Career plans and views of trainees in the Academic Clinical Fellowship Programme in England

Abstract

Background: The Academic Clinical Fellowship (ACF) programme in England was introduced in 2007 to support the training of clinical academics.

Aim: To report on career plans and views of ACF trainees.

Method: Questionnaire survey of trainees appointed in 2008.

Results: Of 102 responders, 63% expected to work eventually wholly in clinical academic posts, 34% in clinical service posts with some teaching and research, and none in clinical service posts with no teaching or research. Of factors that had influenced the choice of an academic career ‘a great deal’, 83% of responders cited having a ‘varied and stimulating career’, 79% the ‘intellectual environment’ of academic departments, 78% the ‘challenge of research’ and 62% the ‘stimulation of teaching’. The most important factors that might dissuade them from eventually pursuing an academic career were ‘difficulty obtaining research grants’ (specified by 42%), followed by ‘competing pressures in the three areas of research, clinical work and teaching’, lack of ‘pay parity with NHS colleagues’, and concerns about adequate availability of academic posts at senior levels.

Conclusions: The responders were highly motivated by the challenges of academic work. However, policymakers need to consider what, if anything, might realistically be done about potentially demotivating factors.

Introduction

In the past 20 years, concerns have been expressed in the UK that academic medicine has become an unattractive career with uncertain career pathways (Weatherall 1991; House of Lords Select Committee on Science and Technology 1995; Richards 1997; Goldacre et al. 1999; Clark & Smith 2003; International Working Party to Promote and Revitalise Academic Medicine 2004). In recent years, new programmes have been developed, aimed at increasing access to academic careers. The Academic Clinical Fellowship (ACF) programme is a training scheme in England, introduced in 2007 by the English National Institute for Health Research, as an initiative to increase numbers of junior doctors entering formal and structured training programmes that will lead to clinical academic careers. The programme was established to implement recommendations from a committee, chaired by Professor Sir Mark Walport of the Wellcome Trust, which had been commissioned by the English Department of Health to design a clear, coherent and integrated career pathway for medically and dentally qualified academic staff. The report of the committee (Walport 2005) advocated the establishment of an explicit academic training pathway for medical and dental staff which would consist of three increasingly senior levels of post – ACFs, Clinical Lectureships and Clinical Senior Lectureships. The ACF posts are the first stage of the academic career pathway, though some post-holders enter the academic training programme a couple of years after starting their higher specialist training in other posts; and the posts are typically intended for people who do not yet have a higher degree such as an MD or PhD.

The ACF programmes combine academic training and work, generally in a university environment, with NHS specialist training in the chosen specialty based on the principles of postgraduate training specified by Modernising Medical Careers (MMC 2007). MMC provides for a structured training programme in each clinical specialty with a clearly defined beginning (entry to a formal programme) and end (the certificate for completion of training). The formalised academic training is intended to support the ambitions of the NHS to strengthen clinical research in the NHS as outlined in the Department of Health's (2006) Report, Best Research for Best Health.

We were commissioned by the English Department of Health to conduct a survey of the ACF trainees appointed in 2008. Its aim was to report on the basic demographic characteristics of the trainees, their future career plans and their views on incentives and disincentives in pursuing a clinical academic career. We report our findings from the survey.

Table

Practice points

Doctors considering a clinical academic career are most attracted by the prospect of variety, working in an intellectual environment and the challenge of research. Doctors would be discouraged from continuing to follow an academic career by difficulty in obtaining research grants; competing pressures from research, teaching and service work; and loss of pay parity with NHS clinical colleagues.

Method

The survey questionnaire was designed by drawing on the UK Medical Careers Research Group's experience in conducting surveys of medical career intentions in general (Lambert et al. 1996, 2006), and of views of junior doctors and dentists in clinical academic posts in particular (Goldacre et al. 1999, 2000; Lee & Goldacre 2002). The questionnaire was developed with input from ACF trainers and was piloted on a group of ACFs who had entered the programme in 2007 (the previous year). Sections of the questionnaire are reproduced as an Appendix to this article. Survey participation was developed as an online activity. Questionnaire software was prepared which enabled the data to be captured from responders, who completed the survey via a Web interface, and stored in a database.

