Introduction

Over a number of years now, the number of UK Foundation Programme (FP) doctors pursuing higher training has declined.1–3 In 2017, the figures showed that only 42.6% of those completing the FP were pursuing specialty or core training posts at the end of the FP,4 which is the first possible time to apply for specialty (residency) training within the UK. Instead, most doctors at this stage of their career are opting to take a career break or work in non-training posts (clinical fellowships, locum posts, academic study or service provision roles). This has negative implications for service delivery in terms of unfilled training posts, and longer-term consequences in terms of insufficient doctors’ training to consultant level.

The initial career choice of medical students has been shown to be a good predictor of eventual career behaviour.5–9 Medical students who have an original intention to work in certain specialities or locations throughout medical school are more likely to pursue these interests in their early postgraduate years or as qualified doctors many years later.6 9 10 In addition, qualified physicians who show intentions to leave clinical practice have a greater likelihood of doing so than their counterparts without these intentions.11 12

These findings, that intention is strongly related to future (career) behaviour, are in line with the theory of planned behaviour (TPB).13–15 According to the TPB an intention to undertake a behaviour is a consequence of person’s attitude towards it, subjective norm (social pressure to perform a behaviour) and perceived behavioural control (the ease or difficulty of performing a behaviour).16–18 Thus, intentions are a prerequisite of behavioural intentions, and intention becomes an accurate predictor of a planned behaviour.14 18 Studies have highlighted the association between TPB variables, self-efficacy and demographic factors in predicting career intentions of multiple occupational groups and diverse populations.16–21 However, within the context of medicine and career behaviour, the literature on career intention and social demographics is typically atheoretical, shows mixed results and usually focuses on medical students or qualified healthcare professionals,18 22–34 and/or other recruitment and retention of early career doctors into rural or primary care posts.6 10

Many authors have focused on medical student career decision-making, particularly specialty choice.5 22 26 27 32 However, to the best of our knowledge, there has been no previous research looking at the association between initial postgraduate career intention and career intentions in doctors at the stage of applying for a specialty training post. Yet, this intelligence is critically important as it can inform policy in terms of how many more doctors are needed to be trained in order to have an adequate consultant workforce in the future, as well as informing the future research agenda on this topic.

To address this gap in the literature, our aim was to examine the relationship between early postgraduate career intentions and social demographic factors, and career behaviour (or next career step). Drawing on previous studies, we were particularly interested in the influence of gender and graduate status,29 31 35 36. Our assumption was that those who entered medicine as graduates may be more likely to move through the postgraduate training pathway without taking time out compared with their peers who studied medicine as an undergraduate degree (as is still the norm in the UK). Although previous studies have identified gender differences in medical careers preferences,28 30 34 more recent work with early career UK doctors has shown few differences between men and women37 so we anticipated limited differences between the career intentions of these groups. Finally, and as discussed above, our final focus was relationship between career intention and career choices given the wider literature and our own previous qualitative work.6 10 38 39

Methods

Results

The Career Destinations Survey was sent out to F2 doctors via email by all 22 UK Foundation Schools Programme directors in August 2017 (n=6890). Unfortunately, the approach to survey administration meant some respondents completed the survey more than once and some doctors received and completed the survey in error, giving 7563 responses. After cleaning (removing duplicates, and invalid responses), we had a total of 5570 usable responses. This gives a response rate of 80.1%. Additionally, only complete cases where used in the analysis of the χ² tests and the multinomial regression analysis.

Participant characteristics can be seen in table 1. Of our respondents, 55.9% (n=3853) were female and 43.2% (n=2977) were male. Sixty participants did not indicate their gender preference and thus were coded as missing data. The χ² showed statistically significant associations between gender and career behaviour. Please see table 2 for the full results of the χ² tests. Approximately half of male (52.0%, n=1452) and female F2 (49.7%, n=1804) doctors opted for UK employment/further study or a career break after the F2 programme. A slightly lower proportion of male doctors (41.7%, n=1164) pursued specialty training compared with their female peers (44.2%, n=1607). Approximately 6% of males (6.4%, n=178) and females (6.1%, n=223) went abroad to work after the F2 programme.

Over three-quarters—76.7% (n=5287)— were non-graduates on entry to medical school and 22.8% (n=1572) were graduates reflecting UK norms. Thirty-one respondents did not indicate whether they were a graduate or not. 86.7% (n=5977) were under 29 years old and 13.1% (n=904) were over the age of 29 years old. Nine individuals did not indicate their age. The χ² test for graduate status and career behaviour was significant. The majority of those who entered medical school as graduates opted for a training post immediately after the FP (52.7%, n=780). This compares to 40.2% (n=2000) of those who entered medicine without a first degree (typically directly from school, as is the norm in the UK). In keeping with this pattern, more non-graduates (53.2%, n=2643) were pursuing UK employment/further study or a career break after F2 than F2 doctors who were graduates on entry to medical school. More of those taking medicine as their primary degree (non-graduates) planned to work abroad after the FP (6.7% (n=332) than did their graduate-entry peers (4.7% (n=70)).

