UK Medical Careers Research Group, Department of Public Health, University of Oxford, Headington, Oxford
UK Medical Careers Research Group, Department of Public Health, University of Oxford, Headington, Oxford
Department of Psychiatry, University of Oxford, and Oxfordshire Mental Healthcare NHS Trust, Warneford Hospital, Oxford
UK Medical Careers Research Group, Department of Public Health, University of Oxford, Headington, Oxford
Correspondence: Michael J. Goldacre, UK Medical Careers Research Group, Department of Public Health, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, UK. E-mail: michael.goldacre{at}dphpc.ox.ac.uk
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ABSTRACT |
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Aims To report career choices for and career progression in psychiatry.
Method Postal questionnaire surveys of qualifiers from all UK medical schools in eight qualification years since 1974.
Results Totals of 75% (21 845 out of 28 980) and 74% (17 741 out of 24 044) of doctors responded at one and three years after qualification. One and three years after qualification, 4-5% of doctors chose psychiatry. This has changed very little between 1974 and 2000. Most doctors who chose psychiatry one and three years after qualification were working in psychiatry at year 10. Hours and conditions of work, the doctor's personal assessment of their aptitudes and skills and their experience of the subject as a student influenced long-term career choices for psychiatry.
Conclusions Greater exposure to psychiatry for clinical students and in junior hospital jobs might improve recruitment.
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INTRODUCTION |
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METHOD |
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One of the questions asked is What is your choice of long-term career? We ask the doctors to be as general or specific as they wish and, if they have more than one choice, to list up to three in order of preference. We also ask recipients whether they have definitely, probably or not really made up their mind about their choice of long-term career. 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.
A variable percentage of doctors, generally between 10% and 15%, give two
first choices with equal weight (which we term tied choices) and
a much smaller percentage give three tied choices. In this paper, for
simplicity, we have counted each individual who gave psychiatry as a tied
first choice as a doctor choosing psychiatry. In some previous analyses, we
have counted those who gave a tied choice as a 0.5 equivalent
(or 0.3 equivalent as appropriate) doctor choosing the specialty
(Lambert et al,
1996a,b,
2003). As a consequence, the
percentages quoted in this paper may exceed the whole time
equivalent percentages choosing psychiatry, and may exceed those
published previously as such for each cohort by a few tenths of a percentage
point but always by less than 1%. Comparisons of responses between groups of
doctors and tests of their statistical significance were made using
2 statistics, binary logistic regression and correlation
analysis.
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RESULTS |
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Early career choices for psychiatry
In the first year after qualification, 4.1% of men, 4.5% of women and 4.3%
of all respondents signified that psychiatry was their first choice of
long-term career (Table 1;
21=2.7, P>0.05, comparing men and
women). At the end of the third year after qualification, psychiatry was the
first choice of 4.3% of men, 5.6% of women and 4.9% overall
(
21=16.6, P<0.001, comparing men and
women). There are some small differences from year to year in whether a higher
percentage of women than men chose psychiatry. As reported previously
(Parkhouse, 1991), a slightly
higher percentage of women than men in the early cohorts signified psychiatry
as their first choice of long-term career in year 1 and year 3. However, this
was not consistently the case in later cohorts
(Table 1). There was no
significant linear trend in the level of first- or third-year choices for
psychiatry for men, women or total (all P values >0.05 using
2 test for trend).
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Considering all career choices - first, second and third choices -
psychiatry was chosen by 7.6% of men, 8.4% of women and 7.9% overall in year 1
and by 6.1% of men, 8.5% of women and 7.2% overall in year 3
(Table 2). In response to the
question of whether the respondents had definitely,
probably or not really made up their minds about
their specified first choice of career, the levels of certainty of choice for
psychiatry were similar to those expressed by those choosing other careers in
the first year after qualification (Table
3; 21=1.3, P>0.05). At the
third year after qualification, 52.8% of those choosing psychiatry regarded
their career choice as definite, compared with 46.9% of those choosing other
careers (
21=11.2, P=0.001).
