Career choices for anaesthesia: national surveys of graduates of 1974–2002 from UK medical schools{dagger}

G. Turner1, M. J. Goldacre1,*, T. Lambert1 and J. W. Sear2

1 UK Medical Careers Research Group, Department of Public Health, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK. 2 Nuffield Department of Anaesthetics, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK

* Corresponding author. E-mail: michael.goldacre{at}dphpc.ox.ac.uk

Accepted for publication May 12, 2005.


    Abstract
 Top
 Footnotes
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Background. Knowledge about UK doctors' career intentions and pathways is essential for understanding future workforce requirements. The aim of this study was to report career choices for and career progression in anaesthesia in the UK.

Methods. Postal questionnaire surveys were undertaken of qualifiers from all UK medical schools in nine qualification years since 1974.

Results. 74% (24623/33417) and 73% (20709/28468) of doctors responded at 1 and 3 yr after qualification. At 1 and 3 yr after qualification, on average, 8% of doctors chose anaesthesia. Between 1974 and 2002 the percentage of doctors choosing anaesthesia, 1 yr after qualification, increased from 5 to 12%. A majority of doctors who chose anaesthesia 1 and 3 yr after qualification were working in anaesthesia 10 yr after qualification. In addition to doctors' enthusiasm for the specialty, career choices for anaesthesia were positively influenced by their perception of working hours, conditions of work, and career and promotion prospects.

Conclusions. Anaesthesia has become increasingly popular as a career choice in the UK. Training numbers could be increased in the short term to speed up the process of providing a consultant-delivered service.

Keywords: anaesthesia ; anaesthetists, workforce ; education, medical ; junior doctors, career choice


    Introduction
 Top
 Footnotes
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
We have undertaken surveys of all graduates from all medical schools in the UK in selected years since 1974. Among other topics, we ask about the doctors' choice of future careers. We have published our findings on the career choices of doctors in their early years after qualification, as they have emerged from each survey,1 5 and have communicated them to policy makers in medical education and workforce planning. In this paper we summarize and expand on our findings, from all cohorts studied by us, about early career choices for anaesthesia.


    Methods
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 Footnotes
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Surveys have been undertaken by the UK Medical Careers Research Group of the UK medical graduates of 1974, 1977, 1980, 1983, 1993, 1996, 1999, 2000, and 2002. Our methods have been described in detail elsewhere.3 4 In brief, towards the end of the first and third years after graduation, and at longer time intervals after that, we send postal questionnaires to all medical graduates from each UK medical school. Up to four reminders are sent to non-respondents. In 1974 the graduates of all medical schools in England, Wales, and Scotland were surveyed. From the cohort of 1977 onwards, the surveys covered the whole of the UK including Northern Ireland. All analyses shown were calculated with and without the data from Northern Ireland. Results were very similar and so those including Northern Ireland are presented.

The doctors mailed in the first survey of each cohort comprised the whole cohort as it was at the time of qualification. Subsequent surveys of a cohort exclude only those doctors who previously had indicated that they did not wish to participate, or who were untraceable, or who were known to have died. For the initial survey, addresses were obtained from the doctors' registration with the General Medical Council. For follow-up surveys, we used the addresses supplied by the doctors at each previous survey and/or those identified from the most recent Medical Registers and Medical Directories.

One of the key questions asked is ‘Have you made up your mind about your choice of long-term career?’ We ask the doctors to choose a response from ‘definitely’, ‘probably’, or ‘not really’. We then invite them to specify their choice in their own words and to be as general or specific as they wish. If they have more than one choice, we ask them to list up to three in order of preference and, if applicable, to indicate that choices are of equal preference. Additionally, we invited those graduating in 1993 and 1996 to signify which factors, from a list of 11 possible factors specified in the questionnaire, had influenced their choice of career ‘a great deal’, ‘a little’, or ‘not at all’.

Before 1993, the few early career choices specified as terminal care or palliative care were coded by us as anaesthesia. From 1993 onwards, career choices specified by graduates as terminal care or palliative care have been allocated by us to a separate specialty grouping of palliative care and are not included in this paper.

