Reasons for considering leaving UK medicine: questionnaire study of junior doctors' comments
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《英国医生杂志》
1 UK Medical Careers Research Group, Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford, Oxford OX3 7LF
Correspondence to: M J Goldacre michael.goldacre@dphpc.ox.ac.uk
Abstract
An increase in the number of doctors working in the NHS in England is a major policy initiative in the NHS Plan.1 The "improving working lives" programme aims to ensure that everything is done to encourage doctors, once recruited, to remain in the NHS.2 3 Although loss of junior doctors from the NHS has been a longstanding concern of policy makers, the loss of young home trained doctors from the UK medical workforce does not seem to have increased during the 1980s and 1990s.4 However, in our regular surveys, the proportion of pre-registration house officers who have reported their intention to "continue practising medicine in the United Kingdom for the foreseeable future" declined from around 90% in the 1980s to 75% in the 1990s.5 In the past, early expressed intentions have been shown to be a reasonable predictor of subsequent career pathways. Whether or not early indications are followed, it is important to understand why some doctors say that they may want to leave. We report a systematic qualitative study, in which we explored the distinction between the factors that would be amenable to policy initiatives to encourage doctors to stay in UK medicine and other factors that are largely beyond the influence of policy.
Methods
Overall, 2727 (64.6%) of 4221 doctors replied to our questionnaire. Of these, 1777 (65.2%) did not definitely intend to practise medicine in the United Kingdom (fig). The data for analysis comprised comments from 1326 of these doctors (the rest did not provide comments or provided comments that we were unable to code), of whom 1047 indicated that they were considering leaving the United Kingdom and 279 were considering leaving medicine. Overall, 16.0% (212/1326) reported that they were probably not or definitely not going to continue to practise in the United Kingdom, practise medicine, or both. Table 1 summarises the main reasons given for considering leaving the United Kingdom, medicine, or both. Table 2 and table 3 provide a more detailed breakdown of the most common reasons. The box contains exemplar text extracts of reasons given by doctors for leaving medicine, the United Kingdom, or both.
Table 1 Summary of the main reasons given for considering leaving the United Kingdom or leaving medicine. Values are numbers (percentages*) of respondents who did not definitely intend to practise in the United Kingdom
Table 2 Examples of reasons for considering leaving the United Kingdom. Values are numbers (percentages*) of all respondents who did not definitely intend to practise in the United Kingdom for the foreseeable future
Table 3 Examples of reasons for considering leaving medicine. Values are numbers (percentages*) of all respondents who did not definitely intend to practise in the United Kingdom for the foreseeable future
Our response rate of 64.6%, although high for a postal questionnaire survey, might lead to concerns about non-responder bias. As this was the first occasion on which we had surveyed these doctors, our only information about non-responders was their sex and (clinical) medical school attended. In line with our previous surveys,7 and the general experience of survey researchers, we had a higher response from women than from men—71.4% (1568/2195) of women in the cohort and 57.8% (1171/2026) of men responded (2 = 85.4, df = 1, P < 0.001). The response rate showed some variation by medical school in (2 = 80.2, df = 22, P < 0.001); the only significant outliers (based on analysis of adjusted residuals), both significantly high, were Oxford medical school with 81% response and Birmingham with 79% response.
Doctors who were considering leaving the United Kingdom but staying in medicine
Almost two thirds of doctors considering leaving the United Kingdom gave reasons related to lifestyle choices, two fifths gave reasons associated with UK working conditions, and almost a fifth of respondents commented on a positive work related purpose in leaving the country (table 1). In the lifestyle responses, the most commonly reported reasons included general comments about seeking a better quality of life, the wish to broaden personal horizons, a wish to do relief work overseas, and the desire to travel (table 2). Under working conditions, the most common comments were about poor working conditions in the United Kingdom, perceived low levels of pay, and excessive working hours. Doctors whose reasons were work related intended to broaden their medical experience by spending some time abroad.
Women were more likely than men to comment that they wanted to work in medicine abroad to broaden their work experience (women 21%, men 13%; 2 = 11.6, P < 0.01), to do relief and voluntary work abroad (women 14%, men 9%; 2 = 7.0, P < 0.01), or to travel abroad for its own sake (women 14%, men 9%; 2 = 6.4, P < 0.05). Men were more likely than women to give reasons related to perceived underfunding and poor facilities in the United Kingdom (men 3%, women < 1%; 2 = 11.3, P < 0.001), generally poor working conditions (men 29%, women 21%; 2 = 8.8, P < 0.01), and low levels of job satisfaction (men 5%, women 3%; 2 = 5.0, P < 0.05).
