Dollars and pounds

Authors: Caroline Elton 

Publication date:  07 Aug 2012

Caroline Elton compares the commitment and costs reported by US medical students with those of their UK counterparts

Whatever one’s line of work, there is something about seeing how people do it in another country that makes one think critically about how we do it back at home. This was definitely the case with my recent visit to a US medical school, where my work training faculty members in careers support skills got me questioning how we expect medical students and junior doctors to make career decisions in the United Kingdom.

The first thing that struck me was how committed the students in the United States were to medicine. For example, many faculty looked blank when I asked them about students who were enrolled on a medical training course but didn’t really want to become doctors. Typically, it was only after some time that faculty could start to identify any students who may have fallen into that category.

Of course, I realise that my role in the careers unit at London Deanery gives me a skewed vantage point. Even though the unit as a whole (working in conjunction with the University of London Careers Service) offers careers support to all doctors in training, the smaller subset of doctors whom I see for in-depth career counselling tends to have more complex career concerns, including wondering whether medicine was the right career choice. But even allowing for the fact that I see a skewed sample, it is still the case that each year a number of doctors approach the unit because they are having doubts about medicine.

The careers counselling provided by the careers unit always starts by reviewing the doctor’s educational and career history. The aim of this is to place the current career dilemma that the doctor is facing in the broader context of their career trajectory to date. Among those doctors who are wondering whether medicine is right for them are people who say that they drifted into medicine because they were good at science at school and didn’t know what else to do, as well as those who were strongly encouraged into the profession by parents or school teachers, or both, even though they weren’t sure it was right for them.

These reasons for choosing medicine are not necessarily bad, and many doctors who end up loving their profession may initially have chosen medicine for similar reasons. However, when I compare some of the junior doctors I see with the students I encountered in the US, I wonder whether not having to choose medicine until after graduation, as is always the case in the US, diminishes this “drifting-in” effect and reduces the potential impact of parents and teachers on one’s chosen career. I also see a number of unhappy junior doctors who went into medicine as graduates, so it is definitely not a cure-all, but the passion for medicine that I saw in the students I encountered in the US made me think about the effect of graduate entry on longer term motivation.

On the other hand, although students who enter medical school as graduates may be more motivated, the other thing that struck me on my visit was the terrible burden of student debt that US doctors have to bear. By the time the students I worked with graduate from medical school, they may have incurred debts of more than $200 000.

At the state medical school I visited, many of the students came from non-traditional backgrounds and were financing their studies by taking out student loans. Part of my work at the school was to run some discussion sessions on specialty choice, and it became apparent that students who were initially drawn to specialties such as family practice were beginning to question these choices because of anxiety about how they would pay back their student loan if they opted for a lower earning specialty.

Although the situation in the UK isn’t as bad as in the US, students at medical school here are likewise going to leave with considerable debts, not least as a result of the huge increase in university fees starting this September. This will be the case for students who complete a five or six year undergraduate programme, and things will be even worse for those who choose medicine as a second degree, who typically will not have paid off their first student loan before they embark on a second round of costly training.

The absence of anything comparable to the NHS in the US means that the huge earning differentials between specialties doesn’t map neatly on to the UK context. But if the lessons learnt from across the pond are anything to go by, future generations of medical students, saddled with enormous debt, may find themselves drawn to specialties that have the greatest potential for private practice.

Competing interests: None declared.

Caroline Elton chartered psychologist and head of careers unit London Deanery, London, UK

Cite this as BMJ Careers ; doi: