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Career choices for public health: cohort studies of graduates

from UK medical schools


Michael J. Goldacre, Louise Laxton, Trevor W. Lambert, Premila Webster
Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
Address correspondence to Michael Goldacre, E-mail: michael.goldacre@dph.ox.ac.uk
ABSTRACT
Background The aim of this paper is to describe UK-trained doctors early intentions about seeking careers in public health and their eventual
speciality destinations.
Methods Analysis of longitudinal studies of medical graduates from all UK medical schools in selected year-of-qualication cohorts from 1974
to 2008; data collected by postal questionnaires at various times after qualifying; and selection, for this paper, of doctors who expressed an
early preference for a career in public health and/or who eventually practised in it.
Results Of all doctors eventually practising in public health, for whom we had early choices, public health had been the unreserved rst
choice of 8% (10/125) in their rst post-qualication year, 27% (33/122) in their third year and 59% (51/86) in their fth year. Including rst
choices for public health tied with an equal preference for a different speciality, and doctors second and third choices for public health, 19%
(24/125) of practising public health doctors had considered public health as a possible career in their rst post-graduation year, 41% (50/122)
in the third and 83% (71/86) in the fth year.
Conclusions Comparisons with other specialities show that doctors in public health chose their speciality relatively late after qualication.
Keywords education, employment and skills, health services, public health
Introduction
Thriving specialities in medicine need adequate numbers of
recruits. Public health has sometimes been designated as a
shortage speciality in the UK NHS. A shortage speciality is
one in which, at the time, numbers of senior posts exceed
numbers of suitably qualied physicians. About half of the
current workforce in public health career posts in England
(i.e. excluding trainees) is estimated to be 50 years of age
and over.
1
Data collected by the Faculty of Public Health in
2006 suggests that the average retirement age for public
health physicians was then 58 years.
1
Workforce modelling
indicates that if numbers in training remain at current levels,
there will be a decrease in the size of the specialist
workforce.
1
Workforce planning needs to be underpinned by knowl-
edge of doctors career intentions in respect of speciality
choice and future intentions to practise. The planning of
specialist postgraduate medical education needs to consider
the timing of when doctors make denitive decisions about
which speciality they wish to pursue. The aim of this paper
is to describe UK-trained doctors career intentions about
seeking careers in public health, the timing of their decisions
and their eventual destinations.
Methods
The UK Medical Careers Research Group undertakes
surveys of the career intentions and progression of graduates
from all medical schools in the UK in selected
year-of-qualication cohorts. The surveys, undertaken by
Michael J. Goldacre, Professor of public health
Louise Laxton, Research ofcer
Trevor W. Lambert , Statistician
Premila Webster , Consultant in public health medicine
616 # The Author 2011, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.
Journal of Public Health | Vol. 33, No. 4, pp. 616623 | doi:10.1093/pubmed/fdr067 | Advance Access Publication 12 September 2011

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postal questionnaires, have covered the graduates of 1974,
1977, 1980, 1983, 1993, 1996, 1999, 2000, 2002, 2005 and
2008. The doctors are surveyed towards the end of their
rst, third and fth years after graduation, and at longer time
intervals thereafter (see Appendix for mailing strategy).
25
In
the rst wave of surveys, undertaken from 1974 to the
mid-1980s, public health was not coded as a distinct special-
ity (a combined code was used for public health, community
medicine and community health). When funding for the
early surveys came to an end, the original forms (though not
the coded data) had to be destroyed and therefore the
doctors original written intentions are no longer available.
Accordingly, most of the data in this paper cover surveys
from 1993 when the current wave of surveys recommenced
and thus includes the 1993, 1996, 1999, 2000, 2002, 2005
and 2008 cohorts. However, data on qualiers from the
1974, 1977 and 1983 cohorts, whose subsequent career pro-
gression in public health is known to us, have been used in
our analysis of the early choices of doctors who later work in
public health (see the Results section). The 1980 cohort was
followed for only 5 years post-graduation and hence has
been omitted from the analyses in this paper.
One of the questions asked in the surveys is What is
your choice of long-term career? Responders are asked to
be as general or specic as they wish in specifying their
speciality choice and, if they have more than one choice, to
list up to three. For the purpose of this paper, the career
choices are grouped into 14 mainstream specialities.
6
If
doctors specify more than one choice, they are asked
whether the choices are in order of preference or whether
they are of equal preference (which we term tied choices).
7
If the tied choices are for different mainstream specialities
(e.g. public health and general practice), we have analysed
the choice as tied between mainstream specialities.
7
Results
Response rates
One year after graduation, the 1974, 1977, 1983, 1993,
1996, 1999, 2000, 2002, 2005 and 2008 cohorts of UK
medical graduates were surveyed. These cohorts comprised
in total 41 877 graduates, of whom 28 203 (67.3%) replied.
Three years after graduation, the 1974, 1977, 1983, 1993,
1996, 1999, 2000, 2002 and 2005 cohorts were surveyed.
These cohorts comprised in total 35 082 graduates, of
whom 23 331 (66.5%) replied. Five years after graduation,
the 1974, 1977, 1993, 1996, 1999, 2000 and 2002 cohorts
were surveyed. These cohorts in total comprised 26 108
graduates, of whom 17 523 replied (67.1%).
Aggregating gures for all cohorts at our most recent
survey date, 146 graduates were known by us to be
deceased, 323 were self-declared non-participants, 10 had
never registered with the General Medical Council and 1729
were untraceable at their last known address.
Early career choices for public health in the 1993,
1996, 1999, 2000, 2002, 2005 and 2008 cohorts
Public health was specied as the preferred rst choice of
career by 0.6% of both men and women in Year 1
(Table 1), by 0.6% of men and 0.9% of women in Year 3
and 0.5% of men and 0.9% of women in Year 5 (Table 1).
x
2
-tests showed that some of the differences between men
and women were statistically signicant (Table 1). One
hundred and twenty-eight respondents specied a rst
choice for public health in Year 1, of whom 71 (55%) gave
it as a rst choice tied with a choice for another speciality.
Of those who gave public health as their rst choice in
Table 1 Percentages and numbers of respondents who specied
public health as rst, second or third choice (including choices tied
with other specialities) at 1 (1993, 1996, 1999, 2000, 2002, 2005 and
2008 cohorts), 3 (1993, 1996, 1999, 2000, 2002 and 2005 cohorts)
and 5 years (1993, 1996, 1999, 2000 and 2002 cohorts) after
graduation
Percentages Numbers
Men Women Total Men Women Total
Year 1
First choice 0.6 0.6 0.6 52 76 128
Second or 3rd choice 0.7 0.9 0.8 58 108 166
First, 2nd or 3rd choice 1.3 1.5 1.4 110 184 294
Year 3
First choice 0.6* 0.9* 0.8 43 82 125
Second or 3rd choice 0.8 1.0 0.9 57 95 152
First, 2nd or 3rd choice 1.4* 1.9* 1.7 100 177 277
Year 5
First choice 0.5* 0.9* 0.7 32 65 97
Second or 3rd choice 0.8 1.3 1.1 49 92 141
First, 2nd or 3rd choice 1.4** 2.1** 1.8 81 157 238
Because of rounding of decimals, some of the percentages do not
quite add up. The denominator includes those who responded to each
survey but gave no rst choice. The total number of respondents were
8573 (men), 11 887 (women) and 20 460 (total) in Year 1; 7167
(men), 9305 (women) and 16 472 (total) at Year 3; and 5837 (men),
7329 (women) and 13 166 (total) in Year 5.
*Signicant difference between men and women at P , 0.05.
**Signicant difference between men and women at P , 0.01.
CAREER CHOICES FOR PUBLIC HEALTH 617

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Years 3 and 5, 34% (43/125) and 19% (18/97), respectively,
specied it as a tied rst choice.
Analysis of individual cohorts, for rst, second and third
choices for public health combined (Table 2), showed that
Year-1 choices were mostly stable from the cohort of 1993 to
that of 2005 but that they increased from 1.3% in the cohort
of 2005 to 2.3% in the cohort of 2008 (Table 2). As Table 2
shows, there was no noteworthy change in Year-3 choices for
public health between the cohorts of 1993 and 2005 (i.e.
Year-3 choices made in 1996 and 2008); and there was a non-
signicant decline in Year-5 choices between the cohorts of
1993 and 2002 (i.e. Year-5 choices made in 1998 and 2007).