All 13 English postgraduate deaneries were contacted. The purpose of the survey was explained to them, and the survey team asked for permission to contact their ACF trainees individually by email, providing in the email a direct link to the survey's Web address. Although the project had national ethical approval, DH support, and support from postgraduate deanery staff responsible for training the ACFs, it proved difficult to obtain email details from some deaneries. Five deaneries agreed to supply email addresses to us for their ACFs appointed in 2008. Four other deaneries agreed to send emails about the study to their ACFs on our behalf.

The logging of replies in the database was secured as follows. Each reply initiated the creation of a record of the doctor's replies in the database and, in parallel, an email from the doctor containing the replies to the questions was sent to the research team. Replies in the database were matched against the emails received to check for consistency, and non-responders to the first emailing were identified and re-emailed. For those deaneries which had not provided us with email addresses, a ‘broadcast’ message was sent to the ACFs by the deanery staff, and this was repeated later as a reminder to non-responders.

The data were imported into SPSS for analysis.

Results

Response rates

Nine English deaneries participated in the study. The response rate in the five deaneries which allowed us to send emails to their trainees was 65% (85/131) after two mailings. The response rate in the four deaneries that sent the emails themselves, on our behalf, was 29% (17/59 doctors). There were therefore 102 responders. Below, we generally provide percentages and, because the number of responders is so close to 100, have not shown the numbers on which the percentages are based.

Demographic characteristics

In this study, 56% of responders were men, 42% were women, and two responders did not specify their sex. The women were slightly younger than the men: 66% of the women were under 30 years of age, compared with 48% of the men. Overall, 32% of the doctors were aged under 28 years, 24% 28–29, 17% 30–31, and 25% were 32 or over.

Of the responders, 65% signified their ethnicity as white, 24% as Asian, 5% as other minority ethnic groups and 6% did not give their ethnicity. Of the ACFs of white ethnicity, 78% (50/64) were UK-born; by comparison 50% (15/30) of the non-whites were UK-born (χ²(1) = 6.3, p = 0.01).

Of the responders, 55% were in the ST1 year (i.e. the first year of specialist training), 10% ST2 (the second year), 31% ST3 and 3% ST4. Only six trainees were working less than full time.

Of the ACFs, 22% were in surgical specialties, 39% in the medical hospital specialties and 37% in other specialties, mainly in hospital but also a few in general practice or public health.

Only 18 of the 102 responders had degrees on entry to medical school, 11 of whom gained first class honours. During their undergraduate studies, 69 had obtained an intercalated degree, and of these 40 had gained first class honours. Thus, in all, 50% had a first-class honours undergraduate degree. A total of 51 responders had obtained additional academic qualifications since leaving medical school, or were studying for them: 15 had obtained a bachelor's degree, 15 had obtained an MSc, 8 had obtained a PhD (with a further 4 in progress), and 7 had obtained an MD (with a further 2 in progress).

Future career intentions: specialty choice

The doctors were asked ‘Have you made up your mind about your long-term choice of specialty?’ and were asked to choose between the three responses ‘definitely’, ‘probably’ and ‘not really’. Responses from men and women were very similar: 77% regarded their career choice of specialty as definite, 22% as probable, and only one person was unsure.

Those who replied that they were not definite about their eventual specialty choice were working in surgery (six responders), medical hospital specialties (four), psychiatry (three), paediatrics (three), public health (three) and there were three others.

The responders were presented with a closed list of 12 factors and asked whether each had affected their career choice ‘not at all’, ‘a little’ or ‘a great deal’. Analysis showed that the response ‘a great deal’ was the best discriminator between the factors, for the purpose of summarising and reporting the results. The 12 factors are presented in Figure 1 ranked in descending order of the percentage responding ‘a great deal’.

Figure 1. Factors affecting specialty choice: highly rated factors.