Respondents who reported that they were probably or definitely going to leave the United Kingdom mentioned lifestyle choices much more often than working conditions (table 1). In the detailed breakdown (not shown in the tables), responses were spread over several factors: the desire to undertake overseas relief work (mentioned by 32 doctors); return to country of family origin (30 doctors); domestic, family, and personal reasons (20 doctors); travel (19 doctors); broadening personal horizons (18 doctors); and quality of life factors (17 doctors). Of these respondents, 22.6% (237/1047) gave reasons related to working conditions alone, and 43.3% (453/1047) gave reasons related to lifestyle choices alone.
Doctors who were considering leaving medicine
Three quarters of doctors considering leaving medicine gave reasons related to UK working conditions, about one fifth gave reasons associated with lifestyle choices, and about one twelfth gave a positive work related purpose for wanting a different career (table 1). The most commonly reported comments about UK working conditions concerned long and unsocial working hours, low levels of pay, and dissatisfaction with working in medicine (table 2). Under the heading of lifestyle choices, the most common comments were about quality of life factors; domestic, family, and personal reasons; and the desire to broaden life experiences and travel. Those whose reasons were work related reported that they were considering, or had available to them, other career interests and options.
Women were more likely than men to refer to general lifestyle choices (women 30%, men 13%; 2 = 10.9, P < 0.001), domestic and social commitments (women 10%, men 2%; 2 = 7.4, P < 0.01), and onerous working hours that could be "antisocial" (women 38%, men 24%; 2 = 5.8, P < 0.05). Men were more likely than women to mention poor job and career prospects (men 10%, women 4%; 2 = 4.2, P < 0.05) and perceived low levels of funding and poor facilities in UK medicine (men 5%, women 1%; 2 = 5.2, P < 0.05).
Respondents who reported that they were probably or definitely going to leave medicine also cited UK working conditions much more often than lifestyle choices (table 1). In the detailed breakdown (not shown in the tables), lack of job satisfaction (mentioned by 14 doctors) was the most important factor for the subgroup who were probably or definitely intending to leave medicine, ahead of general comments on working conditions (nine doctors), working hours (nine doctors), or pay (eight doctors). Of these respondents, 59.1% (165/279) gave reasons relating to working conditions alone, and 9.0% (25/279) gave reasons related to lifestyle choices alone.
Quotations from the doctors who were considering leaving UK medicine
(Grouped into reasons given; each quote is from a different doctor and is reproduced as originally written)
Working conditions
Working conditions as a motivation to go abroad
Better working hours in other countries
... hope for better working conditions, especially hours
Desire to go abroad where hours are shorter
Working in a country where you are paid for hours worked and at reasonable rates
Poor working conditions and pay in UK medicine. Love the job, hate the fact I feel abused doing it
Working conditions as a motivation to leave medicine
Terrible working conditions and hours for UK doctors
The long hours and impossible working conditions experienced in my medical house job
Leaving medicine because of poor rate of pay in relation to hours worked and sacrifices involved
Unable to perform to a satisfactory level (for myself) due to workload and hours, i.e. poor job satisfaction.
A dreadful, dangerous, unsupported system that ruthlessly exploits juniors and views them as more expendable than venflons.
Working conditions with lifestyle or social factors
Working conditions with lifestyle or social factors as a motivation to go abroad
More sociable hours in e.g. Australia.
Experience of living abroad, travelling, better pay, better hours and more time to enjoy life out of work
Hope of better hours and better family life
Working conditions with lifestyle or social factors as a motivation to leave medicine
I want a life which allows other interests and spare time
Unsociable hours, having no life outside of medicine a lot of the time
Hours and fatigue dominating private and personal life too much
Lifestyle choices
Lifestyle choices as a motivation to go abroad
Preferable social conditions overseas
Better lifestyle options abroad, especially for doctors
I would like to work abroad for a time, in order to experience different culture/lifestyles
Experiencing the cultures and people of other countries generally, not only different medicine
Would like to live in other part of the world, where there is arguably a greater need for doctors e.g. Africa/L.America
Wish to work involving third world and humanitarian issues
I would like to do aid work, e.g. Medicins Sans Frontieres for a few years
Always intended to take advantage of the opportunity to travel/work abroad which medicine offers
I enjoy travelling
Lifestyle choices as a motivation to leave medicine
I do not enjoy the lifestyle that surgery provides and I am not interested enough in other areas to pursue a career
Other careers promote better lifestyle
Personal. Husband moving overseas. Unenthusiastic to stay in UK NHS system
Family reasons and future relationships
Broaden my horizons. Live to the full and be satisfied and happy
I don't know what the future holds but I want to travel
Two reasons—want to travel and find I would sooner give up medicine than work in the NHS as I have found it so far
Respondents who definitely intended to pursue a career in UK medicine
This study focused on the views of those doctors who did not definitely wish to pursue a career in UK medicine. We did not ask the doctors who were definite about a UK career to give their reasons. However, all respondents were asked to respond to several attitude statements, and we compared the responses of doctors who were definite about a UK career with the responses of those who were not. We thought a priori that these two groups may differ in their views of their career prospects, their career advice, their enjoyment of the pre-registration house officer year and the leisure time they had available, and the confidence they had in their current career choice, so we examined the results from attitude statements related to these topics.
Presented with the statement "I am satisfied with my future career prospects," 73.3% (602/821) of those doctors who definitely intended a UK career agreed or strongly agreed, compared with 59.9% (925/1543) of those who were not definite about a UK career (2 = 41.3, df = 1, P < 0.001). We found no significant difference between the two groups on the statement "I have been able to obtain useful career advice since graduation," for which the corresponding percentages were 39.5% (323/817) and 35.8% (558/1557) (2 = 3.0, df = 1, P = 0.08). Those who were definite about a UK career had a mean score of 7.3 when asked to score the statement "How much have you enjoyed the PRHO year overall?" on a scale from 1 (not enjoyed it at all) to 10 (enjoyed it greatly), compared with a mean score of 6.8 for those not definite (t test, P < 0.001). Those who were definite about a UK career had a mean score of 4.8 when asked to score the statement "How satisfied are you with the amount of time the PRHO year has left you for family, social, and recreational activities?" on a scale from 1 (not at all satisfied) to 10 (extremely satisfied), compared with a mean score of 4.3 for those not definite (t test, P < 0.001). When asked "Have you made up your mind about your choice of long term career?" and asked to reply definitely, probably, or not really, those certain about a UK career were more likely to reply "definitely"—35.8% (332/927) compared with 21.6% (380/1756) of those not definite about a UK career (2 = 61.8, df = 1, P < 0.001).
Discussion
Department of Health. The NHS plan: a plan for investment, a plan for reform. London: Department of Health, 2000.
Department of Health. Investment and reform for NHS staff—taking forward the NHS plan. Department of Health. London, 2001.
Department of Health. Delivering the NHS plan: next steps on investment, next steps on reform. Norwich: Stationery Office, 2002.
Goldacre MJ, Lambert TW, Davidson JM. Loss of British-trained doctors from the medical workforce in Great Britain. Med Educ 2001;35: 337-44.
Lambert TW, Goldacre MJ, Parkhouse J. Intentions of newly qualified doctors to practise in the United Kingdom. BMJ 1997;314: 1591-2.
Parkhouse J. Doctors' careers: aims and experiences of medical graduates. London: Routledge, 1991.
Lambert TW, Goldacre MJ, Edwards C, Parkhouse J. Career preferences of doctors who qualified in the United Kingdom in 1993 compared with those of doctors qualifying in 1974, 1977, 1980, and 1983. BMJ 1996;313: 19-24
Lambert TW, Goldacre MJ. Career destinations seven years on among doctors who qualified in the United Kingdom in 1988: postal questionnaire survey. BMJ 1998;317: 1429-31.
Davidson JM, Lambert TW, Goldacre MJ. Career pathways and destinations 18 years on among doctors who qualified in the United Kingdom in 1977: postal questionnaire survey. BMJ 1998;317: 1425-8.
NHS Management Executive. Junior doctors: the new deal. London: Department of Health, 1991.
Department of Health. Guidance on working patterns for junior doctors, Nov 2002. www.dh.gov.uk/assetRoot/04/06/63/66/04066366.pdf (accessed 28 Sep 2004).
Department of Health. Junior doctors' contract compliance rates: summary 2000. www.dh.gov.uk/assetRoot/04/03/46/16/04034616.pdf (accessed 28 Sep 2004).
Department of Health. Junior doctors' contract compliance rates: summary 2003. www.dh.gov.uk/assetRoot/04/03/45/17/04034517.pdf (accessed 28 Sep 2004).
