One of the great satisfactions of editing career focus is looking back over the archive and marvelling at the diverse range of activities that people with a medical degree can get involved with. Medicine is truly a broad church, and it is one of the tenets of Career focus that dissatisfied doctors have yet to find a niche or working pattern that suits them. We reasoned that better information could only help in that process,1 although, of course, articles alone do not supply the proactive approach necessary to achieve the balance between ambition and lifestyle that each doctor must achieve.
About a third of articles arrive spontaneously; the rest are commissioned, often as a result of a response to a reader's inquiry. Many can be published with minimal editing. When this is not so, and the idea is a good one, our approach has been to nurture the article through the revision process rather than reject outright. Our regular readership surveys suggest that you enjoy the section: a third of the BMJ's readership read it every or most weeks, and a further third read it sometimes or occasionally.
Career focus has unashamedly pursued an agenda that promotes maximum choice and information for the individual and equal opportunities for all, both areas which have been in short supply in the British medical profession. Editorially, the section has been a little different too.
Firstly, there is no such a thing as the definitive article on any career topic: it would have been a mistake, for example, to commission articles on careers in a particular speciality only from the appropriate royal college. Often the best person to write about a specialty is an active member of such an organisation, but much of the realism of the section has come from inviting doctors researching their own prospects to take notes as they go or to elaborate on personal experiences. When the section was first envisaged, we had the hazy idea that a weekly series would cover most of the ground in a year or two, and then might start to repeat and update articles. The fact that we are still so far from that point is evidence both for the diversity of the profession and of the necessity of taking a general view of what is relevant when considering the personal and professional development appropriate for doctors in today's society.
We know that most doctors make their choice of career based on their experience as students.2 This is in part appropriate, but consideration of other, more objective factors could be helpful. The approach of Career focus might be naive, but we hope that an invitation for readers to consider the many factors that may affect satisfaction in a specialty could be valuable. More research in this area would be welcome; the theories that occupational psychologists have developed in many aspects of employment 3 4 have yet to find wide application in the medical profession.
It was also a deliberate policy from the start to illuminate specialties and aspects of medical work that have a low profile on the undergraduate curriculum or are, for various reasons, not necessarily obvious. It is easier, for example, to find out about a career in general internal medicine or orthopaedics than audiological medicine.
Career focus has taken a deliberate lead in promoting equal opportunities within medicine. There is still evidence of both sexist and racist employment practices in the profession.5 This should both be a cause of shame and a spur to action. For example, 14% of consultants are from an ethnic minority, yet only 5% hold distinction awards.6 While idealistic concern for a just society constitutes quite sufficient reason to pursue this, the business case for fair employment practice should not be overlooked. Denying the legitimate aspirations of both men and women for time to pursue relationships and family life erodes morale and can result in the loss of expensively trained professionals.
Linked with this is a reluctance to face the full consequences of a move to a consultant based rather than consultant led service. These chronic problems arise from a conflict of financial interest at the highest levels of the profession. An undersupply of doctors and specialists tends to keep prices for medical services high. In crude terms, consultant expansion is contrary to the economic interests of existing specialists. On the government's side, the situation is tolerated for several reasons. Firstly, expanding the numbers of specialists would mean that the cost of providing health services would rise: doctors are not just expensive to employ but generate the most costs within the service. Doctors are also expensive to train&emdash;a figure often quoted is £200 000, but that cost is calculated by dividing by the number of medical students by the total funding for medical schools and bears little relation to the marginal cost of training each additional medical student.
Like the old Soviet 5 year plans, the size of the medical workforce is planned at national level, in the hope that supply will meet demand, with one important difference: producing a fully trained specialist takes a lot longer than 5 years. So even if techiques for estimating current demand were perfect now, any small perturbation in the future will set the estimates out a long way.7
The present crisis, in which 200 fully trained obstetricians face unemployment, suggests that planning is far from perfect. This unwieldy planning is also the root cause of the recent unpleasant pronouncement that there can be no prospect of a 48 hour working week for junior doctors for at least 13 years.
Other countries do things differently but pay the price of unfeasibly large classes in the early years of medical school, and, later, a degree of medical unemployment.8 Medical unemployment has potential implications for the quality of care. Although clinical skills such as history taking and examination seem to be retained almost indefinitely once learnt, a surgeon may feel trepidation about returning to operating after only a short period such as two week holiday. (CL Welsh, personal communication). Often surgeons will organise "warm up lists" of relatively simple procedures on the first day back. Plainly, doctors are not devices that can be switched on and off according to society's wish to pay the bill.
Just as teachers get frustrated by the fact that everyone is an expert on education, because they have been to school, so perhaps it is a truism that everyone is an expert on careers: because they have had one. If gathering information from individuals about individual careers has been a strength of Career focus, the amount of epidemiological data we have published on medical workforce statistics has been disappointing. Major reports are flagged up in Briefing as they appear, but our ambition is to publish more secondary analysis of the volumes of data about the medical workforce generated by the Department of Health and others.
There are two main reasons why this has not yet been realised. Firstly, the section is not externally peer reviewed, is not indexed in Medline, and does not earn citation credits. This has been a disincentive for academics obsessed with such ratings, although this disadvantage is diminishing as ePrint archives and web based citation enter the medical mainstream. And, of course, authors who merely care about being widely read will still want to be published here. Interpreting workforce epidemiology is a major intellectual undertaking, and there are not many studies out there to be published. One consequence of the information revolution will be that many of the databases currently held internally by governments and academic institutions should become available for wider analysis.
Career focus was the first section of the BMJ to be freely available in its entirety on the web. However, an information architecture that worked well with only a few articles is starting to look a little tired with 150. The section will shortly be joining the rest of the BMJ on the Highwire site, which will make searching the archive easier and ensure that its contents will be available to users of the eBMJ from whichever direction they alight on the site. It will also enable all of the other features, such as customised alerts, and the development of collected resources. There are also plans to enhance the advertisements within the electronic version of the classified supplement.
There are still many gaps in the archive to be filled (including many of the major specialties), and your suggestions and contributions continue to be welcome. The best starting point for any intending author is the Career focus web archive&emdash;if the article you want to read is not there, please do feel free to suggest it or even supply it.
Douglas Carnall, BMJ
1 Carnall D, Smith R. Careers advice for doctors. BMJ 1996;313:3.
2 Allen I. Doctors and their careers. London: Policy Studies Institute, 1988.
3 Cook M. Traditional ways of selecting medical staff [career focus]. BMJ 1998:316(classified section 7 Mar):2-3.
4 Cook M. New approaches to selecting medical staff [career focus]. BMJ 1998:316(classified section 14 Mar):2-3.
5 Esmail A, Carnall D. Tackling racism in the NHS. BMJ 1997:314;618
6 Briefing [career focus]. BMJ 1998;316(classified section 28 Mar):2-3.
7 Department of Health. 3rd report of the Medical Workforce Standing Committee 1997. http://www.open.gov.uk/doh/medical/mwsca3.htm.
8 Bamforth I. Life as an omnipraticien in France. [career focus]. BMJ 315(classified section 8 Nov):2-3