Why do women drop out?
As women become increasingly involved in the medical fraternity, concerns have been highlighted by high-profile figures that care of patients in the National Health Service (NHS) may suffer as female doctors go on to prioritise their families over their patients’ needs. Surgery in particular has traditionally been seen as one of the most competitive and time-consuming specialties.1 Other countries have previously investigated those trainees who chose to leave medical training pathways (whether that be owing to dissatisfaction or other commitments) but as yet no literature exists on ‘dropout’ from higher surgical training that is specific to England. Without any rigorous evidence, it is therefore difficult to comprehend how this fear of an absent workforce has arisen. In order to further understand the situation in England about who is leaving surgical specialty training and for what reasons, a simple study was conducted requesting basic data from every deanery.
The training system and structure of the NHS is respected worldwide, with countries such as Australia basing their healthcare system to an extent on the UK model.2 With the exception of the US, the UK’s royal college membership examinations are considered the world standard.3–5 The NHS itself and its underlying concept of free health at the point of care is a rallying point to our international neighbours, and a key weapon in the UK as a soft-power influence overseas. Attrition of UK surgical trainees from NHS posts should therefore not be taken lightly. In a national healthcare system threatening to buckle under financial constraints, it is important that we can reassure the public that the training of our medical professionals is a valuable and necessary investment.
Specialties like surgery rely on apprenticeship and practice to acquire skills. Consequently, it is unfortunate that changes in the surgical training pathway in the UK have resulted in decreased hands-on experience, altering the balance of curriculum content. More recent changes may have been the most influential: the European Working Time Regulations have limited trainee working hours and caused expansion in trainee numbers.6 This means that there is an impact on the amount of operative experience a single trainee can achieve and some feel that patient management and continuation of care will inevitably suffer.
It has been suggested that holders of the Certificate of Completion of Training may in fact lack the depth of knowledge and operative experience required – even more so than current trainees.7 This led figures at the annual British Medical Association meeting to question whether the new system allowed enough time to adequately train to consultant surgeon level. Concern has been raised as changes have resulted in shortened and broadened training structures. Parsons et al found that trainees were spending less time in surgery and felt their surgical training was getting worse.8 The proportion of operations performed by SHOs and SpRs has declined over the past decade. These observations have coincided with the implementations of structural changes but also reflect the drive in the NHS for a consultant-led health service.
In addition, since the application of the Modernising Medical Careers programme, some trainees can now be selected for run-through training programmes in a single surgical specialty. In Scotland, it was found that the most important factor affecting career choice in surgery (or decisions to stay in that training pathway) was enjoyment.9 Having an acceptable work–life balance was also a highly significant factor in predicting surgical trainee attrition, showing that both social and professional factors impact on career choice.
Controversially, there has been feeling in the media (fuelled by comments from figures such as Professor Thomas) that sex of trainees may affect whether they complete their training, regardless of whether they will be adequately trained professionals by the end of the scheme.10 When it comes to the apparent discrepancies in skill between men and women undertaking higher surgical training, women are at a higher risk of receiving less input than their male counterparts. The General Medical Council (GMC) national training survey for 2014 showed that 11.3% of higher surgical trainees were part time and of these, 80.4% were women.11 However, McNally found that women are in fact more likely to obtain a surgical training position than men, suggesting that ‘only the most able women apply’.1 This challenges the view that positive discrimination leads to incapable women surgeons causing a burden to the NHS.
Currently, there is no denying that surgery is a male-dominated area. Despite a 55% female intake to medical school, only 28% go on to higher surgical training.12 Peters et al suggest this is because women grow to believe they do not fit into the specialty as they progress through their surgical training.13 It has been proposed that the lack of female role models is to blame, with experiences of women in medical school entrenching the idea that surgery is a sex-specific specialty.14,15
According to the 2014 GMC national training survey, overall satisfaction of surgical trainees increases as they progress through their training.11 Nevertheless, even though satisfaction with the surgical training pathway has been increasing since 2006, it consistently has the lowest average score when compared with other specialties.
