Background In the UK, recruitment of adequate numbers of doctors to emergency medicine (EM) has been problematic. With this as background, we analysed data about career choice for, and progression in, EM in a large multi-purpose study of doctors’ careers.
Methods Questionnaire surveys of medical graduates of 1993, 1996, 1999, 2000, 2002, 2005, 2008 and 2009 from all UK medical schools.
Results EM was specified as a first choice of career by 4.2% of graduates in postgraduate year 1, 4.8% in year 3, and 3.8% in year 5. Graduates who chose EM were much less likely to be certain about their choice than those who chose other specialties. Of those who specified EM as their first choice of career in year 1, only 26% still had it as their first choice in year 5. Of those who gave EM as their first career choice in year 5, only 27% had given EM as their first choice in year 1. Switches to EM were made, notably, by doctors who previously favoured surgical specialties, hospital physician-led specialties and anaesthetics.
Conclusions Early career choices for EM are less predictive of career destinations than choices for other specialties, and, compared with many other specialties, doctors who pursue it may turn to it relatively late. Training policies on transferable competencies should enable clinical trainees in other related specialties to bank some of their skills if they transfer to EM, rather than necessarily having to start core training in year 1 of EM specialty training.
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Emergency medicine (EM) is the term used in the UK for the hospital-based clinical specialty that encompasses knowledge, skills and competencies required for the prevention, assessment and management of acute and urgent aspects of illness and injury.1 Over the past three decades in the UK, EM, previously known as the specialty of accident and emergency, has gone through several stages of development, which have resulted in increasingly well-defined training pathways. Notable landmarks were the establishment of the Intercollegiate Board on Accident and Emergency Medicine in 1991 and the inauguration of the Intercollegiate Faculty of Accident and Emergency Medicine in 1993.2
The specialty continues to develop. The College of Emergency Medicine (CEM) has published recommendations for expansion of the EM consultant workforce.3 Its case, based on a review by the Academy of Medical Royal Colleges,4 is that expansion is essential for providing the best possible specialist emergency care for patients. The CEM recommends that every emergency department should have a minimum of 10 whole time equivalent EM consultants, more in larger departments, to provide up to 16 h of immediate on-site cover 7 days a week. The current average number of EM consultants per UK emergency department is 4.4.3 The expansion of the consultant workforce would require a substantial increase in the number of training posts.
With this as background, we have analysed data in a large multi-cohort, multi-purpose study of doctors’ career choices and progression covering eight UK cohorts of doctors who graduated between 1993 and 2009. In this paper, we report on early career choices for EM, whether early choices for EM are predictive of eventually working in the specialty, and doctors’ reasons for selecting and rejecting EM as a career.
Our study included the medical graduates of 1993, 1996, 1999, 2000, 2002, 2005, 2008 and 2009 from all medical schools in the UK. Our methods have been described in detail elsewhere5 ,6 and in the online supplementary methodological appendix. In brief, towards the end of the first, third and fifth years after qualification, and at longer time intervals after that, postal (and, more recently, web-based) questionnaires are sent to all doctors in each cohort. We ask structured questions about the doctors’ preferences for future specialty career and about factors that have influenced their choice, and we track, through subsequent questionnaires, their actual career progression.
Excluding those who were deceased, had never registered with the General Medical Council, or who explicitly declined to participate, these eight cohorts comprised 39 015 graduates, of whom 23 378 (59.9%) replied in the first year after graduation. Three years after graduation, seven cohorts were surveyed comprising 32 359 doctors. Of these, 19 700 (60.9%) replied. Five years after graduation, 15 529 out of 25 522 (60.8%) replied, covering six cohorts (1993–2005).
Career choices for EM
Combining the cohorts of 1993–2009, EM was specified as a first choice of career by 4.2% (95% CI 4.0% to 4.5%) of graduates in year 1, 4.8% (95% CI 4.5% to 5.1%) in year 3, and 3.8% (95% CI 3.5% to 4.1%) in year 5. A higher percentage of men than women specified a career preference for EM, although the difference was statistically significant at year 1 only (table 1). Percentages who chose EM varied a little between cohorts but there was no consistent trend overall (table 1). Differences between medical schools are described in online supplementary appendix I.
