Career choices for obstetrics and gynaecology - Wiley Online Library

DOI: 10.1111/j.1471-0528.2006.00848.x www.blackwellpublishing.com/bjog

Opinion/Comment

Career choices for obstetrics and gynaecology: national surveys of graduates of 1974–2002 from UK medical schools G Turner,a TW Lambert,a MJ Goldacre,a D Barlowb a UK Medical Careers Research Group, Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford, Oxford, UK b Faculty of Medicine, University of Glasgow, Glasgow, Scotland, UK Correspondence: TW Lambert, UK Medical Careers Research Group, Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK. Email [email protected]

Accepted 7 December 2005.

Objective To report the trends in career choices for obstetrics and

gynaecology among UK medical graduates. Design Postal questionnaire surveys of qualifiers from all UK

medical schools in nine qualification years since 1974. Setting United Kingdom. Population All graduates from UK medical schools in 1974, 1977,

1980, 1983, 1993, 1996, 1999, 2000 and 2002. Methods Postal questionnaire surveys. Main outcome measures Career choices for obstetrics and

gynaecology and factors influencing career choices for obstetrics and gynaecology. Results Seventy-four percent (24 623/33 417) and 73% (20 709/ 28 468) of doctors responded at 1 and 3 years after qualification. Choices for obstetrics and gynaecology fell sharply during the 1990s from 4.2% of 1996 qualifiers to 2.2% of 1999 qualifiers, and

rose slightly to 2.8% of 2002 qualifiers. Only 0.8% of male graduates of 2002 chose obstetrics and gynaecology compared with 4.1% of women. Forty-six percent of those who chose obstetrics and gynaecology 1 year after qualification were working in it 10 years after qualifying. Experience of the subject as a student, and the influence of a particular teacher or department, affected longterm career choices more for obstetrics and gynaecology than for other careers. Conclusions The unwillingness of young doctors to enter

obstetrics and gynaecology may be attributable to concerns about workforce planning and career progression problems, rather than any lack of enthusiasm for the specialty. The number of men choosing obstetrics and gynaecology is now very small; the reasons and the future role of men in the specialty need to be debated. Keywords Career choice, medical education, obstetrics and

gynaecology, postgraduate training.

Please cite this paper as: Turner G, Lambert T, Goldacre M, Barlow D. Career choices for obstetrics and gynaecology: national surveys of graduates of 1974–2002 from UK medical schools. BJOG 2006; 113:350–356.

Forecasting the NHS’s future workforce requirements for clinical consultants is notoriously difficult. Workforce planning has been particularly problematic for obstetrics and gynaecology over the past 10 years.1–4 In the UK in the 1990s, following the implementation of the Calman report,5 there were major changes to postgraduate training for all clinical specialties, based on the expectation that the number of consultant posts would increase considerably. In the early post-Calman years, consultant expansion did not occur in obstetrics and gynaecology. There was then a concern that there would be many more holders of the Completed Certificate of Specialist Training than consultant opportunities in

the specialty.1,6,7 Consequently, reductions in training numbers in the specialty were imposed.1 By 2002, a significant increase in consultant expansion was underway and has been sustained.3,4 However, currently, the numbers of trainees in obstetrics and gynaecology are so low that, at least in the short to medium term, a deficit in the number of consultants is now anticipated.4 The negotiation of additional training posts with National Training Numbers (NTNs), in addition to replacement numbers,4 should enable the shortfall to be reduced in the longer term, but only if sufficient trainees can be attracted to the specialty. Our regular surveys of graduates from UK medical schools show that a career in obstetrics and gynaecology is not as popular a choice for young doctors as it once was, particularly

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ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology

Introduction

Career choices for obstetrics and gynaecology

among men.8 In fact, the decline in the popularity of the specialty among men predated the workforce planning problems of the late 1990s. In this study, we explore trends in career choices for the specialty and consider whether it is likely to become almost exclusively staffed by female doctors.

Comparisons of responses between groups of doctors and tests of their statistical significance were made using chisquare statistics. To establish whether the percentage of doctors who chose the specialty varies by medical school, we fitted a binary logistic regression model with the choice of obstetrics and gynaecology as the outcome, and sex, year of graduation and medical school attended as predictors.

Methods Surveys have been undertaken of the graduates of 1974, 1977, 1980, 1983, 1993, 1996, 1999, 2000 and 2002 towards the end of the first and third years after qualification, and at longer time intervals after that. Our methods have been described in detail elsewhere.8–12 One of the questions asked is ‘What is your choice of longterm career?’ We asked respondents to be as general or specific as they wish in specifying their specialty choice and, if they had more than one choice, to list up to three in order of preference. Additionally, we invited those graduating in 1993 and 1996 to signify which of 11 possible factors had influenced their career choice ‘a great deal’, ‘a little’ or ‘not at all’. On average, 9% of doctors across all surveys gave two or three choices with equal preference (which we term tied choices). In some previous analyses, we counted those who gave tied choices as a ‘one-half’ or a ‘one-third’ equivalent doctor choosing each specialty.10,12 In this study, for simplicity, we count the number of doctors who chose obstetrics and gynaecology as a first choice, whether or not the choice was tied with another specialty.

Results The survey questionnaires were sent to a total of 33 417 doctors covering all nine cohorts in the preregistration year. A total of 24 623 (73.7%) replied. Three years after qualification, the survey questionnaire was sent to 28 468 doctors covering the first eight cohorts. A total of 20 709 (72.7%) replied.

Early career choices for obstetrics and gynaecology In recent years, in both the first (year 1) and third (year 3) years after qualification, there has been a decline in the percentage of doctors who specified obstetrics and gynaecology as a long-term career choice, particularly among men (Tables 1 and 2). For women, in the first year after qualification, obstetrics and gynaecology was the first choice of 5.5% of those who qualified in 1974, 6.4% in 1996, 3.5% in 1999 and 4.1% in 2002 (Table 1). For men, the corresponding figures were 4.5% of those who qualified in 1974, 1.8% in 1996, 0.5% in 1999 and 0.8% in 2002. In the third year after qualification,

Table 1. Percentage (and numbers) of respondents who specified obstetrics and gynaecology as their first choice of eventual career at 1 and 3 years after graduation, 1974–2002 Cohort

1974 1977 1980 1983 1993 1996 1999 2000 2002 Total

Percentages choosing obstetrics and gynaecology

Number choosing obstetrics and gynaecology

Year 1

Year 1

Year 3

Year 3

Men

Women

Total

Men

Women

Total

Men

Women

Total

Men

Women

Total

4.5 3.1 3.6 2.9 3.2 1.8 0.5 1.1 0.8 2.6

5.5 4.9 4.6 4.8 7.2 6.4 3.5 3.9 4.1 4.9

4.8 3.7 4.0 3.7 5.2 4.2 2.2 2.7 2.8 3.6

2.6 2.3 3.5 2.8 2.9 1.0 0.5 1.1 N/A 2.2

4.6 3.4 3.6 3.0 4.8 4.5 2.6 2.8 N/A 3.6

3.2 2.7 3.5 2.9 3.9 2.9 1.7 2.0 N/A 2.8

64 54 67 56 42 25 6 14 9 337

29 43 47 60 95 98 54 65 69 560

93 97 114 116 137 123 60 79 78 897

28 36 63 51 41 13 6 15 N/A 253

19 27 37 37 67 65 38 45 N/A 335

47 63 100 88 108 78 44 60 N/A 588

Numbers of respondents were 13 172 (men), 11 451 (women) and 24 623 (total) in year 1, and 11 352 (men), 9357 (women) and 20 709 (total) in year 3. Chi-square test for trend—year 1: men, x 21 5 96.0*; women, x21 5 34.4*; total, x21 5 60.6* and year 3: men, x21 5 57.0*; women, x 21 5 18.6; total, x 21 5 36.1* (* indicates P 0.001).


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the decline in choices for obstetrics and gynaecology was similar to that in the first year (Table 1). Considering all choices—first, second and third—the percentage of women who specified an interest in the specialty in year 1 fell from 15.8% of the qualifiers of 1974 to 6.6% of those of 2002 (Table 2). The percentage of men who specified an interest in the specialty fell from 12.0% of the 1974 qualifiers to 1.6% of those of 2002.

from others’ and ‘experience of jobs so far’ had influenced their career choice a great deal (Table 3). In year 3, factors that influenced career choice were broadly similar to those in year 1, with two exceptions. ‘Experience of jobs so far’ and ‘enthusiasm/commitment: what I really want to do’ became more important among those who chose obstetrics and gynaecology, the percentages rating these two factors as having a great deal of influence on their career choice rising to 66% and 85%, respectively.

Choices by medical school There were significant differences between the medical schools: in year 3 (Figure 1), the specialty was the choice of a significantly higher (P < 0.05) than average percentage of graduates from Aberdeen (4.0%), Dundee (3.9%), Edinburgh (3.6%), Belfast (4.1%), Bristol (4.1%) and Liverpool (3.9%), and a significantly lower than average percentage of graduates from Leeds (1.1%), Birmingham (1.5%) and Wales (1.5%).

Other factors influencing career choice One and 3 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 (Table 3). In year 1, a significantly higher percentage of those who chose obstetrics and gynaecology than those who chose other careers considered ‘experience of chosen subject as a student’ and ‘a particular teacher/department’ to have influenced their career choice a great deal. A significantly lower percentage of those choosing obstetrics and gynaecology than those choosing other careers signified that ‘hours/working conditions’, ‘advice

Ten years after graduation Ten years after graduation, 46% of those whose sole first choice of long-term career was obstetrics and gynaecology in year 1, and 68% of those whose sole first choice was obstetrics and gynaecology in year 3, were working in obstetrics and gynaecology (Table 4). Graduates who specified a tied preference for a career in either obstetrics and gynaecology or another specialty (see Methods for explanation) were much less likely than those whose sole first choice was obstetrics and gynaecology to be working in the specialty 10 years after graduation. Of those who were working in obstetrics and gynaecology 10 years after graduation, 63% (142/226) had chosen it in year 1 and 83% (180/217) had chosen it in year 3. Less than 1% of those who chose another specialty in either year 1 or year 3 were working in the obstetrics and gynaecology 10 years after graduation but, nonetheless, these graduates accounted for one-third (year 1) and one-sixth (year 3) of the total numbers working in obstetrics and gynaecology 10 years after graduation.

Table 2. Percentage (and numbers) of respondents who specified obstetrics and gynaecology as their first, second or third choice of eventual career at 1 and 3 years after graduation, 1974–2002 Cohort

1974 1977 1980 1983 1993 1996 1999 2000 2002 Total

Percentages choosing obstetrics and gynaecology

Number choosing obstetrics and gynaecology

Year 1

Year 1

Year 3

Year 3

Men

Women

Total

Men

Women

Total

Men

Women

Total

Men

Women

Total

12.0 8.7 8.3 6.3 4.7 3.5 1.2 1.5 1.6 5.7

15.8 12.7 9.4 9.6 10.0 11.1 5.0 6.1 6.6 8.8

13.0 10.0 8.7 7.6 7.4 7.5 3.4 4.1 4.6 7.1

4.6 4.7 5.4 3.7 3.4 1.7 0.7 1.4 N/A 3.4

6.3 6.4 5.8 4.3 6.0 5.2 3.6 3.5 N/A 4.9

5.0 5.3 5.5 4.0 4.7 3.5 2.4 2.6 N/A 4.1

169 153 153 119 61 49 14 19 18 755

84 111 95 121 132 170 79 102 111 1005

253 264 248 240 193 219 93 121 129 1760

49 75 98 67 48 21 8 19 N/A 383

26 50 59 53 83 75 52 58 N/A 456

75 123 157 120 131 96 60 77 N/A 839

Numbers of respondents were 13 172 (men), 11 451 (women) and 24 623 (total) in year 1, and 11 352 (men), 9357 (women) and 20 709 (total) in year 3. Chi-square test for trend—year 1: men, x21 5 274.7*; women, x 21 5 68.0*; total, x 21 5 218.8* and year 3: men, x 21 5 72.3*; women, x 21 5 10.5*; total, x 21 5 49.0* (* indicates P 0.001).

