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 173 Journal of the Royal Society of Medicine 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 174 J R Soc Med 2012: 105: 166 –176. DOI 10.1258/jrsm.2012.110173  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 175 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. References 1 2 3 4 5 6 7 8 McManus C, Goldacre MJ. Predicting career destinations. In: Carter Y, Jackson N, eds. Medical Education and Training. From Theory to Delivery. Oxford: Oxford University Press, 2009:59– 77 Lambert TW, Davidson JM, Evans J, Goldacre MJ. Doctors’ reasons for rejecting initial choices of specialties as long-term careers. Med Educ 2003;37:312 – 8 van der Horst K, Siegrist M, Orlow P, Giger M. Residents’ reasons for specialty choice: influence of gender, time, patient and career. Med Educ 2010;44:595 – 602 Creed PA, Searle J, Rogers ME. Medical specialty prestige and lifestyle preferences for medical students. Soc Sci Med 2010;71:1084 –8 Dacre J, Shepherd S. Women and medicine. Clin Med 2010;10:544 –7 Medical Women’s Federation. Making part time work. London: Medical Women’s Federation, 2008 Goldacre MJ, Turner G, Fazel S, Lambert T. Career choices for psychiatry: national surveys of graduates of 1974-2000 from UK medical schools. Br J Psychiatry 2005;186:158– 64 Goldacre MJ, Laxton L, Harrison EM, Richards JM, Lambert TW, Parks RW. Early career choices and successful career progression in surgery in the UK: prospective cohort studies. BMC Surg 2010;10:32