‘I don't belong anywhere’: Identity and professional development in SAS doctors

Abstract

Specialist, associate specialist and specialty (SAS) doctors constitute a marginalised professional group who can struggle to achieve the professional development they desire. Our primary objective was to understand, from a theoretically informed perspective, the ways in which the professional identity of SAS doctors influences their professional development opportunities, including through appraisal. Ten UK SAS doctors participated in in-depth, narrative interviews. Participants were drawn from six medical specialities, and ranged in experience (2.5–15 years) and country of primary medical qualification. Interview transcripts were analysed via critical discourse analysis using Figured Worlds theory. The position of SAS doctors within the Figured World was at times unstable, ambiguous and context dependent. They were often relative outsiders, not immediately trusted by colleagues. Some found their development needs eclipsed by the priorities of colleagues, typically consultants and postgraduate trainees. Appraisal was often not perceived to have successfully addressed these issues. This study enhances our understanding of the lived experience of SAS doctors, which is often in stark contrast to formal policy on the range of roles that they can fulfil. The struggles and successes of SAS doctors described here suggest that there is scope to improve the professional status and professional development opportunities for SAS doctors, including through appraisal.

Summary.

What is known?

• •SAS doctors can be considered to comprise a marginalised group in medicine, who struggle to achieve the professional development that they desire, including through appraisal, an established process for supporting doctors’ professional development in the UK.

What is the question?

• •How are SAS doctors positioned within the professional hierarchy in UK hospital medicine?
• •How does the position of SAS doctors affect their professional development opportunities?
• •To what extent does appraisal provide support for SAS doctors’ professional development?

What was found?

• •Using Figured Worlds theory, we found that SAS doctors could comprise an ‘outsider’ group, not immediately trusted by colleagues, whose position in the medical hierarchy was often unstable, ambiguous and context dependent. This presented challenges for their professional development that were not always successfully addressed via appraisal.

What is the implication for practice now?

• •There is scope to bring the professional development opportunities for SAS doctors more fully into line with published policy, including the SAS Charter. Appraisal may provide a supportive mechanism for doing so, but the professional status of SAS doctors must also be enhanced to improve their professional life chances.

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Introduction and background

Specialist, associate specialist and specialty (SAS) doctors are doctors working in the UK who are appointed on specific contracts.¹ International medical graduates and Black, Asian and minority ethnic people are over-represented in the cohort,^1,2 and there is increasing recognition that SAS doctors constitute a marginalised group^1,3,4 who sometimes struggle to achieve the professional development that they desire.⁵ This is despite the existence of policy guidance entitling these doctors to a range of professional and career development opportunities that are routinely available to consultants, including holding important and influential non-clinical roles.6, 7, 8 There are major workforce implications arising from the challenges in retaining these doctors,¹ linked, in large part, to a lack of development opportunities.

Although the professional development of UK doctors is complex and multifaceted, one important element of the established mechanisms for supporting their professional development is appraisal.^5,9 However, previous research suggested that the professional development difficulties of some SAS doctors are not necessarily addressed by the appraisal process and, at times, may be perpetuated through it.⁵

Rationale for the research

SAS doctors range from those with relatively little clinical experience to very experienced doctors, some of whom have held senior clinical roles in non-UK healthcare systems.¹ Importantly, regardless of experience, and despite some individual SAS doctors achieving significant career success, SAS doctors as a group lack professional status, with implications for their position within the medical hierarchy¹⁰ and their professional development opportunities.^5,11 (This situation is changing, not least through the efforts of SAS doctors themselves; however, research suggests that this is still largely the case.) As researchers, we were keen to understand, from a theoretically informed perspective, the connection between the professional identity of SAS doctors and the professional development opportunities available to them, with a particular emphasis on appraisal as a mechanism for supporting these important members of the medical workforce.

Therefore, we investigated the following research questions:

• •How are SAS doctors positioned within the professional hierarchy in UK hospital medicine?
• •How does the position of SAS doctors affect their professional development opportunities?
• •To what extent does appraisal provide support for professional development among SAS doctors?

Methods

Conceptual orientation

Professional identity

For the purposes of our work, we took professional identity to mean the combination of two important, intersecting dimensions. The first was professional status, that is, the standing of individuals or groups within a profession and the resulting opportunities that are offered to them.¹² The second dimension was professional learning, or ‘expertise’. Importantly, this concept of professional identity recognises that professional status (and opportunity) may be enhanced by developing one's professional expertise, but that this is not always the case;¹³ it is possible for professional development to lead to an enhancement of skills, with no corresponding improvement in professional status and attendant career opportunities,¹³ because of the way that individuals or groups are viewed by others.

