Country of training and ethnic origin of UK doctors: database and survey studies
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《英国医生杂志》
1 UK Medical Careers Research Group, Department of Public Health, University of Oxford, Oxford OX3 7LF
Correspondence to: M J Goldacre michael.goldacre@dphpc.ox.ac.uk
Abstract
Immigration to the United Kingdom in recent decades has changed the ethnic composition of the medical workforce in two major respects. Firstly, the NHS has relied heavily, and increasingly, on the immigration of doctors to make up the shortfall in numbers of "home trained" doctors. Secondly, the ethnic composition of doctors trained in UK medical schools has changed as second and third generation UK educated pupils from ethnic minorities have entered medicine in increasing numbers. We report on these trends.
Methods
Consultants in post in 2001: distribution by ethnic group and specialty
The figure shows the percentages of NHS consultants by ethnic group and place of training grouped by the year of their first consultant appointment. The distribution of consultants by each demographic group has changed over time: the percentage who trained abroad increased most substantially in the last 10 years covered by the 2002 database. Accordingly, we have summarised the results for consultants who were first appointed before 1992, and for those appointed between 1992 and 2001.
Percentage of NHS consultants by ethnic group and place of training grouped by the year of their first consultant appointment
Table 1 shows the percentage of consultants in each specialty from each demographic group. Of all consultants first appointed during 1964-91, 81.5% were UK trained and white, 3.3% were UK trained and non-white, 6.2% were trained abroad and white, and 9.1% were trained abroad and non-white. Of those first appointed during 1992-2001, 68.6% were UK trained white, 7.2% were UK trained non-white, 10.0% were trained abroad white, and 14.1% were trained abroad non-white. Thus, the percentage of newly appointed consultants who were trained abroad increased from 15.3% in 1964-91 to 24.1% in 1992-2001, and the percentage from ethnic minorities increased from 12.4% in 1964-1991 to 21.3% in 1992-2001.
The consultants first appointed during 1964-91 showed significant and substantial differences in the distribution of the four demographic groups between specialties (, P < 0.001) (table 1). Compared with their overall percentages in the consultant workforce, significantly and substantially lower percentages of UK trained white doctors, and higher percentages of non-white doctors trained abroad, were in geriatric medicine, genitourinary medicine, general psychiatry, old age psychiatry, and learning disability (significance assessed by 2 tests with adjusted standardised residuals); and significantly higher percentages of UK trained white doctors, and significantly lower percentages of non-white doctors trained abroad, were in general medicine and general surgery. In addition, in radiology there was a significantly higher percentage of UK trained white doctors than of other demographic groups, in psychiatry a significantly higher percentage of white doctors trained abroad, and in genitourinary medicine a significantly higher percentage of UK trained non-white doctors. We also found significant differences between the demographic groups in the specialties of employment of the consultants who were first appointed in 1992-2001 (, P < 0.001) (table 1).
Among all consultants in post in 2001 who had been appointed from 1964 to 2001, the differences between specialties in the representation of the four demographic groups were significant (, P < 0.001). Non-white consultants who had trained abroad made up 11.9% of the consultant workforce. They were significantly over-represented in geriatric medicine (22.0%), genitourinary medicine (21.4%), paediatrics (17.2%), learning disability (36.2%), and old age psychiatry (18.4%) and were significantly under-represented in general medicine and public health medicine. Consultants who were white and had trained abroad made up 8.4% of the workforce. They were significantly over-represented in general psychiatry (12.9%) and significantly under-represented in general medicine (6.8%) and general surgery (5.4%). UK trained non-white doctors comprised 5.5% of all consultants and were significantly under-represented in psychiatry (3.4%). There were no other significant differences.
A higher percentage of white than of non-white consultants were women (24.0% of white consultants (4729/19710) v 18.4% of non-white doctors (763/4150), , P < 0.001). This difference was more pronounced among consultants trained abroad (27.4% of white doctors were women (547/1994) v 17.4% of the non-white doctors (495/2840), , P < 0.001).
Ethnic group of graduates from UK medical schools
Table 2 shows the distribution of white and ethnic minority doctors among responders to surveys undertaken by our Medical Careers Research Group. Of the respondents who graduated in 1974, 96.7% gave their ethnic group as white and 3.3% as non-white. We reanalysed the data excluding those from homes abroad or who were overseas students (as defined by the level of tuition fees paid to their UK medical schools): the percentages in 1974 were then 98.4% white and 1.6% non-white. In contrast, respondents from the cohort who qualified in 2000 comprised 74.4% white doctors and 25.6% from ethnic minority groups (78.5% and 21.5%, respectively, after excluding overseas students).
Table 2 White and non-white doctors who qualified in each year from UK medical schools. Values are numbers (percentages) of those who replied to questionnaires from Medical Careers Research Group unless stated otherwise
We used data from the Universities and Colleges Admissions Service (UCAS) on admissions to medical school to estimate details of ethnicity and sex of future medical graduates (table 3). The percentage of doctors from ethnic minority groups who were admitted to UK medical schools in 1996, and therefore due to graduate in or soon after 2001, was 26.9% (20.7% Asian, 2.1% Chinese, 1.5% black, 2.5% other non-white) (UCAS Data and Analytical Services, private communication, November 2003). The corresponding percentage of ethnic minority doctors graduating from UK medical schools by 2004-7 is projected to be 28-29%. By comparison, in 2001, 9% of the population of England and Wales were from ethnic minority groups, and, among people aged 20-24 years (the typical age range for medical students), 12.8% were from ethnic minority groups. People of Asian ethnic origin (including Chinese) comprised 8.0% of the population in this age range and 20.8% of the accepted medical students in 2002. People of black ethnic origin comprised 2.5% of the population and 2.6% of the medical students. White people comprised 87.2% of the relevant resident population and 72.0% of the medical students.4 White men comprised 43.5% of the UK population aged 20-24 years but only 26.0% of the UK medical students in 2002.
Table 3 Ethnicity and sex of students accepted at UK medical schools between 1996 and 2002 compared with UK population of comparable age. Values are percentages
Career choices of newly qualified doctors by ethnic origin
Table 4 shows the career choices of doctors in their preregistration year who qualified from UK medical schools in 1993, 1996, 1999, and 2000 (based on responses to our surveys) grouped by ethnic origin. We have shown previously that men and women make different choices of specialty.2 In the present analysis, career choices varied significantly with ethnic origin for both men and women (for men, ; for women, ; P < 0.001 in both cases). Analysis of adjusted standardised residuals showed that non-white men were more likely than white men to choose specialist surgery and less likely to choose anaesthetics. Non-white women were less likely than white women to choose general practice and more likely to choose general medicine.
Table 4 Career choices of newly qualified doctors of 1993, 1996, 1999, and 2000 by sex and ethnicity. Values are percentages
There were no significant differences between different ethnic subgroups in men's choices of mainstream specialty, but there was a significant difference for women (, P < 0.001). Chinese women were significantly more likely than women from other ethnic minority groups to choose general medicine, and significantly less likely to choose general practice; women from the Indian subcontinent were significantly more likely than other women from ethnic minorities, though a little less likely than white women, to choose general practice. (See extra table on bmj.com for details of specialty choice by ethnic subgroup.)
Discussion
Lambert TW, Goldacre MJ, Vallance E, Mallick N. