Purpose of the study The National Health Service is experiencing a recruitment crisis across many medical specialties. Diabetes and endocrinology (D&E) is failing to fill training posts with only 77%, 83% and 73% of posts filled overall in 2016, 2017 and 2018, respectively.
Study design We surveyed 316 final-year medical students and undifferentiated trainees (from foundation programme doctors to core medical trainees), across the South Thames, Northern and West Midlands deaneries in England to gain an understanding of perceptions of the specialty.
Results 9% of respondents were considering a career in D&E. Factors such as ‘being the medical registrar’ (27%), being a ‘non-procedural specialty’ (23%) and ‘looking after majority of general medical admissions’ (22%) were cited as the most common reasons why D&E is an unattractive career choice. 51% reported inadequate exposure to D&E. Factors that made respondents more likely to want to pursue a career in D&E included having undertaken a placement in the specialty and having exposure to outpatient clinics. Methods to improve awareness and uptake, such as increased teaching and clinical exposure, and the opportunity to attend taster events were frequently highlighted.
Conclusions The results from this survey, the first of its kind on perceptions of D&E as a career pathway, reveal a worrying lack of interest in, and exposure to, D&E among current final-year medical students and undifferentiated trainees. These issues must be addressed in order to improve D&E recruitment rates.
- diabetes & endocrinology
- medical education & training
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Hospital medicine is facing a recruitment crisis. The Royal College of Physicians (RCP) report ‘Underfunded, underdoctored, overstretched: The NHS in 2016’ has outlined a number of reasons for the shortage of doctors choosing to undertake specialist training including a fall in medical student numbers between 2010 and 2016, increasing numbers of core medical trainees (CMTs) not choosing to progress to specialty training and the relative lack of CMT doctors compared with medical registrar posts.1–3 Negative perceptions of specialist medical and general internal medical (GIM) training, in particular the perceived unmanageable and increasing workload of medical registrars, are also deterring CMTs, foundation doctors and medical students from seeking a career in hospital medicine.4 Less than half of junior doctors who express an initial interest in hospital medicine progress to higher specialty training, in contrast to those who express an initial preference for primary care, of whom 90% go on to general practitioner training.5 Despite these problems, some specialties, for example, cardiology, dermatology and gastroenterology, are filling their training posts year on year. However, other specialties, for example, acute medicine, genitourinary medicine and rehabilitation medicine, are struggling to fill their training posts.
In 2016, data from the JRCPTB show that 98 national training numbers (NTNs) were available in diabetes and endocrinology (D&E) in the UK and that, over 2 recruitment rounds, 75 of these (77%) were filled. In 2017, 88 posts were offered but only 73 (83%) were filled. In 2018, 84 of 115 posts (73%) were filled nationally. There was marked variation across the country, with some regions filling all of their NTNs in round one and others filling only one quarter. Although D&E fares better than some other specialties in terms of recruitment, the above figures mean that just under one quarter of training posts go unfilled. Failure to train enough specialists results in problems further up the ‘food chain’. The RCP census of consultant physicians and higher specialty trainees 2015/2016 highlighted that 44% of advertised consultant physician posts were unfilled due to a lack of appointable candidates.6
With training numbers going unfilled each year in comparison with other specialties, it begs the question as to whether D&E has an image problem? We undertook a survey of final-year medical students, foundation programme (FP) doctors and CMTs in three regions of England to determine perceptions of the specialty, what makes it attractive or unattractive as a future career and how perceptions could be improved.
An anonymous questionnaire to determine perceptions of D&E training was initially created utilising a focus group of specialty trainees and junior doctors and piloted at a single trust in the West Midlands with subsequent revision for further use. The revised paper questionnaire (online supplementary appendix a) was then distributed in person at teaching sessions to final-year medical students, FP and CMT doctors in three deaneries (South Thames, West Midlands and Northern). Results were collated and analysed using χ2 tests in SPSS Statistics V.24. A significance threshold of p<0.05 was applied.
