RESEARCH
Doctors who considered but did
not pursue specific clinical
specialties as careers:
questionnaire surveys
Michael J Goldacre
• Raph Goldacre • Trevor W Lambert
Medical Careers Research Group, Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford,
Old Road Campus, Oxford OX3 7LF, UK
Correspondence to: Trevor W Lambert. Email: trevor.lambert@dph.ox.ac.uk
DECLARATIONS
Competing interests
None declared
Funding
This is an
Summary
Objectives To report doctors’ rejection of specialties as long-term
careers and reasons for rejection.
Design Postal questionnaires.
Setting United Kingdom.
independent report
commissioned and
funded by the Policy
Research
Programme in the
Department of
Participants Graduates of 2002, 2005 and 2008 from all UK medical
schools, surveyed one year after qualification.
Main outcome measures Current specialty choice; any choice that
had been seriously considered but not pursued (termed ‘rejected’ choices)
with reasons for rejection.
Health. The views
expressed are not
necessarily those of
the Department
Ethical approval
National Research
Ethics Service,
following referral to
the Brighton and
Mid-Sussex
Research Ethics
Committee in its role
as a multi-centre
research ethics
committee (ref 04/
Q1907/48)
Guarantor
Michael J Goldacre
is guarantor
Contributorship
Results 2573 of 9155 respondents (28%) had seriously considered but
then not pursued a specialty choice. By comparison with positive choices,
general practice was under-represented among rejected choices: it was
the actual choice of 27% of respondents and the rejected choice of only 6%
of those who had rejected a specialty. Consideration of ‘job content’ was
important in not pursuing general practice (cited by 78% of those who
considered but rejected a career in general practice), psychiatry (72%),
radiology (69%) and pathology (68%). The surgical specialties were the
current choice of 20% of respondents and had been considered but
rejected by 32% of doctors who rejected a specialty. Issues of work-life
balance were the single most common factor, particularly for women, in
not pursuing the surgical specialties, emergency medicine, the medical
hospital specialties, paediatrics, and obstetrics and gynaecology.
Competition for posts, difficult examinations, stressful working
conditions, and poor training were mentioned but were mainly minority
concerns.
Conclusions There is considerable diversity between doctors in their
reasons for finding specialties attractive or unattractive. This underlines
the importance of recruitment strategies to medical school that recognize
diversity of students’ interests and aptitudes.
All authors had full
access to all of the
166
J R Soc Med 2012: 105: 166 –176. DOI 10.1258/jrsm.2012.110173
Doctors who considered but did not pursue specific clinical specialties as careers
data (including
Introduction
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 TWL
planned and
designed the survey.
All authors planned
the data analysis. RG
undertook the data
analysis. TWL
provided statistical
support. RG and
MJG wrote the first
draft of the paper. All
authors contributed
to further drafts and
approved the final
version. All had final
responsibility for the
decision to submit
for publication
Acknowledgements
Medicine is a single profession with a very wide
variety of jobs. There are likely to be many differences between doctors in their interests in, and
aptitudes for, such diverse areas of work as
general practice, surgery, psychiatry, laboratory
medicine and public health. Factors that influence
specialty career choice include fundamental interest in the specialty, aptitude, temperament and
personality, preferred styles of working, opportunities, luck and other practicalities.1 The process
of making a choice consists partly of selection of
a chosen path and partly of decisions not to
pursue alternatives.2 Studies of doctors’ choice of
specialty tend to focus on what they choose, and
why, rather than what they reject and why.3
In recent national surveys of doctors’ career
choices in the UK, we have asked both about
positive specialty choices and about any specialty
that the doctors have seriously considered and
then not pursued. We report here on the findings
from surveys of graduates of 2002, 2005 and 2008
undertaken towards the end of the first postqualification year. We were interested in whether
some specialties had been considered and rejected
more commonly than others, and, if so, whether
particular specialties were rejected for distinctive
reasons.
We would like to
thank Emma Ayres
Methods
who administered
the surveys, Janet
Justice and Alison
Stockford for their
careful data entry,
and all the doctors
who participated in
this survey
Reviewer
Bill Irish
Postal questionnaires were sent to all doctors
who qualified from all medical schools in the
UK in the years 2002, 2005 and 2008. The
Medical Register, supplied to us by the General
Medical Council, was the principal source of
doctors’ names and addresses. Postal questionnaires were sent towards the end of the year following graduation. Up to four reminders were
sent to non-respondents. Our methods have been
described in detail elsewhere.2 Respondents were
asked to specify their choice(s) of future specialty:
they were given the option to list a first choice, a
second choice, and a third choice, and to specify
whether any of these choices were tied in terms
of preference. They were also asked: Is there a
choice of long-term career which you have seriously
considered but have now decided not to pursue? If
they answered ‘yes’, they were asked What was
that choice? and What are your most important
reasons for rejecting that choice? Reasons for rejection were sought as free text responses. Some
respondents gave a single reason for rejection;
others gave several reasons. We read the responses
and developed a coding scheme to reflect the main
themes raised by respondents. Two coders then
independently coded all the reasons given, by
theme, and then compared each other’s coding.
Any differences between coders were resolved
through discussion.
We coded each reason given by an individual
doctor into individual categories within a coding
frame with fine categories. Where these categories
were similar, for some purposes we grouped them
into broader categories. For example, it was
common for a doctor to give reasons why he/she
did not enjoy the clinical nature of the rejected specialty and why he/she preferred the work of the
chosen specialty. In the fine coding frame, we
coded this as one comment about the nature of
the work in the rejected specialty, and as a
second comment about the nature of the work in
the preferred specialty. In the broader groupings,
we considered such comments, combined, as a
single doctor commenting on the nature of specialty work.
Specialties were grouped into thirteen mainstreams – general practice, the hospital medical
specialties, surgery, paediatrics, emergency medicine, obstetrics and gynaecology, anaesthetics,
radiology, clinical oncology, pathology, psychiatry,
public health, and all other specialty choices. For
the purposes of this paper, we omitted from the
analysis those doctors who rejected a specialty
which was in the same mainstream specialty
as that of their chosen specialty (e.g. a doctor
who considered and rejected cardiology and
chose thoracic medicine), on the basis that these
doctors had not rejected a mainstream area of
specialty work. A small number of reasons that
we were unable to code were also omitted from
the analysis.
Results
Questionnaires were sent to 16,361 doctors; and
9155 (56%) replied. The percentages of respondents
J R Soc Med 2012: 105: 166 –176. DOI 10.1258/jrsm.2012.110173
167
Journal of the Royal Society of Medicine
who specified that they had considered and
rejected an individual specialty was 29% (797/
2778) of the qualifiers of 2002, 27% (843/3128) of
2005, and 29% (933/3249) of 2008. Across all
three cohorts, these comprised 29% of the men
(969/3394) and 28% of the women (1604/5761).
After exclusions, as specified above in relation to
grouped specialties and uncodable reasons, there
were 2267 respondents – 811 men and 1456
women – who had considered but rejected an
alternative mainstream specialty and who gave
at least one classifiable reason for doing so (25%
of the total number of respondents).
Chosen and rejected specialties
Some specialties are chosen much more commonly
than others. We regarded the distribution of untied
first-choice specialties as the reference distribution
against which to compare the profiles of rejected
specialties. We considered a specialty to be
under-represented among rejected choices if the
percentage of rejected choices for it was less than
the percentage of actual choices for the specialty;
and ‘over-represented’ if the percentage of rejected
choices was higher than that of actual choices.
Table 1 shows the comparison between chosen
and rejected specialties by sex. The most striking
differences between choices and rejections were
for general practice and for surgery. General practice was the chosen career preference of 27% of all
respondents (18% of men, 32% of women); and, of
all doctors who considered and then rejected a
specialty, only 6% rejected general practice (4%
of men, 7% of women). The surgical specialties
were the chosen career preference of 20% of
respondents (32% of men, 12% of women); and,
of all who considered and rejected a specialty
and gave reasons for doing so, 32% rejected
surgery (37% of men, 29% of women). Both for
men and for women, anaesthetics had a significantly lower percentage of rejected than of
current choices; and paediatrics, obstetrics and
gynaecology, and emergency medicine had a significantly higher percentage of rejected than
current choices.
