What factors are critical to attracting NHS foundation doctors into specialty or core training? A discrete choice experiment

Improving recruitment to occupational health professions through highlighting intrinsic rewards

BACKGROUND

There are currently 2.5 million people economically inactive in the UK due to sickness. The government is considering a range of new initiatives to bring them back into the workforce; however, a lack of occupational health (OH) professionals, who play an important part in the recovery of physical and mental conditions that would otherwise inhibit employees from working, is hindering these efforts.

AIMS

To identify factors that make OH attractive as a source of employment with the aim of assisting those undertaking recruitment to the specialism.

METHODS

We conducted a qualitative study comparing the views of 13 OH nurses and doctors ('insiders') and 45 students and professionals from other medical and nursing fields ('outsiders') across the UK. Both groups provided their perceptions about what makes OH an attractive career. Data collection involved a mix of interviews and focus groups conducted from March to July 2023. Transcripts were thematically analysed using NVivo 14 to manage the data.

RESULTS

Both groups highly valued the work-life balance offered by OH work, which represents a positive point of attraction to employment. In addition, people working in OH talked extensively about more intrinsic rewards-the opportunity to be impactful, to enjoy job variety and to practise preventative approaches.

CONCLUSIONS

The intrinsic rewards that OH work brings need to be advertised more widely to attract potential recruits who are 'a good fit' to OH and will be committed to the field.

UK trainees' perceptions of leadership and leadership development

PURPOSE

This paper reports on trainees' perceptions of leadership and leadership development, to inform the support that may be provided to them. It draws on a formative evaluation of the new role of clinical leadership mentor (CLM), introduced by Health Education England South-West in 2018. CLMs are responsible for 'overseeing the process and progress of leadership development among the trainees within their Trust/Local Education Provider'.

METHODS

The evaluation was a formative evaluation, based on interviews with CLMs, trainees and trainers and a survey of trainees and trainers. Recruitment was through 8 of the 19 CLMs in the South West. A report for each participating CLM was available to support the development of their individual role. In exploring trainees' perceptions of leadership and leadership development, this paper draws on data from trainees: 112 survey returns which included over 7000 words of free text data and 13 interviews.

FINDINGS

Our findings suggest a more nuanced understanding of leadership in medical trainees than was previously reported in the literature, and a wider acceptance of their leadership role. We highlight the problem of considering postgraduate doctors as a homogeneous group, particularly with reference to specialty. We also highlight that the organisational context for leadership development can be supportive or non-supportive. Leadership learning through genuine leadership experience with appropriate support from trainers and the wider Trust offers opportunities for both trainees and Trusts.

PRACTICAL IMPLICATIONS

Trainees are accepting of their roles as leaders. The value of leadership learning through genuine leadership experience was highlighted. Improving the environment for leadership development offers Trusts and trainees opportunities for genuine service improvement.

Upper gastrointestinal training in the UK and Ireland: a Roux Group Study

INTRODUCTION

Surgical training programmes in the United Kingdom and Ireland (UK&I) are in a state of flux. This study aims to report the contemporary opinions of trainee and consultant surgeons on the current upper gastrointestinal (UGI) training model in the UK&I.

METHODS

A questionnaire was developed and distributed via national UGI societies. Questions pertained to demographics, current training evaluation, perceived requirements and availability.

RESULTS

A total of 241 responses were received with representation from all UK&I postgraduate training regions. The biggest discrepancies between rotation demand and national availability related to advanced/therapeutic endoscopy and robotic surgery, with 91.7% of respondents stating they would welcome greater geographical flexibility in training. The median suggested academic targets were 3-5 publications (trainee vs consultant <3 vs 3-5, p<0.001); <3 presentations (<3 vs 3-5, p=0.002); and 3-5 audits/quality improvement projects (<3 vs 3-5, p<0.001). Current operative requirements were considered achievable (87.6%) but inadequate for day one consultant practice (74.7%). Reassuringly, 76.3% deemed there was role for on-the-job operative training following consultant appointment. Proficiency in diagnostic endoscopy was considered a minimum requirement for Certificate of Completion of Training (CCT) yet the majority regarded therapeutic endoscopy competency as non-essential. The median numbers of index UGI operations suggested were comparable with the current curriculum requirements. Post-CCT fellowships were not considered necessary; however, the majority (73.6%) recognised their advantage.

CONCLUSIONS

Current CCT requirements are largely consistent with the opinions of the UGI community. Areas for improvement include flexibility in geographical working and increasing national provisions for high-quality endoscopy training.

Career intentions of medical students in the UK: a national, cross-sectional study (AIMS study)

OBJECTIVE

To determine current UK medical students' career intentions after graduation and on completing the Foundation Programme (FP), and to ascertain the motivations behind these intentions.

DESIGN

Cross-sectional, mixed-methods survey of UK medical students, using a non-random sampling method.

SETTING

All 44 UK medical schools recognised by the General Medical Council.

PARTICIPANTS

All UK medical students were eligible to participate. The study sample consisted of 10 486 participants, approximately 25.50% of the medical student population.

OUTCOME MEASURES

Career intentions of medical students postgraduation and post-FP, motivations behind these career intentions, characterising the medical student population and correlating demographic factors and propensity to leave the National Health Service (NHS).

RESULTS

The majority of participating students (8806/10 486, 83.98%) planned to complete both years of the FP after graduation, with under half of these students (4294/8806, 48.76%) intending to pursue specialty training thereafter. A subanalysis of career intentions after the FP by year of study revealed a significant decrease in students' intentions to enter specialty training as they advanced through medical school. Approximately a third of surveyed students (3392/10 486, 32.35%) intended to emigrate to practise medicine, with 42.57% (n=1444) of those students not planning to return. In total, 2.89% of students intended to leave medicine altogether (n=303). Remuneration, work-life balance and working conditions were identified as important factors in decision-making regarding emigration and leaving the profession. Subgroup analyses based on gender, type of schooling, fee type and educational background were performed. Only 17.26% of surveyed students were satisfied or very satisfied with the overall prospect of working in the NHS.

CONCLUSIONS

The Ascertaining the career Intentions of UK Medical Students study highlights UK students' views and career intentions, revealing a concerning proportion of those surveyed considering alternative careers or emigration. Addressing factors such as remuneration, work-life balance and working conditions may increase retention of doctors and improve workforce planning efforts.

Exploring doctors' trade-offs between management, research and clinical training in the medical curriculum: a protocol for a discrete choice experiment in Southern Africa

INTRODUCTION

Medical curricula should prepare doctors for roles that extend beyond that of a clinician. But the formal inclusion of both management and research training still appear to be neglected. It is important to understand what the profession would be willing to give up in terms of clinical training time for management and research content teaching prior to making any changes in a medical curriculum.

METHODS AND ANALYSIS

A discrete choice experiment will elicit the preferences and trade-offs that medical doctors in Southern Africa are prepared to make about the management, research and clinical training. Attention will also be given to the teaching method and placement of the content. DCE data will be collected using an online survey with an estimated sample size of 368 medical doctors. Data regarding participants' preference for a traditional or revised curriculum will be assessed using the Resistance to Change-Beliefs (RC-B) scale and demographic information will also be collected to assess preference heterogeneity.Analysis of the DCE data will be based on the Random Utility Maximisation framework using variants of the multinomial logit model. Data quality will be assessed. Value will be estimated in terms of clinical time, that is, how much clinical training time medical doctors are willing to give up to have research and management training within a curriculum that has a maximum of 40 hours per week. Observed preference heterogeneity will be assessed using the RC-B scale data and characteristics of respondents. Latent class models will be used to test for unobserved heterogeneity.

ETHICS AND DISSEMINATION

The research ethics and institutional committees of the sites have approved the study. The survey includes an informed consent section. Study findings will be reported to the medical schools and papers will be submitted to peer-reviewed, accredited journals and higher education and health economic conferences.

Ascertaining the Career Intentions of Medical Students (AIMS) in the United Kingdom Post Graduation: Protocol for a Mixed Methods Study

BACKGROUND

Among doctors in the United Kingdom, there is growing sentiment regarding delaying specialist training, emigrating to practice medicine abroad, or leaving the profession altogether. This trend may have substantial implications for the future of the profession in the United Kingdom. The extent to which this sentiment is also present in the medical student population is not well understood.

OBJECTIVE

Our primary outcome is to determine current medical students' career intentions after graduation and upon completing the foundation program and to establish the motivations behind these intentions. Secondary outcomes include determining which, if any, demographic factors alter the propensity to pursue different career paths available to a medical graduate, determining which specialties medical students plan on pursuing, and understanding current views on the prospect of working in the National Health Service (NHS).

METHODS

The Ascertaining the Career Intentions of Medical Students (AIMS) study is a national, multi-institution, and cross-sectional study in which all medical students at all medical schools in the United Kingdom are eligible to participate. It was administered via a novel, mixed methods, and web-based questionnaire and disseminated through a collaborative network of approximately 200 students recruited for this purpose. Both quantitative and thematic analyses will be performed.

RESULTS

The study was launched nationally on January 16, 2023. Data collection was closed on March 27, 2023, and data analysis has commenced. The results are expected to be available later in the year.

CONCLUSIONS

Doctors' career satisfaction within the NHS is a well-researched topic; however, there is a shortage of high-powered studies that are able to offer insight into medical students' outlook on their future careers. It is anticipated that the results of this study will bring clarity to this issue. Identified areas of improvement in medical training or within the NHS could be targeted to improve doctors' working conditions and help retain medical graduates. Results may also aid future workforce-planning efforts.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45992.

Valuing place in doctors' decisions to work in remote and rural locations

Recruitment and retention of medical practitioners is a challenging contemporary issue for rural and remote areas. In this paper, we explore the importance of what it is that doctors value in rural and remote places from their own personal, organisational, social and spatial lives. We do this by drawing on original research from Scotland that explored doctors' decisions on choosing, or not, to work in remote and rural locations. Three themes are explored: moving and staying, using place to think holistically about places beyond the language of work that recruitment and retention implies; how doctors' professional values and their capacity to enact those values change with time; and how policy landscapes interact and shape rural and remote locations as valued places for doctors to live and work. We end the paper by reiterating the World Health Organization findings that a whole-of-society approach is required to support rural and remote communities to flourish, thus, encouraging doctors and their families to value such places and, ultimately, move and stay.

What do Turkish, Spanish, and Pakistani medical students value in specialty training positions? A discrete choice experiment

BACKGROUND

The aim of this study was to find out specialty training preferences of senior medical students from three medical schools in Turkey, Spain, and Pakistan.

METHODS

A Discrete Choice Experiment was carried out using an electronic form for students in three countries in 2021-2022 term. Each choice set in the form consisted of two hypothetical specialty training positions. The attributes were location, earnings, working conditions, personal perspective, quality of education, probability of malpractice, and prestige. Conditional logit model was used to estimate participants' preferences and "willingness to accept" values.

RESULTS

The most valued attribute was "personal perspective on specialty area" for Turkish and Spanish students, while this attribute was not meaningful for Pakistani students. Turkish students needed a 204% of change in their income for a swap between the specialty that they like and not like. This tradeoff necessitated a 300% change for Spanish students. The most valued attribute for Pakistani students, which was "working conditions", necessitated a 97% increase in income to switch from working in good conditions to working in poor conditions.

CONCLUSION

In this first multinational DCE study in the medical education literature, we found the preferences of medical students in Turkey, Spain, and Pakistan are affected to various extents by several factors.

"Important but risky": attitudes of global thought leaders towards cost and value research in health professions education

Studies of cost and value can inform educational decision making, yet our understanding of the barriers to such research is incomplete. To address this gap, our aim was to explore the attitudes of global thought leaders in HPE towards cost and value research. This was a qualitative virtual interview study underpinned by social constructionism. In telephone or videoconference interviews in 2018-2019, we asked global healthcare professional thought leaders their views regarding HPE cost and value research, outstanding research questions in this area and why addressing these questions was important. Analysis was inductive and thematic, and incorporated review and comments from the original interviewees (member checking). We interviewed 11 thought leaders, nine of whom gave later feedback on our data interpretation (member checking). We identified four themes: Cost research is really important but potentially risky (quantifying and reporting costs provides evidence for decision-making but could lead to increased accountability and loss of autonomy); I don't have the knowledge and skills (lack of economic literacy); it's not what I went into education research to do (professional identity); and it's difficult to generate generalizable findings (the importance of context). This study contributes to a wider conversation in the literature about cost and value research by bringing in the views of global HPE thought leaders. Our findings provide insight to inform how best to engage and empower educators and researchers in the processes of asking and answering meaningful, acceptable and relevant cost and value questions in HPE.

Who cares where the doctors are? The expectation of mobility and its effect on health outcomes

Doctors are typically portrayed as active agents in their work lives. However, this paper argues that this construction of agency ignores the effects of the healthcare structures that constrain choice, which in turn affects population health outcomes. Medical training pathways, regional boundaries, and rationalisation all have a long-lasting impact on the provision of healthcare. Using a mobilities lens to examine the movement of doctors, this paper examines how the expectation of movement built into training programmes perpetuates unequal access to healthcare. Long waiting times, poor care quality and lack of preventative care all perpetuate health inequalities; as one of the socio-economic determinants, access to healthcare affects health outcomes.

What do Iranian physicians value most when choosing a specialty? Evidence from a discrete choice experiment

BACKGROUND

Choosing a specialty by physicians is fundamentally linked to the performance of health systems and public health outcomes. Identifying the determinants of specialty selection is important to health policy for targeting resources and planning the development of services. This study examined preferences of Iranian physicians for medical specialty using a discrete choice experiment (DCE) method.

METHODS

In this study, the attributes of the DCE were determined using rigorous qualitative approach. Then we applied D-efficiency criteria to design the DCE and validated it at a pilot study. In the final survey, we recruited participants from six Iranian provinces and analyzed data using conditional logit model. We estimated willingness to pay (WTP) for non-monetary attributes.

RESULTS

The WTP analysis revealed that the most important non-monetary attributes in the selection of a specialty were job burnout, opportunity for procedural activities, and job prestige. The results imply that the attributes that were related to the quality of personal life was more important only for physicians who preferred to choose non-surgical specialties.

CONCLUSIONS

The findings demonstrate that traditional gender patterns of specialty selection are changing and quality of personal life characteristics might be the most important factor when developing policies to recruit physicians into non-surgical specialties.

Tackling brain drain at Chinese CDCs: understanding job preferences of public health doctoral students using a discrete choice experiment survey

BACKGROUND

Given the demands for public health and infectious disease management skills during COVID-19, a shortage of the public health workforce, particularly with skills and competencies in epidemiology and biostatistics, has emerged at the Centers for Disease Controls (CDCs) in China. This study aims to investigate the employment preferences of doctoral students majoring in epidemiology and biostatistics, to inform policy-makers and future employers to address recruitment and retention requirements at CDCs across China.

METHODS

A convenience sampling approach for recruitment, and an online discrete choice experiment (DCE) survey instrument to elicit future employee profiles, and self-report of their employment and aspirational preferences during October 20 and November 12, 2020. Attributes included monthly income, employment location, housing benefits, children's education opportunities, working environment, career promotion speed and bianzhi (formally established post).

RESULTS

A total of 106 doctoral epidemiology and biostatistics students from 28 universities completed the online survey. Monthly income, employment location and bianzhi was of highest concern in the seven attributes measured, though all attributes were statistically significant and presented in the expected direction, demonstrating preference heterogeneity. Work environment was of least concern. For the subgroup analysis, employment located in a first-tier city was more likely to lead to a higher utility value for PhD students who were women, married, from an urban area and had a high annual family income. Unsurprisingly, when compared to single students, married students were willing to forgo more for good educational opportunities for their children. The simulation results suggest that, given our base case, increasing only monthly income from 10,000 ($ 1449.1) to 25,000 CNY ($ 3622.7) the probability of choosing the job in the third-tier city would increase from 18.1 to 53.8% (i.e., the location choice is changed).

CONCLUSION

Monthly income and employment location were the preferred attributes across the cohort, with other attributes then clearly ranked and delineated. A wider use of DCEs could inform both recruitment and retention of a public health workforce, especially for CDCs in third-tier cities where resource constraints preclude all the strategies discussed here.

Factors affecting the UK junior doctor workforce retention crisis: an integrative review

OBJECTIVES

To determine the factors contributing to the junior doctor workforce retention crisis in the UK using evidence collected directly from junior doctors, and to develop recommendations for changes to address the issue.

DESIGN

Integrative review.

DATA SOURCES

Searches were conducted on Ovid Medline and HMIC to locate evidence published between January 2016 and April 2021. This was supplemented by publications from relevant national organisations.

ELIGIBILITY CRITERIA

English-language papers relating to UK junior doctor retention, well-being or satisfaction which contained data collected directly from junior doctors were included. Papers focusing solely on the pandemic, factors specific to one medical specialty, evaluation of interventions, or numerical data with no evidence relating to causation were excluded. Review papers were excluded.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and coded on NVivo by FKL, then thematic analysis was conducted.

RESULTS

47 papers were included, consisting of academic (qualitative, quantitative, mixed and commentary) and grey literature. Key themes identified were working conditions, support and relationships, and learning and development, with an overarching theme of lack of flexibility. The outcomes of these factors are doctors not feeling valued, lacking autonomy, having a poor work-life balance, and providing compromised patient care. This results in need for a break from medical training.

CONCLUSION

This review builds on findings of related literature regarding working environments, isolation, stigma, and desire for autonomy, and highlights additional issues around learning and training, flexibility, feeling valued, and patient care. It goes on to present recommendations for tackling poor retention of UK junior doctors, highlighting that the complex problem requires evidence-based solutions and a bottom-up approach in which junior doctors are regarded as core stakeholders during the planning of interventions.

Does performance at the intercollegiate Membership of the Royal Colleges of Surgeons (MRCS) examination vary according to UK medical school and course type? A retrospective cohort study

OBJECTIVES

The knowledge, skills and behaviours required of new UK medical graduates are the same but how these are achieved differs given medical schools vary in their mission, curricula and pedagogy. Medical school differences seem to influence performance on postgraduate assessments. To date, the relationship between medical schools, course types and performance at the Membership of the Royal Colleges of Surgeons examination (MRCS) has not been investigated. Understanding this relationship is vital to achieving alignment across undergraduate and postgraduate training, learning and assessment values.

DESIGN AND PARTICIPANTS

A retrospective longitudinal cohort study of UK medical graduates who attempted MRCS Part A (n=9730) and MRCS Part B (n=4645) between 2007 and 2017, using individual-level linked sociodemographic and prior academic attainment data from the UK Medical Education Database.

METHODS

We studied MRCS performance across all UK medical schools and examined relationships between potential predictors and MRCS performance using χ2 analysis. Multivariate logistic regression models identified independent predictors of MRCS success at first attempt.

RESULTS

MRCS pass rates differed significantly between individual medical schools (p<0.001) but not after adjusting for prior A-Level performance. Candidates from courses other than those described as problem-based learning (PBL) were 53% more likely to pass MRCS Part A (OR 1.53 (95% CI 1.25 to 1.87) and 54% more likely to pass Part B (OR 1.54 (1.05 to 2.25)) at first attempt after adjusting for prior academic performance. Attending a Standard-Entry 5-year medicine programme, having no prior degree and attending a Russell Group university were independent predictors of MRCS success in regression models (p<0.05).

CONCLUSIONS

There are significant differences in MRCS performance between medical schools. However, this variation is largely due to individual factors such as academic ability, rather than medical school factors. This study also highlights group level attainment differences that warrant further investigation to ensure equity within medical training.

Won't you stay just a little bit longer? A discrete choice experiment of UK doctors' preferences for delaying retirement

INTRODUCTION AND AIMS

Health systems around the world face difficulties retaining their workforce, which is exacerbated by the early retirement of experienced clinicians. This study aims to determine how to incentivise doctors to delay their retirement.

METHODS

We used a discrete choice experiment to estimate the relative importance of job characteristics in doctors' willingness to delay retirement, and the number of extra years they were willing to delay retirement when job characteristics improved. 2885 British Medical Association members aged between 50 and 70 years, registered with the General Medical Council, practising in Scotland (in December 2019), and who had not started to draw a pension were invited. We compared the preferences of hospital doctors (HDs) and general practitioners (GPs).

RESULTS

The response rate was 27.4% (n = 788). The number of extra years expected to work was the most important job characteristic for both respondents, followed by work intensity for GPs, whereas working hours and on-call were more important for HDs. Personalised working conditions and pension taxation were the least important characteristics for both groups. Setting all characteristics to their BEST levels, GPs would be willing to delay retirement by 4 years and HDs by 7 years.

CONCLUSIONS

Characteristics related to the job rather than pension could have the greatest impact on delaying retirement among clinicians.

