Choosing a career in paediatrics: do trainees' views change over the first year of specialty training?

OBJECTIVES: To look at why a regional cohort of UK doctors chose a paediatric career and to ascertain views on their career near the end of training year one.
DESIGN: A 20-item questionnaire was sent to all new regional paediatric specialty trainees. Three focus groups were held with trainees near the end of year one to elicit key themes.
SETTING: West Midlands Deanery, UK. PARTICIPANTS: Twenty-nine new regional paediatric specialty trainees in year one completed the questionnaire. A total of 15 trainees participated in the focus groups near the end of year one training. MAIN OUTCOME MEASURES: Reasons for choosing a paediatric career and factors which further influence career choice for trainees during their first specialty training year.
RESULTS: Key influencing factors for choosing paediatrics were enjoying working with children and positive undergraduate experience of the specialty. All trainees had paediatrics as their first choice specialty and undertook a paediatric Foundation post. Near the end of year one, doubts were cast on career aspirations due to seeing middle grade colleagues struggling with work-life balance and a growing feeling that family came first.
CONCLUSIONS: Senior trainees need to be aware that they act as powerful role models for their more junior colleagues and therefore have an influential role on how juniors perceive a paediatric career. Family friendly flexible working patterns in paediatrics are vital to retain junior trainees. All paediatric staff are role models and need to be enthusiastic, keen to teach and to promote a positive working environment.

Introduction

Choosing a career in paediatrics is influenced by paediatricians’ enthusiasm, keenness to teach and the atmosphere on the wards, as well as trainees having a personal desire to work with children and past experience of doing so.[1,2] It is important to have exposure to the specialty from early in undergraduate training as well as continuing opportunities to gain more insight into the specialty by special student models and Foundation doctor ‘taster’ placements of up to one week.[1] Paediatrics has been viewed as a difficult specialty with a high workload and poor social life.[3] There has been much input into improving recruitment into UK paediatrics with a focus on careers events both in undergraduate and postgraduate training.[4] These events are important to help dispel some of the myths about paediatrics and give a balanced view of the specialty.

One in 10 trainees in UK paediatric medicine drops out of training by specialty training year 3 (ST3).[5] In addition, over 40% of trainees have seriously considered leaving the specialty.[6] The majority of trainees who left paediatrics chose general practice and did so for work–life balances reasons.[5] This study looks at the influencing factors for regional trainees choosing a career in paediatrics and ascertains their views on their career near the end of training year one.

Methods

Prior to posts beginning in September 2011, all 38 new specialty trainees in year one (specialty training, ST1) were asked to complete a 20-item questionnaire looking at influencing factors for choosing a career in paediatrics. This was sent electronically and returned anonymously to the School of paediatrics administrator. Data were entered into an Excel database and analysed using SPSS version 18.0.

Three focus groups were held in May 2012 attended by 15 of the 38 trainees to explore their views of paediatrics as a career when nearly at the end of first-year specialty training. Five semi-structured questions were used looking at (1) key factors which led to choosing a paediatric career, (2) current concerns about specialty choice, (3) whether trainees were likely to change their career choice, (4) advice trainees would give to medical students considering a paediatric career and (5) any other issues. Interviews were digitally recorded, transcribed verbatim and thematic analysis undertaken (by HG and TB).

Results

Twenty-nine of 38 (76%) trainees completed the questionnaire. paediatrics was the first choice specialty of all respondents. Two-thirds (20/29) were female, four were graduate entrants to medical school and two trainees worked part time reflecting the demographics of the cohort. The majority (83%) had attended medical school in the UK. Nearly half (14/29) were not definite about specialty choice until after the end of the first year of Postgraduate training (Foundation year one). Influential factors were finding out more about paediatric careers by means of special student study modules (9 trainees, 31%), student electives (9, 31%), taster sessions (6, 21%) and careers fairs (24, 83%). All trainees had undertaken a paediatric Foundation post, 20 (69%) in Foundation year one and 11 (38%) in Foundation year two, with 2 (7%) having a paediatric post in both Foundation years. Foundation posts were felt to be helpful to gain real life experience of the specialty which was different to that of a student and to confirm career choice. The other key factors influencing career choice were enjoyment of working with children and undergraduate and postgraduate experience. Respondents ranked highly the teaching given in paediatrics, consultants’ enthusiasm and the good working atmosphere with questionnaire respondents feeling part of the team.

