Abstract
Objective
To report the career choices and career destinations in 1995 of doctors who qualified in the United Kingdom in 1988.
Design
Postal questionnaire.
Setting
United Kingdom.
Subjects
All doctors who qualified in the United Kingdom in 1988.
Main outcome measures
Current employment.
Results
Of the 3724 doctors who were sent questionnaires, eight had died and three declined to participate. Of the remaining 3713 doctors, 2885 (77.7%) replied. 16.9% (608/3593; 95% confidence interval 16.1% to 17.8%) of all 1988 qualifiers from medical schools in Great Britain were not working in the NHS in Great Britain in 1995 compared with 17.0% (624/3674; 16.1% to 17.9%) of the 1983 cohort in 1990. The proportion of doctors working in general practice was lower than in previous cohorts. The percentage of women in general practice (44.3% (528/1192)) substantially exceeded that of men (33.1% (443/1340)). 53% (276/522) of the women in general practice and 20% (98/490) of the women in hospital specialties worked part time.
Conclusions
Concerns about recruitment difficulties in general practice are justified. Women are now entering general practice in greater numbers than men. There is no evidence of a greater exodus from the NHS from the 1988 qualifiers than from earlier cohorts.
Key messages
This study reports the career progress to September 1995 of doctors who qualified in 1988
Loss from the British NHS, at 16.9% (95% confidence interval, 16.1% to 17.8%), was no greater than among earlier qualifiers at the same time after qualification
The proportion of doctors working in general practice (38%) was lower than in earlier cohorts studied
In this generation of doctors, women in general practice now outnumber men
Fifty three per cent of the women in general practice and 20% of the women in hospital specialties were working on a part time or flexible basis
Introduction
There is continued interest in the career destinations of junior doctors in the United Kingdom.1 Data have already been published on doctors who qualified in 1974, 1977, and 1983.2,3 To understand career progression in a more recent cohort we undertook a survey of all doctors who qualified in the United Kingdom in 1988, and we compared their career progression with those who qualified in 1977 and 1983.2 We used capture-recapture analysis (see Appendix) to give more precise estimates of loss from the NHS than have ever previously been made.4
Subjects and methods
Our methods are described elsewhere.2,3 We identified doctors from lists of qualifiers from UK medical schools in 1988. We sent up to four reminder mailings to non-respondents, and we analysed career destinations as they were on 30 September 1995. Fourteen specialty groups were defined.
Since 1988 the Department of Health has kept a record of doctors working in the NHS in Great Britain. We used this record to supplement our data to estimate loss from the NHS in Great Britain. Doctors with honorary NHS contracts—notably those in university posts—were counted as being in the NHS. We compared 1988 qualifiers in 1995 with 1983 qualifiers in 1990, at the same time from qualification.
Results
In 1988, 3739 doctors qualified. We excluded six doctors who qualified but did not register and nine doctors for whom we had no recent address. Of the 3724 doctors who were sent questionnaires, eight had died and three declined to participate, leaving 3713 in the study. Of these, 2039 (54.9%) were men and 1674 (45.1%) were women. The overall response rate was 77.7% (n=2885): 73.4% (n=1497) of the men and 82.9% (n=1388) of the women responded (χ2=47.3, df=1, P<0.001). The employment status of 1988 qualifiers in 1995 and of 1983 qualifiers in 1990 was very similar (table 1).
Table 1.
Employment status in September 1995 of respondents who qualified in the United Kingdom in 1988, with comparable data from 1983 qualifiers in 1990. Values are numbers (percentages)
| Employment sector | 1988 qualifiers in 1995*
|
1983 qualifiers in 1990†
|
||||||
|---|---|---|---|---|---|---|---|---|
| Men (n=1480) | Women (n=1383) | Total (n=2863) | Men (n=1533) | Women (n=1044) | Total (n=2577) | |||
| Respondents in United Kingdom | 1377 (93.0) | 1287 (93.1) | 2664 (93.0) | 1428 (93.2) | 975 (93.4) | 2403 (93.2) | ||
| In medical employment: | 1340 (90.5) | 1192 (86.2) | 2532 (88.4) | 1401 (91.4) | 892 (85.4) | 2293 (89.0) | ||
| NHS | 1065 (72.0) | 1061 (76.7) | 2126 (74.3) | 1133 (73.9) | 784 (75.1) | 1917 (74.4) | ||
| Universities and research | 212 (14.3) | 109 (7.9) | 321 (11.2) | 195 (12.7) | 78 (7.5) | 273 (10.6) | ||
| Other public sector‡ | 1 (0.1) | 6 (0.4) | 7 (0.2) | 2 (0.1) | 5 (0.5) | 7 (0.3) | ||
| Non-public sector | 17 (1.1) | 9 (0.7) | 26 (0.9) | 21 (1.4) | 19 (1.8) | 40 (1.6) | ||
| Her Majesty’s armed forces§ | 45 (3.0) | 7 (0.5) | 52 (1.8) | 50 (3.3) | 6 (0.6) | 56 (2.2) | ||
| Other: | 37 (2.5) | 95 (6.9) | 132 (4.6) | 27 (1.8) | 83 (8.0) | 110 (4.3) | ||
| Non-medical employment | 12 (0.8) | 13 (0.9) | 25 (0.9) | 14 (0.9) | 6 (0.6) | 20 (0.8) | ||
| Not in paid employment | 25 (1.7) | 82 (5.9) | 107 (3.7) | 13 (0.8) | 77 (7.4) | 90 (3.5) | ||
| Respondents abroad | 103 (7.0) | 96 (6.9) | 199 (7.0) | 105 (6.8) | 69 (6.6) | 174 (6.8) | ||
| In medical employment | 95 (6.4) | 72 (5.2) | 167 (5.8) | 105 (6.8) | 65 (6.2) | 170 (6.6) | ||
| Other: | ||||||||
| Non-medical employment | 3 (0.2) | 1 (0.1) | 4 (0.1) | 0 | 0 | 0 | ||
| Not in paid employment | 5 (0.3) | 23 (1.7) | 28 (1.0) | 0 | 4 (0.4) | 4 (0.2) | ||
Excludes 22 respondents who gave no employment details for 1995.
Excludes data from 141 doctors who responded in 1994 but did not provide details of work for 1990.
Includes doctors in the civil service, public health laboratory service, and public sector occupational health.
Respondents defined as UK doctors regardless of geographical location.
Non-response rendered our data incomplete. Comparison of our replies from doctors with the Department of Health record showed that its record was also incomplete. Using capture-recapture (see Appendix) we estimated a loss from the NHS in Great Britain of 16.9% (608/3593, 95% confidence interval 16.1% to 17.8%) of the qualifiers in Great Britain in 1988, which comprised 16.5% (269/1632) of the women and 17.7% (347/1961) of the men. For the 1983 cohort in 1990 we estimated a loss from the NHS in Great Britain of 17.0% (624/3674, 16.1% to 17.9%), which comprised 18.8% (264/1401) of the women and 16.0% (364/2273) of the men.
There was a small increase over time in the percentage of male respondents outside medical employment, whether in the United Kingdom or abroad, seven years after qualification (table 1): 1.8% (27/1533) and 3.0% (45/1480) from the 1983 and 1988 cohorts respectively (χ2=4.7, df=1, P=0.03). The women showed no change: 8.3% (87/1044) and 8.6% (119/1383) from the 1983 and 1988 cohorts respectively (χ2=0.03, P=0.87).
Of 2532 respondents in medicine in the United Kingdom seven years after qualification (table 2), 971 (38.3%) were in general practice compared with 45.9% (1054/2296) of the 1983 cohort. More women than men were in general practice, psychiatry, paediatrics, and community health, and more men than women were in the surgical specialties and the hospital medical specialties (all P<0.01 using χ2 test (df=1), table 2).
Table 2.
Specialty profile in September 1995 of respondents from 1988 qualifiers in medical employment in United Kingdom. Values are numbers (percentages)
| Specialty group | Men (n=1340) | Women (n=1192) | Total (n=2532) | P value * |
|---|---|---|---|---|
| General practice | 443 (33.0) | 528 (44.3) | 971 (38.3) | <0.01 |
| Medical specialties | 194 (14.5) | 114 (9.6) | 308 (12.1) | <0.01 |
| Paediatrics | 46 (3.4) | 78 (6.5) | 124 (4.9) | <0.01 |
| Accident and emergency | 24 (1.8) | 37 (3.1) | 61 (2.4) | <0.05 |
| Surgical specialties | 212 (15.8) | 40 (3.4) | 252 (9.9) | <0.01 |
| Obstetrics and gynaecology | 57 (4.2) | 48 (4.0) | 105 (4.1) | NS |
| Anaesthetics | 138 (10.3) | 89 (7.5) | 227 (9.0) | <0.05 |
| Radiology | 40 (3.0) | 23 (1.9) | 63 (2.5) | NS |
| Clinical oncology | 11 (0.8) | 21 (1.8) | 32 (1.3) | NS |
| Pathology | 40 (3.0) | 27 (2.3) | 67 (2.6) | NS |
| Psychiatry | 84 (6.3) | 115 (9.6) | 199 (7.9) | <0.01 |
| Community health | 7 (0.5) | 30 (2.5) | 37 (1.5) | <0.01 |
| Public health medicine | 16 (1.2) | 21 (1.8) | 37 (1.5) | NS |
| Other specialties | 28 (2.2) | 21 (1.8) | 49 (2.0) | NS |
NS=not significant (P⩾0.05).
χ2 test for sex difference in percentage working in each specialty.
The difference between the percentage of women and of men in general practice seven years after qualification increased in successive cohorts: the difference was 2.9% (46.0% of women, 43.1% of men) in the 1977 cohort, 7.6% (50.5% of women, 42.9% of men) in the 1983 cohort, and 11.3% (44.3% of women, 33.0% of men) in the 1988 cohort.