The most striking difference between men and
women was that a disproportionately high percentage of women considered but rejected a career in
surgery (29% of rejected choices, made by women,
Table 1
All respondents, showing percentage distribution of their current choice; and respondents who had
considered but rejected a specialty choice, showing percentage distribution of rejected specialties
Specialty group
Medical hospital specialties
Paediatrics
Emergency medicine
Surgery
Obstetrics & gynaecology
Anaesthetics
Radiology
Clinical oncology
Pathology
Psychiatry
General practice
Public health
Other medical specialties
Totals
Rejecting
Choosing
Men
Women
All
Men
Women
All
21.0
3.2
3.0
32.4
1.4
10.2
2.5
1.1
2.4
3.7
17.6
0.4
1.0
2772
20.7
8.7
3.1
12.4
5.2
8.7
1.3
1.6
1.9
3.0
32.4
0.4
0.6
4627
20.8
6.6
3.1
19.9
3.8
9.3
1.7
1.4
2.1
3.2
26.9
0.4
0.8
7399
25.3
9.6
5.3
37.1
3.8
4.2
2.2
0.4
1.7
4.2
3.8
0.1
2.2
811
19.6
12.4
5.4
29.1
11.5
4.1
0.8
1.0
2.5
4.5
6.6
0.2
2.5
1456
21.7
11.4
5.4
31.9
8.7
4.1
1.3
0.8
2.2
4.4
5.6
0.2
2.4
2267
Significance tests for differences of percentages, comparing each pair of chosen and rejected specialties in
each specialty row:
Denotes P < 0.01, denotes P < 0.001, otherwise not statistically significant (P ≥ 0.01).
168
J R Soc Med 2012: 105: 166 –176. DOI 10.1258/jrsm.2012.110173
Rejecting
Choosing
Specialty group
J R Soc Med 2012: 105: 166 –176. DOI 10.1258/jrsm.2012.110173
Medical hospital
specialties
Paediatrics
Emergency
medicine
Surgery
Obstetrics &
gynaecology
Anaesthetics
Radiology
Clinical
oncology
Pathology
Psychiatry
General practice
Public health
Other medical
specialties
Totals
2002
graduates
in 2003
2005
graduates
in 2006
2008
graduates
in 2009
22.2
21.1
19.3
6.5
3.2
5.8
3.2
21.8
2.4
All
2
All
χ2 linear
trend
( p value)
χ linear
trend
( p value)
2002
graduates
in 2003
2005
graduates
in 2006
2008
graduates
in 2009
20.8
0.01
21.2
24.1
19.7
21.7
0.42
7.6
2.8
6.6
3.1
0.10
0.49
12.2
3.1
9.3
5.5
12.6
7.3
11.4
5.4
0.77
<0.001
21.2
3.5
16.7
5.4
19.9
3.8
<0.001
<0.001
34.7
6.2
35.3
8.1
26.2
11.6
31.9
8.7
<0.001
<0.001
9.4
2.0
1.4
7.7
1.4
1.4
10.7
1.9
1.5
9.3
1.7
1.4
0.09
0.66
0.95
4.5
1.1
0.8
3.3
0.4
0.4
4.5
2.3
1.1
4.1
1.3
0.8
0.94
0.04
0.50
2.4
3.6
23.7
0.2
1.2
1.9
2.7
29.0
0.5
0.7
1.9
3.5
27.7
0.6
0.3
2.1
3.2
26.9
0.4
0.7
0.24
0.95
0.002
0.01
<0.001
2.1
4.8
5.5
0.1
3.5
1.8
3.7
5.5
0.0
2.6
2.6
4.7
5.8
0.4
1.1
2.2
4.4
5.6
0.2
2.4
0.46
0.94
0.79
0.25
0.004
2361
2501
2537
7399
711
763
793
2267
Trend between 2002 and 2008 either in chosen specialty or in rejected specialty
Doctors who considered but did not pursue specific clinical specialties as careers
Table 2
All respondents, showing percentage distribution of their current choice by cohort; and respondents who had considered but rejected a specialty
choice, showing percentage distribution of rejected specialties, by cohort
169
Journal of the Royal Society of Medicine
compared with 12% of current choices, P < 0.001).
For men, the percentage who rejected surgery was
in line with their distribution of actual choices (for
men, the surgical specialties represented 37% of
rejected choices, 32% of actual choices, a nonsignificant difference, P > 0.01).
Comparing the cohorts who qualified in 2002,
2005 and 2008 (Table 2), there was a significant
decline in the percentage of doctors who rejected
surgery (chi square for linear trend P < 0.001),
but there was also a decline in the percentage
who gave surgery as their current career preference (chi square for linear trend P < 0.001). There
was a significant rise in the percentage of
doctors who chose obstetrics and gynaecology,
and also a significant rise in the percentage
who rejected obstetrics and gynaecology (both
P < 0.001). There was a significant rise in the percentage who considered but rejected a career in
emergency medicine (P < 0.001). There was no
significant trend in either the choice of a career
in general practice or in considering but rejecting
general practice.