Certainty of choice
Participants were asked whether they had denitely, prob-
ably or not really made up their minds about their choice
of long-term career (Table 3). Those who chose public
health were considerably less certain about their career
choice than those who chose other medical careers
(Table 3). In the rst year, 4% of men and 12% of women
who expressed a preference for a career in public health
specied that they were denite about their choice. Even at
5 years after qualication, only 19% of men who specied a
Table 2 Percentage of respondents who specied public health as
their rst, second or third choice of career (including tied choices) by
year-of-qualication cohort
Cohort Year 1 Year 3 Year 5
All respondents
1993 0.8 2.0 2.2
1996 1.2 1.8 2.3
1999 1.2 1.7 1.4
2000 1.6 1.4 1.6
2002 1.3 1.7 1.4
2005 1.3 1.6 na
2008 2.3 na na
Men only
1993 1.0 1.6 1.9
1996 1.2 1.7 1.6
1999 1.2 1.7 1.0
2000 1.1 0.7 1.0
2002 1.1 1.6 1.4
2005 1.7 1.1 na
2008 1.7 na na
Women only
1993 0.7 2.5 2.6
1996 1.2 1.8 2.9
1999 1.3 1.7 1.8
2000 2.0 2.0 2.1
2002 1.4 1.7 1.5
2005 1.1 1.8 na
2008 2.6 na na
x
2
-tests for heterogeneity, and for linear trend, of percentages across
graduation years were all NS (P . 0.05), except for all respondents,
and for women only, in Year 1 which showed an increase over time
(P ,0.001 both for heterogeneity and for linear trend).
Table 3 Percentages (and numbers) of doctors who specied whether
they had denitely, probably or not really made up their minds
about their rst choice of long-term career at 1, 3 or 5 years after
qualication,
a
comparing those who chose public health with those
who chose the other speciality mainstreams
b
Percentages
Year 1 Year 3 Year 5
Public
health
Other Public
health
Other Public
health
Other
Men
Denitely 3.8 29.8 27.9 47.0 18.8 71.0
Probably 48.1 48.1 46.5 41.9 56.3 24.7
Not really 48.1 22.1 25.6 11.1 25.0 4.3
Women
Denitely 12.0 26.2 24.4 46.0 33.8 67.1
Probably 52.0 47.7 45.1 41.0 52.3 27.9
Not really 36.0 26.1 30.5 13.1 13.8 5.0
Total
Denitely 8.7 27.7 25.6 46.4 28.9 68.8
Probably 50.4 47.9 45.6 41.4 53.6 26.5
Not really 40.9 24.4 28.8 12.2 17.5 4.7
Numbers on which the percentages are based
Men 52 8398 43 6877 32 5715
Women 75 11 648 82 9037 65 7187
Total 127 20 046 125 15 914 97 12 902
Numbers of respondents who gave no response to the certainty
question were 1 (public health), 287 (other) in Year 1, 433 (other) in
Year 3 and 167 (other) in Year 5. Differences between public health
and other specialities in certainty of choice in Years 1, 3 and 5 are all
signicant at P , 0.001; differences between men and women in
levels of certainty, comparing public health with all other specialities,
are all signicant at P , 0.01.
a
One year after qualicationthe 1993, 1996, 1999, 2000, 2002,
2005 and 2008 cohorts; 3 years1993, 1996, 1999, 2000, 2002 and
2005 cohorts; 5 years1993, 1996, 1999 and 2000 cohorts.
b
The mainstream specialities in this paper included all other clinical
specialities and were grouped by us as general practice, the hospital
medical specialities, the surgical specialities, paediatrics, obstetrics and
gynaecology, accident and emergency, anaesthetics, radiology,
pathology, psychiatry and clinical oncology.
618 J OURNAL OF PUBLIC HEALTH

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rst choice for public health and 34% of women were de-
nite about their speciality choice (Table 3).
Factors inuencing choice
Participants were asked to score each of 11 factors, specied
by us, for its degree of inuence on their choice of special-
ity, by selecting one of three responses: a great deal of inu-
ence, some inuence and no inuence. For this paper,
we present ndings on the percentages of participants who
scored each factor as having inuenced their choice a great
deal (Table 4; for description of results, see Appendix).