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Figure 1. Year 3 choices for obstetrics and gynaecology: odds ratios for choice relative to clinical medical school attended.

Discussion Obstetrics and gynaecology in the UK is currently facing a shortage of newly trained specialists.4 The implementation of additional training posts will help to alleviate this situation eventually. In the meantime, planning for the consultant workforce in obstetrics and gynaecology is likely to remain fraught as the numbers of trainees who train flexibly increases,4 the average length of training increases,4 the European Working Time Directive (a measure that limits the length of the working week for individual doctors) is implemented,13 the Senior House Officer grade is reformed,14 the

Foundation Years programme15 is introduced (changes that will offer earlier experience of obstetrics and gynaecology but may require earlier decision making about career choices; see below), subspecialisation within the specialty increases,16 and the outcome of the review of basic medical education in Scotland is implemented.17 Considerable challenges still lie ahead for the specialty.

Factors influencing career choice Three factors had a greater influence on choices for obstetrics and gynaecology than on choices for other careers: experience of the chosen subject as a student, the influence of a particular

Table 3. Percentages and numbers of doctors who specified each factor as influencing their choice of long-term career a great deal: graduates of 1993 and 1996 surveyed 1 year after graduation Factor

Domestic circumstances Hours/working conditions Future financial prospects Career and promotion prospects Self-appraisal of own skills/aptitudes Advice from others Experience of chosen subject as a student A particular teacher/department Inclinations before medical school Experience of jobs so far Enthusiasm/commitment: what I really want to do

Percentages

Numbers

Obstetrics and gynaecology

Other careers

Obstetrics and gynaecology (n = 260)

Other careers (n = 5287)

105 163 89 286 453 78 757 323 155 297 745

169 421 124 260 522 155 402 218 146 481 660

27 42 23 73 117 20 196 83 40 77 193

883 2205 648 1363 2731 810 2108 1140 765 2524 3427

Figures in bold denote significant differences at P 0.001 when comparing obstetrics and gynaecology and other careers. The numbers of respondents to each statement varied between 255 and 259 of those choosing obstetrics and gynaecology, and 5192 and 5247 of those choosing other careers.


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Table 4. Percentages and numbers of doctors who originally chose obstetrics and gynaecology and were working in obstetrics and gynaecology 10 years after qualification, 1974, 1977, 1983 and 1993 cohorts Original choice

Obstetrics and gynaecology in year 1 (untied first choice) Obstetrics and gynaecology in year 1 (tied first choice) Other career in year 1 Total Obstetrics and gynaecology in year 3 (untied first choice) Obstetrics and gynaecology in year 3 (tied first choice) Other career in year 3 Total