Figured worlds

The theory of Figured Worlds provides a way of looking at the social forces that influence the ways that people behave, speak and practice in social spaces.14, 15, 16 In particular, the theory highlights how influential individuals (those who hold power and esteem within hierarchical systems) can ‘position’ individuals and groups in ways that make certain identities accessible or inaccessible. In UK healthcare, these ‘esteemed’ individuals might include consultants, specialty trainees and others whose positions are associated with status and access to professional development and career opportunities. This can be troubling for individuals in less powerful positions, and can influence their identity development and career trajectory.¹⁷ Identifying which individuals hold the most esteemed positions can facilitate an analysis of how others within the Figured World create their identity, including those who have difficulties in identifying with the most esteemed positions.¹⁷

Despite these social forces, individuals, including those who do not hold esteemed positions, possess agency (ie a ‘capacity to act’¹⁸) in the Figured World. In other words, rather than simply accepting particular constraints or barriers that might get in the way of becoming the sort of professional they wish to be, individuals can use various strategies to overcome these challenges.¹⁹ One such strategy is called ‘authoring’: individuals can tell others about the sort of person they claim to be,²⁰ in an attempt to position themselves within the Figured World, through the picture they paint of themselves or their role. For instance, an SAS doctor might choose to refer to themselves as ‘a surgeon’, or even ‘a senior surgeon’, to be perceived as someone who belongs and contributes significantly to the surgical team. Conversely, they might refer to themselves as ‘an SAS doctor’, if they want to demonstrate that they are distinct in some way from the consultants and trainees in the team.

Alternatively, agency can be expressed through ‘improvisation’,²⁰ a process in which individuals work around the barriers or constraints they face, usually in creative ways, which can lead to the development of new identities or positions in the Figured World.^16,20 This might mean encouraging an employer to create a role that previously did not exist, or taking the initiative to create an informal role for themselves, such as being an SAS advocate. ‘Vectoring’,²¹ another way of demonstrating agency, describes the various courses that individuals can take as they navigate the professional world, where they might choose to travel toward or to distance themselves from particular identities or positions. For example, an SAS doctor might choose to work their way toward becoming a consultant; alternatively, they might choose to take their career in a different direction, perhaps to retain their work–life balance or focus on a particular aspect of clinical work.

In summary, Figured Worlds theory sheds a light on the structural forces at work that position SAS doctors in particular ways, with implications for their professional development. It also illuminates the ways in which SAS doctors attempt to navigate these social spaces, including by exhibiting agency as they seek to establish their professional identity and pursue professional and career development.

Methodology and study design

We conducted a qualitative interview study to explore the lived experiences of SAS doctors of identity, professional development and appraisal.²²

Sampling and data collection

SAS doctors are understood to comprise a highly heterogeneous group;^1,2 thus, we chose an approach that allowed us to listen to the experiences of individuals. Our research followed a cross-sectional case study format, involving in-depth narrative interviews with key informants. Participants were recruited via an online social media campaign and emails to established SAS doctor networks. Interviews, which were audio recorded and professionally transcribed, were conducted by two researchers (EC and MP), with the researchers making contemporaneous and reflective field notes, all of which were considered during data analysis.

Data analysis

The analytical process comprised three main phases. The first was an empirically driven inductive thematic analysis,²³ with transcripts being annotated by two researchers (MP and EC) independently. Themes were discussed, modified and agreed iteratively throughout. A subsequent round of theoretically informed analysis was undertaken, drawing on Figured Worlds theory, with comparisons being made within and across cases. There was then a final integrative phase in which the findings were drawn together to answer our research questions.

The results are presented thematically, using Figured Worlds theory to illuminate key aspects of identity, positioning and agency in the professional development of SAS doctors, before looking at the ways in which appraisal has contributed to their development opportunities.

Participants have been given pseudonyms throughout to allow discussion of personal stories without overt identification of individuals.

Results

Our research involved 10 doctors from various specialties and countries of primary medical qualification, with experience ranging from 2.5 to 15 years (Table 1).

Table 1.

Study participant pseudonyms and demographic information.

