Motivations of medical students and doctors leaving the NHS explored in a residency training application webinar series

Introduction

The UK has historically been highly regarded among other developed countries such as the USA and Australia as a place for doctors to pursue undergraduate medical training and postgraduate specialty training, given its position in the forefront of medical education development.1 The UK specialty training programme is known for its competitive nature and rigorous training progression towards achieving expertise.1 2 However, in the past few years, reports have shown that an average of 1 out of 10 UK-graduate doctors leave the country to pursue specialty training elsewhere.3–6 As stated in the UK Foundation Programme Career Destination Report in 2018 and 2019, the percentage of junior trainees leaving the National Health Service (NHS) is 11.4% and 9.3%, respectively.6 The individual motivations for this vary from trainees feeling burnt-out due to the demanding nature of the job to higher pay scales to better work-life balance offered in other countries for trainees.3 6–10 The future of UK-graduate doctors is further compounded by the changes in medical workforce regulations in preparation for Brexit.11–14 As the official date of Brexit was on 1 January 2021, the colloquial term ‘Drexit’ had been a hot topic in the past few months, describing UK-trained doctors who leave the NHS as a consequence of Brexit.11–14

The decision to leave the NHS can be complex. UK medical students and junior doctors who are at crossroads in considering whether to pursue specialty training in the UK or overseas, such as the USA, Canada and Australia, should know the application process for their overseas residency training programmes can be equally competitive. Hence, careful planning and preparation are required for international medical graduates (IMGs) to obtain their job of choice. By definition, IMG is a term used to describe a doctor who is pursuing training in an overseas country other than the country in which their medical degree was obtained.15 In the context of this article, a UK-graduate who seeks training overseas other than the UK is deemed an IMG.15

The high percentage of doctors leaving the NHS inspired a local UK-based undergraduate society, Cardiff Healthcare International Perspective Society (CHIPS), to focus on a webinar series to highlight and inform potential IMGs—medical students and doctors—on the residency training application process to six countries/regions. These were the USA, Canada, Australia, Singapore, Malaysia and Hong Kong.

The present study was conducted with the aim to identify and evaluate the most relevant factors for doctors leaving the NHS and the time in their training pathway of which they plan to leave.3–6

MethodsOrganisation of the webinar

A six-part webinar series, detailing the application process for UK graduates to pursue residency overseas, was organised online on Zoom (San Jose, California). Australia, Canada and the USA were included as published literature16 has shown that these are common residency destinations for local graduates. Malaysia, Singapore and Hong Kong were also included as a majority of international students in the UK are from these countries/regions. The webinars were organised an hour-long on Sundays, between 2 August 2020 and 13 September 2020. The speakers invited for the webinars are UK graduates who have secured a residency position in their respective countries within the last 5 years.

Posters and a sign-up form to a mailing list for the webinars were disseminated through the CHIPS Facebook (Menlo Park, California), Twitter (San Francisco, California), LinkedIn (Sunnyvale, California) and Instagram (Menlo Park, California) pages prior to and during the course of the series. Participants were required to be on the mailing list in order to attend any of the webinars.

Dissemination of the surveyData collection

Information on the webinar series was shared with all medical schools in the UK. A novel, 22-item, self-administered questionnaire was developed by medical students from the CHIPS committee as the sign-up form to the mailing list. The questionnaire was developed through discussion of published literature relevant to reasons medical students and doctors want to leave the NHS.3 10 11 The questionnaire included a 5-point Likert scale, checkboxes, multiple-choice, and free-text questions to improve the granularity of the data. A pilot survey was distributed to other members of the CHIPS committee, who were not involved in study conception or design, to seek feedback, improve clarity and ensure objectivity. A copy of the final questionnaire can be found in online supplemental table 1.

Data processing and storage

To prevent data re-entrance, each response was limited by a single valid email. Any identical email records were deleted prior to data analysis. Between any identical records, the entry which was more complete was retained. If the entries were deemed to have similar completeness, the last entry was retained.

Throughout the period of data collection, the information received was kept in a password-protected Excel file. Prior to data analysis, all data was de-identified and stored securely. All relevant information remained non-identifiable throughout this study.

