainty than the others, though not all of them conformed to this type. Potential general practitioners were the most anxious group. In Australia, Davies & Mowbray (1968) and Mowbray & Davies (1971) also found personality differences between those specializing in medicine, surgery and psychiatry. Surgeons and psychiatrists were more extrovert than physicians, who had higher neurotic scores. Throughout this research, the specialties most consistently identified in terms of personality types were surgeons and psychiatrists. There is evidence that these two choices are made early and are more consistently adhered to than others (Becker et a/., 1961; Wasserman et a/., 1969; Kritzer & Zimet, 1967; Coker et al., 1960; Otis & Weiss, 1972). Some researchers have claimed a success rate in prediction of over 50% for surgery and psychiatry (Donovan et a/., 1972) and the prediction rates may well improve as the work continues. Nevertheless, in other specialties the choice is made later and less firmly, often after experience in other fields (see, for example, Back et al., 1958) and here there has been much less success both in consistently identifying types who enter the specialties and in predicting specialty choice. The field of personality differences in relation to specialty, important as they are, is not a promising one for policy-makers who wish to put right particular imbalances in the supply of doctors. 3. Factors connected with the educational system There is a feeling among some of those engaged in medical education that the medical schools’ selection system combined with the careers advice given at school may affect the kind of people who become doctors and therefore the kind of specialty they are likely to choose. Do the three science Alevels the medical schools require supply the kind

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of mixture of doctors that the community requires? How will the ever increasing level of performance at A-level which entrance to medical school demands affect the kinds of doctors of the future? Thompson (1961) examined the effectiveness of selection by interview at Birmingham, though not in relation to specialty choice. Ellis (1971), Perry (1966) and Sheldrake (1975) also discuss selection procedure, Sheldrake concluding that once the ‘political’ decisions in relation to, for example, sex and nationality of entrants to medical school had been made, and if minimal academic qualifications were met, selection might just as well be done randomly as by any ‘selection method’. Johnson (1971b) analysed the social and academic background of the rejects, and also found that a great deal of pre-selection is done through careers advisers and head teachers before application to medical school is made (Johnson, 1971a). The question of selection in relation to specialty has not been examined in any systematic way. One question which has been examined is the closely related one of the students’ image of the various specialties. In the United States Becker et al. (1961) gathered information from the Kansas students he studied which he used to differentiate the stereotypes they held of six different specialties. For instance, general medicine was seen as offering the broadest intellectual interest, general surgery as needing a responsible, practical appraoch but as being intellectually narrowing. Bruhn & Parsons (1964) studied student attitudes to four specialties at Oklahoma Medical School. Zimny & Thale (1970) at St Louis Medical School compared students’ stereotypes of the specialists rather than the specialisms and found that surgeons were thought of as decisive, efficient, impersonal and autocratic ; paediatricians as warm, friendly, responsible people ; internists as intelligent and responsible; psychiatrists as placid, self-concerned and emotionally uninvolved. At Edinburgh, Martin et al. (1967) reported on the professional stereotypes of doctors held by first year medical students. General practitioners were seen as poorly paid, subject to rather unsatisfactory and unsatisfying working conditions, and as not having high status. Surgeons, however, were seen as having high status and although working long hours they had satisfying and not irregular work. Psychiatrists were thought to have satisfactory working hours, status among their peers, and satis-

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factory pay, also more intellectual stimulation than other specialties, but to be less satisfied with their status in the community at large. Dean (1972) surveyed students at five British medical schools to discover what they thought about a career in general practice. Students became more favourably disposed towards general practice as they moved through medical school and their reasons were not merely those of expediency. They were particularly drawn towards general practice because of its social and environment aspects. The changes in the career preferences of students from twenty-four British medical schools, as they went through their courses, were analysed by Martin & Boddy (1962). They noted that general practice became more popular and the research and laboratory specialties less, as the students became more senior. The changes noticed by several researchers in attitudes during the time spent in training brings us to another factor affecting career choice-the training system itself. In the United States Eron (1955) found evidence that medical students became more cynical as they went through their training and that this effect could not be attributed simply to increasing maturity. Becker et al. (1961) held that this tendency was reversed when the students actually began practising. This conclusion was supported by Gray et al. (1965, 1966) who found that although there was no difference in the level of cynicism of those entering different specialties, the cynicism of the graduating student decreased significantly when he began practising, especially if he went into a specialty involving plenty of patient contact. The changing attitudes of U.K. students in response to training environments was also noted by Gale & Livesley (1974) in their article on geriatrics. Their survey at King’s College Hospital revealed more favourable attitudes towards geriatrics among students than among junior medical staff. While Atkinson (1973) emphasized that even within the same medical school learning environments can differ and have different effects on one specialist group as against another, and Last & Stanley (1968) found very different distributions of career choice between one school and another. Closely related to these studies is the work of Coker et al. (1960) who enquired into the effects of faculty influence on the specialty interests of medical students and found that 54% of the students they surveyed acknowledged that informal faculty influence had had some bearing on their career

