Lessons from the class of 1970: male school leaver entrants to medical school versus male graduate entrants and women

Authors: Alison M Leak, Toby J L Humphrey 

Publication date:  02 Jun 2012

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Do men who went straight to medical school from secondary school differ in their contribution to medicine from male graduate entrants and women? Alison Leak and Toby Humphrey review the evidence from a qualitative survey of a 1970 London medical school cohort

Trends indicate that women will make up the majority of general practitioners by 2013 and the majority of UK doctors by 2022. What impact will this have on medicine? A review published by the Royal College of Physicians in 2009 concluded that workforce planning would be helped by more longitudinal analysis of career paths and working patterns, including career breaks and part time work over the course of careers.[1]

Women made up 55.3% of those going to medical school in 2010 and are changing the face of the workforce. The four year graduate entry medical course now accounts for 10.9% of all entrants to medical school.[2] This figure excludes those graduates who enter a standard five or six year course, and the proportion of older graduates may therefore be as high as 15%.

To open further debate about these issues, 54 doctors from the 1970 second MB entry to St Thomas’ Hospital Medical School in London (thought to be the full class except one, who had died) were invited to complete a questionnaire about their careers on the Survey Monkey website, which included tick box responses and free text. Forty seven (87%) replied; box 1 shows their demographic details.

Postgraduate training and choosing a specialty

Training in the 1970s was different from today. The timing of the start of junior doctor jobs was not coordinated, and many doctors spent several years in senior house officer posts without formal assessment or careers advice. Compulsory GP training was introduced in 1981, and structured Calman specialty registrar training began in 1995, while supernumerary part time training started in 1979 (Department of Health, personal memorandum 1979).[3] National competition for flexible training posts under deanery management was introduced in 1993. Of the doctors surveyed:

• 19 (40%) were appointed as GPs after an average period of training of 3.6 years (range 1.5 to five years), and

• 28 (60%) were appointed as specialists after average training of 8.9 years (3-14).

More than a third (36%) of the respondents had changed their career specialty plans during training. Some reasons were that:

• They believed that career prospects were better in another specialty

• They failed postgraduate exams

• They were too old for long training in a specialty

• They saw hospital medicine as incompatible with family or personal life

• “It took me a while to work out what I wanted to do and to grow up enough to pursue it”

• “I worked for a very poor role model . . . a very prestigious professor. He nearly put me off entirely!”

No direct discrimination during training in the United Kingdom was reported, although two women had been asked at interview whether they intended to get pregnant. One doctor experienced discrimination abroad. A belief that family life and hospital medicine are not compatible can be seen as indirect discrimination.[3]

Only a third of the respondents recalled receiving career advice, but most of these found it useful. In addition, 18 (38%) recalled a role model affecting their specialty choice, including eight of nine surgeons, who cited a strong male role model.

Final specialties

Table 1 shows the final specialties of the doctors surveyed, six of whom were in North America or Australia at this stage. Five of seven (71%) graduate entry doctors became GPs, while 69% of those with an intercalated BSc became specialists, particularly in medicine, pathology, or psychiatry.

Table 1

	Men	Women	Graduate entrants	School leaver entrants
General practice	14	5	5	14
Surgical specialties	8	1	1	8
Medical specialties	6	1	1	6
Anaesthetics or intensive care medicine	6	0	0	6
Pathology	2	1	0	3
Psychiatry	1	1	0	2
Paediatrics	1	0	0	1
Total	38	9	7	40

Of seven non-respondents, one is a GP and six are specialists (two surgical, two medical, two anaesthetists).

A weak link between graduate entry to medicine and general practice has previously been shown.[4] Three year GP training entices older graduates to general practice, but lengthening the training (being currently considered) may encourage more of these people to undertake hospital medicine.

Part time work

Two thirds of respondents had always worked full time, but women were much less likely to have done so (one of the nine women (11%) versus 31 of the 38 men (82%)) (table 2). Only one woman, a consultant with children, both trained and worked full time. Overall, more GPs trained or worked part time than specialists (10 versus five).