Respondents were asked to recall their first choice of career on qualifying. A first choice for a career in general practice was given by 40% (754/1905), 30% (411/1360), and 17% (227/1297) of the men from the 1983, 1988, and 1993 cohorts respectively,6 whereas in women the corresponding percentages were 52% (662/1263), 40% (500/1246), and 34% (450/1324).
NHS contracts in hospital specialties were held by 1118 doctors in the 1988 cohort, of whom 19.8% (124/628) of men and 19.9% (96/490) of women had reached senior registrar status or above (excluding locum appointments) by September 1995. Only seven were consultants. In general practice, 72% (301/419) of men and 61% (317/522) of women were principals. The 118 male non-principals comprised 67 locums, 41 trainees, 7 assistants, 2 retainees, and 1 who gave no grade. The 205 female non-principals comprised 96 locums, 45 trainees, 44 assistants, and 20 retainees.
In the hospital specialties, 20.0% (98/490) of women and 1.4% (9/628) of men were working on a flexible or part time basis whereas in general practice the corresponding fiures were 53% (276/522) and 11% (44/419).
Discussion
This is the first cohort since that of 1983 to be surveyed by us several years after qualifying. For 1983 and 1988 respondents, similar percentages were found for those working in medical practice, abroad, or in non-medical employment, and not in paid employment. We estimate that 16.9% (608/3593) of 1988 qualifiers from Great Britain in 1995 and 17.0% (624/3674) of 1983 qualifiers in 1990 were not working in the NHS in Great Britain. These similarities matter because we have not wanted to attach undue weight to data from the 1983 cohort alone.
Important differences were apparent: 38.3% (971/2532) of 1988 respondents in UK medicine were working in general practice in 1995 compared with 46% (1054/2293) of 1983 respondents in 1990 and 44% (1068/2428) of 1977 respondents in 1984. Consequently, the percentage of respondents working in other specialties was generally higher. Allowing for this, compared with the 1983 qualifiers, recruitment was higher to paediatrics and accident and emergency and lower to pathology than expected from the general increase in the hospital specialties.
This cohort was surveyed for the first time several years into the qualifiers’ medical careers. We are cautious about interpreting recalled career choices because they may be influenced by the passage of time. None the less, the decline in choice of general practice as a first career between 1983 and 1988 and between 1988 and 1993 suggests that interest in general practice among newly qualified doctors has fallen gradually.
We showed that, by 1995, the number of 1988 qualifiers who had left the NHS was no higher than that of 1983 qualifiers by 1990. However, there was a small but significant increase in the percentage of male doctors who were not in medical practice.
Acknowledgments
We thank all the doctors who participated. We thank Janet Justice and Alison Stockford for coding data, Karen Hollick for help with tables, and Jean Davidson for assisting with programming.
Appendix
Capture-recapture estimates of numbers of 1988 qualifiers working in NHS in Great Britain in 1995 were calculated, as shown in the table (above right), from numbers of doctors known to the Medical Careers Research Group and to the Department of Health.
Table.
Capture-recapture estimates of numbers of 1988 qualifiers working in NHS in Great Britain in 1995
| Group | Denoted by | Men | Women | Total |
|---|---|---|---|---|
| Known to MCRG and DoH | a | 990 | 815 | 1805 |
| Known to MCRG but not to DoH | b | 228 | 314 | 542 |
| Known to DoH but not to MCRG | c | 322 | 169 | 491 |
| Estimated additional doctors in NHS* | d = bc/(a+1) | 74 | 65 | 147 |
| Estimated total | T = a + b + c + d | 1614 | 1363 | 2985 |
| Known total population (cohort size) | P | 1961 | 1632 | 3593 |
| Participation rate (%) | R = 100 T/P | 82.3 | 83.5 | 83.1 |
| Loss (%)† | L = 100 - R | 17.7 | 16.5 | 16.9 |
MCRG=Medical Careers Research Group; DoH=Department of Health.
Unrecorded by both MCRG and DoH. The total estimated additional doctors (n=147) does not exactly equal the sum of separate estimates for men (n=74) and women (n=65). This is a consequence of the higher response rate to our surveys from women than from men. Estimates for subpopulations in capture-recapture methods do not total to estimates for pooled populations, if individuals in each subpopulation differ in their likelihood of being observed.[6] The effect on estimated loss rates is small.
Estimated using known cohort size of qualifiers in Great Britain.
Confidence intervals for the number of doctors in the NHS were obtained by calculating the standard error of d using the formula
 |
and multiplying by 1.96 to give the half width of a 95% confidence interval.
For example, the half width of the confidence interval for the total of 1988 qualifiers in the NHS in 1995 is 31 doctors; the 95% confidence interval for the total is therefore 2985±31—that is, 2954 to 3016, or 82.2% to 83.9% of the 1988 cohort of 3593 doctors.
Footnotes
Funding: The UK Medical Careers Research Group is funded by the Department of Health. The Unit of Health-Care Epidemiology is funded by the Anglia and Oxford Regional Office of the NHS Executive.
Competing interests: None declared.
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