Reasons for rejecting a career choice
Table 3 shows the percentage distribution of the
reasons for rejection given by men and women,
for all specialties combined. The numerators are
the numbers of doctors who cited each reason,
and the denominators are the numbers of
doctors who cited any reason (for examples of
Table 3
Doctors who considered but rejected a specialty: distribution of reasons given, as a percentage of all
doctors who considered but rejected a specialty , by sex
Reason for rejection
Men
(%)
Women
(%)
All
(%)
Men
(n)
Women
(n)
Work-life balance
Job content
Nature of work/type of patients in rejected specialty
First-hand experience of the rejected specialty
Administration/bureaucracy
Preference for current specialty choice
Competition and/or exams
Too few/competition for training posts
Competitive specialty/“competition”
Exams – too difficult, or too many
Stress and/or working conditions
Training content and/or quality
General content and/or structure and/or quality
Too much requirement to do research
Training too long
Working relationships
Self-appraisal
Litigation
Lack of exposure to rejected specialty
Lack of long-term career stability
Change in personal circumstances
Advice
Inadequate salary
May not be jobs where I want to live
Total (n = 100%)
28.2
39.6
14.5
12.3
1.5
12.7
13.8
5.1
8.3
1.4
11.7
11.2
10.6
1.2
5.4
5.4
4.7
1.4
2.0
3.3
0.7
1.5
2.2
0.5
47.0
32.4
11.0
11.0
1.0
10.6
11.3
4.5
6.6
1.0
9.4
6.3
5.4
1.0
4.9
4.9
4.4
3.0
2.1
1.2
1.9
1.4
0.7
0.5
40.3
35.0
12.3
11.5
1.2
11.4
12.2
4.7
7.2
1.1
10.2
8.1
7.2
1.1
5.1
5.1
4.5
2.4
2.1
2.0
1.5
1.5
1.2
0.5
229
321
118
100
12
103
112
41
67
11
95
91
86
10
44
44
38
11
16
27
6
12
18
4
811
684
472
160
160
15
155
164
66
96
14
137
92
78
15
72
71
64
43
31
18
28
21
10
7
1456
Some doctors gave more than one reason, and hence the number of reasons shown exceeds the
numbers of doctors.
Tests for significant differences between men and women: denotes P < 0.001 denotes P < 0.01
170
J R Soc Med 2012: 105: 166 –176. DOI 10.1258/jrsm.2012.110173
All
(n)
913
793
278
260
27
258
276
107
163
25
232
183
164
25
116
115
102
54
47
45
34
33
28
11
2267
Doctors who considered but did not pursue specific clinical specialties as careers
Box 1
Examples of reasons given by doctors for rejecting various specialty areas, categorised by theme
Work-life balance
Job content
Nature of work/type of patients in
rejected specialty
Domestic circumstances, hours worked. (female rejecting hospital
medicine)
Antisocial working hours. (female rejecting emergency medicine)
Not compatible with having a family. (female rejecting surgery)
Long hours and working lots of nights and weekends. (female
rejecting hospital medicine)
Hours, hours and hours. (female rejecting surgery)
I want a life. (male rejecting surgery)
Not suitable realistically for a working mum. (female rejecting
surgery)
Long out-of-hours commitment. (female rejecting anaesthetics)
Shift work. (male rejecting emergency medicine)
Working hours. (female rejecting obstetrics and gynaecology)
On-call commitment. (male rejecting surgery)
Violent patients. (female rejecting psychiatry)
Unrewarding. Difficulty to make people ‘better’. (female rejecting
psychiatry)
Too dull & monotonous. Not practically challenging. Too many
‘social’ patients. (male rejecting GP)
I think I would find it boring. (female rejecting GP)
The hours, lack of continuity. (female rejecting emergency
medicine)
I missed the acutely ill patients and practical procedures. (female
rejecting GP)
Realizing the number of persistent complainers that are the
mainstay of GP. (female rejecting GP)
Lack of patient and social contact. (female rejecting pathology)
First-hand experience of the rejected
specialty
Experience during F1 post. (male rejecting psychiatry)
Bad experience as PRHO surgery. (male rejecting surgery)
Administration/bureaucracy
Too much management involved, paperwork and not enough
clinical practice. (female rejecting GP)
4-hour treatment. (male rejecting emergency medicine)
Preference for current specialty
choice