Table 2

	Women	Men
Part time training	3	0
Career break >6 months	5	1
Part time GP (long term contract)	3	0
Part time GP (short term contract)	2	8

Doctors who undertook part time work for a few years later in their career cited reasons including poor health, personal choice, and preparation for retirement (or because of retirement). Most doctors found it easy to organise part time work, but nearly a third had difficulties. Three men said that they would have liked to work part time but had not applied.

With greater numbers of women in medicine and also more men wishing to improve their work-life balance, in future more doctors may choose to work less than full time. Setting up a job share as a trainee or a consultant is a good long term option but is often difficult and time consuming to arrange.[5] Equally, negotiating with your employer to reduce your hours can be problematic if you are a consultant.[5] Making it easier to reduce the total hours worked in later years will keep older doctors in medicine, as well as making more leisure time available.[6] Employers need to understand the legitimate needs of the evolving medical workforce while maintaining patient centred care.[7]

Other professional activities

Three quarters (77%) of the doctors surveyed had undertaken important academic, management, or leadership work in the past 10 years while working as clinicians, including all the graduate entry doctors and five of the women (56%). The commonest activities were NHS management or committee work, but many did NHS or university teaching or university research. Most found that the satisfaction gained from these activities was similar to that from their clinical work.

With more women working as part time GPs, there is concern about where the medical leaders and academics of the future will come from. Women and graduate entry doctors need to provide positive role models, encouraging the current generation of juniors to do this work in future. An acceptance of portfolio careers for men and women should bring personal satisfaction, enrich the skills base, and reduce the risk of burnout.[8]

Current status

Two of the doctors (one woman and one man) took early retirement, in 1990 and 2000, and a further five retired between 2006 and 2010 (table 3). Most (81%) of the men who were school leaver entrants are still working full time, in contrast to male graduate entry doctors and to women (33%).

Table 3

	Retired	Part time	Full time
Women	3	3	3
Male graduate entrants	2	2	2
Male school leaver entrants	2	4	26

Over half of those still working expect to retire in the next five years. Several are keen to retire at 60 or when their full pension is achieved. One hoped to work part time after 60, “grey cells, energy, and the will of my employers permitting.” Concern about NHS reforms and tax changes for high earners could hasten voluntary early retirement, if financial considerations allow.

Reflections

Of the doctors surveyed, 85% were completely or well satisfied with their careers, and 89% would follow the same career given their time again. Many described their work as fulfilling, rewarding, challenging, enjoyable, a great privilege, and secure, but some described hard work having negative effects (boxes 2 and 3).

Summary

All those surveyed had continued to work as doctors, and women were no more likely than men to leave medicine. Few had fully retired in spite of being in medicine for 40 years. Being a doctor had provided most with a satisfying career.

A strength of our survey was the high response rate of 87% as a result of the direct approach by a medical school peer and use of an electronic survey. Although this is a small, retrospective survey, the length of time covered provides reassurance that all respondents had contributed extensively as doctors in many varied roles. Use of focus groups or one to one interviews would improve understanding of the reasons behind career decisions. Those who failed to respond may have had less satisfying experiences in their medical careers but were known not to have dropped out altogether.

Women doctors were more likely to become GPs, work part time, or have retired 40 years after entry to medical school. Female role models in various specialties and leadership roles are needed to influence the current generation of female doctors in their careers.

This survey showed that, in comparison with school leaver entrants, those entering medical school with a degree were more likely to become GPs, to arrange part time work, and to have retired. Numbers of graduate entrants have increased considerably over the past 10 years, and their commitment to work outside the clinical sphere, as seen here, is important. Older medical graduates need appropriate career advice to maximise their potential over shorter careers. Employers can retain experienced doctors by agreeing flexible work patterns before retirement.

We thank all those who responded to the survey and F Nicol for her helpful critical advice in discussion about the project.

Competing interests: None declared.

Alison M Leak retired consultant rheumatologist, East Kent Hospitals University NHS Foundation Trust
Toby J L Humphrey graduate entry medical student, University of Nottingham Medical School

 alisonleak@doctors.org.uk