Career preferences of doctors

Medicine is no longer staffed by men working full time in one specialty for 40 years

Where do our young doctors think they are going? Do they actually end up there? These questions have been posed by the Medical Careers Research Group in a series of cohort studies of British medical graduates since 1974. The career preferences of graduates from 1974, 1977, 1980, and 1983 were examined about a year after qualification,1 and the results are compared with those from the 1993 cohort in a paper in this edition of the BMJ (p 19). 2

Planning the medical workforce has been a recurrent theme in Britain for over 50 years,3 with successive governments seeking to forecast demand and supply in the labour market for doctors. Britain now has a Medical Workforce Standing Advisory Committee, which has published two reports.4 5 And yet crucial questions still remain unanswered as the experts juggle figures and try to establish how many doctors we need to train to maintain some kind of equilibrium.

In the meantime the world moves on. Not only is the NHS of 1996 completely different from that of 1948, but so are the needs and demands of the public, the potential skill mix needed to match these requirements, and, perhaps most importantly, the profile of the medical profession itself. Half of the doctors graduating from our medical schools are now women, and their career paths are likely to be quite different from those of most male doctors of their own generation, let alone those of even 20 years ago.6 And yet the medical career structure remains much the same as 50 years ago.

What do these cohort studies tell us? The latest one reports that only 26% of the 1993 graduates wanted to enter general practice,compared with 45% of the 1983 graduates.2 The decline in interest among the men (from 40% to 17%) was even greater than among the women (52% to 34%), and this means that general practice was attracting twice as many women as men.Hospital medicine was much more popular among the 1993 graduates than among the 1983 graduates, with surgery continuing to be unpopular among young women in spite of schemes designed to attract them.7

But how useful is this information? These cohort studies1 8 and other research show that young doctors change their minds time and time again. In our most recent study of 1986 British medical qualifiers,6 we found that by the time we interviewed them four years after registration only 60% of the men and less than half of the women were still in the same specialty they had chosen at registration. Intended specialties,even at registration, are clearly not much of a guide to what actually happens.

Many of these doctors are not going to end up in hospital medicine, simply because there is no room for them all, and far more will enter general practice than these figures indicate. But what will have happened to them in their early years of postgraduate training? Will they be wise in trying to start careers in which many will not succeed? Will the men elbow out the women in specialist hospital training? What will happen to those who want more flexible training posts, a group which includes increasing numbers of men? The implications of the Calman report are far reaching here.9 The associate postgraduate deans have continued to draw attention to the problems associated with flexible specialist training, but who is listening?

The Medical Careers Research Group's papers contain matters of grave concern, even if the authors seem reluctant to draw out the important policy messages of their findings. The recruitment problems in general practice have major implications at a time when a “primary care-led NHS” is generally accepted to be a good thing. The present problems may simply reflect a cyclical fashion, or they may have deeper roots. The demand for radical changes in the organisation of general practice, with far more opportunities for part time principals and more flexible conditions of working, has been well demonstrated in research in recent years,10 11 and yet the major policy changes have centred on the development of general practice fundholding rather than on who is actually going to deliver the services in the future.

There is no room for complacency. The exodus from medicine may not have happened yet,8 but there are plenty of indications that a radical assessment is needed of how we are to make use of the talents of the brightest and best of successive generations of young people who enter medicine. Assumptions still predicated on a medical workforce made up of men working full time mainly in one specialty for 40 years are hopelessly misguided, and it is time that the medical profession and the government woke up to this fact. A strategic overview is urgently required of what we need from tomorrow's doctors and how we should plan to achieve it.