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Women choosing psychiatry
Women comprised 27.3% (530 out of 1940) of the total cohort of respondents
of 1974 and 56.1% (1669 out of 2975) of those of 2000. Of the doctors who
chose psychiatry as their first choice of career in year 1, women comprised
32.5% (26 out of 80) of the 1974 qualifiers and 52.5% (64 out of 122) of the
2000 qualifiers. In the cohorts of 1974 and 1999, 35.6% (21 out of 59) and
62.6% (82 out of 131) of those who chose psychiatry in year 3 were women. The
figures were broadly similar when considering all choices - first, second and
third - for psychiatry: in year 1, of the doctors who specified the choice of
psychiatry, 33.5% (62 out of 185) of the 1974 qualifiers were women compared
with 53.9% (97 out of 180) of the 2000 qualifiers. In the cohorts of 1974 and
1999, 37.0% (34 out of 92) and 67.4% (118 out of 175) of those who chose
psychiatry in year 3 were women.
Choices by medical school
Table 4 shows first choices
from each medical school. There is variation between medical schools in the
percentages of their graduates who signified psychiatry as a first choice of
career. To determine the significance of these observed differences, we fitted
a binary logistic regression model with the choice of psychiatry as the
dependent variable and gender, the year of graduation (1974-1983 or 1993-2000)
and the medical school attended as categorical predictors. In year 1, there
were no differences in the level of first choices for psychiatry by gender, by
year of graduation or by medical school (21=2.3,
21=0.4,
222=31.5;
P>0.05 in each case). Therefore, compared with the average of 43%
across all medical schools, no school was significantly higher or lower than
the national average. In year 3, fitting the same model, differences in the
level of first choices for psychiatry were not significant by year of
graduation (
21=2.1, P>0.05) but were
significant by gender (
21=16.1,
P<0.001), with a higher percentage of women than men choosing
psychiatry, as noted above, and by medical school
(
222=50.8, P<0.001). In interpreting
comparisons between medical schools in the model, we used a significance level
of P=0.01 to take account of the fact that we made multiple
comparisons across the schools. On this criterion, comparing the percentage of
doctors from each medical school who chose psychiatry with the overall average
of 4.9%, a significantly higher percentage of graduates from Edinburgh (7.2%)
and a significantly lower percentage from Imperial College London (3.2%) chose
psychiatry. Correlation analysis between the two broad time periods of
1974-1983 and 1993-2000 shows that there was no consistency across time in the
percentages of graduates choosing psychiatry at each school, either in year 1
or in year 3 (r=-0.02 for year 1; r=0.09 for year 3;
P>0.05 for a test of zero correlation in each case).
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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, enthusiasm/commitment: what
I really want to do was rated as having influenced career choice
a great deal by 75% of respondents choosing psychiatry; a
majority of those choosing psychiatry also rated as influential hours
and working conditions, selfappraisal of own
skills/aptitudes and experience of chosen subject as a
student (Table 5). Each
of these four factors was rated as influential by a higher percentage of those
choosing psychiatry than of those choosing other careers, although the
difference for enthusiasm/commitment: what I really want to do
did not attain statistical significance.
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Experience of jobs in psychiatry became an increasingly important influence on choices made in year 3. In year 1, 23% specified that their inclinations prior to medical school had a great deal of influence on their career choice of psychiatry (Table 5). This was a higher percentage, but not significantly so, than for those who chose other careers.
We re-analysed the data on factors that influenced choice, excluding doctors whose first choice was general practice. We did so because the influences on choices for general practice tend to be different from those for hospital specialties (Lambert et al, 1996a). The differences between the proportions of those choosing psychiatry and those choosing other careers who were influenced a great deal changed substantially for three factors (Table 5). Compared with those choosing psychiatry, domestic circumstances and hours and working conditions were rated as influential by a smaller percentage of those choosing other careers. The influence of a particular teacher or department was rated as influential by more of those choosing other careers than those choosing psychiatry.
Ten years after graduation
Ten years after graduation, 64% of those whose sole first choice was
psychiatry in year 1 and 81% of those whose sole first choice was psychiatry
in year 3 were working in psychiatry (Table
6). Graduates who specified an equal preference for a career in
either psychiatry or another specialty (see Method for explanation) were half
as likely as those whose sole first choice was psychiatry to be working in
psychiatry ten years after graduation. Of those who were working in psychiatry
ten years after graduation, 52% (224 out of 428) had chosen it in year 1 and
71% (308 out of 434) had chosen it in year 3.
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DISCUSSION |
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In 1995 Mental Health Officer status, which allowed psychiatrists to retire early on full pensions, was abolished. Although this may have potentially affected recruitment, we found no evidence for this: there was little difference between the percentages choosing psychiatry in 1993 and 2000.
Factors influencing career choice
Three factors had a greater influence on choices for psychiatry than on
choices for other careers in both one and three years after graduation:
experience of the chosen subject as a student, their own assessment of their
skills and aptitudes and the anticipated hours and working conditions. The
doctor's enthusiasm and commitment to the specialty was also a more
influential factor for those who chose psychiatry than those making other
career choices, particularly in the first year after graduation, although this
difference did not reach statistical significance.
Experience of jobs undertaken so far was less influential in year 1 for those choosing psychiatry than for those choosing other careers. This no doubt reflects the very limited exposure to the work of psychiatry in the pre-registration year. By year 3, experience of jobs undertaken so far became as important for those choosing psychiatry as it was for those making other career choices. The fact that, in responses at the end of the pre-registration year, work experience is a more important determinant of career choice for other careers than psychiatry suggests that an increase in early opportunities to work in psychiatry may have a beneficial effect on recruitment to the specialty. The new foundation years programme (NHS Executive, 2002; Department of Health, 2003a) in UK medicine could be an opportunity to offer experience in psychiatry to doctors at an early stage in their working careers.
The doctors' responses on their high level of enthusiasm for psychiatry, and assessment of their own skills and aptitudes, suggest that these are important motivating factors in choosing a career in psychiatry. The responses on hours and conditions of work suggest that these, too, have some influence. As new ways of working in clinical practice are implemented, including the mandatory upper limits on numbers of working hours (Department of Health, 2001), psychiatry may lose some of its perceived advantage over other medical careers in these respects. The responses on experience of the chosen subject as a student suggest that this can be an important determinant for some doctors' career choice for psychiatry.
Only one in five of those wanting a career in psychiatry cited inclinations prior to medical school as a strong influence on their choice. This was a higher percentage than for other career choices, albeit not significantly so. It is evident that specialty preferences before medical school entry are not a major determinant, generally, of doctors' eventual choice.
Ten years after graduation
It is sometimes argued that early choices of long-term career are a poor
predictor of eventual career choice. However, two-thirds of those whose sole
first choice was psychiatry in their pre-registration house officer year and
four-fifths of those whose sole first choice was psychiatry in their third
year after graduation were working in the specialty ten years after
graduation. It is an interesting observation on the good predictive
characteristics of early career choices that, of those who gave an early tied
choice for psychiatry and a different specialty, about half as many eventually
pursued psychiatry as those who specified psychiatry as their sole first
choice.
Thus, a clear early choice for psychiatry was a strong indication of a subsequent career in the specialty. Concerns that the reform to the training grades, and perhaps particularly to the senior house officer grade (NHS Executive, 2002; Department of Health, 2003a) will force young doctors into specialist schemes too soon or prematurely may be unfounded with respect to psychiatry, as many of those who became psychiatrists chose to do so within three years after graduation. Equally, however, flexibility needs to remain for the minority, still reasonably large in number, who decide to pursue psychiatry later in their junior years.
