Doctors leaving the training grades in obstetrics and gynaecology: a ...

British Journal of Obstetrics and Gynaecology December 1996, Vol. 103,pp. 1243-1246

Doctors leaving the training grades in obstetrics and gynaecology: a study of the years 1985 to 1988 *John Atkins Consultant (Obstetrics), **Richard Warren Consultant (Obstetrics and Gynaecology), **Paul Hilton Consultant (Gynaecolo,ig and Urogynaecology) *Conference of CollegesRepresentative on Specialist WorkforceAdvisoty Group; **Manpower Committee, Royal College of Obstetrics and Gynaecology

Objectives To determine the numbers of doctors leaving the specialty after obtaining the Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG), and the factors influencing their decisions to seek alternative career paths. Design Retrospectivepostal questionnaire based survey. Participants One hundred and sixty-eight doctors who had passed the MRCOG examination between 1985 and 1988 but were not known to have achieved Consultant or Senior Registrar status in the British Isles by 1993. Results The response rate was 80%. The crude leaving rate was 3 1%, although 7.5% had never intended to seek consultant appointment in the specialty in the UK. The majority left shortly after obtaining the Part 2 MRCOG examination, 75% within the first two years thereafter. The perception of the lifestyle of a consultant and poor job prospects were commonly seen as the critical factors causing trainees of both sexes to leave the specialty, although hours of work was the single most commonly cited factor among female trainees. Conclusions A consistently high rate of loss from the specialty of obstetrics and gynaecology has been demonstrated in surveys covering the period 1978 to 1988. Approximately one-quarter of this loss reflects trainees who had never intended to pursue consultant appointment in the specialty in the British Isles, half reflects factors which may improve with the implementation of the recommendations contained in the New Deal and the ‘Calman’ report, and one-quarter reflects loss for inevitable reasons. Loss of trainees for these reasons is therefore a crucial element in manpower calculations.

INTRODUCTION In 1988 the Royal Colleges were required to submit information to the Joint Planning Advisory Committee in order to calculate the required number of registrars training for consultant posts in England and Wales. An important part of the submission was to calculate the number who leave the training grades and to determine whether this was because of insufficient opportunities to become consultants, or for other reasons, such as change of life plans or a different original career intention. In the same year a detailed survey by the Royal College of Obstetricians and Gynaecologists (RCOG) of the 3 19 trainees from the UK and Eire who passed the Part 2 MRCOG in the years 1978 to 1982 was carried out and formed part of the submission to the Joint Planning Advisory Committeei. This survey showed that 33% of these trainees had not achieved consultant or senior registrar status within at least five years of passing the

h4RCOG. A further similar survey of those passing the Part 2 MRCOG in the years 1983 and 1984 showed a loss rate of 27%. The main reasons given by trainees leaving the specialty in each survey were domestic difficulties or development of a preference for another specialty. Structured training and the unified training grade are about to be introduced and should address some of the training difficulties encountered. Before its submission to the Specialist Workforce Advisory Group, the RCOG realised the importance of obtaining up-to-date information on wastage from the specialty to assist calculation of the number of trainees required in the new unified training grade. Such an exercise would also provide a yardstick against which the influence of the proposed changes in training on retention and satisfaction with the specialty might be measured.

METHODS Correspondence: Mr P.Hilton, Department of Gynaecology, 2nd Floor, Leazes Wing, Royal Victoria Infirmary, Newcastle-upon-Tyne NEl4LP, UK.

In the years 1985 to 1988 inclusive 371 candidates who had qualified in the UK or Eire passed the Part 2

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Table 2. Overall outcome. SR = senior registrar.

Table 1. An analysis of the uncorrected returns by year.

1985

1986

71 MRCOGpasses Questionnaires sent 24 No. returned 19 79 % returned

103 44 32 72

1987

1988

TOTAL

84

113 59 52 88

371 168 135 80

41

32 78

MRCOG. Of these, 124 consultants and 84 senior registrars were identified from the RCOG’s membership database. Hence at first sight only 208/371 (56%) were, or were likely to become, Consultants; the status of 163 remained to be investigated. Of the 124 consultants, eight had overseas appointments in obstetrics and gynaecology or other specialties; these were included in the survey to establish whether their original career intentions had changed, increasing the number to be surveyed to 171, of whom addresses were known for 168. A detailed questionnaire was sent to these 168 individuals to establish whether they had in fact achieved consultant or senior registrar status in the UK or Eire since our last information. For those who had not, the questionnaire sought to establish whether they were likely to do so, and if not, the possible reasons. They were asked about difficulties with training, career opportunities, the effect of such training on family life, and also whether any change in their career plans was influenced by their growing realisation of the true lifestyle and workload of consultants in the specialty. They were also asked what could be changed to encourage them to have remained. This questionnaire is available from the authors on request.