Certainty of choice
In year 1, 11% of those who chose EM as first choice described their career choice as definite. By year 3 this figure had risen to 30%, and by year 5 to 57%. Those selecting EM were much less definite about their career choice than those who chose other specialties (figure 1). Gender differences in the percentage who chose EM and who were definite about their choice were not significant (p>0.01 in each of years 1, 3 and 5 using χ2 tests).
There has been a pronounced increase in the latest two cohorts surveyed (those of 2008 and 2009) in the percentages who specified that their choice of EM was definite (table 2), but the percentages remain lower than the levels of certainty of choice expressed by doctors who chose other specialties.
Inclusion of second and third choices
Overall, EM was chosen as a first, second or third choice by 9.9% (95% CI 9.5% to 10.2%) of graduates in year 1, 9.2% (95% CI 8.8% to 9.7%) in year 3, and 5.7% (95% CI 5.4% to 6.1%) in year 5 (table 3). Comparing men and women, a higher percentage of men than women gave EM as one of the choices in year 1 (11.5% men vs 8.6% women, χ21=49.5, p<0.001), year 3 (10.3% men vs 8.5% women, χ21=17.4, p<0.001) and year 5 (6.3% men vs 5.3% women, χ21=7.7, p=0.006).
Factors that had influenced their choice ‘a great deal’
For EM, as for other choices of clinical specialty, the most influential factors were enthusiasm/commitment: what I really want to do (rated as a great deal of influence by 65.4% who chose EM in year 1), experience of jobs so far (53.5%), and self-appraisal of own skills (49.4%, table 4). Of other factors that influenced doctors’ choice, the large differences were between the hospital specialties and general practice. For the latter, ‘lifestyle factors’, notably their own domestic circumstances and considerations of hours/working conditions, are important influences on specialty choice. Differences between EM and the generality of hospital specialist practice in factors influencing choice were modest, although some attained statistical significance (table 3).
Doctors who considered EM as a career before foundation year 2 but decided not to pursue it
This part of the study was based on questionnaires that had been sent to 16 361 doctors who had qualified in 2002, 2005 or 2008 1 year after graduation; 9155 (56%) replied. Of these, 2267 (25%) specified that they had seriously considered but then not pursued a specialty and gave a reason for not pursuing it (there were no important differences between the cohorts in this respect). Of these respondents, 5.4% (122/2267) specified that they had considered and then decided not to pursue EM (5.3% of men, 5.4% of women). The percentage considering and rejecting EM showed an upward linear trend across the cohorts: it was 3.1% in the cohort of 2002, 5.5% in 2005, and 7.3% in 2008 (χ21=13.1, p=0.001).
We compared the reasons given by doctors who rejected EM with those given by doctors who rejected other specialties (for the latter, we combined the results for all specialties except EM). Statements that we classified as ‘work–life balance’ were by far the most frequently mentioned reason for rejecting EM. They were given by 70.5% of the doctors who rejected EM, compared with 38.6% of doctors who rejected other specialties (χ21=47.6, p<0.001). The statements about EM that were placed into this category (quoted as written by the doctors) included ‘terrible shifts’, ‘anti-social working hours’, ‘poor lifestyle for having a family’, ‘difficulty with getting good work/social balance’ and ‘anti-social hours even when senior’.
The second most common reason was the ‘job content’ of the specialty, which was mentioned by 29.5% of doctors who rejected EM and 35.4% of those who rejected other specialties (χ21=1.5, p=0.22). Illustrative examples on EM are ‘little time with each patient’, ‘lack of continuity of care’, ‘no follow through of patients admitted into hospital or feedback that your initial management worked’, and ‘not finding out what was actually wrong with patient’.
There was no significant change in percentages who mentioned ‘work–life balance’ (χ22=1.6, p=0.44) or ‘job content’ (χ22=0.7, p=0.70) as reasons for rejecting EM between the three graduation years. Reasons relating to competition for posts in the specialty were mentioned by 13% of doctors rejecting specialties other than EM but were not mentioned by anyone rejecting EM.
Changing from and to a career choice for EM between years 1 and 5
In all, 12 410 graduates responded to both year 1 and year 5 surveys. Of those who listed EM as their first choice of career in year 1, only 26% (men 27%, women 25%) still had it as their first career choice in year 5. As a comparison, 80% of doctors who specified general practice as their choice in year 1 retained their year 1 choice in year 5, as did 61% of those whose preference was surgery, 55% who chose anaesthetics, and 71% who chose psychiatry.