The analysis of the focus groups showed three themes: (1) reasons for applying for paediatrics, (2) how trainees had found the job and (3) current thoughts and feelings about a paediatric career. Verbatim illustrative quotes are shown in Table 1. Reasons for applying for paediatrics agreed with the questionnaire findings. Trainees had enjoyed their first training year, although starting in neonatal paediatrics was regarded as scary with the first few weeks considered difficult. Trainees had mixed feelings about their future in paediatrics. The main concerns were around work–life balance, resident night shifts and the fact that these shifts continued as a consultant. Seeing middle grade colleagues struggle with balancing work and family commitments was a negative influence for the trainees. There was a strong feeling that if a choice had to be made between career and family, then family would come first (see verbatim quotes in Table 1) and trainees would leave paediatrics.

Table 1.

Verbatim comments from focus group participants.

Theme 1: Reasons for applying for paediatrics

• ‘I always wanted to do paeds before starting medicine’

• ‘I have done a lot of work with children before coming to medical school’

• ‘I enjoyed my paediatric placement as a medical student’

• ‘Paediatricians I have encountered have been supportive and encouraging of learning as well as an attitude of how interesting their specialty is’

Theme 2: How trainee had found the job

• ‘Very supportive specialty – always registrars around. The consultants are very involved in patient care’

• ‘Everyone is easy to talk to – paediatric wards are very nice’

• ‘I was really anxious about starting neonates’

Theme 3: Current thoughts on a career in paediatrics

• ‘I don’t mind the fact that is an 8 year run-through programme’

• When I think of the future I don’t know how I will combine family with this job’

• ‘If family comes my priorities will change – if I have to choose I will choose family’

• ‘Nights shifts to contend with – that is just a bit of a concern’

• ‘I am on maternity leave – a bit difficult to get back into work’

• ‘Even at senior level you are expected to be resident – it is such an involved career’

• ‘You see the registrars, the higher trainees who are struggling to balance family commitments’

Discussion

Factors influencing career choice including previous work with children, consultants’ enthusiasm and teaching commitment agree with the findings of previous reports.[1-4] There has been a lot of careers input into paediatric recruitment and this has paid dividends with a majority of the study cohort having attended a careers event as well as having the benefit of paediatric student electives, special student study modules and foundation taster weeks.

It was pleasing that, in general, trainees were enjoying their paediatric posts and felt well supported by middle grade and consultant colleagues as well as the extended paediatric team. Noteworthy is the concern regarding commencing training in neonatal paediatrics of which a minimum of a six-month posting is mandatory in the first three years of training. Thought needs to be given on how to further improve this experience and allay anxieties.

Although paediatrics was the first choice career for all study trainees, they were concerned about the impact of a family on their future career. Increasing emphasis is being put on work–life balance by trainees and has been previously noted to be a key reason for rejecting paediatrics as a specialty,[1,7] It is important that all paediatric staff – not just consultants – are aware that they are role models, especially middle grade trainees who had a big impact on our study trainees when seen to be struggling with balancing work and family commitments.

This cohort of regional trainees with nearly 70% being female is representative of the demographics of the specialty. There is an increasing need to provide working hours which are more family friendly and flexible for paediatric trainees as work–life balance is important to this workforce. Such working patterns would do much to counteract the negative image of resident nights continuing even at senior level.

Our study has limitations. It looked at one region of the UK and although we have 10% of the UK trainees in our region, future work would ideally look at trainees' views from across the UK to see if there is any regional variation. It will be important to follow this cohort and see how their views change as they continue to progress in training and also to ensure interviews are undertaken with any trainees who leave paediatrics to gain further insights into why trainees leave the specialty.

Conclusions

All paediatric staff are role models and need to be enthusiastic, keen to teach and to promote a positive working environment. By the nature of the specialty, paediatricians hopefully all like children and therefore should be in agreement with trainees’ need to put family first. The challenge is to focus on solutions which make it easier than at present for junior colleagues to have both a career and a family and by doing so help to reduce the attrition rate from paediatric specialty training.