Participant no.	Pseudonym	Specialty	Year qualified	Time as an SAS doctor	Training UK/non-UK
1	‘Aldo’	Surgery	1996	15 years	Non-UK (EU)
2	‘Kate’	Oncology	2001	3 years	Non-UK (EU)
3	‘Ivan’	Psychiatry	2007	2.5 years	Non-UK (EU)
4	‘Roy’	Anaesthetics	1996	15 years	UK
5	‘Binita’	Psychiatry	2007	8 years	Non-UK, non-EU
6	‘Sophia’	Medicine	1989	4 years	Non-UK, non-EU
7	‘Matthew’	Surgery	2006	9 years	UK
8	‘Maria’	Surgery	2008	6 years	Non-UK (EU)
9	‘Laila’	Emergency medicine	2003	7 years	Non-UK, non-EU
10	‘Carol’	Emergency medicine	2007	6 years	UK

Positions in hospital medicine

Participants identified three main professional groups within the Figured World of hospital medicine: consultants, trainees and SAS doctors. Consultants were considered expert clinicians and held the most esteemed position:

We have always thought that a person who is a Consultant is the best. That's what we have traditionally been led to believe, that if you are a Consultant, what you say is right. (Binita, Psychiatry)

Consultants also occupied other significant identities, such as ‘Manager’, ‘Researcher’, ‘Trainer’ and ‘Appraiser’, each comprising a distinct position. Trainees were postgraduate doctors aspiring to become fully trained consultants and were regarded by participants as ‘consultants-to-be’. This allowed them to occupy another esteemed position, albeit one that ranked below consultants in the hierarchy.

By contrast, SAS doctors were often positioned as relative outsiders. Their identity was often defined by what they were not: non-consultants and non-trainees.

So the best thing, the only way I can try to make [colleagues] understand, is that we are permanent doctors, we are not consultants and we are not trainees (Roy, Anaesthetics, our emphasis).

By definition [an SAS doctor is] a non-training grade, non-consultant grade doctor. (Carol, Emergency Medicine, our emphasis)

This ‘null’ identity caused isolation and difficulties in establishing a clear role within the medical hierarchy.

It's quite interesting because I kind of call myself ‘I don't belong anywhere’ (Aldo, Surgery, our emphasis)

It's very easy to feel lost as a SAS doctor because you don't belong to any of the groups of people […] and I think it also comes from other people's perception of you, so people are not quite sure who you are and what you actually do. (Kate, Oncology)

Some SAS doctors positioned themselves as ‘in the middle’ between consultants and trainees:

A trainee […] asked me ‘what is your grade?’ So I said, ‘I'm an SAS doctor’. She said ‘what is this? What are you doing? Who are you?’ I said ‘I am somewhere in the middle’. (Sophia, Medicine, our emphasis)

However, this ambiguous identity proved unstable and resulted in a somewhat precarious identity:

Sometimes if the Department or the Unit need a senior […] then I've been acting as a consultant. However, I don't get into the emailing list for the consultants and then when they send junior emails to the trainees, I'm in that trail of emails. (Aldo, Surgery)

Furthermore, there was evidence that SAS doctors were at times positioned below trainees in the hierarchy, with contrasting professional development expectations and resources afforded to them:

As an SAS doctor you have to scream and shout to find that opportunity [to progress] as compared to trainee doctors where they are wishing you to find opportunities; your Deaneries or your consultants would want you to find something. As an SAS doctor, I don't think there are any obvious opportunities for you.’ (Ivan, Psychiatry)

Furthermore, SAS doctors struggled to gain the trust of their colleagues, facing doubts and scepticism because of their grade.

So [I said] ‘I don't think this [diagnosis] is right’ […] And then this guy turned round and he said ‘Sorry, what grade are you?’ And I said ‘I'm an SAS doctor, I've just joined.’ And he said ‘Right, can I have a chat with someone else?’ And he asked the other doctor, who was a Trainee, but was much junior and hadn't had much experience. He said ‘So what do you think it is?’ And the trainee looked at me, because I was the senior, and he's like, ‘What she said.’ [laughter] (Laila, Emergency Medicine)

However, individual factors and gaining colleagues’ confidence over time could contribute to being perceived as more of a trusted insider.