The F3 phenomenon: Early-career training breaks in medical training. A scoping review

BACKGROUND

Since 2017, more than 50% of UK doctors have undertaken a 'Foundation 3 (F3) Year' training break after completing their foundation programme (the first two years following graduation), rather than immediately enter specialty training. The reasons for, and consequences of, the growing F3 trend are largely unknown. This scoping review presents the current evidence and identifies future research in this field.

METHODS

Following Arksey and O'Malley's guidelines, 12 databases and three UK-based national postgraduate organisation websites were searched for articles published in English (final searches January 2020). Multiple search terms were used to capture articles relating to the 'F3' time-period, including 'post-foundation' or 'pre-specialty' training. Title, abstract and full-paper screening selected articles reporting any aspect of F3, including within a wider context (eg postgraduate training breaks), and then underwent mixed-methods analysis.

RESULTS

Of 4766 articles identified, 45 were included. All articles were published after 2009; 14/45 (31.1%) were published in 2019. 27 articles reported research, and the remainder were opinion/commentaries. Specific personal (including demographic), professional and organisational factors, particularly the UK postgraduate training structure, are associated with undertaking an F3. The majority of F3 training breaks last 1 year and involve working (clinically or non-clinically) and/or travel. The decision to undertake an F3 is made either prior to or during foundation training. Evidence regarding the impact of F3 on health care service provision was limited but evenly balanced.

CONCLUSIONS

In summarising the existing F3 evidence, this review has highlighted important issues including health care workforce equality and diversity, training pathway inflexibility and the effect of negative early-career experiences on subsequent career decisions. More research is needed to understand the financial impact of training breaks on health care service provision, how training programmes must adapt to retain more trainees and the long-term effects of training breaks, such as F3, on subsequent career progression.

Performance of Queen's University Belfast graduates at core and speciality application

INTRODUCTION

The general medical council (GMC) conducts the National Training Survey (NTS) annually. Part of the survey illustrates the statistics of United Kingdom medical school graduates in core and speciality application. We aimed to review the speciality training application and performance of graduates of Queen's University Belfast (QUB), and compared with graduates of medical schools in England, Scotland, and Wales.

METHOD

The progression reports from the GMC NTS 2016-2019 were accessed on the GMC website. All data available were extracted in April 2020. The mean results for all graduates of 33 UK medical schools in Northern Ireland, England, Scotland, and Wales were collated from the NTS. Applications to the seven specialities with the greatest number of posts available across the UK were analysed.

RESULTS

No differences were noted in the majority of the application stages when comparing graduates from QUB with other UK medical school graduates. However, QUB graduates were less likely to be invited for an interview when applying for core surgical training AND receive an offer for Core Anaesthetic and ACCS Training. QUB graduates were less likely to apply for General Practice training.

CONCLUSION

Our study evaluates the performance of QUB graduates compared to other UK medical graduates in core/speciality application. Based on our findings, QUB and postgraduate deaneries may consider focussing on strengthening applications for aspiring surgeons, improving interview performance for anaesthetics and ACCS applicants, and attracting trainees to pursue a career in General Practice.

Spending Wisely: The Role of Cost and Value Research in the Pursuit of Advancing Anatomical Sciences Education

Studies of "cost and value" in anatomical sciences education examine not only what works, but at what cost, thus evaluating the inputs and outputs of education. This research provides insights into how to use available resources (e.g., academic time, budgets, infrastructure) as a mechanism to obtaining the maximum outcomes available. The purpose of this viewpoint article is to expand on the application of cost and value concepts to anatomical sciences education, contextualizing these concepts through a deeper dive into the more costly educational approaches of human donor dissection. In doing so, both questions and opportunities are raised for the discipline of anatomical sciences going forward. Educational decisions, inclusive of cost and value appraisals, consider the range of outcomes for which the activity is designed to achieve, and the activity's integration with the philosophy of the educational program it is contributing to; these decisions, thus, evaluate more than just cost alone. Healthcare students' engagement with human donor dissection pedagogy offers an array of reported non-economic benefits, including non-traditional discipline-independent skill (NDIS) development (e.g., professionalism, teamwork skills). These skills are often harder to measure, but are no less important to the final pedagogical decision-making process. The goal of cost and value research is to create an evidence-base toward education that delivers maximum value for a given spend. Anatomy educators, researchers, and decision makers who embrace cost and value dialogue, and interpret and apply findings from studies of educational costs, are best positioned to improve the educational value for their learners and provide effective outputs for all stakeholders.

"You can't always get what you want…": economic thinking, constrained optimization and health professions education

Every choice we make in health professions education has a cost, whether it be financial or otherwise; by choosing one action (e.g., integrating more simulation, studying more for a summative examination) we lose the opportunity to take an alternative action (e.g., freeing up time for other teaching, leisure time). Economics significantly shapes the way we behave and think as educators and learners and so there is increasing interest in using economic ways of thinking and approaches to examine and understand how choices are made, the influence of constraints and boundaries in educational decision making, and how costs are felt. Thus, in this article, we provide a brief historical overview of modern economics, to illustrate how the core concepts of economics-scarcity (and desirability), rationality, and optimization-developed over time. We explain the important concept of bounded rationality, which explains how individual, meso-factors and contextual factors influence decision making. We then consider the opportunities that these concepts afford for health professions education and research. We conclude by proposing that embracing economic thinking opens up new questions and new ways of approaching old questions which can add knowledge about how choice is enacted in contemporary health professions education.

The new cultural norm: reasons why UK foundation doctors are choosing not to go straight into speciality training

BACKGROUND

The number of UK foundation doctors choosing to go straight into speciality training has fallen drastically over the last 10 years: We sought to explore and understand the reasons for this change.

METHODS

We undertook semi-structured interviews with 16 foundation year two doctors, who had not applied to speciality training, from two regional foundation schools. Transcripts were thematically analysed.

RESULTS

The reasons that foundation doctors are choosing not to go straight into speciality training centre around the themes of feeling undervalued, career uncertainty and a new cultural norm. They report major feelings of uncertainty regarding career choice at such an early stage of their profession and this challenge was magnified by a perceived lack of flexibility of training and the growing normality of taking time out from training. Trainees feel a lack of support in planning and undertaking an "FY3" year and being helped back into the workforce. Trainees overwhelmingly reported that they feel undervalued by their employers. Importantly, however, not going into training directly was not always a reflection of dissatisfaction with training. Many trainees spoke very positively about their planned activities and often saw a break in training as an excellent way to recharge, develop skills and prepare for the rest of their careers in medicine.

CONCLUSIONS

Taking a year or more out of training after foundation years has become the new cultural norm for UK junior doctors and reasons for this include feeling undervalued, career uncertainty and the perception that this is now "normal". Exploring these factors with participants has generated a number of recommendations related to improving the workplace environment, allowing more flexibility in training and supporting those who chose to take an FY3.

Today's doctors: What do men and women value in a training post?

OBJECTIVES

Recent studies suggest that traditional male-female differences may be changing in terms of what is valued in a medical career but there have been no studies directly quantifying the relationship between gender and stated career-related preferences. To address this gap, we examined the differences between male and female doctors in terms of the strength of their work-related preferences at the point of eligibility to enter residency or specialty training in the UK.

METHODS

This was a quantitative study using a survey incorporating a discrete choice experiment (DCE). Respondents were asked a series of questions in which they had to choose between two or more scenarios, differing in terms of attributes. The attributes were: location; familiarity with specialty; culture of the working and learning environment; earnings; working conditions, and opportunities for professional development. The main outcome measure was willingness to accept compensation to forgo a desirable attribute within a training position. Conditional logistic regression models were run separately for males and females.

RESULTS

A total of 5005 out of 6890 (73%) Foundation Year 2 doctors completed the DCE. The relative value of each attribute was similar for males and females, with location most valued and familiarity with the specialty least valued. There was a pattern of female respondents valuing the move between the best and worst levels of each training attribute more than men, and significantly more than men in respect of the importance of working culture.

CONCLUSIONS

This study adds to existing knowledge in terms of quantifying gendered values in respect of training or residency preferences. That men value a supportive working culture significantly less than women is well established. However, our findings that location, working conditions and working culture are increasingly important to both men and women, suggests that traditional gender norms may be changing. This intelligence can inform gender-responsive workforce planning and innovation, and future research.

Does initial postgraduate career intention and social demographics predict perceived career behaviour? A national cross-sectional survey of UK postgraduate doctors

OBJECTIVE

Studies indicate that initial career intentions and personal characteristics (eg, gender) can influence medical career decision-making. However, little is known about how personal characteristics and intention interact with career decision-making. To address this gap, we examined the link between career intention at the start of the 2-year UK Foundation Programme (FP) and career intentions on its completion.

METHODS

Data came from the 2017 UK National Career Destination Survey, a cross-sectional study completed by all second year foundation doctors. We included respondents' demographics (gender, graduate status on entry to medical school, career intention on starting the FP) and career intention as an outcome measure (eg, specialty (residency) training (UK), NHS non-training posts/further study, career break, working abroad). Multinomial regression was used to assess the independent relationship between background characteristics and career intention.

RESULTS

There were 6890 participants and 5570 usable responses. 55.9% of respondents were female and 43.1% were male, 77.1% were non-graduates and 22.9% were graduate entrants to medical school. Approximately two-thirds (62.3%, n=2170) of doctors who had an original intention to pursue specialty training after F2, still intended to do so on completion. Most of those who stated at the start of F2 that they did not want to pursue specialty indicated at the end of F2 they would be undertaking other employment opportunities outwith formal training. However, 37.7% of respondents who originally intended to pursue specialty training on FP completion did something different. Graduate entrants to medicine were more likely to immediately progress into specialty training compared with their peers who did medicine as a primary first degree.

CONCLUSION

Original intention is a strong predictor of career intentions at the end of the FP. However, a considerable proportion of doctors changed their mind during the FP. Further research is needed to understand this behaviour.

General practice recruitment - a survey of awareness and influence of the Scottish Targeted Enhanced Recruitment Scheme (TERS)

The World Health Organisation reported that health-care systems worldwide have problems with the recruitment and retention of general practitioners (GPs) into clinical practice, particularly to rural and under-served areas. A recent survey of United Kingdom (UK) trainees found that they valued posts with good training conditions, were in desirable locations and gave opportunities for their partner. The Scottish Government has set a target to increase the number of GPs in Scotland by 800 in the next 10 years. In recent years, GP speciality training recruitment has been challenging with significant vacancies in some training programmes, primarily in rural areas, or urban areas with a history of poorer recruitment. Recruitment incentive schemes are in operation in different countries in the UK. The Scottish Government introduced a Targeted Enhanced Recruitment Scheme (TERS), offering a £20,000 payment to GPST trainees accepting a targeted post. This study aimed to evaluate awareness and influence of the TERS initiative on programme choice in Scotland in August 2017. A survey was developed and sent to GP trainees taking up a GPST post in August 2017. Ninety-five out of 245 doctors responded (response rate of 39%). Almost two-thirds (65.3%) were aware of TERS at the time of application and this was via word of mouth and from the National Recruitment Office website. Only 21% of GPSTs aware of TERS were influenced by it in their choice of training location. The locations of family, spouse or partner, and of pre-existing geographical preferences were more influential than TERS.