Statistical analysis
We used {chi}2 statistics for assessing the statistical significance of percentage differences, and logistic regression to compare the percentages of graduates from each medical school who chose anaesthesia, adjusting for sex and year of qualification. We calculated adjusted odds ratios with 95% confidence intervals (CI) to compare choices for anaesthesia at each medical school with the overall average.


    Results
 Top
 Footnotes
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
The survey questionnaires were sent to a total of 33417 UK doctors covering all nine cohorts in the pre-registration year. A total of 24623 (73.7%) replied. Three years after qualification the survey questionnaire was sent to 28468 UK doctors covering the first eight cohorts (1974–2000): 20709 (72.7%) replied.

Early career choices for anaesthesia
In the first year after qualification, across all cohorts 7.4% of men, 8.0% of women, and 7.7% of respondents signified that anaesthesia was their first choice of long-term career (Table 1). The percentages of men and women choosing anaesthesia were not significantly different (, P>0.05). At the end of the third year after qualification, anaesthesia was the first choice of 8.9% of men, 7.2% of women, and 8.1% overall. The higher percentage of men than women who chose anaesthesia is statistically significant (, P<0.001). In year one, anaesthesia was chosen as a first, second, or third choice by 13.9% of doctors overall, and by 14.0% of men and 13.7% of women (, P>0.05). In year three, anaesthesia was chosen by 10.9% of doctors overall, and by 12.1% of men and 9.4% of women (, P<0.001; Table 2). The percentage of respondents whose first choice was anaesthesia increased in more recent cohorts in both the first and third year after qualification (Table 1). With the exception of women's choices in year three, the upward linear trend in the choice of anaesthesia was statistically significant (Table 1).


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Table 1 Percentage (number) of respondents who specified anaesthesia as their first choice of eventual career at 1 and 3 yr after graduation, 1974–2002.

 

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Table 2 Percentage (number) of respondents who specified anaesthesia as their first, second, or third choice of eventual career at 1 and 3 yr after graduation, 1974–2002.

 
Respondents whose first choice was anaesthesia in the first year after qualification were less definite about their career choice than were those who chose other careers (, P<0.001, Table 3). At the third year after qualification, the certainty of choice for anaesthesia was similar to that of other careers (, P=0.20).


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Table 3 Comparison of those who chose anaesthesia with those who chose other careers, percentage (number) of doctors who specified whether they had definitely, probably, or not really made up their minds about their first choice of long-term career, 1 and 3 yr after graduation, 1974–2002.

 
Women choosing anaesthesia
Women comprised 27.3% of the total cohort of UK respondents of 1974 and 27.0% of the qualifiers of 1974 who chose anaesthesia in the first year after qualifying. Women comprised 60.5% of the UK responders of 2002 and 57.5% of those who chose anaesthesia. In other words, the fact that the number of women who want a career in anaesthesia in the UK has increased considerably in recent years simply reflects the general increase in numbers of women entering the medical profession. The male–female profiles were broadly similar when considering all choices—first, second and third—for anaesthesia.

Choices by medical school
There were significant differences between medical schools in the percentages of graduates who chose anaesthesia. Choices in year one (Fig. 1A) for anaesthesia were significantly high for graduates from Bristol (10.5%), Edinburgh (10.3%), Southampton (10.4%), Queen Mary and Westfield (9.2%), and Imperial College (8.5%) and low for graduates from University College London (5.5%), Cambridge (4.7%), and Liverpool (4.7%). Choices in year three (Fig. 1B) were significantly high for graduates from Bristol (10.7%), Aberdeen (10.6%), and Queen Mary and Westfield (10.5%) and low for those from Oxford (5.7%) and Cambridge (5.5%).



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Fig 1 (A) Year one first choices for anaesthesia: odds ratios for choice relative to clinical medical school attended. (B) Year three first choices for anaesthesia: odds ratios for choice relative to clinical medical school attended.