Over time I realised that nobody really takes an SAS doctor seriously, unless they get to know you over a period of time and they get to work with you and they realise what kind of doctor or physician you are. Then they learn to trust you, but they learn to trust the person, not the grade. So that's a difference. (Laila, Emergency Medicine)

Nonetheless, even established SAS doctors perceived that they were subject to a hierarchical culture, such that access to certain positions was at times not even offered, affecting their professional development opportunities in the process:

When it comes to management, you see some people that they are in several committees and you think “Well, I can take that off you and that would make your life a little bit easier,” but they don't want that because they feel that you are not our class, if you want, you are second-class. (Aldo, Surgery)

Troubled and untroubled identities

We found that origin stories (the narratives that people recounted about becoming an SAS doctor) were often connected with doctors’ troubled or untroubled identity and their resulting identity and professional development trajectories.

These stories generally fell into one of two broad categories: perceived career failure, and positive career choices, in which doctors made a conscious decision to choose the SAS doctor grade.

Perceived career failure: Kate's story

In recounting her origin story, Kate, who had been working as an SAS doctor for 3 years, authored herself as a failure, and equated the decision to pursue ‘the SAS route’ with having ‘given up’ (Box 1). However, Kate had shown agency, in the form of improvisation, in carving out a role for herself in a specialty and organisation in which SAS doctor careers were not well understood. Nonetheless, Kate remained troubled by her current identity: as with several of our interviewees, she was disappointed by not being able to achieve what she had set out to achieve as a medical student or newly qualified doctor.

Box 1. Kate's story.

Becoming an SAS doctor: Kate's story

Long story. I was an [Specialty] Registrar for 9 years…and I always worked part-time, but unfortunately I have not been able to pass the very last of the exams…and I've sat it five times in total over the period of three years. In the end I've just given up and decided I'm not going to be a registrar; I'm going to pursue the SAS route […]

SAS doctors are not very common in [my specialty] […] there are very few of us. I kind of had to convince… I was at [named hospital] at the time and they wanted to keep me, but they weren't quite sure what capacity to keep me in, so I had to kind of essentially create my own job and tried to guide the management through what SAS doctors are about and how it would work and I spent…my contract was actually just a clinical fellow contract…then I spent two years trying to make them understand and get them to offer me the SAS contract […]

The question of identity is more about not being a Consultant, I think that's something that I've struggled with and I'm still coming to terms with it, is the fact that when you start your training, you are always assuming you are going to get to a Consultant position and not getting that is actually quite difficult. It is, emotionally.

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Positive career choices: Matthew's story

In contrast to Kate, Matthew had been on a consultant-bound trajectory as a surgical trainee before deciding to rebalance his career and personal life (Box 2). Despite Matthew having made a positive choice to relinquish a specialty training post and pursue an SAS doctor career, he was clearly not content with all aspects of his experience, in particular the discrepancy between his salary and that of his senior colleagues.

Box 2. Matthew's story.

Becoming an SAS doctor: Matthew's story

Basically, went through the usual routes, core training, etc., and then got to the stage of applying for jobs. […] I was looking at options, the job that I'm currently in came up with no weekends and no nights, so I applied for that and also applied for a permanent training number and got offered them both. But my first choice, because of the work-life balance, I do a lot of youth work with church, so wanted to continue doing that, so didn't want medicine or surgery taking over my life. […]

If I wanted the recognition or wanted a big name in private practice or to become famous worldwide, I would have gone the Consultant route. This was a choice. […]

If I'm working close to the Consultant level, the discrepancy at the minute is quite large in our salaries. And more so actually to my colleague, the other middle grade who is an Associate Specialist who does not take on the responsibility that I take on and does not operate surgically at the standard I work, but yes will take probably 30 grand more than me home per year […] It sits a bit uncomfortably. […]

I think the introduction of the Specialist* role is very important, particularly for those people where they can get closer to a Consultant's salary without being quite on the same salary.[…] I'll be honest about it and say it's only because of the money.[…] The title doesn't matter to me, call me whatever you want, I'm not fussy. […] That's it, that's fine. I don't need a big title. I don't want to be ‘the boss’ or the highest recognised person in the place.

*The recently introduced Specialist role is, in effect, a senior SAS doctor role, which represents career and pay progression for SAS doctors in the UK.

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However, Matthew was not troubled by his identity per se. He felt that his particular issue would be resolved by a new contract, with an attendant salary increase reflecting more accurately the value of his clinical work.

Agency of SAS doctors

SAS doctors exhibited agency in their professional development through three key improvisational strategies: vectoring, world-making and tactical behaviour.