Doctors were asked to indicate their next career destination (after completing F2 training). 40.5% (n=2792) were going directly into specialty training. 33.9% (n=2337) were going directly into a non-training position within the UK. 13.8% (n=951) were undertaking a career break. However, only 5.9% (n=404) were going abroad to work. Eighty participants did not complete this question, 4 did not indicate where their next position would be located, 103 turned down specialty due to location, 178 had deferred training and 41 had left medicine, and thus were omitted in the final analysis. Please see figures 1 and 2 for a full breakdown of those excluded from the final analysis. The χ² tests for intention at the start of the FP and intended career behaviour at the end of the FP were significant. Approximately two-thirds (62.3%, n=2170) of doctors who had an original intention to pursue specialty training after F2 did so on F2 completion. Similarly, most of those who stated at the start of F2 that they did not want to purse specialty training, did not do so, 52.8% (n=1055) pursued other UK employment or further study, 21.2% (n=423) undertook a career break and 12.1% (n=242) went abroad. However, ~40% (24.5%, n=854) of those who had originally intended to pursue specialty training did not do so, instead opting for UK employment/further study (24.5%, n=854) (ie, clinical teaching fellowships, locum posts, further academic study, NHS non-training posts), a career break (10.5%, n=366) or went abroad to work (2.7%, n=93). Conversely, 13.9% (n=270) of those individuals who did not intend to pursue specialty training at the outset of the FP, did apply for a specialty/core/GP training post.

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Figure 1

Career destination omissions.

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Figure 2

F1 intention omissions.

Discussion

To the best of our knowledge, this is one of the first studies that has directly examined the relationship between individual (sociodemographic) characteristics with doctors’ career intentions at the very beginning of generic postgraduate training (the FP) and at the time when they are first eligible to apply for specialty training (in the second year of the FP, F2). This is an important step forward as the Career Destinations Survey data are influential in terms of workforce planning and policy and this paper provides more nuanced analysis than has been available previously.

We found that most respondents behaved in line with their original F1 intentions whether these intentions be to immediately progress into a specialty training post or pursue another option (such as an NHS post outside recognised training structures, or fellowship). Interestingly, those doctors who indicated their original intention was to pursue specialty training were more likely to pursue this behaviour than any other. However, ~38% of doctors who had the intention to go directly into a training post at the end of F2 did not do so. In contrast, only 14% of those without this original intention changed their mind and did go into a training post at the end of F2.

This highlights that a considerable proportion of doctors change their mind about their career during the FP, and for most of them this is in the direction of taking time out of training. The nature of the data does not allow us to identify what influences this switch but recent research with F2 doctors has confirmed that positive or negative relationships and or experiences throughout the FP is enough to influence whether doctors will go immediately into training or take some time out.39 41 42 The UK-GMC National Training Survey43 Initial Findings report notes that nearly a quarter of trainees feel burnt out, a third feel exhausted and worn out and a half work over their rostered hours on a daily or weekly basis. This may provide circumstantial explanation of trainees’ change in intention.

Those who entered medical school as graduates were more likely to take up a training post immediately post-FP compared with non-graduates. The nature of the data does not provide an explicit reason for this. However, it may be that those entering medical school as graduates, who tend to have more life experience, feel more confident or more prepared for specialty (residency) training than their younger peers.44 From a theoretical perspective, this would be in line with Banduras concept of self-efficacy which relates to an individual’s confidence or belief in their own abilities to perform a given behaviour.45–47 This pattern in the survey responses merits further study, ideally using qualitative methods to explore the differences between the two groups in more depth.

Additionally, and possibly more likely, foundation doctors who were graduate entrants to medicine are likely to be older (ie, over 29 years old), have more financial debts2 48 and more likely to have a family or spouse for whom they are responsible,29 so delaying entry into training may be unattractive for practical reasons. However, older mature junior doctors have more problems in progressing through their specialty training29 and they are more likely to experience higher levels of psychological distress than their younger counterparts.49 Again, this deserves further exploration. However, in short, our data coupled with previous research does not suggest that a wholesale shift to graduate entry will address training post recruitment issues.

The results indicated that more males were pursuing other employment opportunities than their female counterparts. Further exploration is needed to explain this phenomenon in more detail. The results indicated that for all other career behaviours there was no significant differences within the groups. The fact there are few differences between male and female doctors may be due to all doctors, irrespective of gender, starting to value similar characteristics within career posts or sharing similar work-life values.50–52 Given this, perhaps medicine needs to be promoting all training routes and flexible working for everyone regardless of gender or family status.