‘Enthusiasm/commitment/what I really want to do’ was the strongest factor, followed by the ‘opportunity to conduct research’. ‘Experience of jobs so far’, and ‘self-appraisal of own skills and aptitudes’, were cited as having influenced their career choice a great deal by approximately half the responders. The role of a particular teacher or department was also influential, career and promotion prospects less so. Although not statistically significant, men had higher scores than women on the degree to which their choice was influenced by the opportunity to conduct research (χ² = 1.6; p = 0.2) and by career and promotion prospects (χ² = 1.7; p = 0.2). More women than men ascribed a great deal of influence to acceptable hours and working conditions, or to wanting a career that fits their domestic circumstances; the difference between men and women was significant when comparing those who specified that either or both factors had a great deal of influence (χ² = 4.84, p = 0.03). Future financial prospects were a very minor motivator for specialty choice.

Future career intentions: working in UK medicine

Responders were asked whether they ‘intended to work in medicine in the UK for the foreseeable future’, with possible responses ‘yes-definitely’, ‘yes-probably’, ‘undecided’, ‘probably not’ and ‘definitely not’. No responder selected either of the last two options. In this study, 83% (82/99) ‘definitely’ or ‘probably’ intended to stay in the UK and 17% were undecided (three doctors did not answer the question). In all 23% of women (10/43) and 13% of men (7/55) were undecided (χ²(1) = 1.2, p = 0.3; sex unknown in one case).

Future career intentions: type of post

As Table 1 shows, 63% of responders intended to work in clinical academic posts, with smaller percentages expecting to work in service posts with some teaching, research, or both. No responder specified work in a service post without teaching or research; 12 were undecided. Differences between men and women were small (Table 1).

Table 1.  Career intentions: type of post

In your long-term career, do you intend mainly to work in:	Total (n = 102)^a		Men (n = 57)		Women (n = 43)
Clinical academic posts	64	(63%)	35	(61%)	28	(65%)
Clinical service posts with some teaching and research	22	(22%)	11	(19%)	10	(23%)
Clinical service posts with some research	3	(3%)	2	(4%)	1	(2%)
Clinical service posts with some teaching	1	(1%)	1	(2%)	0	(0%)
Clinical service posts without teaching or research	0	(0%)	0	(0%)	0	(0%)
Undecided	12	(12%)	8	(14%)	4	(9%)

Note: ^aTwo responders did not specify whether male or female.

The decision to undertake an academic career

Figure 2 shows the percentage of doctors who cited each of several factors as having had ‘a great deal of influence’ in deciding to pursue an academic career. The factors that were accorded the greatest level of influence by the responders were ‘the opportunity to have a more varied and stimulating career than that of an NHS consultant or GP’ (cited as having a great deal of influence by 83%), ‘the intellectual environment in an academic unit’ (79%), and ‘the challenge of research’ (78%). The opportunity to make discoveries which may ultimately benefit patients, the stimulation of teaching students and young doctors, and the stimulation of supervising research teams were also described by over half the responders as having had a great deal of influence on their decision to follow a clinical academic career (Figure 2). Lack of enjoyment with service work and the lack of availability of service training posts were unimportant for most responders. Approximately 20% admitted that a desire to gain experience which would give them ‘an advantage when later applying for service posts’ had been a great deal of influence in their decision to follow an academic training route. The opportunity to travel, and recognition by peers, had only influenced a small minority in their decision to pursue an academic training route (Figure 2).

Figure 2. Factors influencing the decision to undertake an academic career.

Factors that might dissuade responders from pursuing an academic career

We asked responders to rate the importance of a number of factors that might dissuade them from pursuing a clinical academic career, using a three-point scale covering ‘a great deal of influence’, ‘a little’ and ‘no influence/not at all’ on their wish to continue. Although each of the factors given was cited by less than half the responders (Figure 3), there were appreciable minorities for most of the factors listed. The factors that were most commonly mentioned were difficulty obtaining research grants (cited as potentially having a great deal of influence by 42%); competing pressures from service, teaching and research (33%); possible loss of pay parity with NHS service colleagues (28%); and a possible shortfall of senior clinical academic posts (28%).

Figure 3. Factors which might dissuade responders from continuing in an academic career in the long term.

Factors influencing choice of a specific training programme

We asked about possible factors which may have influenced the decision to follow a specific ACF training programme. Figure 4 shows the percentage of responders who said that each factor had a great deal of influence on their decision to undertake a specific programme.

Figure 4. Factors affecting the decision to undertake a specific ACF programme.