Working in obstetrics and gynaecology 10 years after qualification n

Total

n

Percent working in obstetrics and gynaecology 10 years after qualification %

142

311

45.7

10

85

11.8

74 226 180

8615 9011 264

0.9 2.5 68.2

1

16

6.3

36 217

8214 8494

0.4 2.6

teacher or department and the doctors’ enthusiasm for and commitment to the specialty. In principle, these findings augur well for recruitment to the specialty if young doctors can be persuaded that career progression will not be problematic. The low percentage of those choosing obstetrics and gynaecology who said that hours and working conditions influenced their choice a great deal indicates that very few who chose the specialty were daunted by the prospect of long and unsocial hours. This reinforces the finding that those who chose the specialty did so because they really wanted to work in it. However, as mandatory upper limits on numbers of working hours are implemented,13 obstetrics and gynaecology may become more attractive to doctors who might otherwise have been discouraged by perceptions of long hours and tough working conditions in the specialty. Experience of jobs undertaken ‘so far’ was less influential in year 1 for those choosing obstetrics and gynaecology than for those choosing other careers. This reflects the limited exposure to obstetrics and gynaecology in the preregistration year. By year 3, experience of jobs undertaken so far became as important for those choosing obstetrics and gynaecology as it was for those choosing other careers. This suggests that an increase in early postgraduate opportunities to work in obstetrics and gynaecology may be beneficial to recruitment to the specialty. The new ‘foundation years’ programme14,15 could be an opportunity to increase doctors’ experience of obstetrics and gynaecology at early stages in their careers.

to the training grades, and particularly to the senior house officer grade,14,15 will force young doctors to specialise too early may be unfounded for obstetrics and gynaecology as many of those who were working in the specialty chose to do so within 3 years after graduation. Equally, however, flexibility needs to remain for those who, later in their junior years, change their minds for or against pursuing a career in obstetrics and gynaecology.

The decline in doctors, particularly men, seeking a career in obstetrics and gynaecology

Of the doctors whose sole first choice was obstetrics and gynaecology, one-half (year 1) and two-thirds (year 3) were working in it 10 years after graduation. Concerns that reforms

The recent declines in choice for obstetrics and gynaecology, among both men and women, are probably attributable to graduates’ perceptions that it had become a risky specialty to enter because of problems with workforce planning. Of those who did enter it, there seems to be no lack of enthusiasm for the specialty itself. It seems likely that the recruitment of women could increase with greater certainties about career progression. This is probably not so for men. In every survey undertaken by us, the percentage of men who specified a choice for obstetrics and gynaecology was exceeded by the percentage of women (Table 1). The gap has widened over time, and there has been a long-term decline, substantially predating the workforce planning problems in the specialty, in the percentage of men choosing the specialty as their first choice. Furthermore, if men do not make it their first choice, Table 2 shows that, currently, they are unlikely to consider it at all. In practice, in the UK, the gender balance within the specialty is more equal than our data might imply because male representation happens to be supplemented by male overseas trained graduates, a practice that may be to the considerable detriment of their country of training.

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Early choices as predictors of future careers


Why male graduates have turned away from obstetrics and gynaecology as a career choice has not been addressed in our surveys. Research elsewhere suggests that the growing gender imbalance is related to several issues including a perception that most patients prefer female, rather than male, gynaecologists;18,19 that women patients, in general, prefer doctors whose communication style is associated more with women than with men20,21 and that male doctors are dissuaded from entering the specialty because female doctors, in training assessments, achieve better results than their male colleagues.18,22 In the UK, the number of trainees in each specialty is controlled by the issue of one of a limited ‘stock’ of NTNs to each trainee. The recent increase in the number of available NTNs in obstetrics and gynaecology4 may lead to an overall increase in the numbers of UK graduates of both sexes choosing a long-term career in obstetrics and gynaecology. However, if there is a wish to increase the proportion of male graduates who apply for training, other means may be needed to attract them into the specialty. We suggest that there needs to be a more explicit debate about the role of male doctors in obstetrics and gynaecology.

veys, Janet Justice and Alison Stockford for data preparation and Jean Davidson for programming support.

Funding The UK Medical Careers Research Group is funded by the UK Department of Health. The Unit of Health-Care Epidemiology is funded by the NHS National Centre for Research Capacity Development.