RESULTS Of the 168 questionnaires sent out, 135 (80%) were returned (Table 1). From these, a firther 11 consultants and 29 senior registrars were identified whose status had changed since the latest information to the RCOG’s manpower information systems. An additional 10 were identified who in the opinion of the authors might still achieve consultant status in the British Isles. These were individuals who were in academic training posts, who had spent a considerable time in flexible training, or who had left training temporarily for domestic reasons. Hence 50 individuals (1 1 consultants, 29 senior registrars plus 10 possible successes) of the 135 who returned the questionnaire were not considered true losses from training; this left 85 individuals who were known to have abandoned consultant training. Using the RCOG membership database and the annual manpower census database, a further analysis

SRor Othercareer True No Consultants equivalent intentions losses information TOTAL Men 97 Women 31 Total 128

65 59 124

20 14 34

36 36 72

9 4 13

227 144 371

was then undertaken of the 33 individuals who did not return the questionnaire. This identified one newly appointed part-time consultant and one newly appointed senior registrar. It also identified six doctors abroad who had fulfilled their original career intention. There were 15 definite losses among this group of 33, consisting of six who changed specialty (four going to general practice, one becoming a community gynaecologist who originally aimed for a consultant post in obstetrics and gynaecology, and one voluntary removal from the RCOG register) and nine who still worked in the specialty; this latter group included two overseas consultants who originally aimed for consultant posts in the UK, three clinical assistants, two staff grades, one associate specialist, and one research registrar. Ten could not be traced at their last known address. The outcome is shown in Table 2. There were thus 106 individuals who had definitely abandoned UK consultant training, including the 85 confirmed in the 135 returned questionnaires, and 21 of the traced 33 nonrespondents, of whom 15 had not achieved their initial career intentions and six had. This left 13 unknowns from the total cohort of 371: the 10 untraceable from the 33 unreturned questionnaires, and the original three for whom the RCOG had no address. If we assume that these 13 are representative of the 135 who returned their forms and who showed a ‘leaving’ rate of 63%, then we should add eight of this 13 to the ‘leavers’ to give a likely loss of 114 from the original 371. In the unlikely extremes of the missing 13 being all losses or all nonlosses, there is a maximum loss of 119 (32%) and a minimum of 106 (29%). Hence the likely leaving rate from UK consultant training for the 1985 to 1988 cohort is 3 1% with a possible range of 29% to 32%. An analysis of the 85 returned questionnaires from individuals who appeared unlikely to achieve consultant status in the British Isles identified 28 whose initial career aims had been something other than a consultant in the specialty (Table 3). At least 28 persons of the original group of 371 (8%) had the right to train for a UK consultant post but had no intention of so doing. There were a further six traced nonretumed questionnaires from overseas successes. This 34 (9%of the total) did fill training posts and in 0 RCOG 1996 Br J Obstet Gynaecol 103, 1243-1246

ABANDONMENT OF TRAINING IN OBSTETRICS AND GYNAECOLOGY

Table 3. Those with initial career intentions other than consultant appointment in obstetrics and gynaecology in the British Isles (not including the six nonretumoverseas successes). Overseas UK Non-consultant Consultant Non-consultant Undecided TOTAL ~

Men 0 Women 2 Total 2

13 4 17

1 5 6

~

~~

1 2 3

15 13 28

the future would need to compete for and obtain a national training number. Hence it would be necessary to make allowance for these when estimating the size of the UK career trainee cohort. Previous surveys have identified the two main reasons for trainees leaving UK Consultant training as domestic difficulties and a preference for a different discipline. The current survey asked in greater detail why trainees left the specialty, and asked what changes were felt to be needed to improve training. Women more often identified the actual reasons for leaving, and there were subtle differences between the sexes. Preference for another specialty, in contrast to previous surveys, was no longer a major reason for leaving. Poor job opportunities were seen as the major concern of male trainees, whereas female trainees cited long hours as the major factor (Table 4). The time at which those leaving training in the specialty actually left is shown in Fig. 1. The 85 leavers were asked what changes to UK consultant training might have altered their decision to leave. The results are considered separately for those still in obstetrics and gynaecology (n = 49), and for those who have left the specialty (n = 36). The number responding to this part of the survey was surprisingly low, though most respondents listed several needs. (Table 5). At the end of the survey questionnaire, respondents were invited to comment and a number of problems were highlighted. Many complained of their treatment as trainees with criticism of consultants’ attitude, and the need for patronage.

DISCUSSION There appears to be no significant change in loss from training since previous surveys with a rate of 33% among those obtaining MRCOG in 1978 to 1982 (the 1988 survey), a rate of 27% in 1983 to 1984 (the 1990 survey), and of 31% in 1985 to 1988 (the current survey). It must be appreciated that the original career intention of some trainees had not been to aim for a consultant post in obstetrics and gynaecology in the UK, but for other career outlets. These doctors should 0 RCOG 1996 Br J Obstet Gynaecol 103, 1243-1246

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Table 4. Main reasons given by men and women for leaving the speciality from 85 respondents (most gave multiple reasons). Values are given as percentages. Reasons Hours too long Lifestyle unattractive Poor job opportunities Change of life plan Domestic difficulties Trainingtoo long Prefer other discipline Fear of litigation Abortion act Unable to obtain senior registrar post Technical difficulties

Female

Male

81 57 47 38 29 29 19 19 19 5 5

13 33 40 27 29 20 20 20 20 21 13

Table 5. Major perceived needs for change by respondents still in obstetrics and gynaecology (19149) [O&G]and those responding who have left the speciality(28/36). Values are given as n. Those still in O&G Those who have left O&G Better job opportunities Better part time opportunities Shorter hours Shorter training Better consultant lifestyle Less litigation Protection from abortionact

8 6 5 4 3 2 1

18 I1 17 10

13 11 5

not be seen as a failure of the training system. It is important to identify and count them, however, as they have the right to proceed to train for a UK consultant appointment and take up manpower approvals, now national training numbers, for UK specialty trainees. They are considered as ‘passengers’. The crude leaving rate of 31% is therefore unrealistic. It has been shown above that 9% of these were passengers and never intended to stay, despite their right to do so. The authors suggest that the true wastage rate should thus be 22%. It may be unique to obstetrics and gynaecology that such a large proportion of those who had a right to continue to train for a consultant post in the specialty had no intention of so doing. There is no reason to think that this will change in the immediate future, and so it will be necessary to allow national training numbers for these passengers in the future. This training would appear to be appropriate for their needs. This phenomenon may in part be due to the fact that the RCOG is an international college. Those leaving UK consultant training do so surprisingly quickly after passing the Part 2 MRCOG examination, 58% within one year and 75% within two years, with an early decision by most not even to attempt further progress up the career ladder. This tends to refute the usual explanation that only

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Fig. 1. Time of leaving consultant training.

trainees who are ‘stuck’ in training leave the specialty. The discovery of 11 trainees still trying unrealistically for a UK consultant post at least six years after passing the Part 2 MRCOG, and without extenuating circumstances such as a career break or academic and research training, endorses the view that there is poor career guidance. Examination of the career maps of these trainees showed that they had spent considerably longer than usual at the registrar grade and had often made many unsuccessful senior registrar applications. The small number with any research experience or second qualification highlights possible blocks to career progression under the current system. The perception that a consultant’s lifestyle is no longer attractive may not surprise the many consultants whose workload has increased markedly over the years, but it is of grave concern to the specialty. The large number, 57% of women and 33% of men, who gave this as a reason for leaving warrants consideration. Has the job become less attractive, are trainees more discerning, or are consultants promoting an unpopular image? In their submissions to the Specialist Workforce Advisory Group, other Colleges and disciplines have quoted rates of loss from the training grades of between 1% and 5% overall. In calculating the numbers

of trainees required to fill needed consultant posts, the Advisory Group used a default rate of 3% per year. We believe that no other discipline has measured its losses from training grades as accurately (and over such a time span) as obstetrics and gynaecology, and that this may explain our apparently high attrition rate. This paper suggests that if the changes of structured training, the unified training grade, the reduced hours and time in training and the resulting better career confidence are successfully introduced the losses from the specialist registrar grade in obstetrics and gynaecology will be very close to the Specialist Workforce Advisory Group’s default figure of 3% per year. These changes should do much to meet the criticisms of long hours, long training, poor job opportunities, and the registrar to senior registrar block. However, they depend on consultant expansion actually occurring, and this cannot be guaranteed. The impact of these changes on manpower planning and indeed on the training and experience of the trainee are difficult to predict. Reference 1 Royal College of Obstetricians and Gynaecologists. Manpower in

Obstetricsand Gynaecologv.London: RCOG Press, 1990.

Received 30 April 1996 Accepted 7 June I996 0 RCOG 1996 Br J Obstet Gynaecol 103, 1243-1246