Among men who chose EM in year 1, 26.5% chose anaesthetics in year 5 (the most common change of specialty choice for men), 16.4% changed their choice to general practice, 14.3% to the hospital medical (ie, physician-led) specialties, and 11.3% to surgical specialties. Among women, 28.4% changed their choice to general practice (the most common change of choice for women), followed by anaesthetics (17.6%) and hospital medical specialties (12.2%).
Conversely, of those who gave EM as their first choice in year 5, only 27% (27% of men, 28% of women) had given EM as their first choice of eventual career in year 1. Among men, 31% of those who had EM as their first career choice in year 5 had specified surgical specialties as their first career choice in year 1, 21% had specified hospital medical specialties, 12% anaesthetics, and 9% general practice. Among women, 21% of those who had EM as their first career choice in year 5 had specified hospital medical specialties as their first career choice in year 1, 20% had specified surgical specialties, 15% general practice, 11% anaesthetics, and 8% paediatrics.
Between years 1 and 5, respondents switched from and to a preferred career in EM in similar numbers: 397 respondents changed their mind from EM as their first career choice to other specialties, and 363 changed their mind from other specialties to EM.
Looking forwards from early career choices to later destinations
Ten years after graduation (cohorts 1993 and 1996) and 7 years after (cohorts 1999 and 2000), 24.1% of those whose first choice of long-term career in year 1 had been EM were working in EM, as were 46.2% of those who had given EM as their first choice in year 3, and 68.8% of those who had given EM as their first choice in year 5 (table 4). Thus over 30% changed their choice from EM even later into their training than their fifth postgraduate year. In comparison, 89% of those who chose general practice in year 5 were later working in general practice, and 90% of those who chose surgical specialties were later working in surgical specialties. The corresponding figures for anaesthetics, the hospital medical specialties and psychiatry were 90%, 82% and 91%, respectively.
Doctors in EM were also more likely than others to be in ‘staff grade’ NHS service posts (ie, posts that were neither specialty training posts nor consultant posts). For example, of the qualifiers of 1993 in 2003, 18% in EM were in staff grade posts compared with 3% of doctors in other hospital specialties. Of the qualifiers of 2000 in year 7, 10% were in staff grade posts in EM compared with 2% in other hospital specialties.
Looking backwards from later destinations (at years 10 or 7) to early choices
Of those who worked in EM, 23.2% had specified it as their first career choice in year 1, 58.2% had done so in year 3, and 74.4% had done so in year 5. The most common early career choices, other than EM, of those who eventually worked in EM were hospital medical specialties, surgical specialties, general practice and anaesthetics (table 5).
About 4% of medical graduates gave EM as their first choice of career a year after graduation. However, this single figure, which has changed little over the years, does not give the full picture of what is important to know about choices for this specialty. Graduates who chose EM were much less likely to be certain about their choice than those who chose other hospital specialties or general practice. A higher proportion of doctors who chose EM than those who chose other specialties changed their minds between years 1 and 5 about their chosen career. Even 5 years after graduation, those who chose EM were less likely to be sure of their choice than those who chose other hospital specialties or general practice; and they were less likely eventually to work in their year 5 first choice than doctors who chose other specialties. Of those who eventually worked in EM, only a quarter had chosen it in year 1, and only three-quarters in year 5. We also report an increase among recent graduates in the percentage considering, but then rejecting, EM as a career choice early on, rising from 3.1% among 2002 graduates to 7.3% among 2008 graduates.
However, the level of certainty about the choice of EM as a future career, among doctors who choose it, has increased over the past decade. Notably, the graduates of 2008 and 2009 were much more likely than their predecessors to be definite about their choice for EM in year 1. This is not unexpected. Before the implementation of Modernising Medical Careers (MMC) in 2005, routes into EM were more flexible, and previous relevant training in other specialties was ‘counted’ when calculating remaining training time required in EM. Now there is one prescribed route into EM and, currently, no facility to have previous training recognised for doctors who want to move into a different specialty. It is both more difficult than in the past to transfer from EM into another specialty and to transfer from another specialty into EM. Thus, since MMC, trainees have to be more certain about their choices for EM.