Discovered I loved surgery. (female rejecting GP)
Realized surgery was much more exciting! (female rejecting GP)
I love surgery! (female rejecting psychiatry)
Miss adult medicine. (male rejecting paediatrics)
Competition and/or exams
Too few/competition for training
posts
Lack of training places. (male rejecting surgery)
So few posts, very competitive. (female rejecting surgery)
Competitive specialty/“competition”
Competition. (male rejecting paediatrics)
The competitive nature of the training. (female rejecting
surgery)
Exams – too difficult, or too many
Requirement to get MRCP. (male rejecting hospital medicine)
Too many exams. (MRCP, MRCPath, PhD etc) (male rejecting
pathology)
(Continued)
J R Soc Med 2012: 105: 166 –176. DOI 10.1258/jrsm.2012.110173
171
Journal of the Royal Society of Medicine
Box 1
Continued
Stress and/or working conditions
Training content and/or quality
Training content and/or structure
and/or quality
Intense workload. (female rejecting paediatrics)
Stress. Potential for litigation. (female rejecting obstetrics and
gynaecology)
General surgical training. (male rejecting surgery)
Unclear ‘specialist training’ put forward by MMC. (female rejecting
surgery)
Research requirements
Too academic. (male rejecting hospital medicine)
I don’t enjoy research. (female rejecting hospital medicine)
Training too long
Longer training pathway. (male rejecting hospital medicine)
Prolonged and competitive training. (male rejecting surgery)
Working relationships
Male dominated surgical world unattractive as a female. (female
rejecting surgery)
The attitudes of surgeons. (female rejecting surgery)
comments classified under each main theme, see
Box 1).
The most frequently mentioned reasons for
considering and rejecting a specialty were those
which we classified as work-life balance, mentioned
by 40% of respondents who rejected a specialty
and gave reasons; job content of the rejected and/or
chosen specialty, mentioned by 35%; competition in
the rejected specialty (including difficult examinations and competition for posts), mentioned by
12%; stress and/or poor working conditions (10%);
and adverse comments on the content or quality of
training (8%).
Comparing men and women, the percentage
of women who gave reasons relating to work-life
balance significantly exceeded that of men (47%
and 28%, respectively). Men were significantly
more likely than women to reject a specialty
because of job content (40% of men, 32% of
women), content and/or quality of training (11%
of men, 6% of women), concerns about the future of
the specialty (3.3% of men, 1.2% of women), and
concerns about salary (2.2% of men, 0.7% of
women).
Trends by cohort
The percentage of respondents who cited work-life
balance issues declined a little in more recent
172
J R Soc Med 2012: 105: 166 –176. DOI 10.1258/jrsm.2012.110173
cohorts (Table 4), although the decline was not
statistically significant (P = 0.045).
There was a significant rise across the cohorts of
2002, 2005 and 2008 in the percentage of doctors
who rejected a specialty because of competition
for training posts/too few training posts (3.4%, 3.9%,
6.7%; P = 0.002). This was predominantly attributable to doctors who rejected surgery, where the
rejection rates on these grounds were 15%, 17%,
and 29% among the graduates of 2002, 2005 and
2008, respectively (P < 0.001).
There was a significant rise in the percentage of
doctors who rejected a specialty because of lack of
exposure to it so far (0.7%, 2.1%, 3.3%; P < 0.001).
Contributing the most to this rise were those
doctors who rejected paediatrics (chi square for
linear trend, P = 0.001), obstetrics and gynaecology (P = 0.06), and anaesthetics (P = 0.02).
There was a borderline significant rise in the
percentage of doctors who rejected a specialty
because of concerns about the future of the specialty
(P = 0.022), which was mentioned increasingly in
relation to the medical hospital specialties,
the surgical specialties, emergency medicine,
and radiology, although in all cases the numbers
were fairly small.
There was a significant decline in the percentage of doctors who rejected a specialty because
of working relationships (P < 0.001). This was
mainly because of a substantial decline in
Doctors who considered but did not pursue specific clinical specialties as careers
Table 4
Doctors who considered but rejected a specialty: distribution of reasons given, as a percentage of all
doctors who considered but rejected a specialty , by year of qualification
Reason for rejection
2002 2005 2008
(%) (%) (%)
Work-life balance
Job content
Nature of work/type of patients in rejected specialty
First-hand experience of the rejected specialty
Administration/bureaucracy
Preference for current specialty choice
Competition and/or exams
Too few/competition for training posts
Competitive specialty/“competition”
Exams – too difficult, or too many
Stress and/or working conditions
Training content and/or quality
General content and/or structure and/or quality
Too much requirement to do research
Training too long
Working relationships
Self-appraisal
Litigation
Lack of exposure to rejected specialty
Lack of long-term career stability
Change in personal circumstances
Advice
Inadequate salary
May not be jobs where I want to live
TOTAL DOCTORS (N = 100%)
42.9
37.0
11.4
12.9
1.1
12.4
12.5
3.4
7.0
2.7
11.8
6.2
4.9
1.4
7.6
7.6
3.8
2.4
0.7
1.5
1.8
1.8
0.7
0.4
40.4
31.3
10.1
8.5
0.9
12.5
11.1
3.9
7.3
0.3
9.4
8.3
8.4
0.5
2.9
5.1
3.1
3.3
2.1
1.2
0.9
0.8
2.0
0.3
37.8
36.7
15.1
13.0
1.5
9.5
12.9
6.7
7.2
0.5
9.6
9.6
8.2
1.4
5.0
2.8
6.4
1.5
3.3
3.2
1.8
1.8
1.0
0.8
All 2002 2005 2008 All
(%)
(n)
(n)
(n) (%)
40.3
35.0
12.3
11.5
1.2
11.4
12.2
4.7
7.2
1.1
10.2
8.1
7.2
1.1
5.1
5.1
4.5
2.4
2.1
2.0
1.5
1.5
1.2
0.5
305
263
81
92
8
88
89
24
50
19
84
44
35
10
54
54
27
17
5
11
13
13
5
3
711
308
239
77
65
7
95
85
30
56
2
72
63
64
4
22
39
24
25
16
9
7
6
15
2
763
300 913
291 793
120 278
103 260
12
27
75 258
102 276
53 107
57 163
4
25
76 232
76 183
65 164
11
25
40 116
22 115
51 102
12
54
26
47
25
45
14
34
14
33
8
28
6
11
793 2267
Some doctors gave more than one reason, and hence the number of reasons shown exceeds the
numbers of doctors.
Tests for significant differences between men and women: denotes P < 0.01 denotes P < 0.001
specification of working relationships among
doctors rejecting surgery, down from 17%, to
13%, to 5% among the graduates of 2002, 2005
and 2008, respectively (P < 0.001).
Reasons given by doctors rejecting
different specialties: Table 5
Doctors who rejected the medical specialties,
paediatrics, emergency medicine, the surgical
specialties, and obstetrics & gynaecology were
most likely to specify reasons relating to work-life
balance. Anaesthetics, radiology, pathology, psychiatry and general practice were rejected most
commonly because of factors related to job content.
Work-life balance was the most common reason
cited by women for rejecting the medical hospital
specialties, paediatrics, emergency medicine, the
surgical specialties, and obstetrics and gynaecology. Among men, work-life balance was the most
commonly cited reason in relation only to rejection
of emergency medicine.
Doctors who rejected general practice were
the least likely to mention work-life balance as
their reason for rejection, with only 1 in 127
rejecting the specialty for this reason. Over
three quarters of all doctors who rejected
general practice did so because of job content
(78%, (99/127)).
Overall, working relationships was not a common
reason for rejecting a specialty, with the exception
J R Soc Med 2012: 105: 166 –176. DOI 10.1258/jrsm.2012.110173
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Table 5
For each specialty, the percentage of men and women who gave each reason for rejecting the specialty
Training content and
quality
Job content
Work-life balance
Stressful environment/
working conditions
Specialty group
M
F
All
M
F
All
M
F
All
M
F
All
Medical specs
Paediatrics
Emergency med
Surgery
Obs & gynae
Anaesthetics
Radiology
Pathology
Psychiatry
GP
34.6
30.8
60.5
27.6
35.5
20.6
11.1
0.0
5.9
0.0
50.3
53.9
75.9
56.5
61.1
28.8
9.1
5.6
4.6
1.0
43.8
46.9
70.5
44.5
57.1
25.8
10.3
4.0
5.1
0.8
39.0
43.6
30.2
28.9
38.7
55.9
72.2
78.6
64.7
71.0
28.7
31.1
25.3
16.5
22.8
47.5
63.6
63.9
75.4
80.2
33.0
34.9
27.0
21.7
25.3
50.5
69.0
68.0
71.7
78.0
8.3
1.3
2.3
19.3
3.2
11.8
16.7
7.1
2.9
0.0
9.4
2.8
0.0
8.7
1.8
1.7
18.2
8.3
1.5
7.3
9.0
2.3
0.8
13.1
2.0
5.4
17.2
8.0
2.0
5.5
20.5
14.1
23.3
6.6
9.7
2.9
11.1
0.0
5.9
9.7
17.5
9.4
11.4
4.7
13.2
5.1
0.0
0.0
9.2
5.2
18.7
10.9
15.6
5.5
12.6
4.3
6.9
0.0
8.1
6.3
Competition and exams
Medical specs
Paediatrics
Emergency med
Surgery
Obs & gynae
Anaesthetics
Radiology
Pathology
Psychiatry
GP
M
F
14.1
12.8
0.0
19.6
6.5
0.0
22.2
14.3
0.0
6.5
12.6
8.9
0.0
20.1
6.6
6.8
9.1
8.3
1.5
2.1
All
13.2
10.1
0.0
19.9
6.6
4.3
17.2
10.0
1.0
3.1
Working relationships
M
F
2.4
3.8
2.3
10.3
6.5
0.0
0.0
0.0
2.9
3.2
0.7
0.6
0.0
13.9
3.0
3.4
0.0
0.0
1.5
0.0
Self-appraisal
All
M
F
1.4
1.6
0.8
12.4
3.5
2.2
0.0
0.0
2.0
0.8
4.9
2.6
2.3
5.3
6.5
2.9
5.6
0.0
8.8
3.2
1.4
6.1
0.0
4.5
3.6
10.2
0.0
8.3
13.8
4.2
Total rejecting (n)
All
2.9
5.0
0.8
4.8
4.0
7.5
3.4
6.0
12.1
3.9
M
F
All
205
78
43
301
31
34
18
14
34
31
286
180
79
423
167
59
11
36
65
96
491
258
122
724
198
93
29
50
99
127
Significance tests for differences of percentages, comparing men and women doctors: denotes p ≤ 0.01,
0.001, otherwise not statistically significant ( p > 0.01).
of the surgical specialties where 12% of all doctors
who rejected the specialty (90/724) cited difficult
working relationships as a reason.
Self-appraisal was cited most often by those
doctors rejecting psychiatry – this reason was
cited by 12% of doctors rejecting the specialty.
Doctors rejecting psychiatry were also the most
likely to have been put off by experience of the
specialty, with 28% of doctors citing this as a
reason for rejecting the specialty.
Recipient specialties
For those who had considered and rejected a
specialty, we termed their current choice as the
‘recipient’ specialty. Overall, general practice
was the most popular recipient specialty: 30% of
those who rejected another specialty went on to
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denotes p ≤
choose general practice. In contrast, 19% chose
the medical hospital specialties, 13% chose
anaesthetics, and 11% chose the surgical
specialties.
We analysed associations between rejected
specialties, recipient specialties, and reasons for
rejecting the rejected specialties. Of doctors
who rejected a specialty for reasons of work-life
balance, 44% chose general practice, 17% the
hospital medical specialties and 11% anaesthesia
(the latter two, notably as recipient specialties
from surgery). Of those who were concerned
about competition for posts and difficult
examinations, 36% chose general practice as the
recipient specialty. Of those who stated that
training was too long in their rejected specialty,
51% chose general practice as their recipient
specialty.
Doctors who considered but did not pursue specific clinical specialties as careers
Discussion
2) Job content
Principal findings
Some doctors consider and reject specialties
because of the job content of the specialties’ work.
For example, some described general practice as
boring; some described psychiatry as unrewarding; and some regarded surgery as intimidating.
Though these are no doubt minority views, they
are held by some. Others indicated that progression in certain specialties, notably in surgery,
may be too difficult for them to pursue it despite
their initial interest.
The specialties (general practice, psychiatry,
pathology) most often rejected for reasons of job
content were also those least likely to be rejected
because of work-life balance. Male-female differences were found in many specialties; men were
more likely to reject a specialty because of job
content than were women.