For 80% of the responders, the choice of programme was influenced ‘a great deal’ by its being in an area of research of personal interest. The opportunity to work in a specific department, the geographical location of the programme and the facilities offered for research, were each influential for about a half of the responders. The opportunity to work with a specific consultant was influential for almost a third of the responders. Scope for teaching, and the opinions of other ACFs, were not particularly important (Figure 4).

Discussion

Three-quarters of responders regarded their choice of future specialty as definite; two-thirds wanted to work eventually in clinical academic posts, and the remainder wanted to work in clinical service posts with research or teaching roles. The great majority specified that they would definitely or probably work in medicine in the UK for the foreseeable future. If these intentions are followed, the ACF programme will achieve the objective of adding the great majority of its trainees to academic roles in UK medicine.

It may be surprising that only three-quarters felt sure about their specialty choice, but, in our general studies of doctors, certainty of choice is expressed by only 43% of responders 3 years after qualifying and by 63% at 5 years (Goldacre et al. 2010). By 5 years in these studies, the majority who were not certain specified that their choice of specialty was their ‘probable’ eventual choice; and the great majority of these doctors do eventually practise in the specialty specified as their ‘probable’ eventual destination (Goldacre et al. 2010). Further, for those doctors in the ACF programme who do switch specialty intention, their experience in the ACF posts will have given them some transferable academic skills and experience.

Our study adds to a systematic review of the existing literature on positive and negative factors affecting academic career choice, carried out in 2006 (Straus et al. 2006). Of factors that had influenced the doctors to favour an academic career ‘a great deal’ in this study, 80% or more cited the prospect of a varied and stimulating career, the intellectual environment of academic departments, and the challenge of research. These are broadly similar to the findings from a survey of MRC and Wellcome academic fellows, a decade earlier, in which 76% of responders cited the ‘challenge of research’ as a strong motivator, 72% cited the opportunity to have a ‘more varied and stimulating career’, and 67% cited the ‘intellectual environment of an academic unit’ (Goldacre et al. 1999). The ‘stimulation of teaching’ was cited by 63% of responders in this study, compared with 34% of the MRC and Wellcome fellows in the earlier study. The responses from the ACFs are characterised by their enthusiasm for academic work. ‘Lack of enjoyment of service work’ and ‘lack of service training posts’ were not important factors for the great majority of responders in their decision to pursue an academic career.

Of factors that influenced the doctors ‘a great deal’ in applying for their specific ACF programme, 80% cited the opportunity to work in an ‘area of research in which I am interested’. This was well ahead of other factors, such as ‘geographical location’ (cited by 48%) or to undertake undergraduate teaching (19%).

The factors that might dissuade the doctors from pursuing an academic career were also similar in this study and the earlier MRC/Wellcome study. The factors that were most commonly cited as potentially important disincentives were ‘difficulty in obtaining research grants’ (cited by 42% in this study, and by 54% in the earlier MRC/Wellcome study, Goldacre et al. 1999), ‘competing pressures’ in the three areas of service work, teaching and research (33% in this study, and 39% in the earlier), uncertainty about maintaining pay parity with the NHS (28% and 44%) and lack of availability of senior academic posts (28% and 32%).

The UK Medical Schools Council has recently stated that, at current levels, junior clinical academics are too few in number to replace the expertise and leadership that will be lost through retirement over the next 10 years (Fitzpatrick 2010). If the shortfall in the medical academic workforce is to be countered, academic career structures need both to attract and retain sufficient numbers of doctors. It is therefore important to consider the disincentives to pursuing academic careers.

Difficulty in obtaining grants may be unavoidable in the competitive world of research. Competing pressures may be unavoidable, too, for doctors whose work spans service, teaching and research. It has, however, been suggested that one ameliorating policy could be to encourage the development of those who excel at any two of these, and formally establish the categories of researcher-teachers, clinician-teachers and clinician-researchers (Aronson 2011). The issue of competing pressures from academic and service work has been found to be a significant concern among doctors at an earlier stage in their career, too, during foundation training (Lyons et al. 2010) and it was a major concern considered in the Richards (1997) report on clinical academic careers. Retaining pay parity and establishing an appropriate number of senior posts to match the number of trained academics who aspire to them, are more amenable to policy decisions.