A total of 316 participants (131 final-year medical students, 132 FP doctors and 53 CMTs) completed the questionnaire across the three participating deaneries (table 1).
Interest in D&E as a specialty
When asked how likely participants were to choose a career in D&E 232 of 316 participants (73%) stated ‘not at all/already chosen a career’ or ‘unlikely’. Twenty-nine of 316 (9%) said that they would ‘possibly’ or ‘likely’ choose D&E as a specialty, whereas 53 of 316 (17%) remain undecided. Two survey participants did not provide a response to this question. A greater number of medical students and foundation doctors remained undecided on their specialty choice (28; 22% and 23; 17%, respectively) compared with CMTs (2; 4%) (p=0.01), reflecting career stage.
Exposure to a clinical placement in D&E
One hundred fifty-one of 316 participants (48%) recalled one or more previous placements in D&E. One hundred eighteen of 155 (76%) of these placements were undertaken as a medical student, whereas 25 (16%) and 12 (8%) were undertaken during FP training and CMT, respectively.
Of the 29 respondents ‘possibly’ or ‘likely’ to pursue a career in D&E, 19 (66%) had undertaken a previous placement in D&E, whereas 10 (34%) had not. Of the 232 participants who stated that they would not consider a career in D&E (‘not at all’ or ‘unlikely’), 104 (45%) had undertaken a previous placement and 127 (55%) had not (p=0.04) (figure 1). One survey participant did not provide a response regarding previous D&E placements.
Clinical exposure to diabetes
The survey revealed that exposure to ‘real life’ clinical diabetes is lacking, with over half (173/316; 55%) of respondents reporting ‘none’ or ‘little’ exposure to diabetes outpatient clinics and just over a third (109/316; 35%) reporting ‘none’ or ‘little’ exposure to inpatient diabetes work (eg, diabetes ward rounds). In contrast, less than a third (90/316; 29%) of survey participants reported ‘none’ or ‘little’ exposure to formal diabetes teaching. However, only exposure to diabetes outpatient clinics appeared to significantly influence participants’ likelihood of choosing D&E as a specialty. Of the 173 participants reporting ‘none’ or ‘little’ exposure to diabetes outpatient clinics, 11 (6%) reported that they would consider a career in D&E. In contrast, of the 141 respondents reporting ‘some’ or ‘plenty’ of exposure to diabetes outpatient clinics, 18 (13%) were likely to consider a career in D&E (p=0.02).
Clinical exposure to endocrinology
Reported exposure to all aspects of endocrinology appears to be poor, with over two thirds of survey participants (217/316; 69%) reporting ‘none’ or ‘little’ time in endocrine outpatient clinics and 197 of 316 (62%) reporting ‘none’ or ‘little’ exposure to inpatient endocrinology work. One hundred and thirty-one of 316 (42%) reported ‘none’ or ‘little’ exposure to formal endocrinology teaching. Again, exposure to endocrinology outpatient clinics appeared to have an influence on the likelihood of choosing D&E as a specialty. Of the 217 individuals reporting ‘none’ or ‘little’ exposure to endocrinology outpatient clinics, 15 (7%) reported that they would consider a career in D&E. In contrast, of the 98 respondents reporting ‘some’ or ‘plenty’ of exposure to endocrinology outpatient clinics, 14 (14%) were likely to consider a career in D&E (p=0.0008).
Early exposure to D&E
Less than half of respondents (155/316; 49%) felt that they had gained enough exposure to D&E at medical school when compared with other specialties. Furthermore, when participants were asked if they knew enough about D&E to make a decision to pursue a career in the specialty, less than a third (98/316; 31%) stated that they did (‘agree’/’strongly agree’). One hundred and thirty-six of 316 (43%) stated that they did not (‘strongly disagree’ and ‘disagree’), 80 of 316 (25%) were undecided and 2 did not give an answer.
Perceived knowledge of D&E
Perceived knowledge of the specialty influences the likelihood of pursuing D&E as a specialty. Of the 98 individuals who reported that they knew enough about D&E to make a decision as to whether to pursue it as a career, 12 of 98 (12%) reported being likely to pursue D&E long term. In contrast, of the 136 individuals reporting that they did not know enough about D&E to make a decision about the specialty long term, only 9 of 136 (7%) reported that they were likely to pursue a career in D&E (p=0.0007).