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decisions; while in the U.K. Last et al. (1967) found that it was the best students who were influenced by the faculty members, who naturally singled them out for special interest. It is possible that students may be influenced in a negative as well as a positive sense by those to whom they relate during training. Another facet of the medical school system which is relevant to specialty choice is examination performance. Last’s team (1967) at Edinburgh have studied this and found that recruits to pathology, bacteriology, basic medical science and internal medicine include the highest proportion of distinguished graduates, and those to general practice and obstetrics and gynaecology included the highest proportion of exam failures. But they did not find any evidence to support the hypothesis that exam performance in particular subjects was related to career choice. On the other hand, it seems likely that if a subject is not examined, its chances of attracting recruits is considerably reduced. Last & Brodie’s work (1970) showed that few students make an early choice of career and adhere to it. Even by the end of their pre-registration year only about half have decided on their specialty (McIntyre & Parry, 1975). Even their stereotypes of the specialties bear little relation to their career choice (Zimny & Thale, 1970). Information about the career prospects in different specialties, disseminated at the right time to students currently making the decision, might well be effective in mitigating the shortage/surplus situation. Although the publication in Health Trends of job availability does not seem to have helped; a positive personal approach in particular areas has done so. 4. Career factors

So far only those factors have been discussed which affect the doctor up to his graduation from medical school. There still remain all the outside factors which differentiate a career in one specialty from those in another. Curiously enough, these have received considerably less attention than the earlier groups although it is, of course, the career factors which policy-makers could most easily use to alter the distribution of doctors between specialties. In Kansas Becker et al. (1961) used twelve criteria for assembling their student stereotypes of specialties. Pay was one of these but it was used by the students interviewed only 4% of the times for differentiating between specialties (compared with

27 % for ‘intellectual breadth’). The reluctance of people to admitting that pay is an influential factor in their career decisions makes it difficult to evaluate the results of those studies. In the U.K., the A.S.M.E. survey in 1961 for the Todd Report (1968) included questions on promotion prospects and income, but little or no correlation between these factors and specialty choice was found, either among students or graduates. Here, the salary scales for different hospital specialties do not differ as such, so that actual pay scales within the N.H.S. cannot be a factor in choices between hospital specialties, but only in choices between hospital-based careers and those outside. A consultant may, however, in exceptional circumstances, be offered a starting salary several points up the scale. On the other hand, there are other income differences besides salaries. The other important source of income for consultants is from distinction awards. In 1964, Stevens (1966) concluded that half the A+ awards were held by three specialties out of a total of twenty-five. In the popular, prestigious specialties as many as 60% of the consultants had awards while in anaesthetics, geriatrics and psychiatry only 13% had awards. Lavers & Rees (1972) studied the distribution of awards and concluded that they were still concentrated more in the high prestige hospital specialties which already have a surplus of candidates and in the London teaching hospitals than elsewhere. Whatever the merits or otherwise of the awards system, it certainly does nothing to reward hard work and long hours in less attractive areas and conditions, or to correct the imbalance in the distribution of medical manpower between specialties and areas. Pay differentials between specialties are also complicated by the question of tax allowances (on which general practitioners seem to do the best), and by varying opportunities for private practice. While the proportion of doctors who derive much income from private practice is small, those who do so are highly concentrated in the London area and in the surgical specialties (Mencher, 1967), thus exacerbating further the maldistribution. The exception to this seems to be private practice among general practitioners which, according to Mechanic (1970a),is mostly in small communities in the southeast and among doctors who began practising before the Health Service came into being. Again the numbers are small. Cartwright (1967) estimated that three-quarters of general practitioners had less than twenty private patients and only 4% had a