Surveying, shoring, strengthening: rebuilding medical morale from its foundations

Significant uncertainty surrounds the sustainability of healthcare services in which junior doctors work. It is essential that student and foundation doctors (SFDs) are actively engaged if workforce morale is rebuilt. This narrative review explores the evidence driving the individual work-streams of the Royal College of Physicians' newly formed Student and Foundation Doctor Network. Undergraduate and postgraduate training reform has coincided with concerning feedback from newly qualified doctors. System-level efforts to address this include a focus on extra-contractual matters, where small, sustainable changes could address training and work issues.Fewer foundation year-2 doctors are entering specialty training immediately after the foundation programme. Providing dedicated careers guidance and highlighting opportunities within traditional placements and other career paths can support doctors who undertake non-traditional career routes, including those who take time out of programme.Disseminating these resources through an effective peer-to-peer framework and a well-established mentoring scheme could be the most appropriate way to spread good practice.

Selection or education? Medical school ranking and medical students' speciality choice preferences in the United States

Limited research exists on the influence of top-ranked medical schools on students' speciality choice. We surveyed medical students (n = 468) at eight medical schools in the United States including two ranked in the top 10. Significance tests and logistic regressions were used to determine the relationship between school ranking and preferences for various speciality attributes. An analysis was conducted separately for students in lower (1st and 2nd) years versus higher (3rd and 4th) years of medical school. Among students in lower years, speciality preferences by students in top-ranked schools were less likely to be influenced by the length of training or work-life balance compared to students in non-top-ranked schools. Among higher year students, speciality preference of students in top-ranked schools was more likely to be influenced by prestige than their peers, with no difference in the influence of other factors. We also found evidence that students in top-ranked schools were less likely to be interested in primary care specialities, and this was more pronounced among those in higher years. Our findings suggest that top-ranked schools may influence speciality choice through both selection and education, and initiatives aimed at changing the emphasis on speciality prestige at top-ranked schools could increase primary care physician output.

Making rural health care better: How to attract interns to rural hospital

OBJECTIVE

We examined the factors that influence medical school graduates' choices for the place of internship, so that they can guide policy-makers to attract interns to rural hospitals.

DESIGN

A national survey.

SETTING

Rural and metropoles of Israel.

PARTICIPANTS

Three-hundred-and-thirty-nine interns who did their internships during the years 2016-2018.

MAIN OUTCOME MEASURE

The participants completed a web survey. We used the results of this survey to deduce which factors were influential in helping the interns choose a hospital for their year of internship.

RESULTS

We received 339 questionnaires from medical school graduates of years 2015-2017. We found that the most influential factors in attracting interns to rural hospital internships are the availability of desired residency and exposure to a rural curriculum in medical school. This far outweighed any economic or life quality incentives. In addition, we found that the exposure to rural hospitals during the medical school years increases the likelihood of choosing an internship in a rural hospital.

CONCLUSIONS

The most important factor for choosing a hospital for internship is the availability of lucrative residencies. Thus, we believe the best way to attract good interns would be to make the desired residency positions available for them. Furthermore, it might be more successful to target either students who have studied in a university affiliated with rural hospital rotations or graduates of universities outside of the country.

Relationship between sociodemographic factors and specialty destination of UK trainee doctors: a national cohort study

OBJECTIVES

Many countries are driving forward policies to widen the socioeconomic profile of medical students and to train more medical students for certain specialties. However, little is known about how socioeconomic origin relates to specialty choice. Nor is there a good understanding of the relationship between academic performance and specialty choice. To address these gaps, our aim was to identify the relationship between socioeconomic background, academic performance and accepted offers into specialty training.

DESIGN

Longitudinal, cohort study using data from the UK Medical Education Database (https://www.ukmed.ac.uk/).

PARTICIPANTS

6065 (60% females) UK doctors who accepted offers to a specialty training (residency) post after completing the 2-year generic foundation programme (UK Foundation Programme) between 2012 and 2014.

MAIN OUTCOME MEASURES

Χ² tests were used to examine the relationships between sociodemographic characteristics, academic ability and the dependent variable, specialty choice. Multiple data imputation was used to address the issue of missing data. Multinomial regression was employed to test the independent variables in predicting the likelihood of choosing a given specialty.

RESULTS

Participants pursuing careers in more competitive specialties had significantly higher academic scores than colleagues pursuing less competitive ones. After controlling for the presence of multiple factors, trainees who came from families where no parent was educated to a degree level had statistically significant lower odds of choosing careers in medical specialties relative to general practice (OR=0.78, 95% CI, 0.67 to 0.92). Students who entered medical school as school leavers, compared with mature students, had odds 1.2 times higher (95% CI, 1.04 to 1.56) of choosing surgical specialties than general practice.

CONCLUSIONS

The data indicate a direct association between trainees' sociodemographic characteristics, academic ability and career choices. The findings can be used by medical school, training boards and workforce planners to inform recruitment and retention strategies.