Royal College of Physicians. The further implementation of the European Working Time Directive to cover junior doctors in training. London: Royal College of Physicians, 2003.(Philip J Moss, social sci)
Correspondence to: M J Goldacre michael.goldacre@dphpc.ox.ac.uk
Abstract
An increase in the number of doctors working in the NHS in England is a major policy initiative in the NHS Plan.1 The "improving working lives" programme aims to ensure that everything is done to encourage doctors, once recruited, to remain in the NHS.2 3 Although loss of junior doctors from the NHS has been a longstanding concern of policy makers, the loss of young home trained doctors from the UK medical workforce does not seem to have increased during the 1980s and 1990s.4 However, in our regular surveys, the proportion of pre-registration house officers who have reported their intention to "continue practising medicine in the United Kingdom for the foreseeable future" declined from around 90% in the 1980s to 75% in the 1990s.5 In the past, early expressed intentions have been shown to be a reasonable predictor of subsequent career pathways. Whether or not early indications are followed, it is important to understand why some doctors say that they may want to leave. We report a systematic qualitative study, in which we explored the distinction between the factors that would be amenable to policy initiatives to encourage doctors to stay in UK medicine and other factors that are largely beyond the influence of policy.
Methods
Overall, 2727 (64.6%) of 4221 doctors replied to our questionnaire. Of these, 1777 (65.2%) did not definitely intend to practise medicine in the United Kingdom (fig). The data for analysis comprised comments from 1326 of these doctors (the rest did not provide comments or provided comments that we were unable to code), of whom 1047 indicated that they were considering leaving the United Kingdom and 279 were considering leaving medicine. Overall, 16.0% (212/1326) reported that they were probably not or definitely not going to continue to practise in the United Kingdom, practise medicine, or both. Table 1 summarises the main reasons given for considering leaving the United Kingdom, medicine, or both. Table 2 and table 3 provide a more detailed breakdown of the most common reasons. The box contains exemplar text extracts of reasons given by doctors for leaving medicine, the United Kingdom, or both.
Table 1 Summary of the main reasons given for considering leaving the United Kingdom or leaving medicine. Values are numbers (percentages*) of respondents who did not definitely intend to practise in the United Kingdom
Table 2 Examples of reasons for considering leaving the United Kingdom. Values are numbers (percentages*) of all respondents who did not definitely intend to practise in the United Kingdom for the foreseeable future
Table 3 Examples of reasons for considering leaving medicine. Values are numbers (percentages*) of all respondents who did not definitely intend to practise in the United Kingdom for the foreseeable future
Our response rate of 64.6%, although high for a postal questionnaire survey, might lead to concerns about non-responder bias. As this was the first occasion on which we had surveyed these doctors, our only information about non-responders was their sex and (clinical) medical school attended. In line with our previous surveys,7 and the general experience of survey researchers, we had a higher response from women than from men—71.4% (1568/2195) of women in the cohort and 57.8% (1171/2026) of men responded (2 = 85.4, df = 1, P < 0.001). The response rate showed some variation by medical school in (2 = 80.2, df = 22, P < 0.001); the only significant outliers (based on analysis of adjusted residuals), both significantly high, were Oxford medical school with 81% response and Birmingham with 79% response.
Doctors who were considering leaving the United Kingdom but staying in medicine
Almost two thirds of doctors considering leaving the United Kingdom gave reasons related to lifestyle choices, two fifths gave reasons associated with UK working conditions, and almost a fifth of respondents commented on a positive work related purpose in leaving the country (table 1). In the lifestyle responses, the most commonly reported reasons included general comments about seeking a better quality of life, the wish to broaden personal horizons, a wish to do relief work overseas, and the desire to travel (table 2). Under working conditions, the most common comments were about poor working conditions in the United Kingdom, perceived low levels of pay, and excessive working hours. Doctors whose reasons were work related intended to broaden their medical experience by spending some time abroad.
Women were more likely than men to comment that they wanted to work in medicine abroad to broaden their work experience (women 21%, men 13%; 2 = 11.6, P < 0.01), to do relief and voluntary work abroad (women 14%, men 9%; 2 = 7.0, P < 0.01), or to travel abroad for its own sake (women 14%, men 9%; 2 = 6.4, P < 0.05). Men were more likely than women to give reasons related to perceived underfunding and poor facilities in the United Kingdom (men 3%, women < 1%; 2 = 11.3, P < 0.001), generally poor working conditions (men 29%, women 21%; 2 = 8.8, P < 0.01), and low levels of job satisfaction (men 5%, women 3%; 2 = 5.0, P < 0.05).
Respondents who reported that they were probably or definitely going to leave the United Kingdom mentioned lifestyle choices much more often than working conditions (table 1). In the detailed breakdown (not shown in the tables), responses were spread over several factors: the desire to undertake overseas relief work (mentioned by 32 doctors); return to country of family origin (30 doctors); domestic, family, and personal reasons (20 doctors); travel (19 doctors); broadening personal horizons (18 doctors); and quality of life factors (17 doctors). Of these respondents, 22.6% (237/1047) gave reasons related to working conditions alone, and 43.3% (453/1047) gave reasons related to lifestyle choices alone.
Doctors who were considering leaving medicine
Three quarters of doctors considering leaving medicine gave reasons related to UK working conditions, about one fifth gave reasons associated with lifestyle choices, and about one twelfth gave a positive work related purpose for wanting a different career (table 1). The most commonly reported comments about UK working conditions concerned long and unsocial working hours, low levels of pay, and dissatisfaction with working in medicine (table 2). Under the heading of lifestyle choices, the most common comments were about quality of life factors; domestic, family, and personal reasons; and the desire to broaden life experiences and travel. Those whose reasons were work related reported that they were considering, or had available to them, other career interests and options.
Women were more likely than men to refer to general lifestyle choices (women 30%, men 13%; 2 = 10.9, P < 0.001), domestic and social commitments (women 10%, men 2%; 2 = 7.4, P < 0.01), and onerous working hours that could be "antisocial" (women 38%, men 24%; 2 = 5.8, P < 0.05). Men were more likely than women to mention poor job and career prospects (men 10%, women 4%; 2 = 4.2, P < 0.05) and perceived low levels of funding and poor facilities in UK medicine (men 5%, women 1%; 2 = 5.2, P < 0.05).
Respondents who reported that they were probably or definitely going to leave medicine also cited UK working conditions much more often than lifestyle choices (table 1). In the detailed breakdown (not shown in the tables), lack of job satisfaction (mentioned by 14 doctors) was the most important factor for the subgroup who were probably or definitely intending to leave medicine, ahead of general comments on working conditions (nine doctors), working hours (nine doctors), or pay (eight doctors). Of these respondents, 59.1% (165/279) gave reasons relating to working conditions alone, and 9.0% (25/279) gave reasons related to lifestyle choices alone.
Quotations from the doctors who were considering leaving UK medicine
(Grouped into reasons given; each quote is from a different doctor and is reproduced as originally written)
Working conditions
Working conditions as a motivation to go abroad
Better working hours in other countries
... hope for better working conditions, especially hours
Desire to go abroad where hours are shorter
Working in a country where you are paid for hours worked and at reasonable rates
Poor working conditions and pay in UK medicine. Love the job, hate the fact I feel abused doing it
Working conditions as a motivation to leave medicine
Terrible working conditions and hours for UK doctors
The long hours and impossible working conditions experienced in my medical house job
Leaving medicine because of poor rate of pay in relation to hours worked and sacrifices involved
Unable to perform to a satisfactory level (for myself) due to workload and hours, i.e. poor job satisfaction.
A dreadful, dangerous, unsupported system that ruthlessly exploits juniors and views them as more expendable than venflons.
Working conditions with lifestyle or social factors
Working conditions with lifestyle or social factors as a motivation to go abroad
More sociable hours in e.g. Australia.
Experience of living abroad, travelling, better pay, better hours and more time to enjoy life out of work
Hope of better hours and better family life
Working conditions with lifestyle or social factors as a motivation to leave medicine
I want a life which allows other interests and spare time
Unsociable hours, having no life outside of medicine a lot of the time
Hours and fatigue dominating private and personal life too much
Lifestyle choices
Lifestyle choices as a motivation to go abroad
Preferable social conditions overseas
Better lifestyle options abroad, especially for doctors
I would like to work abroad for a time, in order to experience different culture/lifestyles
Experiencing the cultures and people of other countries generally, not only different medicine
Would like to live in other part of the world, where there is arguably a greater need for doctors e.g. Africa/L.America
Wish to work involving third world and humanitarian issues
I would like to do aid work, e.g. Medicins Sans Frontieres for a few years
Always intended to take advantage of the opportunity to travel/work abroad which medicine offers
I enjoy travelling
Lifestyle choices as a motivation to leave medicine
I do not enjoy the lifestyle that surgery provides and I am not interested enough in other areas to pursue a career
Other careers promote better lifestyle
Personal. Husband moving overseas. Unenthusiastic to stay in UK NHS system
Family reasons and future relationships
Broaden my horizons. Live to the full and be satisfied and happy
I don't know what the future holds but I want to travel
Two reasons—want to travel and find I would sooner give up medicine than work in the NHS as I have found it so far
Respondents who definitely intended to pursue a career in UK medicine
This study focused on the views of those doctors who did not definitely wish to pursue a career in UK medicine. We did not ask the doctors who were definite about a UK career to give their reasons. However, all respondents were asked to respond to several attitude statements, and we compared the responses of doctors who were definite about a UK career with the responses of those who were not. We thought a priori that these two groups may differ in their views of their career prospects, their career advice, their enjoyment of the pre-registration house officer year and the leisure time they had available, and the confidence they had in their current career choice, so we examined the results from attitude statements related to these topics.
Presented with the statement "I am satisfied with my future career prospects," 73.3% (602/821) of those doctors who definitely intended a UK career agreed or strongly agreed, compared with 59.9% (925/1543) of those who were not definite about a UK career (2 = 41.3, df = 1, P < 0.001). We found no significant difference between the two groups on the statement "I have been able to obtain useful career advice since graduation," for which the corresponding percentages were 39.5% (323/817) and 35.8% (558/1557) (2 = 3.0, df = 1, P = 0.08). Those who were definite about a UK career had a mean score of 7.3 when asked to score the statement "How much have you enjoyed the PRHO year overall?" on a scale from 1 (not enjoyed it at all) to 10 (enjoyed it greatly), compared with a mean score of 6.8 for those not definite (t test, P < 0.001). Those who were definite about a UK career had a mean score of 4.8 when asked to score the statement "How satisfied are you with the amount of time the PRHO year has left you for family, social, and recreational activities?" on a scale from 1 (not at all satisfied) to 10 (extremely satisfied), compared with a mean score of 4.3 for those not definite (t test, P < 0.001). When asked "Have you made up your mind about your choice of long term career?" and asked to reply definitely, probably, or not really, those certain about a UK career were more likely to reply "definitely"—35.8% (332/927) compared with 21.6% (380/1756) of those not definite about a UK career (2 = 61.8, df = 1, P < 0.001).
Discussion
Department of Health. The NHS plan: a plan for investment, a plan for reform. London: Department of Health, 2000.
Department of Health. Investment and reform for NHS staff—taking forward the NHS plan. Department of Health. London, 2001.
Department of Health. Delivering the NHS plan: next steps on investment, next steps on reform. Norwich: Stationery Office, 2002.
Goldacre MJ, Lambert TW, Davidson JM. Loss of British-trained doctors from the medical workforce in Great Britain. Med Educ 2001;35: 337-44.
Lambert TW, Goldacre MJ, Parkhouse J. Intentions of newly qualified doctors to practise in the United Kingdom. BMJ 1997;314: 1591-2.
Parkhouse J. Doctors' careers: aims and experiences of medical graduates. London: Routledge, 1991.
Lambert TW, Goldacre MJ, Edwards C, Parkhouse J. Career preferences of doctors who qualified in the United Kingdom in 1993 compared with those of doctors qualifying in 1974, 1977, 1980, and 1983. BMJ 1996;313: 19-24
Lambert TW, Goldacre MJ. Career destinations seven years on among doctors who qualified in the United Kingdom in 1988: postal questionnaire survey. BMJ 1998;317: 1429-31.
Davidson JM, Lambert TW, Goldacre MJ. Career pathways and destinations 18 years on among doctors who qualified in the United Kingdom in 1977: postal questionnaire survey. BMJ 1998;317: 1425-8.
NHS Management Executive. Junior doctors: the new deal. London: Department of Health, 1991.
Department of Health. Guidance on working patterns for junior doctors, Nov 2002. www.dh.gov.uk/assetRoot/04/06/63/66/04066366.pdf (accessed 28 Sep 2004).
Department of Health. Junior doctors' contract compliance rates: summary 2000. www.dh.gov.uk/assetRoot/04/03/46/16/04034616.pdf (accessed 28 Sep 2004).
Department of Health. Junior doctors' contract compliance rates: summary 2003. www.dh.gov.uk/assetRoot/04/03/45/17/04034517.pdf (accessed 28 Sep 2004).
Royal College of Physicians. The further implementation of the European Working Time Directive to cover junior doctors in training. London: Royal College of Physicians, 2003.(Philip J Moss, social sci)