Looking after children is a richly rewarding career, but with over 60 different specialties to select from how do medical students and young doctors choose their career and what factors influence that choice? Postal questionnaire surveys of UK graduates have shown that since 1993 around 7.2% of doctors select paediatrics as their career choice 1 year after qualifying.1 In the latest survey this has dropped to 5.5% of graduates selecting paediatrics at the end of the Foundation years (quote 1 in box 1).2 Only 44% of those who chose paediatrics were working in the specialty 10 years later (quote 2 in box 1).1 This article explores career guidance in the field of paediatrics and child health.

HOW DO STUDENTS AND JUNIOR DOCTORS GET CAREER ADVICE AND GUIDANCE?

When medical students arrive at medical school they believe that they have made their career choice, only to be faced with the prospect of having to choose a specialty. It is never too early to introduce career choices into the curriculum and this needs to be done from the first year at medical school. It is important that there is an integrated approach to career management by medical schools, trusts, royal colleges and deaneries.3 Not only is career advice needed by students, but 95% of doctors in the first year after qualification wanted career advice.4 It is important to understand the factors influencing career choice and especially those which are important for paediatrics.

Career information sources (box 2)

A wealth of literature is available on different medical careers. Some of this is in written form as books or booklets5 and journal articles.6 7 Information is also widely available on a number of websites including the RCPCH (http://www.rcpch.ac.uk), NHS Careers (http://www.nhscareers.nhs.uk), BMJ Careers (http://careers.bmj.com/careers) and those of the postgraduate deaneries. The national medical career website (http://www.medicalcareers.nhs.uk) was launched in November 2008 and takes the user through four stages of understanding oneself, exploring options, choosing a specialty and getting into training.

Career planning tools (box 3)

There are a number of career planning tools including questionnaires,8 Windmills,9 career sorting cards,10 Sci59 (formerly Sci45)11 and Roads to Success.12 Windmills (http://www.windmillsonline.co.uk/progs_health.html) has a specific 1-day career management programme for doctors to help them make informed career choices and reflect on what they want from their career and life in general using a variety of learning methods. The Intelligent Career Card Sort (ICCS) (http://www.intelligentcareer.net/whatis.html and http://careers.bmj.com/careers/advice/view-article.html?id = 1235) uses a card sort process designed to help individuals engage with their own unique career using three sets of coloured cards, with statements relating to what is important in their careers. Sci59 (http://sci59.open.ac.uk/sci59public/about.php) is a 130 item questionnaire and the answers provide a profile of the skills and aspirations of the individual matched against those needed for specialties. The output is a ranked list of specialties. The Roads to Success handbook (http://careers.kssdeanery.org) is a small handbook which guides doctors through the career planning process with information, self-assessment exercises and useful tips. However, these tools are only successful if used with guidance and not by the student or junior doctor on their own. Sci59 provides an example of this need for assistance if someone is trying to decide between a career in paediatrics and other specialties when paediatrics is not in the top 10 of the list. This could be for a variety of reasons including the fact that the trainee likes seeing geriatric patients as well as children. Reasons for the list of specialties and the order in which they are ranked always needs exploration and this is best done by those trained in career counselling.

Career fairs and events

These are highly valued by students and trainees who see them as a one-on-one opportunity to talk to specialists about careers and what it is really like to work in the specialty13 (quote 3 in box 1). It is vital that paediatricians take part in both large career events (eg BMJ Careers fairs, deanery career fairs) and smaller trust organised events. Paediatrics is usually taught in the final year of the medical school curriculum. Due to late exposure to our specialty, therefore, students may have already made their career choice without considering paediatrics as an option. However, talks at, for example, a career evening could help the student/junior doctor keep an open mind on their final career choice.

THE PAEDIATRIC ENVIRONMENT

The majority of paediatric units, apart from those in separate children’s hospitals, are relatively small compared to adult specialties and are contained within the defined children’s department of the trust. This enables newcomers to the department to integrate, quickly become part of the team and feel valued.