Effect of sex on specialty training application outcomes: a longitudinal administrative data study of UK medical graduates

OBJECTIVES

To examine sex differences in the specialty training recruitment outcomes of UK medical graduates; and whether sex differences were explained by prior academic attainment and previous fitness to practise (FtP) declarations.

DESIGN

Retrospective longitudinal cohort study.

SETTING

Administrative data on entrants to all UK medical schools from the UK Medical Education Database.

PARTICIPANTS

10 559 doctors (6 155; 58% female) who entered a UK medical school in 2007 or 2008 and were eligible to apply for specialty training by 2015.

PRIMARY OUTCOME MEASURE

Odds of application, offer and acceptance to any specialty training programme, and on to each of the nine largest training programmes, adjusting for sex, other demographics, prior academic attainment, FtP declaration and medical school.

RESULTS

Across all specialties, there were no sex differences in applications for specialty training, but women had increased odds of getting an offer (OR=1.40; 95% CI=1.25 to 1.57; p<0.001) and accepting one (OR=1.43; 95% CI=1.19 to 1.71; p<0.001). Seven of the nine largest specialties showed significant sex differences in applications, which remained after adjusting for other factors. In the adjusted models, Paediatrics (OR=1.57; 95% CI=1.01 to 2.46; p=0.046) and general practice (GP) (OR=1.23; 95% CI=1.03 to 1.46; p=0.017) were the only specialties to show sex differences in offers, both favouring women. GP alone showed sex differences in acceptances, with women being more likely to accept (OR=1.34; 95% CI=1.03 to 1.76; p=0.03). Doctors with an FtP declaration were slightly less likely to apply to specialty training overall (OR=0.84; 95% CI=0.71 to 1.00; p=0.048) and less likely to accept an offer to any programme (OR=0.71; 95% CI=0.52 to 0.98; p=0.036), after adjusting for confounders.

CONCLUSIONS

Sex segregation between medical specialties is due to differential application, although research is needed to understand why men are less likely to be offered a place on to GP and Paediatrics training, and if offered GP are less likely to accept.

Geographical mobility of UK trainee doctors, from family home to first job: a national cohort study

BACKGROUND

The UK faces geographical variation in the recruitment of doctors. Understanding where medical graduates choose to go for training is important because doctors are more likely to consider practicing in areas where they completed postgraduate training. The wider literature also suggests that there is a relationship between origin and background, and where doctors wish to train/work. Thus, the purpose of this paper is to investigate the geographical mobility of UK medical graduates from different socio-economic groups in terms of where they wish to spend their first years of postgraduate training.

METHODS

This was an observational study of Foundation Programme (FP) doctors who graduated from 33 UK medical schools between 2012 and 2014. Data was accessed via the UK medical education database (UKMED: https://www.ukmed.ac.uk/ ). Chi-square tests were used to examine the relationships between doctor's sociodemographic characteristics and the dependent variable, average driving time from parental home to foundation school/region. Generalised Linear Mixed Models (GLMM) were used to estimate the effects of those factors in combination against the outcome measure.

RESULTS

The majority of doctors prefer to train at foundation schools that are reasonably close to the family home. Those who attended state-funded schools, from non-white ethnic groups and/or from lower socio-economic groups were significantly more likely to choose foundation schools nearer their parental home. Doctors from disadvantaged backgrounds (as determined by entitlement to free school meals, OR = 1.29, p = 0.003 and no parental degree, OR = 1.34, p < 0.001) were associated with higher odds of selecting a foundation schools that were closer to parental home.

CONCLUSION

The data suggests that recruiting medical students from lower socioeconomic groups and those who originate from under-recruiting areas may be at least part of the solution to filling training posts in these areas. This has obvious implications for the widening access agenda, and equitable distribution of health services.

Does perceived organisational support influence career intentions? The qualitative stories shared by UK early career doctors

INTRODUCTION

The wish to quit or take time out of medical training appears to be related, at least in part, to a strong desire for supportive working and learning environments. However, we do not have a good understanding of what a supportive culture means to early career doctors, and how perceptions of support may influence career decision making. Our aim was to explore this in UK Foundation doctors.

METHODS

This was a qualitative study using semistructured interviews incorporating a narrative inquiry approach for data collection. Interview questions were informed by the literature as well as data from two focus groups. Interviews were carried out in two UK locations. Initial data coding and analysis were inductive, using thematic analysis. We then used the lens of Perceived Organizational Support (POS) to group themes and aid conceptual generalisability.

RESULTS

Twenty-one interviews were carried out. Eleven interviewees had applied for specialty training, while ten had not. Support from senior staff and colleagues influenced participants' job satisfaction and engagement. Positive relationships with senior staff and colleagues seemed to act as a buffer, helping participants cope with challenging situations. Feeling valued (acknowledgement of efforts, and respect) was important. Conversely, perceiving a poor level of support from the organisation and its representatives (supervisors and colleagues) had a detrimental impact on participants' intentions to stay working within the National Health Service (NHS).

CONCLUSION

Overall, this is the first study to explore directly how experiences in early postgraduate training have a critical impact on the career intentions of trainee/resident doctors. We found perceived support in the early stages of postgraduate training was critical to whether doctors applied for higher training and/or intended to stay working in the NHS. These findings have transferable messages to other contexts struggling to recruit and retain junior doctors.