The number of ACFs in the study is fairly small. The response rate from the surveys emailed by the research group is satisfactory; that from the surveys emailed by the deaneries is disappointing. Numbers in each of these two subgroups are too small to warrant detailed comparisons between them. However, the profiles of factors that have encouraged the ACFs to pursue an academic career, and the factors that would discourage them, are similar to those in the earlier study of MRC and Wellcome fellows. This indicates that these findings are probably generalisable to doctors considering an academic career in England at present.

In summary, the responders were highly motivated by the challenges of academic work. Policy makers need to consider what, if anything, might realistically be done about potentially demotivating factors.

Acknowledgements

We are very grateful to all the survey participants and to the Deans for their support.

Declaration of interest: The authors declare that they have no conflict of interest. The authors alone are responsible for the content and writing of the paper.

Ethical approval

This study was approved by the National Research Ethics Service after consideration by the Southampton and South West Hampshire Research Ethics Committee.

Funding

Department of Health. The funding body had no role in the analysis or interpretation of the data. The views expressed in this article do not necessarily reflect those of the funding body.

Appendix

Precise wording of questions

Q 13. How much has each of the following factors influenced your choice of specialty?

• Please answer for each factor, by ticking one of the three boxes: Not at all, a little, a great deal

• Wanting a career that fits my domestic circumstances

• Future financial prospects

• Wanting a career with acceptable hours/working conditions

• A particular teacher/department

• Experience of chosen subject as a student

• Advice from others

• Enthusiasm/commitment/what I really want to do

• Experience of jobs so far

• Self-appraisal of own skills/aptitudes

• Career and promotion prospects

• Inclinations before medical school

• Opportunity to conduct research

• Other reasons*

• *If ‘Other reasons’ influenced your career choice, please give details of those reasons

Q 14. How much has each of the following factors affected your DECISION TO UNDERTAKE AN ACADEMIC CAREER?

• Please answer for each factor, by ticking one of the three boxes: Not at all, a little, a great deal

• The opportunity to have a more varied and stimulating career than that of a NHS Consultant/GP

• The intellectual environment in an academic unit

• The opportunity to make discoveries which may ultimately benefit patients

• The stimulation of supervising research teams in future

• Recognition by peers for achievements in medical research

• The stimulation of teaching students and young doctors

• The opportunity to travel to overseas meetings and meet foreign colleagues

• The challenge of research

• A lack of training posts, currently, in service areas

• Lack of enjoyment with service work

• Wanting to gain experience which will give me an advantage when applying for service posts later on

• Other reasons*

• *If ‘Other reasons’ influenced your career choice, please give details of those reasons

Q 15. How much has each of the following factors affected your DECISION TO APPLY FOR THE SPECIFIC ACF PROGRAMME that you are currently undertaking?

• Please answer for each factor, by ticking one of the three boxes: Not at all, a little, a great deal

• The opportunity to work with a Professor/Consultant/GP whose work I admire

• The opportunity to undertake undergraduate teaching

• The opportunity to work in an area of research in which I am interested

• The facilities offered to help me conduct research

• The opportunity to work in a department which has produced work I admire

• The geographical location of the programme

• The opinion of current ACFs working on the programme was important in making up my mind

• Other reasons*

• *If ‘Other reasons’ influenced your choice of ACF programme, please give details of those reasons

Q 18. How much might each of the following factors DISSUADE YOU from continuing a clinical academic career in the long term?

• Please answer for each factor, by ticking one of the three boxes: Not at all, a little, a great deal

• The pressures of being assessed on all three activities of: clinical service; teaching; and research

• The difficulty of obtaining research grants

• The small number of senior academic appointments available

• Few opportunities for additional pay banding

• Uncertainty about achieving pay parity with NHS colleagues

• Competing pressures from service, teaching, and research

• Less favourable conditions of employment compared with NHS colleagues (in respects other than salary)

• The limited opportunities for private practice

• The possibility of a significantly longer training period to completion of training compared with NHS colleagues

• Other reasons*

• *If ‘Other reasons’ might influence your decision NOT to continue in an academic career in the future, please give details of those reasons: