STRENGTHS AND LIMITATIONS OF THIS STUDY

This study offers unique insight through the lens of reflexive thematic analysis to an under-researched area of professional identity transition in medical careers.

Reflective thematic analysis allows for a rich inductive approach to data analysis.

We offer a conceptual advance on a psychosocial transition theory model in the context of the journey from junior doctor to medical educator.

A limitation of this study is the small sample size of self-selecting participants.

This study is cross-sectional and therefore, while it provides unique insight into participants’ transition experiences, the views are the retrospective perceptions of participants, which may be subject to recall bias.

Introduction

The National Health Service (NHS) Long Term Workforce Plan proposes doubling the number of medical students and accelerating the speed of undergraduate training in England.1 There have been calls for consideration of the impact of growth on funding, research and faculty development within medical education,2 with key stakeholders3 4 warning that additional student numbers will increase demands of already stretched educators. As frontline healthcare services struggle under the weight of increased demand and workforce depletion,5 6 practicing clinicians may find themselves being forced to sacrifice educational commitments to prioritise delivery of patient care.

Not all educators are burdened with such a division of their time and energy. In the UK, a poorly-accounted-for cohort of doctors leave clinical medicine before completion of clinical training (CCT) to pursue a substantive career in education. ‘CCT’ describes successful completion of ‘an approved UK training programme’ and the resulting eligibility for entry onto the specialist or general practitioner (GP) registers. This process can take up to 10 years in some specialties. Any doctor below the level of CCT or specialist level in the UK is currently referred to as a ‘junior doctor’. There are no requirements for medical educators to have reached CCT before undertaking a role in education, however, many medical education leadership roles in NHS trusts and universities are typically held by consultants or specialist doctors who have side-stepped into education.

In a step away from this, some professionals enter the field of medical education at a ‘junior’ clinical stage, before CCT. The point of leaving clinical medicine can vary; with some leaving immediately after Foundation Training with 2 years of postgraduate experience, and others leaving at later stages in their training. Another common route into education is following a period of non-training grade experience, where doctors have gained postgraduate clinical exposure outside of formal training programmes, before making the transition into education.

Several studies have broadly explored the transition from healthcare professional to educator.7–10 However, part of the challenge of understanding such experiences may be that collective labels such as ‘medical educator’ do not reflect an individual’s historic professional identity or background. Further, they give no indication of the proportions of time that an individual spends in a clinical versus educational role. Church and Brown8 champion the value of ‘non-practising clinicians’ in education. Although inclusive, this term encompasses ex-clinicians of all backgrounds and might not reflect the unique experience of doctors leaving clinical medicine without the accreditation of CCT.

This heterogeneity is also reflected in the varied pathways taken by pre-CCT medical educators after leaving clinical medicine. The most widely recognised path into education would be to move into an academic institution or medical school, where the individual may teach across preclinical and clinical stages of undergraduate training. Comprehensively describing the other roles adopted by medical educators in both the NHS environment and private sector is challenging, if not impossible, as there is no data quantifying the number of these professionals, where these individuals work, or the positions and responsibilities commonly held by this group of professionals. It is arguable these challenges are perpetuated by the lack of a single professional body, or indeed any formal recognition of medical education as a specialty. This poses a difficulty obtaining a database or record of these professionals’ roles. Allsopp et al 11 call for recognition of education as a specialism, arguing investment in this field is vital to health professionals’ development and by extension, to the health of the wider public.

A small number of papers describe the motivations of these doctors for entering medical education. Push factors from clinical work such as burnout,12 13 impostor syndrome14 and work-life balance12 are well described. Meanwhile, factors such as quality of life,15 a desire to support students in pastoral roles,9 10 and even serendipity9 have been described as pull factors towards teaching careers. However, many of these papers are single author perspective pieces and while they do describe the push/pull factors, there is a paucity of data describing the experiences of the transition process. One might anticipate that in navigating the path less trodden, these individuals might struggle to identify support or individualised career guidance, particularly given the lack of a recognised pathway into education at a ‘junior level’. Equally, ‘juniority’ might mean professional identity as a clinician is less embedded than in those who have completed clinical training, making their transition in professional identity less burdensome. We might for instance see these individuals being more receptive to change in lifestyle and career than their more senior counterparts. Similarly, those leaving clinical medicine at a younger age, might be less restricted by financial or family commitments and thus more adaptable to the transition.

Sabel and Archer16 describe a ‘triple invisibility of education careers: a lack of recognition, lack of structured pathway and lack of identity’. This is concordant with other literature,17 18 but the narrative they explored was that of educators in fixed term clinical education fellowships, rather than permanent posts or those building lifelong careers in education. It is the process of professional identity formation in these transitioning educators, defined by Trede et al 19 as ‘the development of a sense of belonging in a given profession’, that this study explores. A well-formed professional identity has been associated with increased well-being20 and greater employability of workers.21 Understanding this process in medical educators who transition from clinical practice before completing clinical training may help us to provide increased support for these individuals, and foster increased numbers of successful career changes. Extrapolating this, this could aid increased growth and retention of the educational workforce in a time when expansion to health professions education is imminent and necessary.

This study aimed to: (1) explore the experiences of medical educators who left clinical practice as junior doctors and (2) identify the barriers to professional identity formation in this group.

MethodsResearch approach

This study employs a social constructivist epistemology, which recognises that knowledge and lived experiences are inherently subjective and processed differently by every individual.22 The focus is on individuals’ perceptions of their own career transition and how these are impacted by the wider social context, hence socio-constructivism was felt to offer the most appropriate foundation. In line with this paradigmatic orientation, a qualitative approach was taken. OC is an early-career educator who was navigating the transition of interest at the time of data collection. Undoubtedly one’s own experiences of the transition affects interpretation of others’ narratives but it was felt that this insight created avenues for rich discussion about shared experiences. Conversely, KO is an experienced educator who had 20 years of experience as a GP before entering full-time education. Both authors now work exclusively in education; OC is based in an NHS Medical Education department and KO at a university institution. With personal insights and experiences of the journey from clinical practice to medical education, both authors acknowledge this will influence how we engaged with the data and rather than aiming for absolute objectivity, we considered ourselves part of the research process. Reflexive thematic analysis23 (rTA) therefore, seemed well suited to the task of interpreting this data.

Participants

Given the scarcity of any formal networks or professional bodies specifically representing educators from a junior doctor background, sampling methods were purposive and snowball. We aimed to recruit UK-based educators from a variety of geographically spread institutions who had (1) left clinical medicine before CCT; (2) currently work solely in an education role; (3) do not intend to return to clinical practice or postgraduate medical training.

Recruitment was through a university affiliated Clinical Teaching Network and a small informal support network that extends nationally, established by educators experiencing similar career transitions. Access to these were granted by the founders and information leaflets/consent forms were provided to those interested. No incentives were offered. Participants were provided an opportunity to withdraw at any point up to analysis. There were no withdrawals.

A total of nine individuals participated in the study. All participants provided informed consent. Table 1 details their characteristics. It should be noted that several of the participants had significantly more years of postgraduate experience than typical periods of UK Specialty Training as described in the introduction. These participants had spent time out of formal training programmes in non-training grade clinical positions. We felt it was prudent to acknowledge that several of these participants had extensive clinical experience despite not obtaining CCT prior to leaving patient-facing roles.

Table 1

Participant characteristics

Patient and public involvement

There was no patient and public involvement in this study since the research question focused on transition experiences of healthcare/education staff.

Data collection

We conducted nine, 45 min to 1 hour long semi-structured interviews between April and August 2023. A basic interview guide is included in online supplemental appendix 1. Interviews took place over Microsoft Teams24 to accommodate for geographical distance. Interview topics were developed with the intention of aligning questions with the research aims but also maintaining a conversational approach.

Data analysis

The interviews were transcribed manually by OC. Coding and exploration of possible themes took place alongside data collection as part of a recursive process of analysis. An iterative approach to data analysis was maintained; a minimum of three iterations of each code were developed. Participant names were anonymised prior to transcription and coded with a single-digit number. Braun and Clarke’s six stages25 were followed recursively: (1) familiarisation with data; (2) code generation; (3) searching for themes; (4) reviewing themes; (5) defining and naming themes; (6) producing the report. In keeping with rTA methodology stating that sample size should be determined ‘in situ’ during data collection and coding,22 no such commitment to sample size or saturation was made before commencing. At the point of interview cessation, nine interviews had taken place and the data felt sufficiently complex and meaningful to address the research question.

Results

Through our rTA, we developed 3 broad themes and 11 sub-themes, described in table 2.

Table 2

Themes and subthemes

Push factors from clinical medicine

Participants recognised that burnout and mental ill-health impacted on personal relationships and their social lives. Participants described being ‘overwhelmed’ by challenges with time-management and work-life balance.

I didn’t really feel that I had any life outside of work. I’d get up, go to work …. You’d stay late to finish off stuff and then go to the library to study for exams and then go home, go to sleep and do it all again. (Participant E)

There was interesting interplay between feelings of anxiety and burnout, and a sense of the professional identity infringing on personal relationships.

I had no downtime at all. I think it really impacted who I was as a person and on my relationships because all my friends were medics. I didn’t want to listen to what they were doing in their jobs because it made me anxious about medicine. (Participant A)

Professional identity as a doctor seemed to be consuming, with participants choosing words such as ‘overwhelming’ and ‘inflexible’ to describe their clinical careers. There was a sense of participants losing control or autonomy over their personal lives.

For several participants, personal life events such as births and bereavements acted as catalysts for leaving. These catalysts highlight the inflexibility of the clinical training environment to participants giving a sense of an ‘all-consuming’ professional identity and responsibility that overshadows the personal lives of doctors.

I had a child with special needs and I requested time out of training and it was refused. I said I can’t juggle the needs of my child with the training post, just for a year, and they said there wasn’t enough registrars to allow me out of training. So I said, you know, well, there’ll be one less- and they said fine, you’ll have to resign then. (Participant D)

Pull factors towards medical education

Contrary to the above anecdotes where participants allude to losing control in the training environment, a new-found work-life balance in medical education tied in closely with a reclamation of a sense of personal self.

I sometimes compare myself with people who’ve taken a clinical route … But I have all my weekends and I can go to my child’s assembly and I enjoy my job. I went to a conference for educational supervisors and they were telling people that they should aim for 20% joy in their life. And I thought, hang on a minute, I’ve done alright here. (Participant D)

Educators expressed satisfaction in doing meaningful and valuable work on a wider societal or developmental scale. One participant described a revelation during the COVID-19 pandemic, where they experienced the direct impacts of health inequality on mortality in their work in intensive care and the resulting desire to explore a career in educational policy and medical school curriculum development. Participants perceived their medical education practice to be equally valuable, if not more broadly influential, than their work as clinicians.

Working in clinical practice felt very downstream. You know that metaphor that they tell you in that lecture [about preventative medicine]? That in medicine you’re pulling bodies out at the end of the river, rather than trying to stop them falling in. But in medical education research … it does feel more upstream in terms of what you’re doing. (Participant F)

Medical Education was linked to a variety of opportunities for lifelong professional development, with educational scholarship being a commonly occurring draw into the field, as seen in table 3. Apparent across all participants was the attraction of the breadth of opportunities for holistic development in medical education, such as research, leadership and management.

Table 3

Variety of professional development opportunities in medical education

Navigating professional identity formation as an educatorPractical barriers to achieving success in the transition

Participants reported a lack of guidance and support for transitioning medical educators. There was little baseline understanding of career progression opportunities in medical education. Participants described isolation throughout the journey and a scarcity of formal networks, leading them to establish informal social media groups to facilitate sharing support and advice among one another.

So we set up the group for exactly that reason. It’s just like stepping off the path into some kind of, you know, wilderness. You don’t know where you’re going to end up. (Participant H)

Other practical barriers included financial concerns when losing banded pay supplements associated with on-call work in the NHS.

And I knew the big thing for me was going to be the money because I went from a full year of doing every shift under the sun … So my pay dropped by 50%. (Participant H)

Further to a loss of salary, educators shared a feeling of needing to sustain a loss of perceived reputation as an early-career educator. This was not perceived to be the case for clinicians past the point of CCT, who participants believed were afforded more educational opportunities. Participants felt that clinicians who had achieved CCT were automatically perceived to be senior educators, regardless of their educational experience.

A friend of mine who obtained CCT got an education role. And I was a bit upset because I’ve been developing myself as an educator and working hard to try and climb this ladder and somebody else who had much less experience could come in at a higher level or pay grade as they are clinical. It definitely felt like going in at a junior level, you have to take a drop in salary and take a few steps down the ladder, then start climbing up it again. I think it is much harder. (Participant A)

There was an interesting discussion that those without CCT were forced to start at the bottom of the educational hierarchy, where those with CCT were automatically eligible for senior education positions on the merit of their clinical grade. Equally, the below participant appeared to question their own legitimacy as an educator, which may be in view of the lack of clear guidance on eligibility of non-practicing clinicians for senior education roles that are traditionally filled by consultants.

I suppose there’s quite a lot of jobs that come up … where it needs to be a clinician. Do I count? I have clinical experience, but I’m not practising clinically. Would I be able to take that role or would someone with current clinical experience take that? Even if I’ve got way more educational expertise than them? (Participant F)

Identity evolution during the transition to education

Reflecting on their experiences of their journey, several of the participants commented on the challenges of restructuring their professional identity as educators. When asked how they describe their job to others, only one participant stated they would still define themselves as a doctor (participant D). All other participants referred to their educational titles. Regardless, the identity of ‘doctor’ did remain in some way with participants despite their no longer practicing clinically.

I do say I’m a doctor and that’s interesting to me because I don’t really do much doctoring these days. (Participant D)

Despite this dual-identity tension, many participants commented on a feeling of liberation that came with leaving clinical medicine. Momentous occasions such as changing job title, publishing education research, completing higher qualifications in medical education or leaving the medical register were recognised as positive affirmations of their educational identity.

I dropped the clinical bit from the [Clinical Education Fellow] title and I’d also given up my licence around the same time. It was kind of like positioning myself in education solely as where I was and what I was doing. (Participant A)

I’ve been able to do the masters in Medical Education … and that kind of gives me some legitimacy to my educational practice. (Participant A)

The decision to leave medicine and become a full-time educator appeared to be something participants had actively sought out and worked hard to achieve. This suggests this transition in professional identity was not a reactive or inadvertent occurrence, rather something planned and actively engineered by participants.

And as soon as the opportunity arose [to be full-time], yeah … I fought for it. (Participant C)

External perceptions impact professional identity formation

Apparent across all participant interviews, was that educational experience is perceived by others as less valuable than clinical experience. Participants recalled judgmental comments from clinical colleagues, with many participants concluding that medical education is not a well-respected field in the wider medical world.

At the moment I think it’s very much seen as a ‘have a year out job’, not as a serious thing to do lifelong. (Participant D)

Interestingly, junior doctors were attributed to much of the disapproval. Some perceived them to be projecting their own unhappiness onto those leaving:

It’s not actually their thoughts on it, it’s actually they’re trying to put across their unhappiness. And almost there’s a little bit of jealousy in it. (Participant H)

Participants did report internalising some of these beliefs with one participant describing how other people’s perceptions created a sense of unease about the transition.

At times it’s hard to feel proud of it. But I think that being proud of it and having that visible career route is important for other people to see that it is an option. So, I would say that I try my best to be proud of it, but sometimes it’s still tricky because of those stigmatising perceptions. (Participant F)

DiscussionStatement of principal findings

This study sought to understand why doctors leave clinical medicine at a junior level to become full-time medical educators, and gain an insight into their transition experiences. Most participants reported burnout, inflexible training programmes and poor work-life balance as push factors from clinical medicine. The pull factors to medical education were broad and many reported self-development opportunities in leadership, research and scholarship as positives. There was a general perception of medical education being a poorly respected career choice among clinicians, and participants highlighted they felt disadvantaged in education without the credibility of CCT.

Meaning and possible explanations

While we used a subjectivist inductive approach, it was later noted that the findings drew parallels with a well-known psychosocial transition theory model, Schlossberg’s 4S’s.26 Schlossberg’s model considers the factors that influence an individual’s ability to cope with a transition. These are broadly categorised into 4S’s: situation, the trigger for the transition; self, the sense of individual purpose; support, usually the social support around the individual such as family and friends; and strategies or plans for coping with the transition. This theory was used as an interpretive tool, however, not all findings were readily able to be categorised into this model and the categories of ‘strategies’ and ‘support’ were not hugely influential in elucidating the data. Thus, modifications were made to the existing framework to better reflect this study’s findings. An adapted model is available in figure 1.

Figure 1

Adapted ‘4S’ model: psychosocial influences on the transition from junior doctor to medical educator. Schlossberg’s original components of ‘strategies’ and ‘support’ are replaced with the headings ‘social’ and ‘system’ to reflect these influences on transition in this particular group of individuals.

Situation

Schlossberg’s ‘situation’ category considers precipitants for the transition. The push and pull factors identified in this study fit suitably within this domain.

The push factors or deterrents from clinical medicine appear to align generally with other literature in different groups of healthcare professionals.12 13 Pull factors to medical education appear to be more optimistically and proudly discussed in this cohort of participants than in other studies where push factors from the NHS environment have been the resounding message.16 This may represent a shift in favour of pull factors towards medical education, suggesting more professionals are entering medical education for its benefits, rather for work-life balance alone, a suspicion which is cynically described elsewhere.27 While this may reflect an element of retrospective positivity in a small cohort of successful educators, it may suggest increasing awareness of medical education as a viable career for junior doctors and the benefits that the career has to offer for professional development and well-being.

Self

Contrary to other studies citing serendipitous entry as a major mode of arrival into the profession,9 this study shows participants actively choosing medical education. An earlier scoping literature review identified a loss of agency in the clinical environment, where participants ‘felt forced to find an alternative’.15 Similarly, this study does reflect aspects of loss of control or choice, including the inflexibility of clinical work and the impact of anxiety and burnout. However, in this study, we witness a reclamation of autonomy and personal identity during the transition, rather than participants passively falling into medical education. Participants felt that their professional identity benefitted from milestones in their educational career, such as completion of higher qualifications in medical education or publishing research. Where in some ways participants doubted the value of their educational experience over the clinical experience of those who had reached CCT, tangible accreditations such as Masters or PhD in medical education served as a way of cementing professional identity in education. Indeed, the concept of serendipity is not reflected in this study, with participants actively choosing to enter a career in education and navigating the transition independently, despite a lack of support and guidance available. Participants had set up informal networking groups to support others, had ‘fought’ for scarce substantive positions and had actively chosen to embark on a career aligned with their personal and professional values.

Two proposed new S’s

Every doctor an Educator? 11 challenges the belief that all doctors can teach. Calling for recognition of medical education as a specialty, the authors suggest a shift in culture is needed to reframe medical education as a legitimate specialism that its inhabitants can take pride in. Similarly, our study’s findings suggest that while educators do feel pride in their career decisions, the influence of others’ perceptions should not be underestimated. It is important we recognise that there are social factors here that are potentially affecting the ease of the transition for these educators. Thus, we propose the inclusion of two new S’s.

Social

One of the most striking findings from this study is that participants felt medical education careers were not respected among the wider medical profession. This is to be interpreted with caution as this is information through the eyes of a small number of participants—although it is not unprecedented—in fact it has been reflected in several papers.7–9 16 However, it was surprising to learn that participants had experienced negative judgement from peers of a similar clinical grade. More research is needed to understand junior doctors’ perceptions of education careers, but perhaps this reflects an ignorance of junior doctors as to the viability of this career path. This study warns us that these perceptions do contribute to the experiences of career transition and could deter those who internalise these beliefs from making the right career choice for them.

System

The training programme for UK medical graduates has been criticised for producing ‘fit for purpose’ or ‘one size fits all’ clinicians that are moulded to the ideal professional identity of a doctor.12 28 This does raise the question of the level of support for those who choose to take the path less trodden into non-patient facing careers. We were perhaps, surprised to learn there was little positive sentiment among participants about their experiences of the transition. For instance, one might have anticipated that being more junior, these clinicians might have had contacts within reach at university institutions and thus might have had increased support networks in the field of medical education. Participants attributed part of their desire to cease clinical work to the inflexibility and intensity of the training system, and this does intersect with some of the discussion in the ‘self’ section about professional and personal identity. In a healthcare service where the only visible career pathway for doctors is as a practising clinician, is the individual who finds their professional identity no longer aligns with clinical work left without visible career options in the healthcare system?

Further to this, participants perceived that their ‘junior’ clinical grade disadvantaged, or even deemed them unqualified for educational posts, despite their teaching experience and acumen. Colleagues who had reached CCT were believed to have more educational opportunities afforded to them and participants believed they were eligible for enhanced pay for the same educational roles. Participants felt others perceived clinical grade as a proxy for seniority. We should acknowledge potential bias in recruitment for educational roles and evaluate this to substantiate these claims.

Limitations and scope for further research

No other qualitative research studies have explored professional identity formation in medical educators who have transitioned fully from life as a junior doctor. Other works have either reviewed junior clinicians’ experiences in dual clinical-education roles or do not acknowledge the clinical training grade of participants. However, this is a small study of self-selecting participants, thus limiting transferability. The participants all work in England, but it would be reasonable to transfer the findings elsewhere in the UK given the similarities in the health and higher education systems. The observed lack of respect for medical education within the wider medical profession are perceptions of participants who have experienced the transition. Therefore, further scope for research could review the perceptions of medical education among other healthcare professionals, the public and medical students. This is a cross-sectional study; all the participants are now established in full-time roles and therefore, their narratives might be shaped by the time they have spent in their educational careers. Further to this, we have not captured the perspective of those who may have unsuccessfully attempted to transition. It would be useful to quantify the numbers of junior doctors entering full-time careers in education, to establish the scale of the cohort, which could then help justify the need for interventions to support their transitions.

Conclusion

This study offers an insight into the experiences of junior doctors who leave clinical medicine to become educators, framing these experiences in a revised model. This is a conceptual advance from existing models of transition theory in medical education, reflecting the unique challenge of leaving a strong vocational identity for a career that is not recognised as a specialty. There is increasing impetus to ‘professionalise’ medical education,10 11 but until the wider social context has been addressed and further evaluated, potential educators may continue to be deterred by lack of support. Further, we must challenge the perceptions of medical education as an ‘escape route’ for struggling clinicians, and begin to portray it as the specialism it is developing into.

Pre-CCT level clinicians moving into medical education have the potential to forge lifelong careers as professional educators and, if supported adequately in their transitions, could play an invaluable and legitimate role in the delivery of teaching at a time of great strain on the healthcare system.

Data availability statement

No data are available.

Ethics statementsPatient consent for publication

Not applicable.

Ethics approval

This study involves human participants and was approved by Warwick Medical School’s Research Ethics Committee: REGO-2022 MED_006. Participants gave informed consent to participate in the study before taking part.