Statistical analysis

The data was analysed and cross-checked independently by two authors (SG and CL). Any discordance in results was reviewed and resolved by a third author (TW). A combination of qualitative and quantitative thematic analysis was used. The 5-point Likert scales ranging from ‘strongly disagree, disagree, neutral, agree, strongly agree’ were corresponded to a numerical value of 1–5, respectively. A non-parametric Kruskal-Wallis rank-sum test was used to compare the difference among the reasons students and doctors want to leave the NHS. Post-hoc analysis involved pairwise Wilcoxon test with the Benjamini-Hochberg procedure. An adjusted p value of 0.05 was set to be significant in this study. Statistical analysis and data visualisation was conducted using R statistical programming (V.4.0.2) (Boston, Massachusetts).

Ethical considerations

Participation in the surveys was completely voluntary and confidential. On submitting the forms, participants confirmed their consent to participate in the study and to the handling and processing of data according to Article 6 (1)(a) of the General Data Protection Regulation. Individuals were allowed the right to withdraw consent and request removal of their data from the Google Form platform at any time. Access to the data was only granted to the steering committee of the study. According to advice obtained from the NHS Health Research Authority online decision tool,17 this survey was exempted from formal ethics review by NHS Research Ethics Committees.

ResultsDemographics

Data from the mailing list questionnaire was received from 1118 individuals who are currently enrolled in or had graduated from a medical school in the UK. These individuals were from 38 medical schools, which represents 90.4% (38/42) of UK medical schools recognised by the Medical Schools Council (MSC) at the start of the 2020/2021 academic year.18

Table 1 presents the demographic characteristics of our respondents. The majority of the respondents were women (n=705, 63%) and the median age of respondents was 22 years (IQR: 20–23). One thousand and one (89.5%) participants were medical students, followed by foundation trainees (n=88, 7.9%). Approximately 1 in 10 of the participants are currently enrolled in or have graduated from the Cardiff University School of Medicine (n=123, 11.0%), followed by the University of Manchester Medical School (n=79, 7.1%) and University of Nottingham School of Medicine (n=75, 6.7%).

Table 1

Demographic characteristics of the respondents

When respondents were asked if they had considered leaving the NHS, 12.3% (n=138) strongly agreed and 38.6% (n=432) agreed while 39.6% (n=443) were neutral, 3.0% (n=33) disagreed and 0.4% (n=4) strongly disagreed and 6.1% (n=68) had no intention of leaving the NHS. Responses from all 1118 participants were included for further analysis without any discrimination of their previous considerations to leave the NHS.

When are participants planning to leave the NHS?

The results demonstrate that there was a significant difference (Kruskal-Wallis rank-sum: p<0.0001) between the four periods of leaving the NHS established in this study (figure 1). There was a higher desire for leaving the NHS after completing the Foundation Programme compared with the other periods (p<0.0001 for comparison with all other groups). There was no significant difference between leaving after Internal Medical Training/Core Surgical Training and Specialty Training (p=0.099), however, they were both significantly higher than leaving the NHS after medical school (both p<0.0001) (online supplemental table 2).

Figure 1Figure 1Figure 1

. The dot plot diagram shows the propensity of graduates leaving at different points in the training pathway (pKruskal-Wallis rank-sum<0.0001). The numerical values 1–5 on the y-axis, represented by the desire to leave the National Health Service (NHS), corresponds to the Likert scale ranging from ‘strongly disagree (corresponds to 1), disagree (2), neutral (3), agree (4), to strongly agree (5)’, respectively.

Why do participants want to leave the NHS?

There was a significant difference between the six reasons in this study (Kruskal-Wallis rank-sum between the six groups; p<0.0001) (figure 2). The most agreed reason to leave the NHS was quality of life (post-hoc Wilcoxon test: padjusted <0.0001 compared individually to all other groups), followed by financial prospects (post-hoc Wilcoxon test: padjusted <0.0001 compared individually to all other groups). This was followed by clinical and academic opportunities, and subsequently, family reasons (post-hoc Wilcoxon test: padjusted=0.063 between these two groups). However, clinical/academic opportunities and family reasons were both more significant than role model advice and political reasons (post-hoc Wilcoxon test: padjusted <0.0001 for these comparisons), although there were no significant differences between role model advice and political reasons (post-hoc Wilcoxon test: padjusted=0.253) (online supplemental table 3).

Figure 2Figure 2Figure 2

The dot plot diagram shows the various reasons participants want to leave the NHS. (pKruskal-Wallis rank-sum <0.0001). The numerical values 1–5 on the y-axis, represented by the desire to leave the National Health Service (NHS), correspond to the Likert scale ranging from ‘strongly disagree (corresponds to 1), disagree, (2) neutral, (3) agree, (4) to strongly agree (5)’, respectively.