Looking forward from early choices to eventual
destinations in the cohorts of 1993, 1996,
1999 and 2000
We analysed data on early career choices and eventual desti-
nations at 10 years post-graduation for the qualiers of
1993 and 1996 and at 7 years for the qualiers of 1999 and
2000 (the latest data available). Of 20 doctors who specied
public health as their untied rst choice in Year 1, and
whose destination was known, 4 (20%) eventually practised
in it. Of 41 who gave public health as their rst choice of
career in Year 3, 19 (46%) eventually practised in it, as did
77% (20/26) of those who gave it as their rst choice in
Table 4 Percentage and numbers of doctors who expressed a preference for public health as a rst choice of career who indicated each factor as
having inuenced their choice of long-term career a great deal, at Years 1 (cohorts of 1993, 1996, 1999, 2000, 2002 and 2008), 3 (1993, 1996 and
2002) and 5 (1993, 1996, 1999, 2000 and 2002)
Year 1 Year 3 Year 5
Public
health
GP Hospital
specialities
Public
health
GP Hospital
specialities
Public
health
GP Hospital
specialities
Factorspercentages of responders
Domestic circumstances 32.0 44.9 13.9 28.3 48.7 15.6 40.2 68.6 26.4
Hours/working conditions 61.9 75.1 29.6 64.5 81.6 35.2 63.4 87.8 40.2
Eventual nancial prospects 3.1 15.0 12.0 4.9 22.8 11.2 6.5 17.7 9.2
Promotion/career prospects 11.3 16.2 24.9 19.7 22.8 24.9 19.1 20.6 24.5
Self-appraisal of own skills/aptitudes 59.2 47.8 50.8 68.9 50.0 51.1 73.4 52.6 59.5
Advice from others 8.3 15.6 16.6 13.1 16.6 17.4 5.4 11.5 14.9
Student experience of subject 26.5 36.9 49.1 19.7 20.8 28.0 17.0 19.8 26.5
Particular teacher/department 17.5 13.2 32.7 18.4 11.3 32.1 8.9 5.9 29.3
Inclinations before medical school 19.8 15.1 14.7 21.3 14.7 12.8 16.1 13.0 10.5
Experience of jobs so far 34.3 46.9 53.6 51.7 54.3 69.9 50.0 53.2 71.9
Enthusiasm/commitment 68.7 61.1 71.9 60.7 56.5 67.9 73.4 63.1 80.1
Factorsnumbers of responders
Domestic circumstances 31 1988 1377 17 1075 734 37 2784 1600
Hours/working conditions 60 3340 2952 40 1818 1662 59 3568 2439
Eventual nancial prospects 3 665 1191 3 507 526 6 722 559
Promotion/career prospects 11 718 2475 12 504 1172 18 836 1484
Self-appraisal of own skills/aptitudes 58 2116 5052 42 1106 2400 69 2134 3598
Advice from others 8 689 1652 8 366 815 5 466 902
Student experience of subject 26 1636 4896 12 461 1321 16 801 1604
Particular teacher/department 17 584 3257 7 163 971 4 145 1015
Inclinations before medical school 19 672 1463 13 327 604 15 526 636
Experience of jobs so far 34 2082 5351 31 1204 3297 47 2160 4365
Enthusiasm/commitment 68 2697 7124 37 1250 3191 69 2570 4859
Percentages in the GP and Hospital specialities columns in bold are signicantly different from the corresponding percentage for public health in the
same year, with P ,0.01; percentages in bold and underlined are signicant with P , 0.001. Respondents were allocated to one of four groups:
(i) doctors who gave a rst choice (including ties) for public health, (ii) those who gave a rst choice (including ties) for GP (but no choice for public
health), (iii) those who gave an untied rst choice for any of the hospital specialities and (iv) those who gave none of the above choices. The latter
group was excluded from calculations in this table.
CAREER CHOICES FOR PUBLIC HEALTH 619

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Year 5. This compares with a match rate, between early
choice and eventually destinations, for other specialities
combined of 60.6% (4076/6724), 76.4% (5397/7064) and
87.5% (6544/7475) at Years 1, 3 and 5 (comparing public
health with all other specialities combined: P , 0.001,
,0.001 and 0.20, respectively, for x
2
-test with one degree
of freedom).
Of 13 graduates who specied public health as a tied rst
choice at Year 1, only one was later working in the speciality.
The corresponding gure for tied rst choices in Year 3 was
4 out of 20 (20%) and for tied rst choices in Year 5 it was
3 out of 9 (33%).
Eventual destinations in public health across all
cohorts surveyed: looking back to early choices
In this analysis, in addition to the cohorts of 19932000,
we included the doctors from the cohorts of 1974, 1977
and 1983 who were known to be working in public health
10 years after graduation. These doctors early career
choices had been coded as public health, community medi-
cine or community health (see the Methods section): we
made the assumption that, in their early years, they had
been aspiring public health doctors.
The ndings for the pre- and post-1993 cohorts, see
Appendix for details, were very similar (P 0.4 at Year 1,
P 0.2 at Year 3 and P 0.4 at Year 5 for x
2
-test with
one degree of freedom); hence, we combined them for
further analysis. Of all doctors practising in public health,
for whom we had early choices, public health had been the
untied rst choice of 8% (10/125) in their rst post-
qualication year, 27% (33/122) in their third year and 59%
(51/86) in their fth year.
Including tied rst choices and second and third choices,
19% (24/125) of practising public health doctors had
considered public health as a possible career in their rst
post-graduation year, 41% (50/122) in the third and 83%
(71/86) in the fth year.
Discussion
Main ndings of this study
In the rst 5 years after qualication, around 0.7% of all
UK doctors specied that public health was their rst
choice of eventual career. Counting rst, second and third
choices, around 12% of all doctors had considered a
career in public health. This is appropriate: at the time
covered by our surveys, public health consultants comprised
0.8% of all career grade doctors in England.
5
Early career choices for public health are much less pre-
dictive of eventual speciality destinations than early career
choices made by doctors for other specialities. A much
higher percentage of doctors who eventually practised in
public health, than doctors in practice in other specialities,
rst made their decision to pursue their eventual speciality
several years after qualication.
What is already known on this topic
It is known that medical practitioners who enter public
health have typically done so later in their careers than those
who enter training in other specialities. Doctors entering
public health training in the past often did so after gaining
several years of post-qualication clinical experience.
This is the rst detailed cohort study of its type and scale
in the UK, reporting on early career preferences for public
health and career destinations; and reporting on certainty of
choice and on factors that have inuenced choice.
What this study adds: factors inuencing career
choice for public health
Of factors inuencing career choice (Table 4), doctors who
chose public health were inuenced to a greater extent than
those who chose general practice by self-appraisal of own
skills and aptitudes. The prospect of a career which suited
their domestic circumstances, and one with social hours
and working conditions, was typically more important for
doctors choosing public health than for those who chose
hospital practice; but less important than for those who
chose general practice. In the doctors responses in the rst
year after qualication, student experience of the subject
was less of an inuence on speciality choice for public
health than for general practice or the hospital specialities.
What this study adds: early career choices
and eventual destinations
It is important to study this two ways round: rst, we
started from early choice and identied eventual desti-
nations, and second, we started from eventual destination
and looked back to early choices.
From the perspective of early choice, many doctors who
express a career preference for public health are less denite
about their choice than doctors who specify other medical
specialities. For example, in Year 1 after qualication, only
9% of doctors who chose public health were denite about
their choice and 59% specied that their choice of speciality
was either denite or probable. In contrast, of doctors
who expressed a preference for other specied branches of
medicine, 28% were denite in Year 1 and 76% specied
620 J OURNAL OF PUBLIC HEALTH

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that the speciality was their denite or probable eventual
choice. Even by 5 years after qualication, about one in six
of those who chose public health was not really sure that it
was what they would do eventually.
Early career choice for public health was often tied with a
choice for another speciality. For example, in this study, 55% of
doctors who specied public health in the rst year after quali-
cation did so as a tied choice. In contrast, only 10% of
doctors in our surveys, overall, give a tied choice of speciality in
Year 1.
7
It seems clear that in the early years of career choice, a
substantial percentage of aspiring public health physicians want
to keep their options open. Public health in the UK has been
more greatly affected than most specialities by changes to the
structure of the NHS, because of its close alignment with man-
agement organizations. It is possible that some of the uncer-
tainty expressed by aspiring public health doctors, in not
regarding their choice as denite, and in twinning their choice
with a choice for another speciality, reects uncertainty about
the place of public health in future organizational structures.
From the perspective of eventual destinations, many
doctors who eventually practised in public health had not
chosen the speciality until several years after qualifying. Of all
who did eventually practise in public health, fewer than 10%
had originally told our research group, in their rst year after
qualication, that public health was their rst choice of
career. Only just over a quarter had specied public health as
their rst choice in Year 3. In contrast, match rates between
early choices and eventual destinations are typically much
higher in other specialities.
7
For example, we have reported,
in a previous paper on the graduates of 1993 and 1996 com-
bined, that 82% of doctors who expressed a preference for a
career in general practice, in the rst year after qualifying,
eventually became general practitioners; that 75% who, in
Year 1, chose psychiatry eventually became psychiatrists; and
that 90% of practising surgeons had decided to become sur-
geons by Year 1 after qualication.
