Doctors' Careers

Aims and Experiences of Medical Graduates

James Parkhouse

• Publisher: Taylor & Francis
• Year: 2003
• eBook ISBN: 9781134947201
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

First published in 1991.The training, employment, and career movement of doctors is of fundamental concern to all those working in and administrating the National Health Service and private medicine within Britain and around the world. Doctors' Careers makes available to a wide readership, in one volume, the results of a comprehensive survey of medical choices and career progress of doctors qualifying from British medical schools during a decade, from 1974 to 1983. No other survey of this kind has been carried out over a prolonged period of time. This is a unique record of the aspirations, feelings and experiences of a very large group of doctors, during a time of considerable changes in emigration, training for general practice, and the position of women doctors. The book deals with these issues, and also the reasons for choosing and changing careers within medicine, postgraduate qualifications, internal migration of doctors within the UK, aspects of some important individual specialisms - medicine, surgery, psychiatry, and anaesthetics - and the personal opinions of doctors about their training and the career problems of British medicine. The data has important implications for medical staff planning, and this is taken up in an analysis of the employment status of doctors five years after leaving medical school.

1 The background

The fact that this work on career choices began as a by-product of an interest in medical staffing structure planning gives a fair picture of the relationship between the two pursuits. This introduction sketches some of the relevant things that happened in British medicine during the years before our studies began in the early 1970s, and some of the significant changes that accompanied their continuation into the later 1980s.

Staffing structure planning in medicine has an appeal which was obvious in the UK since the beginning of the National Health Service (NHS) (Parkhouse 1978) and has become an attractive idea to other countries more recently. In theory, one can train the right number of doctors, distribute them appropriately and thus provide a good standard of medical care without unemployment or waste of money. In practice, this works only up to a point, that point depending on the way the planning is done and the degree to which it can be implemented, which has a lot to do with the way doctors earn their living. Forecasting of supply and demand is one thing; bringing about change is another. With increasing medical specialization—itself a matter of serious interest in many countries (World Health Organization 1985; Parkhouse 1989b)—planning involves not only regulating the total number of medical school places, with or without immigration controls, but also sorting out the kinds of work different numbers of doctors do: by chance, choice, direction of labour or a mixture of all three.

Early efforts at medical staffing level planning after the Second World War assumed that doctors, once trained, would work full-time and pretty hard; some would go abroad to the colonial medical service and elsewhere, and little mention was made of foreign doctors coming in, except from Ireland. By the end of the 1970s the changes in social attitudes and in the relevant assumptions were spectacular. It is no surprise that by the mid-1970s the Department of Health (DoH) was commissioning studies on three major areas of concern: factors determining career choice (Hutt et al. 1979), overseas doctors in the NHS (D.J.Smith 1980) and women doctors (Ward 1982).

The consequence of allowing too many doctors to train is potential unemployment, with the related consequences of overspecialization, misuse of skills including excessive treatment, and the brain drain. In the mid-1950s there were already worries that not enough jobs would be available in general practice, and this led indirectly to the Willink Committee’s (Willink Report 1957) recommendation that medical school places should be cut by 10 per cent. In the 1980s there have again been fears of medical unemployment, but well-reasoned reports (DHSS 1985; DoH 1989) have seen no good grounds for cutting back a medical school intake which is far above the Willink level. The consequence of not training enough doctors is to create a potential vacuum, abhorred by those in need of medical help. This is exactly what happened after Willink, and what would have happened without it because 10 per cent either way was nothing compared to what the appetite of the NHS for doctors was unobtrusively consuming. Into the vacuum overseas doctors came by the thousand, for postgraduate training or, more realistically, to keep the NHS alive. During the late 1960s and most of the 1970s the number of overseas doctors entering the UK each year, and finding work in the NHS, was much larger than the number qualifying each year from our own medical schools, giving us a net annual gain in the order of 1,500 doctors. So much for general staffing forecasting; a look inside the system revealed bigger problems still. Most overseas doctors—nearly all in fact—occupied junior hospital posts. The numbers of these posts increased out of all proportion to training needs; more and more patient care was given by senior house officers (SHOs) and registrars, up to 50 per cent or more of whom were from abroad. The career structure, which had always been a problem (Parkhouse 1965), was heading for chaos.

While doctor immigration was for some time a rather un-noticed problem, the emigration of British doctors caused much concern. Estimates published in 1961 and 1962 (Davison 1962; Seale 1966) seemed alarmingly high and created controversy. It took meticulous and wide-ranging research, (Abel-Smith and Gales 1964; Gish 1970) to separate fact from fiction, but the conclusion was that Britain was losing, each year, not far short of 1,000 home-produced doctors. Not all of these doctors stayed abroad permanently, of course, any more than all the immigrant doctors remained permanently in Britain; but the permanent loss was equivalent to about a quarter of the whole output of our medical schools. There was no lack of good prospects in anumber of welcoming countries for high-quality clinical practice and well-funded research, which to many British doctors offered an attractive alternative to the time-serving stuffiness of the hospital specialties and the often rather self-righteous cheeseparing of academic life at home.