Other reasons for leaving the NHS

The mailing list questionnaire also included an optional free-text question for respondents to describe any other reasons for leaving the NHS. 22.7% (n=254) of participants responded to this question. Of those, 0.8% (n=2) answers cannot be comprehended and 71.2% (n=181) responded ‘no further reasoning’ while 28% (n=71) elaborated their reasons further.

Of the 71 respondents, 7 (9.9%) explained that they were originally from another country and would like to return home in the future. One out of the seven were bonded to their home government, while the remaining wanted to voluntarily return to their home country. The responses are shown in Theme 1 of table 2. Two participants stated that they wanted to leave the NHS due to personal reasons and possible family relocation.

Table 2

Thematic analysis of free-text responses on the reasons local UK graduates leave the NHS

Fourteen of 71 (19.7%) of the respondents described that they would like to travel and experience other healthcare systems temporarily, but would consider returning to the NHS eventually. The common responses are demonstrated in Theme 2 of table 2. Six participants were unsure whether to leave or stay and would like to keep their options open.

Five participants stated reasons related to the weather and culture. The common responses are listed in Theme 3 of table 2. The remaining 37 (52%) participants described reasons related to politics, financial compensation and length of training in the NHS. The common responses thematically linked to concerns about career progression and training are shown in Theme 4 of table 2. Responses related to politics, pay and management are shown in Theme 5.

DiscussionKey findings

This study is the first of its kind to describe the reasons and time of which UK medical students and trainees leave the NHS post-graduation. The study gained responses from a large percentage of the current UK medical schools recognised by the MSC. Participants had the highest desire to leave within or after the Foundation Programme and the most significant reason for leaving the NHS was quality of life.

Leaving after foundation training

Our study has indicated that among the participants of this study who wish to leave the NHS, graduates have a higher propensity to leave after Foundation Training in the UK. The Foundation Programme is a 2-year apprenticeship programme bridging medical school and specialty training. It also provides fresh graduates the opportunity to gain experience in a series of either 4-month or 6-month rotations in various specialties.19 20 On completion of the first year of the Foundation Programme, junior doctors are awarded the General Medical Council (GMC) registration, which is recognised and accepted internationally as a completion of internship.19 21 The recognition value of the GMC registration is one of the many reasons why most doctors may prefer to complete the Foundation Programme and to gain a licence to practise before they leave the country.

Besides, junior doctors may take advantage of individual specialty rotations completed during the Foundation Programme as a way to show commitment to certain specialties especially those with highly sought residency training programmes.20 22 23 Furthermore, junior doctors may also choose specific rotations to gain further insight into the challenges and workload of the specialty before applying to its residency training programmes.20 23 Junior doctors may also experience a smoother transition from medical school to junior doctor by working in the NHS on graduation from medical school in the UK.20

The structure of specialty training in the UK could have an influence on why participants hope to leave the NHS after foundation training. For instance, residency in the USA includes choosing a specialty at the start, instead of rotating as in the UK Foundation Programme.24 Some doctors might prefer to experience a more diverse specialty rotation programme, instead of being made to select a limited number of specialties during the 2-year foundation programme. Some may also seek more exposure time in various specialties before deciding an area of interest to pursue.20 23 The exposure of up to four or six different specialties across the 2-year Foundation Programme provides junior doctors an insight into their future career paths and provides adequate time for junior doctors to carry out further research, self-reflection and self-discovery to identify their true passion for certain specialties.23 24 Furthermore, the 2 years of training after medical school might give graduates more time to complete any necessary licensing examinations, such as the United States Medical Licensing Examination, the Hong Kong Medical Licensing Examination and skill acquisition necessary for specialty application in other countries.25 26 All of these would make the option of completing Foundation Training in the UK more attractive.

Exploring potential reasons trainees choose to leave the NHS

This study demonstrated that the most prevalent reasons for medical students and doctors seeking overseas training included quality of life, financial prospects and clinical and academic opportunities. These were consistent with reasons described by Lambert et al.’s analysis of why doctors consider leaving the NHS.3 Among our cohort, quality of life was the most popular rationale. While no consensus exists for the precise definition of quality of life, it is widely agreed that it is a subjective, multidimensional evaluation of an individual’s biopsychosocial status.27 Self-reported positive quality of life is often associated with good physical and mental health, higher income levels, adequate time for leisure activities and professional satisfaction.28 Thus, the relative importance of quality of life may stem from its overlap with multiple other factors including economic prospects and professional development.