Strengths and limitations
The main strengths of the study are that it is large, it includes all UK medical schools, and it has a high response rate for this type of study. The study is prospective and therefore not subject to recall bias: the doctors’ comments about specialty preference, and factors that influenced it, are contemporaneous and therefore not subject to recall bias or faulty recollection. Its longitudinal design also means that doctors’ replies about specialty preference in their first postgraduate year can be compared with their replies, and actual progression and destinations, at later career stages.
Its main weakness is that some level of non-response is inevitable and the possibility of responder bias must be considered. The study only covers UK graduates, and the inward migration of overseas-trained doctors has contributed, at least in the past, quite substantially to the medical workforce in the UK overall.
A special taskforce, which includes representatives from the Royal Colleges, the Department of Health, the General Medical Council and NHS Employers, was set up in 2011 to tackle medical workforce problems. For EM, the now accepted aim of this taskforce is expansion of the consultant workforce.7 ,8 This may be problematic for EM, as the CEM has recently reported shortages of specialist trainees and middle-grade doctors.8 ,9
Among the principal options that are being considered for solving the shortfall of consultants is expanding the training routes into EM. Changes are being considered that would enable core trainees in other related specialties to transfer their skills rather than having to start core training in year 1 of EM specialty training.
The results of our study confirm that expanding the EM consultant workforce will be difficult without changes to policy on training. However, they also show that many of those who work eventually in EM chose this specialty quite late. Therefore, opening up late routes into EM is likely to succeed in increasing specialist trainee numbers and, eventually, the numbers of consultants. Considering the specialty choices from which our respondents tended to switch to EM, training in EM might be most usefully linked to training in surgical specialties, hospital medical specialties and anaesthetics, rather than general practice. General practice has a distinct training route and is a shortage specialty,10 while surgical specialties, hospital medical specialties and anaesthetics are not undersubscribed.11
Another issue to consider is how to retain more trainees who make an early choice for EM. Our findings indicate that the majority of those who reject EM early on (by the end of first postgraduate year) do so because of concerns about whether it can be combined with social and family life. This underlines the importance of job planning, such as the planning of rotas, to maximise doctors’ experience of good work–life balance. The other commonly stated reasons for rejection of EM as a career were job content and working conditions, but these were no more likely to be given for EM than for other specialties.
Working in EM has been described as being characterised by high intensity of work, pressures of meeting administrative targets, poor work–life balance, deficiencies in training and supervision, inadequate senior clinician numbers, and occasional hostility from patients and colleagues.8 ,12 Despite these perceptions about the specialty, our findings indicate that many aspiring EM doctors are in fact strongly and positively influenced by their enthusiasm for the specialty and their view that their skills and aptitudes are suited to it. Another important influence was experience of actually working in EM. Trainees find some of their experiences of working in EM to be rewarding and inspiring.
This is encouraging. However, enthusiasm and positive experiences can only get the trainees so far. It seems that, for many, a commitment to EM does not survive the pressures of working and training in emergency departments, perceived eventual career uncertainties, and lifestyle constraints. Trainees leave EM for other hospital specialties that they perceive as more manageable and predictable, such as anaesthetics, or for the more family-life-friendly specialty of general practice. In conclusion, the serious problems of recruitment and retention in EM will require a multifactor approach to address them.
We are very grateful to all the doctors who participated in the surveys. We thank Emma Ayres for administering the surveys, Janet Justice and Alison Stockford for data preparation, and Louise Laxton for programming support.
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online appendices
Contributors All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. MJG and TL planned and designed the survey. All authors planned the data analysis. LB provided expert medical input. ES undertook the data analysis. TL provided statistical support. ES and MJG wrote the first draft of the paper. All authors contributed to further drafts and approved the final version.
Funding This is an independent study commissioned and funded by the Policy Research Programme (Project 016/0116) in the Department of Health. The views expressed are not necessarily those of the funding body.
Competing interests None.
Ethics approval This study was approved by the National Research Ethics Service, following referral to the Brighton and Mid-Sussex Research Ethics Committee in its role as a multicentre research ethics committee (ref 04/Q1907/48).
Provenance and peer review Not commissioned; externally peer reviewed.
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