7
Limitations of this study: strengths
and weaknesses
The study has several strengths: it covers several national
year-of-qualication cohorts of qualiers from all UK
medical schools; it has a high response rate for this type of
study; and it can be considered as nationally representative
of the UK. It is a prospective cohort study and, as such, not
subject to recall bias about early career intentions. Career
intentions, as they were in Years 1, 3 and 5, were provided
by the doctors at the time.
Non-response is inevitable and the main weakness is
whether there is any important extent of non-responder bias
in respect of speciality choice or reasons given for it.
Although the size of the whole cohort of doctors was large,
public health is the choice of a very small percentage of
doctors; accordingly, the number of public health doctors in
the study is necessarily fairly small.
Limitations of this study: the changing
policy context
At the time of writing, proposed changes to the structure of
the NHS,
8
which will change the organizations in which
public health will work, and planned changes to public
health itself,
9
may affect recruitment in ways that are cur-
rently unpredictable. New entrants to public health need to
be accepting of uncertainty. The English national Centre for
Workforce Intelligence, in a report to the Department of
Health on recommendations for medical speciality training
for 2011,
10
commented that Demand for public health con-
sultants is now more unknowable than ever. Whilst on the
one hand there appears to be a strong commitment from
the government to improve public health, the organisations
that typically employ public health consultants are currently
facing potential reorganisation. It added that It is not yet
clear how public health consultants will be used in the
future to achieve public health goals.
10
It recommended
that the number of training posts should remain at current
levels for now but should be reviewed on an annual basis.
Since 1993, there have been considerable changes both in
the structure of public health and specialist medical training
in the UK. The Faculty of Public Health examination, and
membership, is now open to those from backgrounds other
than medicine. Structured deanery training programmes
now recruit both medical graduates and those from back-
grounds other than medicine to undertake an integrated
training programme in public health. It seems likely, none-
theless, that there will continue to be a requirement in the
public health workforce for the breadth of knowledge of
recruits from a medical background.
The implementation of Modernising Medical Careers, the
programme for postgraduate medical training, introduced in
the UK in 2005, means that doctors are currently required
to choose a speciality after one-and-a-half years of prac-
tice.
11,12
For some public health practitioners, the decision
to work in whole population medicine has been made after
gaining several years of experience treating patients. We have
suggested elsewhere that at least two possible entry points to
specialist training should be available for most specialities
the rst after 1 or perhaps 2 years of foundation training,
for those whose speciality choice is certain, and the other at
(say) 3 or 4 years.
7
CAREER CHOICES FOR PUBLIC HEALTH 621

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If it is expected that choices for public health should be
made after about one-and-a-half years of post-qualication
experience, it is important that appropriate steps are taken
to ensure that recruitment to the speciality is not adversely
affected. Steps to encourage doctors to consider a career in
public health could include early exposure to public health
through pertinent and innovative teaching methods in
medical school, appropriate experience in the foundation
years and relevant information on careers in public health
early in medical training.
Ethical approval
National Research Ethics Service, following referral to the
Brighton and Mid-Sussex Research Ethics Committee in its role
as a multicentre research ethics committee (ref. 04/Q1907/48).
Funding
This is an independent report commissioned and funded by
the Policy Research Programme in the Department of
Health. The views expressed are not necessarily those of the
Department.
References
1 Curson J, Beddow A, Spillane N. Workforce planning for public
health. ph.com. December 2008 (cited 18 March 2011) ISSN
1472-7501. http://www.fph.org.uk/uploads/phcom_December2008.
pdf (3 June 2011, date last accessed)
2 Lambert TW, Goldacre MJ, Edwards C et al. Career preferences of
doctors who qualied in the United Kingdom in 1993 compared
with those of doctors qualifying in 1974, 1977, 1980, and 1983.
BMJ 1996;313:1924.
3 Goldacre MJ, Davidson JM, Lambert TW. Career choices at the end
of the pre-registration year of doctors who qualied in the United
Kingdom in 1996. Med Educ 1999;33:8829.
4 Lambert T, Goldacre MG, Turner G. Career choices of United
Kingdom medical graduates of 1999 and 2000: questionnaire
surveys. BMJ 2003;326:1945; doi:10.1136/bmj.326.7382.194.