A real strength of this study was the high response rate that yielded an opportunity to survey a contemporary population of all F2 doctors in the UK. Additionally, we focused on the link between career intentions at the outset of the FP, and immediate career-related intentions at the end of the second year of the FP (F2), something that has not been done previously. However, our study did have limitations. The survey data are self-reported, and we could not cross-reference survey responses with training post applications and offers. The latter data are held in ORIEL,53 a centralised online system for managing specialty recruitment and career progression in medical training. At the time of this study to have compared responses on the career destination survey with ORIEL data would have required independently linking the two datasets, which are held by different bodies. In the future, this will be possible via UK Medical Education Database (UKMED).54

The destinations survey is not a research tool but a routine, administrative survey used for quality management and workforce planning purposes. Thus, our study was dependent on the equivalent of ‘routine’ clinical data, data which are not collected for research purposes. This posed some difficulties related to question formatting. Some questions asked for career intentions at the beginning of the programme, which participants may not have recalled accurately. The wording of some questions was ambiguous. Some questions used extensive response options or open comment boxes and thus did not lend themselves to statistical analysis. Key sociodemographic data such as country of origin or home country were not collected, so we had no means of assessing how many of the respondents who choose not to apply for specialty training in the UK were not UK citizens. We have given feedback to those managing this survey, and some questions have been amended accordingly. This bodes well for future research using this tool.

This relative consistency between career intention and career behaviour at the early stages of a medical career has been seen elsewhere in the literature.6 9 10 However, previous studies have not framed their research questions theoretically, limiting generalisability. We drew on the TPB as the basis for proposing that intention to engage in a career behaviour would be a predictor that this specific behaviour is likely to occur.14 18 19 Our findings give preliminary evidence to support the utility of using the TPB to look in more detail at the specific factors (in terms of attitudes and beliefs, subjective norms and behavioural control) which drive junior doctor career behaviour. For example, it would be useful to consider how environmental factors, such as experiences during the FP as highlighted in the GMC’s recent report,43 moderate behavioural intention in those who change their career direction between starting and completing the FP. The perceived norm component of the TPB may also provide a framework for considering how behaviour has changed, from almost all foundation doctors going directly into specialty (residency) training, to fewer than half doing so. Understanding medical career behaviour in this way may help inform the design of interventions to increase the attractiveness to Foundation doctors of applying for specialty training at the end of the FP.55

This study has other implications for future research, policy and practice. As discussed above, further research is needed to explore why career intentions change throughout the F2 programme—and what workplace and personal factors, such as wishing to work in the same region as a partner, might be influential. In terms of practice, it may be useful to routinely collect data on training intentions from the point of applications to medical school, as has been done in other contexts in relation to rural working intention.56 This would enable longitudinal follow-up to assess the relative contribution of medical school, FP and other major educational experiences on career intention.

We found that graduate entrants to medical school were more likely to immediately pursue higher training opportunities than those who entered medicine as school leavers. At a superficial level, this might suggest that shifting to graduate entry medicine may be a means of ensuring training posts are filled and junior doctors do not take time out of training. However, we would not advocate graduate entry medicine as a panacea as research discussed previously shows that graduates have their own problems in progressing through specialty training29 and dealing with stress.49 Instead, we propose that careers counselling in medical schools should be targeting ‘non-graduate’ entrant medical students to ensure they are equipped with the appropriate skills and knowledge to allow them to make informed careers decisions by the end of medical school/during the FP. For example, it may be that medical schools could focus more on providing career advice and delivering this in some way, so students are encouraged to reflect on how certain specialities are similar, or different, and to consider what they want in a job (eg, patient continuity, teamworking).

In terms of policy, medical student numbers are highly regulated by the UK governments. This workforce planning needs to take into account that more than half of those finishing the FP do not go directly into specialty training. This does not mean, however, that they are lost to the workforce. We suggest extending the number of opportunities for doctors at this stage of their career, and skills and competences gained in this time formally recognised.

In conclusion, medical education is a huge investment for countries and individuals, so it is crucial to understand factors which might predict doctors’ future career behaviours.55 This study has identified that initial F1 intention is a good indicator of career behaviour at the end of F2. We propose that the discourse in the UK needs to change from concern that F2 doctors wish to take time out of training post-FP, to one of acceptance that things must change, and systems need to adapt.56–58 Most doctors are seeking out other employment or skill development opportunities within the UK after F2 and there may be ways by which these opportunities could be developed further, to help junior doctors develop transferable skills and knowledge which are acknowledged by training systems.