Future prospects
Responses on career influences indicate the importance of a real wish to
practise psychiatry. They also suggest that exposures to positive experiences
of psychiatry as a medical student and in the early postgraduate years are
important. The number of new medical graduates who choose psychiatry has been
lower than that needed to make the UK self-sufficient in the training of
psychiatrists. In general, the UK has trained too few doctors for its own
requirements for decades (Goldacre,
1998) and a number of specialties, including psychiatry, have
experienced a shortfall of home-trained consultants as a consequence. The
percentage of UK qualifiers who specified an early career choice for a
long-term career in psychiatry has been almost stable over the past 25 years.
Given a stable percentage of newly qualified doctors who want a career in
psychiatry, an expansion of the number of UK-trained recruits to psychiatry
can only come from the expansion of medical student intake. Efforts to
increase the percentage of newly qualified doctors who enter psychiatry would
probably require a specific, focused and concerted recruitment strategy.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Department of Health (2001) Improving Working Lives for Doctors. http://www.dh.gov.uk/assetRoot/04/07/42/91/04074291.pdf
Department of Health (2003a) Modernising Medical Careers. http://www.dh.gov.uk/assetRoot/04/05/42/33/04054233.pdf
Department of Health (2003b) Department of Health Vacancies Survey, March 2003. http://www.publications.doh.gov.uk/public/numberstablesmarch2003.xls
Ellin, D. J., Parkhouse, H. F. & Parkhouse, J. (1986) Career preferences of doctors qualifying in the United Kingdom in 1983. Health Trends, 18, 59-63.[Medline]
Goldacre, M. (1998) Planning the United
Kingdom's medical workforce. BMJ,
316, 1846
-1847.
Goldacre, M. J., Davidson, J. M. & Lambert, T. W. (1999) Career choices at the end of the pre-registration year of doctors who qualified in the United Kingdom in 1996. Medical Education, 33, 882 -889.[CrossRef][Medline]
Lambert, T. W., Goldacre, M. J., Edwards, C., et al
(1996a) Career preferences of doctors who qualified
in the United Kingdom in 1993 compared with those of doctors qualifying in
1974, 1977, 1980, and 1983. BMJ,
313, 19-24.
Lambert, T., Goldacre, M. & Parkhouse, J. (1996b) Career preferences and their variation by medical school among newly qualified doctors. Health Trends, 28, 135 -144.
Lambert, T. W., Goldacre, M. J. & Turner, G.
(2003) Career choices of United Kingdom medical graduates of
1999 and 2000: questionnaire surveys. BMJ,
326, 194
-195.
NHS Executive (2002) Unfinished Business: Proposals for Reform of the Senior House Officer Grade. London: Department of Health.
Parkhouse, J. (1991) Doctors' Careers: Aims and Experiences of Medical Graduates. London: Routledge.
Parkhouse, J., Campbell, M. G. & Parkhouse, H. F. (1983) Career preferences of doctors qualifying in 1974-1980: a comparison of pre-registration findings. Health Trends, 15, 29 -35.[Medline]
Royal College of Psychiatrists (1995) Annual Census of Psychiatric Staffing, 1995, Occasional Paper OP34. London: Royal College of Psychiatrists. http://www.rcpsych.ac.uk/publications/op/op34.htm
Royal College of Psychiatrists (1998) Annual Census of Psychiatric Staffing, 1998, Occasional Paper OP46. London: Royal College of Psychiatrists. http://www.rcpsych.ac.uk/publications/op/op46.htm
Royal College of Psychiatrists (2001) Annual Census of Psychiatric Staffing, 2000, Occasional Paper OP53. London: Royal College of Psychiatrists. http://www.rcpsych.ac.uk/publications/op/op53.htm
Royal College of Psychiatrists (2002) Annual Census of Psychiatric Staffing, 2001, Occasional Paper OP54. London: Royal College of Psychiatrists. http://www.rcpsych.ac.uk/publications/op/op54.htm
Received for publication April 28, 2004. Revision received September 14, 2004. Accepted for publication September 24, 2004.