General practice had begun to gain strength after serious confrontations with government in 1965 over terms and conditions of service (Forsyth 1966: ch. 3) resulting in the ‘GPs’ charter’, which offered better financial rewards and much more chance of wellorganized and adequately supported practice, increasingly on a smallgroup basis. The first academic departments with professorships were up and running by the beginning of the 1970s, and although three years of postgraduate training for general practice did not become mandatory in the NHS until the end of that decade, more and more training schemes were developing and being taken up voluntarily during the preceding years. It was not that young doctors had previously gone straight from medical school into general practice; the great majority had always, since the NHS began, looked for some hospital experience first: but whereas the move into general practice had very often resulted from failure to make progress in a preferred hospital career, it came more commonly to be a planned move for positive reasons. This improved status of general practice, which has undoubtedly been coupled with higher standards, was reflected in its rising popularity as a career choice, already evident when our studies began in 1971 and sustained ever since.

The Royal Commission on Medical Education (Todd Report 1968) published its conclusions in 1968, but had already, by way of an interim report, given impetus to a massive reversal of the Willink view—an increase in medical school places from under 2,000 in 1968 to over 4,000 twenty years later. The Todd Report made many other important recommendations which reverberated through the 1970s, particularly regarding postgraduate training. This was a period of optimism and expansion; all of higher education was buoyantly responding to the Robbins Report’s (1963) call for more places and new universities; in the medical schools there was a surge of new posts, new departments and newly designated university hospitals. The NHS was prosperous, by more recent standards, and there was hope of better career planning and progress. A series of meetings between government and the medical profession led to ‘progress reports’ (Report 1969) which laid down a formula for correcting the imbalance between junior and senior hospital posts by allowing only 2.5 per cent growth a year in the junior gradeswhile the consultant grade would expand by 4 per cent a year. All would have been well by 1978 except for the fact that, by then, the junior grades had actually continued to expand far more rapidly than the consultant grade! So much for implementation. Meanwhile, a DHSS programme for redistributing junior posts from well-provided to relatively deprived regions had been abandoned as a total failure because no consultant was willing to surrender a junior post and no power on earth was prepared to try and make him or her do so. Only in 1986, after several years of painful negotiation, was this redistribution exercise revived—tentatively, partially and very slowly—through the Joint Planning Advisory Committee, which also had to deal with the balance between clinical and academic posts in the training grades.

Obviously all was not well with hospital careers. For junior doctors matters reached a crisis amounting to strike proportions in 1976, as a result of which extra duty payments were introduced. This differential system of payment highlighted several dilemmas which continue to niggle within the system: extra money for working too many hours is a poor substitute for having adequate payment for a reasonable working week; in some specialties, such as surgery, junior doctors often want many hours of work at night and at weekends to gain experience, but they should be supervised and taught, and patients should not suffer from their over-enthusiasm and consequent exhaustion; the specialties which attract the fewest extra duty payments are often the ones most lacking in recruits even without the disincentive of lower remuneration; if reducing excessive hours of work is seen as a priority then the ‘new’ financial arrangements seem inappropriate; and—most important of all—if junior doctors are to work fewer hours then either there must be more of them, which is death to any hope of a decent career structure, or trained specialists must take on more out-of-hours commitments. This last proposition, which is the obvious and only long-term solution, had already been given a chilly reception when put forward by Sir George Godber’s Working Party (DHSS 1969).

The mid-1970s saw the beginning of changes in international movement of doctors which have been complex and important. Recognition for registration was withdrawn by the General Medical Council from many medical schools in the Indian sub-continent between 1972 and 1975, and tests of language and medical competence were introduced for overseas doctors in 1975. Opportunities for British doctors abroad were diminishing, as many of the popular countries, such as the USA, Canada, and Australia, began to close their doors or introduce formidableentry tests in response to fears of their own medical unemployment and tightening of their research budgets. Increasing rigidity of postgraduate training requirements deterred many British doctors from stepping aside from the career ladder to work abroad. Entry into the European Community (EC) had little effect and has, in fact, only very recently produced any appreciable rise in movement to and from other countries in the EC. But from the mid-1970s onwards the world has been a smaller place for British medical graduates, while their numbers have grown very greatly. With this and the various changes that have affected overseas doctors intending to enter or remain in the UK, the balance in the junior hospital grades has shifted towards a filling-up of the still too-many posts with home graduates, seeking and reasonably expecting promotion.