 
Other factors influencing career choice
One and three years after graduation, the graduates of 1993 and 1996 were asked to rate the importance of 11 factors that may have influenced their career choices. One year after graduation, two factors—‘enthusiasm/commitment: what I really want to do’, and anticipated ‘hours/working conditions’—were rated as having ‘a great deal’ of influence on their career choice by more than 50% of those choosing anaesthesia (Table 4). Four factors—‘inclinations before medical school’, ‘domestic circumstances’, the influence of ‘a particular teacher/department’, and ‘future financial prospects’—were rated as highly influential by fewer than 20% of those choosing anaesthesia.


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Table 4 Percentage (number) of doctors who specified each factor as influencing their choice of long-term career a great deal: graduates of 1993 and 1996. Figures in bold denote significant differences at P<0.001 when comparing anaesthesia and other careers.

 
Comparing those who chose anaesthesia with those who chose other branches of medicine 1 yr after graduation (Table 4), a significantly higher percentage of aspiring anaesthetists than others rated ‘hours and working conditions’, ‘career and promotion prospects’ and ‘advice from others’ as having had ‘a great deal’ of influence on their career choice.

At 3 yr after graduation, a significantly higher percentage of aspiring anaesthetists than others rated ‘career and promotion prospects’ as having ‘a great deal’ of influence on their choice of speciality. A significantly lower percentage of those who chose anaesthesia than others rated highly the influence of ‘domestic circumstances’, ‘experience of the chosen subject as a student’, or ‘experience of jobs so far’.

Because the influences on choices for general practice tend to be different from those for hospital specialties in the UK,3 we re-analysed the data in Table 4, for those choosing careers other than anaesthesia, excluding the responses of doctors whose first choice was general practice. This emphasized the finding that more of those choosing anaesthesia than those choosing other hospital careers were influenced ‘a great deal’ by ‘hours and working conditions’.

Ten years after graduation
Ten years after graduation from UK medical schools, 60.9% of those whose sole first choice of long-term career was anaesthesia in year one, and 74.9% of those whose sole first choice was anaesthesia in year three, were working in anaesthesia (Table 5). Graduates who specified an equal preference for a career in either anaesthesia or another specialty (see Methods for explanation) were half as likely as those whose sole first choice was anaesthesia to be working in anaesthesia 10 yr after graduation (Table 5). Of those who were working in anaesthesia 10 yr after graduation, 48.8% (293/600) had chosen anaesthesia as their first choice of long-term career in year one, and 79.1% (451/570) had chosen anaesthesia in year three.


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Table 5 Percentage (number) of doctors who originally chose anaesthesia and were working in anaesthesia 10 yr after qualification, 1974, 1977, 1983, and 1993 cohorts

 

    Discussion
 Top
 Footnotes
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Since the early 1970s the range of activities covered by the specialty of anaesthesia has expanded considerably. The role of the anaesthetist has broadened to include not only theatre work, but also the care of patients in areas such as intensive care and high dependency units, as well as acute and chronic pain management. The volume of work has also increased as new operations have been introduced and as procedures, which were once rare have become more common. Consequently, it is estimated that, in the UK, anaesthetists are involved in the care of about two-thirds of all patients admitted to hospital.6 To meet this demand, the requirements of the European Working Time Directive and the challenges of more flexible working and training, consultant numbers are increasing.7 At the same time, because of restrictions on National Training Numbers and the change from a 4-yr to a 5-yr Specialist Registrar training programme in anaesthesia,8 many current consultant posts remain unfilled. In 2003, anaesthesia accounted for 11% (136/1264) of all vacant consultant posts in all specialties in England.9 However, as anaesthesia comprises 15% of all consultant posts, in this respect it has fared no worse than other specialties. Shortfalls in anaesthesia reflect the general shortage of consultants at present in the National Health Service.

Career progression
In the past, the duration of time prior to obtaining a first consultant post was highly variable in the UK. Typically, in anaesthesia, it tended to be short relative to other specialties.10 In the mid-1990s, the British reforms to postgraduate medical training11 shortened the expected time of training for those in fulltime employment. Currently, progression to first consultant appointment takes around 8 yr after graduating from medical school (Table 6).12


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Table 6 Career progression for doctors in anaesthesia, prior to 2005: graduation from medical school to first consultant post.

 
Early career choices for anaesthesia
The percentage of newly qualified doctors, from UK medical schools, who specified that they wanted a long-term career in anaesthesia has increased substantially over time. For example, it increased from 4.6% of the 1974 cohort to 11.5% of the cohort of doctors who graduated in 2002. In part, this increase may be attributable to the fact that, from the early 1980s onwards, anaesthesia, resuscitation, and intensive therapy were increasingly included in the undergraduate curriculum, with attachments lasting from 2 to 4 weeks in most medical schools, rather than being treated mainly as postgraduate subjects.13 14 Furthermore, opportunities for studying anaesthesia and intensive care as special study modules now exist in many medical schools. It also seems likely that the broadening nature of anaesthesia has increased its appeal to more recent graduates. Junior doctors may also be increasingly aware of the fact that anaesthesia is one of the largest specialties in the clinical workforce and that opportunities in it are considerable. For example, large specialties tend to offer greater choice of places to work with more posts giving more opportunities in more locations.

Factors influencing career choice
Three factors had a greater influence on choices for anaesthesia than on choices for other medical careers at both 1 and 3 yr after graduation from UK medical schools: the anticipated hours and working conditions, career and promotion prospects, and advice from others. With respect to hours and working conditions, compared with some other hospital specialties, anaesthesia has been perceived for years as a relatively ‘family friendly’ hospital specialty with a history of well organized rota systems. However, as new ways of working in clinical practice are implemented, including the mandatory upper limits on working hours,15 anaesthesia may lose some of its perceived advantage as a ‘family friendly’ hospital specialty over other hospital careers.

Experience of jobs undertaken ‘so far’ was less influential in year one for those choosing anaesthesia than for those choosing other careers. This reflects, no doubt, the limited exposure to the work of anaesthesia in the pre-registration year. By year three, experience of jobs undertaken so far became almost as important for those choosing anaesthesia as it was for those making other career choices. In responses at the end of the pre-registration year, work experience was a more important determinant of career choice for other medical careers than for anaesthesia. This suggests that an increase in early opportunities to work in anaesthesia may have a beneficial effect on recruitment to the specialty. The new ‘foundation years’ programme16 17 in UK medicine could be an opportunity to offer wider exposure and experience in anaesthesia to doctors at an early stage in their working careers.

Only one in thirty of those wanting a career in anaesthesia cited inclinations before medical school as a strong influence on their career choice. This was a much lower percentage than for other career choices within medicine. However, it is evident from our surveys that specialty preferences before entry to medical school are not a major determinant, generally, of doctors' eventual choice of specialty (Table 4).

Ten years after graduation
It is sometimes argued that early choices of long-term career are poor predictors of eventual career outcomes. However, two-thirds of those whose sole first choice was anaesthesia in their first year, and three-quarters of those whose sole first choice was anaesthesia in their third year after graduation, were working in the specialty 10 yr after graduation. Thus, a clear early choice for anaesthesia was a strong predictor of pursuing a subsequent career in the specialty. Concerns that the reform to the training grades, and perhaps particularly to the Senior House Officer grade,1618 will force young doctors into specialist schemes prematurely may be unfounded with respect to those who choose anaesthesia early in their careers, as many of those who made an early choice for anaesthesia did indeed pursue it as their career. It is important, however, that flexibility should remain for the large group who decide to pursue anaesthesia later in their junior years. For example, only 3.6% of those who chose careers other than anaesthesia at the end of the pre-registration year eventually went into anaesthesia. However, expressed as numbers rather than percentages, the number of such doctors (307, Table 5) is actually larger than the number who chose anaesthesia initially and eventually went into it (257, Table 5).

Future prospects
The number of new UK medical graduates who choose anaesthesia continues to increase and should ensure that the present level of production of 325–350 trained anaesthetists each year8 is at least maintained in years to come. However, with consultant numbers set to expand to provide a fully consultant delivered service, it has been said that, at the current rate of training, it could take up to 12 yr to make up the current consultant deficit.7 There is a strong case for taking advantage of the increasing popularity of the specialty by increasing training numbers in the short term to speed up the process of providing a consultant delivered service.