Ethical approval Ethical approval for the UKMCRG cohort studies has been obtained through the Central Office for Research Ethics Committees (COREC), following referral to the Brighton Mid Sussex and East Sussex local research ethics committee. j

References

We are very grateful to all the doctors who participated in the surveys. We thank Karen Hollick for administering the sur-

1 Warren R. Medical workforce planning in obstetrics and gynaecology— service or training? 2000 [www.rcog.org.uk/resources/public/doc/intro_ 2000.doc]. Accessed 4 January 2006. 2 Warren R. Medical workforce planning in obstetrics and gynaecology— the blueprint and beyond: a workforce review. 2001 [www.rcog.org. uk/resources/public/pdf/introduction.pdf]. Accessed 4 January 2006. 3 Warren R. Medical workforce in obstetrics and gynaecology—meeting service requirements. 2002 [www.rcog.org.uk/resources/public/doc/ Chairmans%20Review.doc]. Accessed 4 January 2006. 4 Blott M. Medical workforce in obstetrics and gynaecology—changing times. 2003 [www.rcog.org.uk/resources/Public/pdf/WF03_chair_review. pdf]. Accessed 4 January 2006. 5 Working Group on Specialist Medical Training. Hospital Doctors: Training for the Future (The Calman Report). London: UK Department of Health, 1993. 6 Ramsay J. Obstetrics and gynaecology: where are we now? BMJ 2003;326:S43. 7 Wright CSW. Specialist registrar training in obstetrics and gynaecology: have we got it wrong? Hosp Med 1999;60:291–3. 8 Lambert TW, Goldacre MJ, Turner G. Career choices of United Kingdom medical graduates of 1999 and 2000: questionnaire surveys. BMJ 2003;326:194–5. 9 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. 10 Ellin DJ, Parkhouse HF, Parkhouse J. Career preferences of doctors qualifying in the United Kingdom in 1983. Health Trends 1986; 18:59–63. 11 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. BMJ 1996;313:19–24. 12 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 Educ 1999;33:882–9. 13 Department of Health. Improving working lives for doctors. 2001 [www.dh.gov.uk/assetRoot/04/07/42/91/04074291.pdf]. Accessed 4 January 2006. 14 NHS Executive. Unfinished Business: Proposals for Reform of the Senior House Officer Grade. London: Department of Health, 2002.


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Conclusions The unwillingness of young doctors to enter obstetrics and gynaecology in the UK may be attributable to concerns about workforce planning and career progression problems, rather than any lack of enthusiasm for the specialty. Our most recent surveys of the graduates of 2000 and 2002 show a slight increase in the number of graduates choosing obstetrics and gynaecology compared with the low point among graduates of 1999. It is too soon to say whether this is the start of a longer term upward trend and, furthermore, is among female graduates only. The number of men choosing obstetrics and gynaecology is now very small; the reasons for this and the future role of men in the specialty need to be debated.

Conflicts of interest None.

Contributors T.W.L. and M.J.G. planned and designed the surveys. T.W.L. coordinated data collection. G.T. and T.W.L. analysed the data and wrote the first draft in collaboration with D.B. All the authors contributed to further drafts and approved the final version.

Acknowledgements

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15 Department of Health. Modernising medical careers. 2003 [www. dh.gov.uk/assetRoot/04/05/42/33/04054233.pdf]. Accessed 4 January 2006. 16 Sands J. RCOG celebrates 75 years of innovation. Hosp Doct 9 September 2004;30–33. 17 Calman K, Paulson-Ellis M. Review of basic medical education in Scotland. 2004 [www.scotland.gov.uk/resource/doc/47251/0013200.pdf]. Accessed 4 January 2006. 18 Higham J, Steer PJ. Gender gap in undergraduate experience and performance in obstetrics and gynaecology: analysis of clinical experience logs. BMJ 2004;328:142–3.

19 Schnuth RL, Vasilenko P, Mavis B, Marshall J. What influences medical students to pursue careers in obstetrics and gynaecology? Am J Obstet Gynecol 2003;189:639–43. 20 Lyon DS. Graduate education in women’s health care: where have all the young men gone? Curr Womens Health Rep 2002;2: 170–74. 21 Hall JA, Roter DL. Do patients talk differently to male and female physicians? Patient Educ Couns 2002;48:217–24. 22 Bienstock JL, Martin S, Tzou W, Fox HE. Medical students’ gender is a predictor of success in obstetrics and gynaecology basic clerkship. Teach Learn Med 2002;14:240–3.

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