BMA cohort study of 1995 medical graduates - ninth report
The BMA cohort study of 1995 medical graduates is a 10-year longitudinal study of the career paths of junior doctors. This is the ninth annual report and provides information on workforce participation, career choice and views about practising medicine. The cohort study complements existing research by allowing data to be collected over a continuous period, thereby addressing the current lack of information on workforce flows. As the data is linked longitudinally, individual careers can be tracked over time enabling the analysis of differential career development. This report will therefore be of interest to those involved in medical workforce planning and policy development, and others interested in medical careers.
Almost three-quarters of cohort doctors are either currently working less than full-time or would like to do so in the future. The key reasons given by doctors for doing so, reflect the desire for improved work-life balance.
A fifth of practising doctors said that their choice of career had changed due to experiences in the last year. The most common reason for changing career was hours of work and working conditions.
The proportion of cohort doctors currently working in general practice has increased from less than a quarter of the cohort in 2001 to more than a third in 2003. An important factor underlying this shift is the perceived greater flexibility of general practice.
Long hours of work continues to be a problem for many cohort doctors. In 2003 more than half of senior house officers typically worked more than the 56-hour limit and around a quarter worked in excess of 64 hours per week. Specialist registrars worked an average of 58 hours per week and 22 per cent typically worked more than 64 hours per week.
Dissatisfaction with practising medicine has increased since graduating from medical school eight years ago. At graduation, 44 per cent of the cohort had a very strong desire to practise medicine, compared with 15 per cent currently. In contrast, the proportion of doctors reporting only a lukewarm desire to practise medicine has almost doubled, from 14 per cent at graduation to almost a quarter currently.
The BMA cohort study is a 10-year longitudinal study of 545 doctors who graduated from UK medical schools in 1995. The study aims to provide information on the careers of doctors, and particularly to:
identify doctors who leave medicine as a career, or who choose to work in another country, to assess the magnitude of this loss and the factors which influence it;
identify patterns of workforce participation and specialty choice of doctors who remain in the UK, and the factors which influence them;
investigate career progression, especially those factors which influence variation between doctors.
The study began in May 1995 when an invitation to participate was mailed to all final year medical students in the United Kingdom. Of the total responses received (1,400/3,500), a random stratified sample of 600 was drawn to ensure that the sample was representative of the population in terms of sex, ethnicity and medical school. The initial questionnaire was mailed in August 1995, around the time of graduation. The mailing received a response rate of 80 per cent, giving a final cohort size of 545.
The collection of data is conducted primarily through a postal questionnaire sent to the 545 participants every August. This process is designed to be both continuous and longitudinal. Information is collected on the preceding 12-month period and linked from year to year which allows for the career paths of the respondents to be tracked over time.
The most recent questionnaire was mailed in August 2003 and received a response from 90 per cent of the cohort. The average age of respondent is 33 and respondents are evenly divided by gender (49% males/51% females). Whilst the majority of respondents are of white ethnic origin, 6 per cent are of Indian ethnic origin and 3 per cent of Pakistani ethnic origin.
The doctors in the study were asked how they had spent the preceding 12 months. The majority of the cohort (91%) spent at least some of the last 12 months working as doctors in the UK. Other activities included working overseas (10%), travelling (3%), and temporary breaks from the workforce for reasons such as domestic reasons or to broaden career opportunities.
A fifth of cohort doctors worked in some form of research post during the past year. The main reasons given by doctors for undertaking research as a research fellow, as part of a post graduate degree or as part of a clinical post were to improve their future career prospects or to improve their prospects of obtaining an SpR post.
Eight years after graduating from medical school, seven per cent of the cohort (17) have left the UK medical workforce. These doctors have either left medicine as a career altogether or are working overseas and do not intend to return to the UK. The most common reasons for leaving medicine as a career were dissatisfaction with medicine, the attractions of other careers and working/pay conditions in the NHS. The main reason for emigration was to accompany spouse or to seek better working conditions/lifestyle.