Our study was designed to investigate whether sex, geographical area and chosen specialty affects attrition of surgical trainees. The aim was to highlight any correlations, thereby enabling calculation of the likelihood of completion of training for different trainee demographics.
Discussion
Sex
There were large differences between the deaneries in terms of the proportion of attrition attributed to female trainees, from 22% to 75% (Figure 1). Although our study did not provide details regarding where trainees go or why they leave, sex-based differences in attrition may be due to regional variation in the level of satisfaction with training programmes experienced by the different sexes, the support offered and perhaps the overall availability of that support.
Despite more women studying at UK medical schools than men (55% in 2011), women are far less likely to go on to become surgical trainees (28% in 2013) and even less likely to qualify as consultants (10% in 2013).12 Peters et al highlighted that contrary to the situation in surgery, women are well represented in general practice and paediatrics, concluding that the lower number of women in surgery was not due to them dropping out to have children.13 Instead, it was attributable to a number of other more complex factors.
If current trends persist, medicine is set to become a female domain by 2017 .16 It is almost inevitable that there will be an increase in women pursuing surgical training but do some regions cater less to female trainees? The information gathered from our study can initiate further investigations into these inconsistencies in sex-based attrition across deaneries.
Geographical areaAttrition rates for the individual deaneries varied between 0.41% and 4.41% (Table 2). Without qualitative data, the reasons for the differences in overall attrition rates between the deaneries are unknown. However, poor trainee satisfaction has been shown to play a key role in determining whether trainees stay on.17
SpecialtyAttrition rates for the various specialties ranged from 0% to 7.14% (Table 3). The paediatric surgical trainee attrition rate in our study (0%) is at odds with data published by the Royal College of Paediatricians and Child Health (RCPCH). In 2010 the RCPCH medical trainee attrition rate was 11% after three years of training.18 Of those who had left the paediatric training programme, 51% went into general practice. Furthermore, the RCPCH national trainees’ survey in 2012 found that 41% of trainees had seriously considered leaving the profession.19 The RCPCH has also noted that women represent a much higher proportion of the training cohort (approximately 75%) than of the consultant workforce (approximately 50%),18 which would have implications for future workforce planning.
Financial implications of attritionThose who are responsible for the upkeep of attrition information may have little interest in its implications. With some deaneries providing inconsistent data and others providing none at all, it is difficult to highlight areas where dropout rates could be reduced or where provisions for trainee support should be distributed. Surely there is a financial incentive to keep track of surgical trainees who do not complete their training?
By the time a doctor has reached higher surgical training, he or she has cost the NHS £435,576.20 It should be an obligation to track this financial investment and follow up the final destination of these highly qualified assets. No deanery collates information as to where these doctors go or who is supporting them both emotionally and fiscally. With such resources now potentially untapped, could these doctors be redeployed elsewhere and could we learn from them why they left?
Conclusions
From the data collected, it can be seen that sex, region and specialty all impact independently on the likelihood of completing higher surgical training. The information highlights vast variations across the country. This suggests discrepancies in how that training and support (or lack thereof) is received and perceived by the trainees themselves. From informal discussions at conferences and in the workplace, interest from juniors and students indicates that data on attrition may even influence decision-making for future job applicants.
In addition to the results of our study, further data acquisition is necessary. It will be imperative to see whether trainee satisfaction correlates with attrition demographics. In conjunction with this, targets can be identified for the provision of increased trainee support, perhaps reducing overall attrition of higher surgical trainees across the country. So as to glean the necessary data, standardised and enforced employee follow-up by the deanery may be prudent. A simple questionnaire requesting their reason for leaving the training programme along with their intentions for the future seems the simplest and most appropriate approach.
AcknowledgementsThe authors would like to thank Mr Amin Elumbarak as well as the Women in Surgery team at The Royal College of Surgeons of England for their support and advice on the completion of this work.
Volume: 98 Issue: 3, March 2016, pp. 134-137
DOI: http://dx.doi.org/10.1308/rcsbull.2016.134
Published online: March 01, 2016
As women become increasingly involved in the medical fraternity, concerns have been highlighted by high-profile figures that care of patients in the National Health Service (NHS) may suffer as female doctors go on to prioritise their families over their patients’ needs. Surgery in particular has traditionally been seen as one of the most competitive and time-consuming specialties.1 Other countries have previously investigated those trainees who chose to leave medical training pathways (whether that be owing to dissatisfaction or other commitments) but as yet no literature exists on ‘dropout’ from higher surgical training that is specific to England. Without any rigorous evidence, it is therefore difficult to comprehend how this fear of an absent workforce has arisen. In order to further understand the situation in England about who is leaving surgical specialty training and for what reasons, a simple study was conducted requesting basic data from every deanery.
The training system and structure of the NHS is respected worldwide, with countries such as Australia basing their healthcare system to an extent on the UK model.2 With the exception of the US, the UK’s royal college membership examinations are considered the world standard.3–5 The NHS itself and its underlying concept of free health at the point of care is a rallying point to our international neighbours, and a key weapon in the UK as a soft-power influence overseas. Attrition of UK surgical trainees from NHS posts should therefore not be taken lightly. In a national healthcare system threatening to buckle under financial constraints, it is important that we can reassure the public that the training of our medical professionals is a valuable and necessary investment.
Specialties like surgery rely on apprenticeship and practice to acquire skills. Consequently, it is unfortunate that changes in the surgical training pathway in the UK have resulted in decreased hands-on experience, altering the balance of curriculum content. More recent changes may have been the most influential: the European Working Time Regulations have limited trainee working hours and caused expansion in trainee numbers.6 This means that there is an impact on the amount of operative experience a single trainee can achieve and some feel that patient management and continuation of care will inevitably suffer.
It has been suggested that holders of the Certificate of Completion of Training may in fact lack the depth of knowledge and operative experience required – even more so than current trainees.7 This led figures at the annual British Medical Association meeting to question whether the new system allowed enough time to adequately train to consultant surgeon level. Concern has been raised as changes have resulted in shortened and broadened training structures. Parsons et al found that trainees were spending less time in surgery and felt their surgical training was getting worse.8 The proportion of operations performed by SHOs and SpRs has declined over the past decade. These observations have coincided with the implementations of structural changes but also reflect the drive in the NHS for a consultant-led health service.
In addition, since the application of the Modernising Medical Careers programme, some trainees can now be selected for run-through training programmes in a single surgical specialty. In Scotland, it was found that the most important factor affecting career choice in surgery (or decisions to stay in that training pathway) was enjoyment.9 Having an acceptable work–life balance was also a highly significant factor in predicting surgical trainee attrition, showing that both social and professional factors impact on career choice.
Controversially, there has been feeling in the media (fuelled by comments from figures such as Professor Thomas) that sex of trainees may affect whether they complete their training, regardless of whether they will be adequately trained professionals by the end of the scheme.10 When it comes to the apparent discrepancies in skill between men and women undertaking higher surgical training, women are at a higher risk of receiving less input than their male counterparts. The General Medical Council (GMC) national training survey for 2014 showed that 11.3% of higher surgical trainees were part time and of these, 80.4% were women.11 However, McNally found that women are in fact more likely to obtain a surgical training position than men, suggesting that ‘only the most able women apply’.1 This challenges the view that positive discrimination leads to incapable women surgeons causing a burden to the NHS.
Currently, there is no denying that surgery is a male-dominated area. Despite a 55% female intake to medical school, only 28% go on to higher surgical training.12 Peters et al suggest this is because women grow to believe they do not fit into the specialty as they progress through their surgical training.13 It has been proposed that the lack of female role models is to blame, with experiences of women in medical school entrenching the idea that surgery is a sex-specific specialty.14,15
According to the 2014 GMC national training survey, overall satisfaction of surgical trainees increases as they progress through their training.11 Nevertheless, even though satisfaction with the surgical training pathway has been increasing since 2006, it consistently has the lowest average score when compared with other specialties.
Our study was designed to investigate whether sex, geographical area and chosen specialty affects attrition of surgical trainees. The aim was to highlight any correlations, thereby enabling calculation of the likelihood of completion of training for different trainee demographics.
Discussion
Sex
There were large differences between the deaneries in terms of the proportion of attrition attributed to female trainees, from 22% to 75% (Figure 1). Although our study did not provide details regarding where trainees go or why they leave, sex-based differences in attrition may be due to regional variation in the level of satisfaction with training programmes experienced by the different sexes, the support offered and perhaps the overall availability of that support.
Despite more women studying at UK medical schools than men (55% in 2011), women are far less likely to go on to become surgical trainees (28% in 2013) and even less likely to qualify as consultants (10% in 2013).12 Peters et al highlighted that contrary to the situation in surgery, women are well represented in general practice and paediatrics, concluding that the lower number of women in surgery was not due to them dropping out to have children.13 Instead, it was attributable to a number of other more complex factors.
If current trends persist, medicine is set to become a female domain by 2017 .16 It is almost inevitable that there will be an increase in women pursuing surgical training but do some regions cater less to female trainees? The information gathered from our study can initiate further investigations into these inconsistencies in sex-based attrition across deaneries.
Geographical areaAttrition rates for the individual deaneries varied between 0.41% and 4.41% (Table 2). Without qualitative data, the reasons for the differences in overall attrition rates between the deaneries are unknown. However, poor trainee satisfaction has been shown to play a key role in determining whether trainees stay on.17
SpecialtyAttrition rates for the various specialties ranged from 0% to 7.14% (Table 3). The paediatric surgical trainee attrition rate in our study (0%) is at odds with data published by the Royal College of Paediatricians and Child Health (RCPCH). In 2010 the RCPCH medical trainee attrition rate was 11% after three years of training.18 Of those who had left the paediatric training programme, 51% went into general practice. Furthermore, the RCPCH national trainees’ survey in 2012 found that 41% of trainees had seriously considered leaving the profession.19 The RCPCH has also noted that women represent a much higher proportion of the training cohort (approximately 75%) than of the consultant workforce (approximately 50%),18 which would have implications for future workforce planning.
Financial implications of attritionThose who are responsible for the upkeep of attrition information may have little interest in its implications. With some deaneries providing inconsistent data and others providing none at all, it is difficult to highlight areas where dropout rates could be reduced or where provisions for trainee support should be distributed. Surely there is a financial incentive to keep track of surgical trainees who do not complete their training?
By the time a doctor has reached higher surgical training, he or she has cost the NHS £435,576.20 It should be an obligation to track this financial investment and follow up the final destination of these highly qualified assets. No deanery collates information as to where these doctors go or who is supporting them both emotionally and fiscally. With such resources now potentially untapped, could these doctors be redeployed elsewhere and could we learn from them why they left?
Conclusions
From the data collected, it can be seen that sex, region and specialty all impact independently on the likelihood of completing higher surgical training. The information highlights vast variations across the country. This suggests discrepancies in how that training and support (or lack thereof) is received and perceived by the trainees themselves. From informal discussions at conferences and in the workplace, interest from juniors and students indicates that data on attrition may even influence decision-making for future job applicants.
In addition to the results of our study, further data acquisition is necessary. It will be imperative to see whether trainee satisfaction correlates with attrition demographics. In conjunction with this, targets can be identified for the provision of increased trainee support, perhaps reducing overall attrition of higher surgical trainees across the country. So as to glean the necessary data, standardised and enforced employee follow-up by the deanery may be prudent. A simple questionnaire requesting their reason for leaving the training programme along with their intentions for the future seems the simplest and most appropriate approach.
AcknowledgementsThe authors would like to thank Mr Amin Elumbarak as well as the Women in Surgery team at The Royal College of Surgeons of England for their support and advice on the completion of this work.
Volume: 98 Issue: 3, March 2016, pp. 134-137
DOI: http://dx.doi.org/10.1308/rcsbull.2016.134
Published online: March 01, 2016