5 Lambert TW, Goldacre MJ, Turner G. Career choices of United
Kingdom medical graduates of 2002: questionnaire survey. Med
Educ 2006; 40(6): 514521.
6 Todd RA. Royal Commission on Medical Education 19651968: Report.
London: HMSO, 1968 (Cmnd 3569).
7 Goldacre MJ, Laxton L, Lambert TW. Medical graduates early
career choices of specialty and their eventual specialty destinations:
UK prospective cohort studies. BMJ 2010;340:c3199; doi:10.1136/
bmj.c.139.
8 Department of Health, 2010. Department of Health. Liberating the
NHS. Legislative Framework and Next Steps. London: Department of
Health, 2010. http://www.dh.gov.uk/prod_consum_dh/groups/
dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_
122707.pdf (3 June 2011, date last accessed)
9 Department of Health. Healthy Lives, Healthy People: Our Strategy for
Public Health in England. London: Department of Health, 2010.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/
@dh/@en/@ps/documents/digitalasset/dh_122347.pdf (3 June
2011, date last accessed).
10 Sharp P. Recommendation for Specialty Training 2011. London: Centre
for Workforce Intelligence, 2010,154. http://www.cfwi.org.uk/
documents/recommendation-for-medical-specialty-training-2011
(3 June 2011, date last accessed).
11 Tooke J. Aspiring to Excellence: Final Report of the Independent Inquiry
into Modernising Medical Careers. London: MMC Inquiry, 2008. http://
www.mmcinquiry.org.uk/MMC_FINAL_REPORT_REVD_4jan.
pdf (3 June 2011, date last accessed).
12 Collins J. Foundation for Excellence. An Evaluation of the Foundation
Programme. Medical Education England, 2010. http://www.mee.nhs.
uk/pdf/401339_MEE_FoundationExcellence_acc.pdf (3 June 2011,
date last accessed).
Appendix
Method: mailing strategy
The doctors mailed in the rst survey of each cohort com-
prised the whole cohort as it was at the time of graduation.
Subsequent surveys of each cohort also started from the
original nominal roll of all graduates, excluding only those
doctors who had previously declined to participate, were
untraceable after exhaustive searching or were known to
have died. For the initial survey, addresses were obtained
from the doctors registration with the General Medical
Council (GMC). For follow-up surveys, the addresses were
those from the current GMC Medical Register sup-
plemented by addresses supplied by the doctors themselves
in previous surveys and by information from published
Medical Directories. Typically, up to four reminders were
sent to doctors who had not yet responded to each mailing.
Results: factors inuencing choice
for public health (Table 4)
For participants choosing public health as their rst choice of
career, the factors with the highest percentage of a great deal
of inuence were enthusiasm and commitment, self-
appraisal of own skills and aptitudes and hours and working
conditions. Hours and working conditions and domestic cir-
cumstances were lesser considerations for doctors considering
public health than for those considering general practice; but
they were greater considerations for aspiring public health
doctors than for doctors considering hospital practice.
Student experience of the subject and experience of jobs so
622 J OURNAL OF PUBLIC HEALTH

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far had less of an inuence on choices for public health than
for hospital practice. Eventual nancial prospects was not an
important consideration. Inclination before medical school
was a strong inuence for only a minority of all doctors; but it
is worth noting that it was specied by a marginally higher per-
centage of aspiring public health doctors than those intending
careers in either general practice or hospital practice.
Results: early choices and eventual
destinations comparing cohorts
from 1993 with earlier cohorts
There were 69 respondent doctors who were practising in
public health from the 1993 or 1996 cohorts 10 years after
graduation or from the 1999 or 2000 cohorts 7 years after
graduation, of whom 60 responded to the Year 1 survey; of
these 7% (4/60) specied public health as their rst (untied)
choice of career. Similarly, 60 of the 69 doctors responded
to the Year 3 survey; of these, 32% (19/60) chose public
health. Sixty-six of the 69 responded in Year 5; 61% (40/
66) chose public health. The ndings for the earlier cohorts
(1974, 1977 and 1983) were similar: of 77 doctors eventually
in public health, 9% (6/65) had specied it as their rst
choice 1 year after qualication and 23% (14/62) at Year 3.
The graduates of 1983 were not surveyed in Year 5; of 23
doctors from the 1974 and 1977 cohorts who eventually
practised in public health, Year-5 choices were known for
20, of whom 55% (11/20) chose public health.
CAREER CHOICES FOR PUBLIC HEALTH 623

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