Until relatively recently the most junior doctor in the paediatric department was the senior house officer. House officer posts were introduced and then Foundation year one (F1) and F2 posts. This is in contrast to general medicine and general surgery where in all departments there are two tiers of junior doctor prior to the middle grade. This has meant that middle grade staff in paediatrics have tended to be more hands on and involved in both typical and complex cases. Consultant involvement in the wards has always been high, particularly since introduction of the Consultant of the Week system. The hierarchical structure perceived to be present in other specialities is less marked in paediatrics, with easy access to all members of the team irrespective of grade. This leads to a nurturing and supportive environment. A good working atmosphere and helpful colleagues have been key factors in women choosing paediatrics as a career.14 Factors affecting career choice that applied more to paediatrics than other medical specialties were experience of it as a student, enthusiasm/commitment and “what I really want to do”1 (box 4).

Using a yearly postgraduate hospital education environment measure (PHEEM)15 is to be encouraged for each paediatric department. It is important to look at the results of PMETB (Postgraduate Medical Education and Training Board) and RCPCH surveys which are based around making the training environment as optimal as possible. Concerns expressed by trainees including shortage of middle grade staff16 and in any of the PMETB domains including handover, educational supervision, clinical experience, feedback and bullying should be addressed without delay.17

PUTTING IT INTO PAEDIATRIC PRACTICE

Involve medical students as much as possible.

A large amount of patient contact was the second highest rated factor in influencing student career choice18 and it has been postulated that medical students who experience enthusiastic and stimulating training in paediatrics are more likely to become paediatricians.1

Special student study modules in paediatrics

Students have a choice of study modules. It is important that academic paediatric departments ensure that a range of paediatric placements is available for special study modules which offer additional and different experiences to those obtained during student placement in paediatrics.

Increase the number of Foundation posts in paediatrics

Since August 2007, GMC regulations have changed so that there is no longer a requirement to complete 3 months of surgery and 3 months of medicine in Foundation year one.19 Provisionally registered doctors need to demonstrate that they meet the outcomes of the first foundation year and this has paved the way for the creation of more F1 posts in paediatrics. In the BMA cohort of 2006, only 2.8% of F1 posts were in paediatrics.2 Paediatric departments need to be proactive, review how many extra training placements they can offer and be ready to volunteer to take on more trainees. Additional places will be needed at F1 due to higher student intakes and increasing numbers of UK medical graduates to ensure the availability of F1 placements and allow the completion of GMC registration.20 Likewise, if there is any rebadging of positions at F2, then more posts may be available for paediatrics and close liaison with the deanery via the head of the postgraduate school or training committee is essential.

Foundation taster weeks

There are only a limited number of paediatric posts in Foundation year one.2 The available posts in Foundation year two, unless they are in the first 4 months, will be too late to help with career choices as interviews for most posts are in early spring and start dates are in August/September. Taster experiences are useful to help Foundation doctors decide on specialty, especially when the specialties they are considering are not included in their F1 or F2 programme.21 A questionnaire survey of 1993 qualifiers found that only about a quarter of doctors change their career choice between year one and year three after qualification.22 In this 1993 study, in contrast to previous cohorts, those who had elected to do a hospital specialty if altering their career choice chose another hospital specialty. In addition, 89% of those who had chosen general practice remained with this specialty. However, less than half regarded their career choice in year three as definite. This is an important message. It is vital that we ensure a positive experience for trainees in paediatric posts. It is, however, inevitable that not all who commence in paediatric specialty training will remain in paediatrics or will be suited to the specialty.