Junior doctors' hours of work
The New Deal was introduced to improve the conditions under which junior doctors work. One of the key features of the New Deal is a limit on the working hours of junior doctors to 56 actual hours of work per week. The survey found that more than half (53 per cent) of senior house officers typically worked more than the 56-hour limit and around a quarter (26 per cent) worked in excess of 64 hours per week. Although, the mean number of working hours for SHOs has declined from 64 hours two years after graduation to 59.5 hours in 2003, this is a slight increase since the previous year. Specialist registrars worked an average of 58 hours per week. Three per cent of SpRs worked more than the 56-hour limit and 22 per cent typically worked more than 64 hours a week.
From August 2004, junior doctors will come within the remit of the European Working Time Directive (EWTD). The average maximum working week for junior doctors will be 58 hours and this will be further reduced to 48 hours a week by 2009. Respondents were asked whether changes had been implemented in their place of work in order to be EWTD compliant. Only a third of doctors report that changes have been implemented in their place of work and the main change introduced is altered shift patterns and rotas. Where such changes have been implemented, only 40 per cent of doctors believe that they have been effective.
Career choice and aspirations
Eight years after graduating from medical school, preferred career options vary somewhat by gender. Males are more likely to choose hospital or research/academic medicine, while females are more likely to choose general practice as their preferred option. Female doctors are also more likely to have left medicine as a career or be undecided about their future career option.
The proportion of the cohort planning to enter general practice has continued to increase from less than a fifth at graduation to more than a third in 2003. The numbers of cohort doctors choosing radiology, anaesthetics, pathology, academic medicine, community and public health have also increased over the nine - year period. In contrast, the numbers planning to specialise in general medicine and surgery have fallen.
Among those doctors who worked as general practitioners, a third worked as full-time GP principals, with the remainder working as locums, salaried GPs or in less than full-time principal positions. 'Improved flexibility' is a key reason given by cohort doctors working as locums in both general practice and hospital medicine, and also by those working in non-consultant career grade or non-standard trust grade posts.
A fifth of practising doctors said that their choice of career had changed due to experiences in the last year. The most common reason given for changing career was 'hours of work and working conditions'. Other key factors for change of career include 'domestic circumstances' and 'career and promotional prospects'.
While a quarter of the cohort currently work less than full-time, a further 45 per cent would consider doing so in the future. The vast majority of female doctors (93%) either currently work less than full-time or may do so in the future, compared with 46 per cent of male doctors. Furthermore, cohort doctors who chose a career in general practice are more likely to also be working less than full-time at some point, compared with doctors who chose a career in hospital medicine.
Cohort doctors were asked to rate satisfaction with their current work-life balance on a scale from 1(least satisfied) to 10 (most satisfied). Whilst the majority of doctors rate their current work-life balance in the upper scale (an average rating of 6) a quarter rate their current work-life balance as unsatisfactory. The main reasons for this dissatisfaction include long hours, heavy workloads and high patient expectations.
Satisfaction with practising medicine
The cohort's desire to practise medicine has declined since graduation. At graduation 44 per cent of the cohort had a very strong desire to practise medicine, compared with 15 per cent currently. In contrast, the proportion of doctors reporting only a lukewarm desire to practise medicine has almost doubled, from 14 per cent at graduation to almost a quarter (23%) currently.
Several factors contribute to this increased dissatisfaction and include:
the pressure to achieve targets and the increased politicisiation of the NHS;
a desire for greater work-life balance, including more flexible working arrangements;
heavy workload and long working hours;
high patient expectations.
An increase in part-time and flexible working opportunities is needed. A flexible training scheme which promotes fairness and consistency of access is crucial and the opportunity to train flexibly should be available for all doctors who wish to train less than full-time.
Creating an environment in which doctors are able to restart career paths, retrain and diversify without attracting criticism or detriment to their career is vital to ensuring high morale and motivation among junior doctors. This needs to be accompanied by better career advice and development, and arrangements for re-entry after career breaks.
Incentives designed to improve the working lives of doctors, value their professional contribution and support the continued development of their educational and training needs are crucial if the flow of doctors seeking a better life outside of the health service is to be stemmed.