Vectoring involved navigating toward established positions, so-called ‘inbound vectoring’, such as by becoming managers or appraisers, or in some cases working toward becoming a consultant:

I'm planning to apply for CESR [seeBox 3]. […] I have ambition and I am not planning to sit as a specialty doctor. I find very difficult in UK to be a specialty doctor [laughs]. (Sophia, Medicine)

Box 3. Definitions.

Certificate of Eligibility for Specialist Registration (CESR) is awarded to doctors practising in the UK who can demonstrate that they have equivalent experience to a UK trainee who has completed a recognised training programme. The certificate allows the holder to be appointed to a substantive consultant role in the UK. The name and process of this route to joining the specialist register is due to change on 30 November 2023 and CESR will be known as the ‘Portfolio Route’. Locum consultants are experienced doctors who are deemed appointable at the consultant level, often for a fixed period of time. They need not have achieved formal completion of specialty training; hence, some experienced SAS doctors who have not completed a recognised UK specialty training programme may be appointed to this senior role.

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I do the appraisals for my trust for other doctors […] I have even done an appraisal for my boss. I've done it for our medical director, assistant medical director… (Binita, Psychiatry)

World-making involved creating professional development opportunities by creating new roles or identities that were not previously recognised:

SAS doctors are not very common in oncology […] so I had to kind of essentially create my own job and tried to guide the management through what SAS doctors are about and how it would work. […] I spent two years trying to make them understand and get them to offer me the SAS contract. (Kate, Oncology)

Kate had engaged in a further world-making step by contributing to the creation of a national SAS doctor network, supporting others in her specialty to move into the SAS role.

Tactical behaviour comprised approaches that exploited existing power structures rather than directly challenging them:

Now I work as a locum consultant [seeBox 3] and I pick the phone up and say ‘Hi, my name's Laila, I'm one of the consultants’ and the tone changes! [laughter] It's like [politely] ‘Yes, hello! How are you?’ What the…? [laughter] Nobody questions me. I can get away with a shit referral now, which I would not possibly have been able to do before, just because I am using the word ‘consultant’. It is sad. (Laila, Emergency Medicine)

The role of appraisal

The doctors in our study were all engaged with appraisal, and some had even trained as appraisers. Some perceived that appraisal had the potential to support their professional development, and had had positive appraisal experiences:

[Appraisal is] a time to reflect… …. you are working on your goals, your perseverance, going about your mission in life […] and appraisal is a time where you could structure that and ask for support from your colleagues and ask for support from your [employer]. (Ivan, Psychiatry)

Others had had negative experiences, and appraisal was seen at times to maintain the established subject positions within medicine, reinforcing the feelings of SAS doctors being outsiders or invisible:

When I went to my appraisal, he will search for some negativity….He was not looking at how I can progress […] he never asked about positivity, he never asked me ‘what do you want? How do you want to progress?’[…] I found this very discouraging. (Sophia, Medicine)

‘I've done the Train the Trainer course, I've done the Supervision…whatever course…but it doesn't mean that they're going to allow you to use it…they don't give you the opportunity to use that.’ (Aldo, Surgery)

Laila described poor experiences of appraisal and shared her perception that SAS doctors’ professional development was viewed differently to that of consultants:

Automatically, the interest level [from the appraiser] goes really down. They're like ‘Oh, it's an SAS doctor. Why don't you just give it to another SAS doctor and they can do the appraisal?’ But they're not really mentoring you, are they? You need someone who's appraising you to be senior […] and then if he's your appraiser for two or three years he can see and help you build up or get connections. Come on, that's how it works. (Laila, Emergency Medicine)

Discussion

Principal findings and meaning

It was clear from our research that there were important social positions that were recognised and celebrated in the Figured World of hospital medicine. Our results suggested that the consultant grade, described by participants as the recognised experts in the field, and the ‘best;’ was the principal example of an esteemed and legitimate position. We have labelled the consultant grade a ‘celebrated subject position’, akin to Carlone et al.’s work,¹¹ where particular norms and practices celebrate certain positions and marginalise others. Furthermore, those who did occupy a celebrated subject position as consultants were often perceived by interviewees to lay claim to a constellation of other celebrated positions, such as ‘manager’, ‘researcher’ and ‘trainer’. Thus, the consultant role opened positions of greater influence and esteem that were not easily accessible for those who did not hold a consultant-grade post, despite formal guidance to the contrary.^6,7 Trainees comprised a celebrated subject position on account of being deemed ‘consultants-to-be,’ and, thus, also had significant status within the community.

Often, SAS doctors found it challenging to achieve recognition in these settings. Whereas some individuals were regarded as trusted insiders, we found that SAS doctors typically constituted an outsider group, at worst a ‘null’ group, often being defined by what they were not. They were positioned by influential others in ways that limited their access to important identities, such as clinical expert, manager or trainer, and some had found their identity to be ambiguous and unstable, with consequential impacts on their professional development opportunities.

Not all SAS doctors were troubled by their position or by their comparatively limited range of professional development options. For those who were dissatisfied with the subject positions they had been offered, professional development efforts were centred on vectoring toward the role of consultant or one of the other esteemed subject positions within the Figured World, such as appraiser, manager or trainer. Alternatively, they engaged in improvisation, creating their own development opportunities.

Appraisal, conceptualised as a person-centred developmental conversation,24, 25, 26 offers a means by which the various, often divergent professional development agendas of individual SAS doctors could be addressed. Although we found that this potential was occasionally met, we also found that appraisal was embedded in a culture in which SAS doctors were not positioned as equals and, thus, their professional development ambitions were at times frustrated: attempts by SAS doctors to improvise or vector toward desired identities were not always supported by appraisal discussions.

Strengths and limitations

A strength of this research lies in the robust qualitative methodology, which was valuable for exploring the complex social issue of SAS doctor professional identity and professional development. Thus, the qualitative approach allowed us to develop a rich and complex account of professional development successes and challenges of SAS doctors, while also raising questions for further research.

However, we acknowledge that, as idiographic research, some of the experiences described here will not be reflected in the careers of all SAS doctors. This is a known feature of qualitative research, which embraces subjectivity and prioritises richness and depth of understanding rather than the objective, statistical demonstration of generalisability.²⁷

Rigour in qualitative research is typically demonstrated through reflexivity, a process that acknowledges the subjectivity that is inherently present in the research process rather than attempting to eliminate it.²⁷ In our work, field notes, coding diaries and regular team discussion were implemented to enhance the reflexivity in our analysis. Methodological reflexivity is enhanced through transparency about methodological decisions.²⁷ To this end, we provided a detailed account of our data collection and analytical methods. Transparency has also been enhanced by providing verbatim quotations to allow readers to draw their own conclusions about the findings.

The Figured Worlds theoretical framework, previously unused in research into the professional identity of SAS doctors, was another strength of the research and has been used to explore identity development in medical students¹⁸ and nursing students.²⁸ The theory illuminated the findings of previous research⁵ by demonstrating how SAS doctors come to inhabit different identities within the healthcare world, and how those identities impact their professional development opportunities, including through appraisal.

Our concept of professional identity was another strength of the work, being a composite of two important aspects of professional identity (status and expertise), both of which are necessary for professional advancement. Although this is a complex idea in one respect, we recognise that it is also limited, in that it does not take account of other important intersecting aspects of identity, including demographic factors, such as gender or ethnicity.

Finally, our recruitment strategy was not systematic and, therefore, might have placed limitations on who was able to respond to our call for participants. However, network-based approaches, such as the one we used, are often preferable for reaching individuals or groups who have been marginalised by prevailing cultures and systems.²⁹

Ultimately, we believe that the best judges of the validity of our research will be SAS doctors themselves, whom we think will find resonance with some of the experiences reported here.

Implications for research and practice

Developmental conversations, such as appraisal, and the opportunities to which they ought to give rise, should take account of the particular goals, ambitions and professional development needs of SAS doctors. Therefore, appraisers should be appropriately trained, aware of the opportunities that exist and willing to support a doctor's exploration of a range of possibilities. These might include pursuing established roles in management, education and research, as well as autonomous, specialist clinical work. They could also include novel or creative options within their current career trajectory, such as creating new roles or convening special interest or advocacy groups. Furthermore, for those doctors who wish to work toward the new Specialty grade, or toward appointment as a consultant, there should be an explicit requirement that they are supported in their aim. This should include support for taking important professional exams for those who wish to do so.

Given the prevailing culture, we echo the call of the Academy of Medical Royal Colleges⁸ that local SAS advocates should be appointed, with responsibility for promoting and monitoring the implementation of the SAS Charter.³⁰ However, in the longer term, more research is needed to explore how culture change might be achieved, such that doctors who follow SAS career paths are genuinely regarded as high-status professional colleagues, aside from instrumentalist arguments that merely objectify SAS doctors as vital members of a struggling healthcare workforce.