It’s the time of year when many junior doctors are applying to vocational training programs. There are those that are set on their future career path but others that may be undecided or unsure. Some recent publications outline some of the determinants of career choice for junior doctors and provide a perspective for supervisors on the provision of career advice (1,2).
Many doctors make a decision on their specialty path whilst a junior doctor. The wrong career decision can mean additional time or money to change career path, or working with a level of dissatisfaction. This is exacerbated by the current inflexible arrangements in vocational training.
A report by the Centre for Research Excellence in Medical Workforce Dynamics titled “A Fork in the Road? A Review of Factors Influencing Medical Career Choice” reviewed factors associated with career choice in medicine (1).
The increasing number of junior doctors is creating bottlenecks into vocational training in some areas whilst other specialties are less popular. This is bad for both junior doctors and the community. Policymakers want to influence career paths to lead to a more efficient and equitable distribution of medical practitioners across specialties and geographic locations. Doctors want autonomy in their career choices.
Can we rely on market forces to effectively distribute our medical workforce? In an ideal system, market forces will influence some junior doctors to opt towards alternative career choices or geographic locations with the knowledge that they have a greater chance of being accepted onto the vocational training scheme and securing a consultant job in the future. But this fundamental principle of a free market requires junior doctors to have accurate information to make informed choices. So it’s important that there is transparent, unbiased information about recruitment, information about progression and what job opportunities are available in the future (3).
Given that much of the career information provided currently is informal, there’s a need to provide quality data to assist junior doctors and their supervisors. The development of the NSW Health Map My Health Career website is a welcome resource that profiles each medical specialty and provides an ability to compare specialties, including whether they are over or undersubscribed (6).
A different perspective on workforce distribution is that supervisors and government bodies should be prioritising the community needs to ensure there is an equal distribution of doctors across specialties and geographic locations. What strategies are available to influence career paths?
Streaming programs in medical school or early prevocational training is seen as a way of ensuring that doctors are exposed to medical specialties of need. However, we want junior doctors with a broad range of skills and knowledge and early streaming may hamper that. Junior doctor training programs need to ensure that there is quality and breadth of exposure to multiple areas. Terms that provide clinical training and not just “service” will likely attract junior doctors towards the vocational specialty.
The quality of the junior doctor term as a positive influence in choice of vocational training programs was borne out in research that I was involved in which highlighted ranges of experiences that both “turn on” and “turn off” junior doctors about a psychiatry. Most specialties will have “good factors” and “not so good factors” for you to consider (7).
In many cases the best way to decide upon a specialty is by obtaining work experience in the field. Unfortunately, there can be some barriers to gaining work experience, including the relatively short length of time between commencing as an intern and applying for training posts, disparity in the numbers and types of terms available at the PGY1 and PGY2 level (e.g. medical, surgical and emergency posts are more prevalent than psychiatry and general practice).
Similarly, junior doctors are predominantly based in hospitals and therefore it is unsurprising that doctors are directed to hospital-based specialties despite significant efforts to target the growth in graduate numbers towards locations and specialty areas of need such as an increasing number of rurally based internships. It is likely that the bulk of the increase in medical school graduates has boosted supply into popular specialties in well-served, inner-metropolitan centres rather than the settings and locations where the majority of doctors are needed.
The important role of mentors and supervisors is influencing career choices is an area that could be developed especially by some of the less in-demand medical specialties. Improving the quality and training of vocational training through engagement and support of the supervisors and or the development of formal mentoring programs may help attract trainees.
While the provision of structured career planning is important, the recent Review of Medical Intern Training recommended changes to the structure of the intern experience to align it with areas of future need (4). This is based on a number of assumptions. Firstly, that the link between junior doctors and consultant training is unfettered. However, structural features of the public health system arguably create perverse career signals, for example, where the number of available vocational training positions reflects service needs met by a registrar-level workforce, rather than expected future demand for specialists (4).
Secondly, given the long lag between commencement of vocational training and seeking a consultant role, junior doctors need to assume that current workforce demand will remain constant over the next 5-10 years. For instance, current workforce shortages tend to be in the generalist-based specialties but with reinvigorated interest in the concept of generalism this is where consultant jobs may be in the next decade. This highlights that junior doctors must not only consider the career market now but also predict the kind and number of doctors needed in the future.
If you are not able to obtain experience in your specialty of choice as a PGY1 or PGY2 then the next best thing is probably to talk to someone training in this specialty. It is important to ask about both the good and not so good bits of training and working in that specialty and also get a feel for what a typical week as a registrar looks like. It is important to look further than the registrar training program and what it’s like to work as consultant in the field as it is likely that your consultant career will be longer.
There is also the underlying hidden curriculum associated with how different specialties are viewed by other groups. Many specialty craft groups are derided by other specialties in how they manage patients. This often occurs within subspecialty teams criticising their generalist colleagues. Similarly, at a career session, one of the speakers told our junior doctors “anaesthetics is the career for doctors who are good at medicine who don’t like speaking to their patients, physician training is for doctors who are good at medicine and like speaking to patients, psychiatry is for doctors who aren’t good at medicine but like speaking to patients”. Stereotyped and stigmatised comments such as these are unfortunately very powerful in shaping junior doctors thinking about different medical careers.
A possibly tougher choice for junior doctors is making the decision that the career is no longer for them after progressing down that career path. This may be because they are not enjoying their work or individual circumstances have changed. Then there is the junior doctor who seems to just miss out on a competitive vocational training and has invested considerable time and effort in pursuit of their desired career. When is enough, enough? Should this be a personal decision or should a trusted consultant or supervisor, tap them on the shoulder and advise them that their window of opportunity has likely closed. This is more difficult for the doctors that have chosen a highly specialised path, as their skills may not be transferrable to other medical specialties.
Curriculum designers need to ensure that prevocation trainees are armed with a wide range of clinical, professional and communication skills that are desired but multiple vocational providers. How doctors now find out about medical careers has been compared to “the way that adolescents used to find out about sex – through the mistaken confused ideas of their peers in the playground” (5). Now you can find out about medical careers, like adolescents currently find out about sex – on the web.