The increasing output of British medical schools brought with it a large rise in the number of young women doctors, in proportions amounting to 50 per cent or more of many graduating classes. The fact that these young women, many of whom would naturally bear children, not only would wish to pursue their careers but also would be depended on to do so created concern about equal opportunities which mirrored the general spirit of the times. It forced attention on part-time medical employment. In fact, many doctors had always worked on a casual or part-time basis in the NHS, for instance as locums, clinical assistants and salaried partners in general practice. Although these relatively lowly forms of employment came to be resented by some strongly career-motivated women, their abolition would have been even more strongly resented by many other women, and by men. In any case it is doubtful if the NHS could survive without them. But the point was well made that women doctors should have the choice, equally with men, of whether to compete for a consultant or general practice principal appointment or opt for a less demanding grade. How to ensure this choice is a difficult matter in a traditionally competitive profession: at what point does the convenience of a parttime post become a necessity, and at what point does equal opportunity become reverse discrimination? Despite these problems, considerable progress has been made, perhaps especially in regard to part-time postgraduate training—much more than in many other countries or professions. Although shifts in attitudes and practice have certainly not been as great as the more determined activists would wish, the influence of this movement, and its more muted counterpart among men, has been more far-reaching than is often recognized. The view that the medical system needs to be infinitely adaptable to therequirements of the individuals within it, rather than the individuals having to fit in as best they can with the system, may provoke snorts of disgust from reactionaries who like to recall the hardships of their own early days, but time will surely tell.

In 1981 the House of Commons Select Committee (Social Services Committee 1981) produced a report which brilliantly described and illustrated the problems of the career structure, and made good, strong recommendations for improving postgraduate training and patient care. These recommendations, for once, were warmly welcomed by the government, and also by junior doctors; the senior members of the profession, and its influential bodies, were cool, suspicious or frankly critical. Not much actually happened, as the Select Committee itself noted with some acerbity four years later (Social Services Committee 1985). The medical profession’s own response to the rising sense that something must be done was embodied in the papers Achieving a Balance (DHSS 1986) and Plan for Action (DHSS 1987b)—a much more cautious and diplomatic attempt to improve career prospects for British medical graduates without antagonizing the consultant body, by separating a reduced number of ‘career’ registrar posts from a potentially unlimited number of non-progressing registrar posts if sufficient overseas doctors with good credentials could be found to fill them. As always, the scheme depended first and foremost on substantial consultant expansion, and after a couple of years this had again failed to materialize. By that time the government had diverted attention by disclosing its own views on the future of the NHS as a whole (Secretaries of State for Health 1989). The title Working for Patients was viewed sardonically by many as a thin veil over a set of proposals which were mostly concerned with political ideology. Some important positive ideas were there: audit, clinical budgeting, financial reward for efficient hospital care, and improved information services. But these needs were already recognized and the means of implementation were vague. Teaching and research seemed likely to fare badly if the plans were fully pushed through, and thoughts of improved personnel planning and a better career structure were rather at variance with a governmental enthusiasm for ‘demand-driven’ higher education, and individual hospitals with freedom to make their own terms with doctors at different grades. It seemed that the medical profession’s almost infinite capacity for sitting on committees might face a stern test.

To secure the morale and well-being of the NHS not only must the doctors, the nurses and others who work in it believe in it, but also the government must believe in it, with aconviction that rings true. When conviction appears to waver, some will say of the NHS, as of medical staffing structure planning, that we might be better off without it; but others will defend the one, or the other, or both, to their last gasp.

2 The study

The Royal Commission on Medical Education (1968) made quite detailed proposals for General Professional Training—a period of three years following the pre-registration year, during which doctors would gain experience in a variety of specialties, by means of sixmonth appointments. This would give an opportunity to sample different kinds of medical work and would, for most people, constitute a broad beginning to specialist training, either in hospital or general practice, by providing relevant experience. A number of general professional training packages were suggested, as examples which would be suitable for doctors with various career intentions. It was obviously meant that existing SHO and registrar posts would provide the material for this scheme; the idea of using these posts in a planned and systematic way, and linking them across specialty boundaries, was new.

The Nuffield Provincial Hospitals Trust gave support for a feasibility study, in Sheffield, to see whether the existing numbers and types of junior hospital posts would make the introduction of the general professional training scheme practicable. To model this, it was necessary to know how medical graduates in the years following 1968 were likely to want to distribute themselves among the broad divisions of medical work—the nine ‘mainstreams’ of the Royal Commission Report: medicine (including the medical specialties and paediatrics), surgery (including the surgical specialties), obstetrics and gynaecology, anaesthetics, psychiatry, pathology, radiology and radiotherapy, general practice, and community medicine. Information was available from an Appendix to the Royal Commission report about the probable career intentions of final-year medical students in 1966, but it was felt that more recent data, and from doctors who had actually qualified, would be useful. Hence our initial interest in career choices.

As an exercise in staffing planning this approach is, educationally speaking, ‘demand-driven’; it assumes that the numbers of available jobs of various kinds should be determined by the demands of those seeking them. But caution is needed about the use of words, as well as about the soundness of the approach. In the usual analysis of the supply and demand equation of medical staff, as for example in the reports of the Advisory Committee on Medical Manpower Planning (DHSS 1985; DoH 1989), the ‘supply’ is the availability of medical graduates entering the profession and the ‘demand’ is the requirement for doctors to meet the needs of the service and the public. In this sense our feasibility study on general professional training was ‘supply’ driven; but the much more important question that remains is whether meeting the career aspirations of newly qualified doctors will also, conveniently, meet the specialty needs of the service. This issue comes up repeatedly in later chapters.

In 1971–3 we had ready access to names and addresses of qualifiers from the Sheffield and Manchester medical schools. We surveyed the career choices of the 1971 qualifiers, with an 88.5 per cent response rate (McLaughlin and Parkhouse 1972) and this gave data for computer modelling. There was enough interest in the career choice findings themselves for us to repeat the Sheffield and Manchester survey for 1972 (McLaughlin and Parkhouse 1974) and again for 1973 (Parkhouse and McLaughlin 1975a) qualifiers. We followed up the 1971 qualifiers in 1974 (Parkhouse 1976b), and the 1972 and 1973 qualifiers in 1976 (Parkhouse and Howard 1978), to see what had happened to them and their career intentions. The full details of these early studies have been published. Their main value was to give an indication from two provincial schools of what the general situation might be, and to encourage us, through the high response rates and interest in the results, to launch out on more comprehensive studies. The Sheffield/Manchester surveys already showed the rising popularity of general practice as a first career choice. They also showed that the majority of doctors at the pre-registration stage had not made definite choices, and that many doctors changed their choices during the subsequent three or four years, with a further shift towards general practice. The commonest reasons for change of choice were domestic circumstances, reappraisal of aptitudes and abilities, experience of the new choice of career, and additional knowledge of promotion prospects and difficulties.

In 1975 we sent a questionnaire to qualifiers from all the medical schools in England, Scotland and Wales in the calendar year 1974, asking about career choices. The response rate was 86.1 per cent. The following year we repeated the survey for1975 qualifiers, including Queen’s University, Belfast. In 1977 we surveyed the career choices of 1976 qualifiers, and also wrote again to 1974 qualifiers to follow their progress. This pattern of surveying each new year of qualifiers and following up previous cohorts at two-yearly intervals continued until 1979. The new medical schools of Nottingham and Southampton were included as their graduates appeared in 1975 and 1977. By 1979 so much data had accumulated that a decision was taken jointly with the DHSS that after 1980 no further new qualifiers would be surveyed until 1983, and two-yearly follow-up questionnaires would be sent only to each third cohort of qualifiers: those of 1974, 1977, 1980 and 1983. In 1980 the Leicester medical school produced its first qualifiers. Up to 1976 fewer than ten students a year entered the clinical part of the undergraduate course in Cambridge; from 1978 onwards the newly developed Cambridge clinical medical school contributed increasing numbers of qualifiers. Our final questionnaires were sent out in 1986 to 1977 qualifiers and in 1987 to 1974 qualifiers. Table 2.1 gives details of the size and dates of the surveys, with response rates.

Table 2.1 Numbers of questionnaires sent and (uncorrected percentage response rates)

Our general policy has always been to keep questionnaires as simple as possible, asking for factual information or relatively simple evaluations of such things as intention of remaining in the UK or the importance of one or more of a list of reasons for career choice or change of choice. There has always been space for individual comment and this has often come in profusion. Additional questions were added to some questionnaires, to obtain information about movement during training, reasons for going abroad and returning, and views on the quality of various aspects of training and its impact on competence. This last topic occasioned the sending of a separate questionnaire to 1974 qualifiers in 1984—a much more searching and detailed inquiry than usual which produce...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Figures and tables
• Introduction and acknowledgements
• 1 The background
• 2 The study
• 3 Career choice
• 4 Career progress
• 5 Career progress
• 6 Career progress
• 7 Career progress
• 8 Career progress
• 9 Women doctors
• 10 Individual specialties
• 11 Individual specialties
• 12 Individual specialties
• 13 Individual specialties
• 14 Individual specialties
• 15 Comments and opinions
• Conclusion
• Appendix
• Bibliography