    Acknowledgments
 
We are very grateful to all the doctors who participated in the surveys. We thank Karen Hollick for administering the surveys, Janet Justice and Alison Stockford for data preparation, and Jean Davidson for programming support. We thank Anna-Maria Rollin and Douglas Justins for their helpful comments on the manuscript. The UK Medical Careers Research Group is funded by the Department of Health; and the Unit of Health-Care Epidemiology is funded by the English National Centre for Research Capacity Development.


    Footnotes
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 Footnotes
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
{dagger} This article is accompanied by Editorial II. Back


    References
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 Footnotes
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
1 Parkhouse J, Campbell MG, Parkhouse HF. Career preferences of doctors qualifying in 1974–1980: a comparison of pre-registration findings. Health Trends 1983; 15: 29–35[Medline]

2 Ellin DJ, Parkhouse HF, Parkhouse J. Career preferences of doctors qualifying in the United Kingdom in 1983. Health Trends 1986; 18: 59–63[Medline]

3 Lambert TW, Goldacre MJ, Edwards C, Parkhouse J. Career preferences of doctors who qualified in the United Kingdom in 1993 compared with those of doctors qualifying in 1974, 1977, 1980, and 1983. Br Med J 1996; 313: 19–24[Abstract/Free Full Text]

4 Goldacre MJ, Davidson JM, Lambert TW. Career choices at the end of the pre-registration year of doctors who qualified in the United Kingdom in 1996. Med Education 1999; 33: 882–9[CrossRef][ISI]

5 Lambert TW, Goldacre MJ, Turner G. Career choices of United Kingdom medical graduates of 1999 and 2000: questionnaire surveys. Br Med J 2003; 326: 194–5[Free Full Text]

6 Simpson P. Possible realistic and practical solutions to the problems of implementing the European Working Time Directive (EWTD) in 2004. 2004; http://www.rcoa.ac.uk/docs/solutionsewtd.pdf

7 Simpson P. Anaesthesia, the family friendly specialty. Bulletin 23, The Royal College of Anaesthetists 2004; 1127–29

8 Simpson P. The impact of the implementation of the European Working Time Directive to junior doctors hours on the provision of service and training in anaesthesia, critical care and pain management. http://www.rcoa.ac.uk/docs/ewtd.pdf

9 Department of Health. Department of Health Vacancies Survey March 2003, Table 1. 2003; http://www.dh.gov.uk/assetRoot/04/06/01/06/04060106.xls

10 Allen P. Medical and dental staffing prospects in the NHS in England and Wales in 1991. Health Trends 1993: 25: 4–12[Medline]

11 Working Group on Specialist Medical Training. Hospital Doctors Training for the Future (The Calman Report). London: UK Department of Health; 1993

12 Royal College of Anaesthetists. Training. http://www.rcoa.ac.uk/index.asp?PageID=33

13 Nunn JF. Development of academic anaesthesia in the UK up to the end of 1998. Br J Anaesth 1999: 83: 916–32[Free Full Text]

14 General Medical Council Education Committee. Recommendations on Basic Medical Education. London: GMC, 1980

15 Department of Health (2001) Improving Working Lives for Doctors. http://www.dh.gov.uk/assetRoot/04/07/42/91/04074291.pdf

16 NHS Executive (2002) Unfinished Business: Proposals for Reform of the Senior House Officer Grade. London: Department of Health

17 Department of Health. Modernising Medical Careers. 2003; http://www.dh.gov.uk/assetRoot/04/05/42/33/04054233.pdf

18 Group of Anaesthetists in Training. Response to ‘Unfinished business: Proposals for reform to the Senior House Officer Grade’. www.aagbi.org/gat_shoreformletter.htm

19 Interim Position Statement of the Royal College of Anaesthetists on Modernising Medical Careers, December 2004; www.rcoa.ac.uk/docs/MMCresponsev4.pdf