Perceived advantages of a career in D&E
Survey respondents were asked what most attracts them to a career in D&E. More than one response to this question was allowed and free text comments were invited. Three hundred and forty-three responses were collected (including 31 free-text comments), whereas 63 individuals did not provide a response to the question. The most frequent response (130/343; 38%) was that the specialty is ‘interesting and rewarding’. Sixty-three of 343 (18%) responses indicated that previous experience working with a friendly, supportive team was an influencing factor. Opportunities in research and academia were also attractive (47/343; 14%), as was being inspired by someone working in the specialty (46/343; 13%). The non-procedural nature of D&E was attractive to a number of survey participants (26/343 responses; 8%). Of the 31 free-text responses (‘other’) to this question, 7 reported that they perceived the specialty as interesting and 3 as intellectual. Five of 31 acknowledged that D&E represents common pathology which makes it an attractive specialty. Nine of 31 individuals used free-text comments to report that ‘nothing attracts me to D&E’(figure 2).
Perceived disadvantages of a career in D&E
Survey participants were asked what least attracts them to a career in D&E. Again, more than one response to this question was allowed and free-text comments were invited. A total of 488 responses were received, including 54 free-text responses, whereas 20 individuals did not provide a response. The most frequent response was ‘being a medical registrar’ (133/488; 27%) followed by D&E being a non-procedural specialty (113/488; 23%). ‘Looking after majority of general medicine admissions’ was also frequently cited as unattractive (107/488; 22%), whereas the “uncertainty of the future of the specialty in secondary care” and “limited job opportunities” were less commonly cited reasons for D&E being unattractive (50/488; 10% and 31/488; 6%, respectively). Common themes from the free text responses include the bulk of the workload constituting diabetes rather than endocrinology (14/54), complexity (4/54), the outpatient nature of the specialty (3/54), looking after inpatients with chronic conditions and social issues (3/54), and diabetic foot problems (3/54) (figure 3).
Survey respondents were asked to list three words that come to mind when thinking of D&E. Common responses, occurring three or more times, are shown in figure 4 as a word cloud. The most frequent responses included ‘complicated’, ‘insulin’, ‘interesting’, ‘feet’, ‘diabetes’, ‘GIM’, ‘hormones’ and ‘boring’.
Finally, respondents were asked what could be done to improve their interest in D&E as a specialty. Common responses (occurring three or more times) are shown in figure 5. Common themes included providing more teaching, greater clinical exposure, placing more of an emphasis on endocrinology (as opposed to diabetes), offering taster events and increasing opportunities to attend outpatient clinics.
With the increasing burden of diabetes and projected prevalence, it is important to train sufficient doctors in understanding and effectively managing diabetes and other endocrine conditions. The TOPDOC study has previously examined trainee doctor confidence in managing diabetes, however, this is the first survey to look specifically at perceptions of D&E and career aspirations among undifferentiated trainees.7
The 2018 specialty recruitment exercise for diabetes and endocrinology has revealed that 73% of posts have been filled over two rounds of recruitment. This is considerably lower than the overall recruitment in 2018 for other medical specialties such as cardiology (100%), gastroenterology (100%) and respiratory medicine (100%).8 Although being allied to general medical on-call is often cited as the reason for poor recruitment in D&E, this does not seem to be hampering recruitment in other GIM-allied specialities, suggesting that the recruitment issue in D&E is more complex than simply its association with GIM. This study has highlighted that GIM training within D&E specialty training as a whole is viewed quite negatively, in particular out of hours work as a general medical registrar on-call and inpatient general medical work on the wards. Negativity towards GIM is not a new problem but cannot be ignored.9 This highlights the need for the RCP to work hard to improve the working conditions of general medical registrars and for D&E specialists to justify and promote the benefits of GIM in our specialty.