Factors we categorized as work-life balance
considerations, job content and previous experience,
competition, training quality and content, and
perceptions about stress levels and working conditions within the specialty, were all important
factors influencing the decision to reject a specialty. Of these factors, work-life balance and job
content were mentioned much more often than
the others.
1) Work-life balance
The acute hospital specialties were more likely
than general practice, psychiatry, and pathology
to be rejected for reasons related to work-life
balance. This is consistent with previous studies
that have sought to rank medical specialties by
lifestyle friendliness.4
Women were significantly more likely than
men to reject these acute specialties for reasons
related to work-life balance. It is well known that
many women prefer part-time and flexible
working.5,6
Contractual arrangements for National Health
Service (NHS) doctors have changed over recent
years. In 2001 it was announced that, from
August 2004, doctors in the NHS would no
longer be excluded from the provisions of the
European Working Time Directive, and that
junior doctors’ working hours would be
reduced to 58 hours a week from August 2004,
then to 56 hours from August 2007, then to 48
in 2009. Each cohort of doctors surveyed in our
study would have been aware of the changes to
doctors’ working hours as announced in 2001,
and the implementation of the changes from
2004 would have affected the working practice
of each cohort to some extent. Despite this, each
cohort (most recent as well as earliest) was
more likely to cite reasons relating to work-life
balance than any other reason, and, taking all
specialties together, there was no significant
declining trend between the first-year graduates
of 2002, 2005 and 2008 in the percentage of
those who rejected a specialty for reasons of
work-life balance.
3) Other reasons for rejection of a specialty
Training content and quality was most often mentioned as a reason for rejecting surgery and radiology, in the case of surgery more so by women
than by men. Working in a stressful environment
was most apparent as a factor in rejecting
the medical specialties and emergency
medicine.
Strengths and weaknesses of the study
The study’s strength is that the data are derived
from large national cohort studies conducted
over three years of graduation with over 9,000
responders, of whom over 2,000 gave comments
concerning rejected choices. The study was conducted independently of employers or senior
doctors and was confidential.
A weakness of the study is that there is a retrospective element to the responders’ recall of specialties rejected and the reasons, and perhaps an
element of rationalization in the responses. There
is also possible responder bias given the overall
response rate to the study of 57%, which is nevertheless high in the context of a postal questionnaire survey.
J R Soc Med 2012: 105: 166 –176. DOI 10.1258/jrsm.2012.110173
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Journal of the Royal Society of Medicine
Meaning of the study
Issues raised relating to work-life balance tended
to be broader than concern about the total
number of hours worked. Avoidance of unsocial
hours and excessive on-call were also important
determining factors in the rejection of some specialties. Workforce planners, health service
administrators and senior medical professionals
should consider the extent to which hours of
work, and intensity of working hours, will dissuade some doctors from considering some specialties as career choices. In some specialties,
unsocial working hours and on-call duties are
unavoidable. Providing that sufficient numbers
of doctors are willing to work in such specialties,
it may not matter that other doctors are not
willing to do so. Any approach to policy
changes must address the imperatives of
service needs, the importance of continuity of
care for patients, and the quality of training
and learning experiences for doctors.
In the case of job content, the important consideration is whether doctors rejecting specialties
on this basis are doing so on the basis of accurate
information about what each specialty entails.
This in turn means that career advice, as well as
early experience of specialties which a doctor
may be considering, would be valuable in ensuring that ill-informed decisions to reject specialties
are less likely to be made.
By definition, analyses of reasons for considering but rejecting specialties are likely to be mainly
negative. The findings must be considered in the
context of positive choices. The great majority of
those who choose each specialty – including
psychiatry and surgery – score the content of the
work in the specialty very highly.7,8 The diversity
of medical practice – for example, the huge differences between the job content of general practice,
176
J R Soc Med 2012: 105: 166 –176. DOI 10.1258/jrsm.2012.110173
psychiatry and surgery – underlines the importance of recruitment strategies to medical school
that include diversity of students’ interests, aptitudes, temperament and personality.
Unanswered questions and future
research
Further work could be undertaken to determine
whether career choices will be made more confidently by future than past medical graduates; and
whether the scale of changes of mind will reduce.
We cannot tell from this study whether reported
reasons for rejection are based on fact or supposition. Further work could be undertaken to investigate how well informed doctors are, about their
future choice of specialty, at the points in their
careers when they make their first choice.
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