Doctors’ career choice hundred. There may be rather more income from N.H.S. patients who occasionally consult doctors privately. General practitioners may also derive extra income from part-time clinical or industrial appointments. Not only levels of pay, but the equally complicated question of when peak income is reached and average life-time earnings are also important (Sloan, 1970; Sandison, 1973). The lack of evidence that young doctors are motivated in their career choice by economic considerations is hardly surprising in view of the complexity of deciding what the income differentials are between specialties. But this is not the same as saying that if a clear difference was apparent it would not be an important factor in choice if students were aware of the facts. Closely bound up with income as a factor in career choice are prospects of promotion. Some specialties, because of the shortage/surplus situation, undoubtedly offer a better chance of promotion at an earlier age than others. The effect this has on doctors’ career choice has not been explored. The prospects of early promotion in the less popular specialties are certainly in conflict with other factors such as the relative prestige and status of the specialties, and the relative proportions of immigrant doctors working in them. Failure to obtain promotion, especially to consultancies, has been given as the main reason for emigration (AbelSmith & Gales, 1964; Gish, 1970a). The peak age for emigration is 3WO. It is then that doctors in the surplus specialties come face to face with their small chances of entering the only specialist grade. A disproportionate number of the emigrants are Oxbridge graduates (Gish, 1970b). Last (1967b) found the largest emigrant group to be surgeons and suggested that this might have been because their skills were more specific to their specialty, and that by temperament they were less able to accept failure to achieve their first goal than other groups. Again the question arises of whether so many would have chosen the overcrowded specialties if the relative career prospects had been put before them clearly and at the right moment. The whole complex set of career factors in connection with specialty choice needs much more investigation.

5. Conditions of work

These factors also have received less than their fair

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share of attention. The geographical distribution of doctors has been studied in the U.S.A. among others by Joroff & Navarro (1971). They explored the distribution of specialists in relation to various community characteristics such as population density, buying power per capita and the age, education and race of the communities. In the U.K., Last (1967a) showed that ‘general practitioners more often than consultants tended to settle in the part of the country where they spent their youth rather than close to the medical schools they attended if these were in different regions’; and concluded that ‘regions short of doctors would be more effectively, expeditiously and economically helped to overcome the shortage by a larger recruitment of students from these regions rather than by establishing medical schools there’. Consultants tended, however, to follow their career interests first and to be more mobile geographically. However, Brown & Walker (1971) concluded that there were two basic types of general practitioner, not only those who committed themselves early to the specialty and settled permanently in a particular locality, but also the more restless who perhaps came into general practice as a second choice and were more prepared to move, both geographically and occupationally.

The effect of location on career choice is closely involved with the condition of and the conditions in one hospital as against another. It is obvious, for instance, that working in an old-fashioned isolated hospital or in an overcrowded, underdoctored one will be unattractive and it is unfortunately true that these kinds of conditions are more often to be found in psychiatric and subnormal hospitals than in others. The length of working hours and their relative regularity have also been the subject of enquiry. Becker’s (1961) students used ‘hours’ to differentiate specialties 9 % of the times; while in the U.K. the most frequently mentioned cause of dissatisfaction among the general practitioners surveyed by Mechanic (1968, 1970b) was shortage of time; time to read professional literature, time to spend longer with each patient, time to do more preventive medicine and time for leisure. Working conditions can be changed, and if research shows that these factors are even moderately important in career choice, it might well be a productive area for policy-makers to consider.

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6. Intrinsic differences between the specialties Whether or not the students’ stereotypes of the various specialties correspond to reality, it is clear that there is, in fact, a tremendous diversity between a choice of career in one specialty rather than another. A choice of specialty can be a choice between dealing with day-to-day problems or with crisis situations, with people or statistics, with amelioration or cure, with problem-solving in an intellectual sense or with helping people to manage their lives. Studies have been made of particular specialties which illuminate these differences. General practice has been well covered by several pieces of researchCartwright’s Patients and their Doctors (1967) investigated the relationship between general practitioners and their patients ; Mechanic’s articles (1968, 1970b) concentrated on the dissatisfactions and problems of general practitioners, while Butler (1975) studied the geographical misallocation of general practitioners and the effect of the designated area system in reducing list size. Parkhouse (1975) and Vickers (1971) studied anaesthesia-the satisfaction and frustration arising from this choice of specialty. In the most recent survey (Parkhouse, 1975) 79% of the consultants and medical assistants replied that they would choose anaesthesia again if they were starting their career now. Psychiatry has also received special study. Freeman (1974) and Maynard (1972) discussed the regional variation in psychiatric care. Brook has published several articles (1971, 1973, 1974a, b) on the training and careers of consultant psychiatrists. Brook is one of the very few who have asked people actually established in a specialty why they chose it and what career alternatives they would have considered if they had not obtained a consultant post. There may be problems of partial or distorted recollection with a retrospective study of this kind but at least it is dealing with an actual situation rather than with a hypothetical set of intentions as a study of students or new graduates does. For this reason Brook’s questions about why the consultants took up psychiatry are more satisfactory than those about possible career alternatives. Thirty per cent of the psychiatrists had decided to enter the specialty before qualifying. Respondents were asked to attach four orders of importance to fourteen reasons for their choice of specialty. Curiously enough, though promotion prospects are mentioned

in the questionnaires, neither pay nor the possibility of private practice is. Fifty-eight per cent endorsed as a ‘very important’ reason for their career choice : ‘Because you felt that psychiatry was an important and interesting branch of medicine’. Thirty-nine per cent endorsed as ‘very important’: ‘Because of a curiosity about or an interest in other people, their emotions and reasons for their actions’. It would be extremely valuable if this kind of study were done for other specialties, but only if the fourteen reasons were broken down more. The interesting question is why they found psychiatry a more interesting branch of medicine than others. The fact is, that all the existing work on doctors’ career choice, careful as it has been, has not provided us with a clear picture of how and why the whole process of preference, choice and decisionmaking operates. The question has been probed with varying degrees of success, from many directions, but some types of factors, notably background and personality factors, have been much more thoroughly researched than others, while career factors and working conditions which may be at least as important in specialty choice have not been approached in a systematic way at all. Moreover, those are the factors which can most easily be changed if the medical manpower situation demands it. Whereas it might theoretically be possible for medical schools to accept relatively more medical students with personality characteristics and personal backgrounds of a kind which increased the likelihood of their choosing particular specialties, it is hardly likely that this would be acceptable in practice. On the other hand, a change in relative pay or conditions, or in the medical educational system could, though not always easily, be brought about. Neither has much work been done on the effects on career choice or intrinsic differences in the specialties themselves. Studies have shown that doctors often claim it is ‘intellectual interest’ which has guided them towards particular specialties, but what is it precisely in one specialty rather than another which attracts or repels them? We need to know retrospectively how doctors recently established in their specialties made their decisions, how their training influenced them and which career factors and what characteristics of the different specialties were important to them in choosing their careers. Some of the work currently in progress on doctors career choice which will help

Doctors’ career choice to fill these gaps is listed in the Appendix to this paper.

Appendix: current work The following list includes some of the work which is currently being done on doctors’ career choice. (i) Dr C. M. Harris of St Mary’s Hospital Medical School is completing a study of ManChester students entering the medical school in 1971. (ii) Professor A. J. Willcocks’ work at Nottingham is financed by the Nuffield Provincial Hospitals Trust. He is studying recruitment to three of the shortage specialties (anaesthetics, radiology and pathology). He is interested in how the image held by students and young doctors of the various specialties changes, what contacts they have with the specialties and what kinds of doctors choose to enter them. (iii) Miss Jennifer Roberts at the London School of Hygiene and Tropical Medicine is surveying a small sample of doctors who qualified in 1972. The objective is to enquire into the factors which determine the choice of qualified medical graduates within medicine. It is hoped to obtain a job profile for the doctors during the early period of their careers and to relate this to life events and to the probability of obtaining jobs in different specialties. (iv) Dr William Kearns, now District Community Physician for Kensington, Chelsea and Westminster Area Health Authority, is completing a study of the distribution of medical graduates between three different specialties and the reasons for their choice. (v) Dr Malcolm Johnson and Miss Mary Ann Elston, at the Nuffield Centre for Health Services Studies, University of Leeds, have started a survey of the career development of two qualifying classes from five English medical schools. In particular the survey looks at doctors’ involvement in decisionmaking in medical policy. (vi) Dame Frances Gardner at The Royal Free Hospital is carrying out a detailed survey of approximately lo00 women who have graduated from that hospital since 1955. The present study is especially designed to see if measures to help married women, recently introduced by the D.H.S.S., have had an appreciable effect. It will give detailed information about the kind of work chosen by women, the progress they have made in that specialty, and the proportion of graduates working overseas.

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(vii) The Institute of Manpower Studies is beginning for DHSS a broad study of qualified doctors and the factors determining their choice of specialty with an emphasis on the implication of the findings for policy implementation.

References

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Doctors' career choice: previous research and its relevance for policy-making.

During the last 10 years, a good deal of interest has been shown by both researchers and policy-makers in the factors which determine doctors' choice ...
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