Our findings reveal that the majority of students and junior doctors surveyed had already ruled out a career in D&E. Questionnaire respondents at all levels listed more negative perceptions of the specialty than positive ones, implying that more needs to be done at both undergraduate and postgraduate levels to highlight and promote the specialty. Many respondents reported that they perceived a lack of teaching and clinical exposure in D&E. As a predominantly outpatient-based specialty, the perceived lack of clinical exposure is not wholly surprising. Nevertheless, this is important as those reporting ‘real life’ D&E experience, for example, through outpatient clinic experience, were more likely to be interested in pursuing D&E as a career. When asked what might increase their interest in D&E, many respondents reported that more bedside teaching, clinical exposure and more formal teaching would be welcome, pointing to an obvious solution to this issue. This needs to be implemented early on in the training pathway, ideally in medical school, with clinical exposure in D&E focused on the outpatient setting where most of our specialty work takes place. In addition, outpatient exposure for rotating junior doctors needs to be ‘built into’ rotations. Involving trainees in designing a clinic rota for D&E placements would allow service pressures to be balanced with training needs on a place-by-place basis. Additionally, utilising the expertise of the D&E multidisciplinary team to promote the specialty among junior doctors that they inevitably encounter in the hospital and community settings, for example, by encouraging junior doctors and medical students to spend time with specialist nurses, dietitians and podiatrists, also provides a valuable training opportunity which is often overlooked.
Current D&E trainees and consultants have a vital role to play in promoting the specialty by acting as positive role models and combating negative perceptions. D&E specialists need to be active in ensuring that both undergraduate and postgraduate teaching programmes have sufficient content to reflect the diverse nature of the specialty while covering the core curriculum. This should not only highlight D&E as a career option and improve recruitment, but should also improve patient care by increasing knowledge and familiarity with common D&E management problems among medical students and junior doctors.
Increasing awareness of D&E as a varied and interesting career option can also be tackled using regional and national taster days aimed at medical students and junior doctors. Many other specialties have been quick to address the issue of recruitment by organising such events. Professional and learned societies allied to D&E have a role in the organisation, coordination and delivery of taster days.
This study was carried out across three centres in England, and therefore the results must be interpreted in this context. Nevertheless, given that over 300 responses were collected and similar themes emerged from all three participating centres, we conclude that the results are generalisable and give an interesting insight into the challenges facing recruitment in our specialty.
Diabetes and endocrinology is a diverse specialty. D&E specialty training involves a significant contribution to inpatient and out-of-hour hospital medicine. Demand for expertise in the specialty will grow as the number of patients with type 2 diabetes increases year on year. It is therefore essential that trainees are attracted to the specialty in order to ensure an adequate future workforce. The results from this survey, the first of its kind on perceptions of D&E as a career pathway, reveal a worrying lack of interest in, and exposure to, D&E among current final-year medical students and undifferentiated trainees. Current specialists need to address this to ensure the specialty continues to attract top trainees.
What is already known on the subject
Trainee doctors lack confidence in management of diabetes and report a need for further training
Specialty training posts in endocrinology and diabetes have been underfilled in recent years
Negative perceptions of specialty medical training and specialty general internal medicine are deterring junior doctors and medical students from hospital medicine
Some medical specialties, including diabetes and endocrinology, are facing a recruitment crisis.
Negative perceptions potentially affecting recruitment include concerns about the general medicine component of training.
Increased exposure to clinical diabetes and endocrinology, in particular in outpatient clinics, is the one suggested way of improving the perception of the specialty for future generations.
Current research questions
Would a reduction in time spent on general medicine commitments result in improved recruitment?
Does the perception of a specialty directly affect recruitment to that specialty?
Would increased exposure to diabetes and endocrinology earlier on in training (such as in medical school) affect the perception of the specialty and/or recruitment?
Contributors AP, MN and AM: planned the study. AP, MB, SE-B, MM and MN: conducted the survey. AP: responsible for overall content. AP, MN, MB and AM: wrote the manuscript with input from MM and SE-B. AP and AM: reviewed the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.
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