Further studies exploring reasons why doctors consider leaving the NHS often describe the theme of salary and financial stability. In general, higher base income and better remuneration for antisocial hours, alongside lower levels of taxation, were common reasons for wanting to practice outside of the UK.3 Smith et al similarly reported in a survey of Foundation Year Two Trainees that attaining a greater salary abroad was a ‘nice bonus’, although many of them did not know what their income abroad would be.29 Interestingly, this was justified as the fact that doctors felt a desire to be paid fairly for their work, as opposed to seeking more lucrative contracts. Uncertainties over pay, particularly in relation to antisocial hours, was a similarly recurrent theme during the controversial Junior Doctors’ contract dispute in 2016.30

Our findings of clinical and academic opportunities, a lack of role models or senior support systems and family reasons (such as relatives living abroad) as reasons for leaving UK medicine were also consistent with prior studies.3 Another determinant were concerns of the negative state of the NHS, including its culture and politics, tied in with difficulties in pursuing work-life balance.3 9 These could in turn impact on trainees’ education and well-being, compounding the perception that their expectations for quality of life and training opportunities may be better met elsewhere.9

Strength and limitations

One of the limitations in this study was participation bias. As the webinar series was mainly advertised on social media, medical students or doctors who do not possess or are not active on their social media accounts may have not learnt about the event. Additionally, our webinar series was limited to six countries. Hence, students and doctors who are not interested in the six countries we have listed may have not attended the event. Our study demonstrated that, in addition to our six countries, 9.74% (109 of 1118) of participants expressed interest in learning about the residency programmes in other countries such as Germany, Switzerland, France, Taiwan, South Korea, India and New Zealand. Moreover, we acknowledge that the survey used in this study is novel and has not been previously validated or published elsewhere. Lastly, the majority of respondents of the survey were medical students who may have limited knowledge on the realities of working in the NHS. Their current reported perceptions may change once they progress into being trainees.

A large proportion of participants who attended our webinar series have considered or are considering to leave the NHS. Hence, the results of the study is a good representation of the motivating factors of the population who plan to leave, as opposed to a survey which captures the views of students regardless of their interest to leave. In addition, the use of webinars was also a strength of our study as it allowed us to reach out to participants from 90.4% of the medical schools in the UK, regardless of their location. Finally, 97.4% of the questionnaire respondents were medical students and foundation doctors. This is a particularly important representation as it may reflect on the medical trainee working force in the NHS in the next 5–6 years. Moreover, to date, this is the largest study involving medical students that investigates the concerns of training locally and motivations to train abroad.

Conclusion

The main findings of the study gives us an important insight into the NHS workforce in the coming years. Future work should address why the quality of life offered in other countries is better than the UK. The definition of a better quality of life should also be explored as this has proven to be a major determining factor for people to consider leaving the NHS. Policymakers should reevaluate junior doctors’ and trainees’ contracts and assess the difference in working hours, on-call hours or wages that may differ among the healthcare systems. This may prevent a further shortage of UK-graduate doctors, a ‘brain-drain’ of local talents and a loss of return of investment of the NHS on our current UK-trained medical students. These changes are necessary as UK-trained doctors feel that the demands of the job lead to a poor work-life balance and it is not reflected in their pay.9

Main messages

The most significant reason for doctors leaving the National Health Service (NHS) is quality of life and participants had the highest desire to leave the NHS within or after the Foundation Programme.

Policymakers should re-evaluate junior doctors’ and trainees’ contracts and assess the difference in working hours, on-call hours or wages that may differ among the healthcare systems to address why the quality of life in other countries is deemed better than the UK.

By addressing this issue, we may prevent a further shortage of UK-graduate doctors, a ‘brain-drain’ of local talents and a loss of return of investment of the NHS on our current UK-trained medical students.

Current research questionWhat is already known on the subject

The UK Foundation Programme Career Destination Report in 2018 and 2019 states that the percentage of junior trainees leaving the NHS is 11.4% and 9.3%, respectively.

The individual motivations for this vary among trainees; these include feeling burnt-out due to the demanding nature of the job to the expectation of higher pay scales to better work-life balance offered in other countries for trainees.

Acknowledgments

We would like to address special thanks to the Malaysian Medics International United Kingdom (MMI UK), Singapore Medical Society of the United Kingdom (SMSUK), Liberty Medics, The Savvy IMG, The Medical Licentiate Society of Hong Kong, who made the webinar series possible.

留言 (0)

沒有登入
gif