More flexible working practices

Compatibility with family life and a good work–life balance are important when choosing a career. The structures within medicine have been found not to be conducive to good family life.23 Quality of life issues are the most common reason why doctors training in a medical or surgical specialty subsequently change their career plans.24 In the past women who chose a career in paediatrics had to make sacrifices in terms of family and personal commitments.14 Currently, 60% of medical students are female and female doctors account for 59% of all paediatric consultants.25 Paediatrics has the highest number of trainees working part time of any single specialty and the majority do so for childcare reasons.26 Work–life balance is important to women consultants27 and some of the problems women faced when seeking a career in paediatrics over 20 years ago have been resolved.28 However, significant problems remain and there must be no complacency. There has been an increase in mature graduates and they are less likely to choose a career in paediatrics than those who were non-graduate entrants to medical school.29 Attitudinal change is still very much needed to enable part-time working to be successful at all levels. Barriers to working part-time need to be removed, especially the bureaucracy which makes it difficult for trainees to set up slotshares.30 Term time working, annualised hours and flexible retirement must all become the norm if we are to continue to attract students, including graduate entrants and junior doctors, to paediatrics.

Good news messages

Other people’s perception of the job was the most important factor in the career choice of Manchester University medical students when surveyed in 2007.18 Paediatrics is known for its heavy workload,6 onerous on-call shifts and consultants being in hospital when on call. What is less known is that if time is spent on call, then this is reflected in the programmed activities (PAs) and many new consultants on a 10 PA contract only work 4 days per week and less if resident on call.31 It is important that the issue of a heavy workload is addressed and solutions to minimise on call duties, such as rationalisation of units, are carefully considered. If as a college we persist with the current working practices and do not look at potential solutions, then we are likely not to attract students and junior doctors to a career in paediatrics. Annualised hours, a reduction in hours before retirement and innovative job design are key considerations.30

National job offer policies

The last few years have been ones of change and uncertainty in postgraduate medical education and training. In 2007, MTAS (the Medical Training Application Service) affected both trainees and trainers. National RCPCH led recruitment for paediatrics has been a positive step with those who are offered a FTSTA/ST post for paediatrics in one deanery able to provisionally accept this post until they know the outcome of their first choice deanery. However, this is not the case when junior doctors have applied for one or more different specialties as well as paediatrics. General practice allows the applicant 48 h to respond to an offer and trainees who would have preferred paediatrics may opt for a secure job offer in this time of job uncertainty. The RCPCH along with the other colleges must campaign to make job offers a level playing field. Much of the career work done is pointless if career choice is going to be influenced by the need to respond to a 48 h job offer!

Career guidance by experts

Career advice and information is key to a person’s ultimate career choice. It is important that medical school career advisors, educational supervisors of Foundation trainees and specialty trainees, RCPCH tutors and postgraduate clinical tutors know where information can be obtained and have a list of contacts so as to point trainees in the right direction. Explicit guidelines on educational supervision are needed as practice is variable32 and never more so than in the area of career guidance. Educational supervisors were used by 67% of Foundation trainees for career advice.33 However, it is clearly stated in the MMC guidelines that those who provide career advice need to be appropriately trained.3 Unbiased opinions are needed and impartial trained career advisors have been shown to be more successful.34 35 Following the publication of the document Career management: an approach for medical schools, deaneries, royal colleges and trusts in 2005,3 deaneries have a structure for educational supervisors to access expert career advice. This structure varies according to region and educational supervisors should start by contacting the RCPCH tutor and postgraduate clinical tutor who will know the local set-up.

OTHER TIPS FOR THOSE CONSIDERING A CAREER IN PAEDIATRICS

A key factor of working in paediatrics is to like children, not just babies but children of all ages including those in pre-school and at school, and in the teenage years. Experience working with children in a voluntary capacity (eg, at a local youth group or playgroup, etc) is helpful. Spending time in paediatrics as part of student elective studies can also be useful. Similarly, any student projects which provide exposure to paediatrics as well as special study modules will also aid with career decision.

SUMMARY

The growing number of medical students in the UK should increase the number of UK paediatricians. However, this will only occur if training is delivered with enthusiasm and is stimulating from the first student encounter on the paediatric wards through to the end of the training grades. This needs to be coupled with flexible working practices which are incorporated into departments as part of everyday paediatric practice (box 5).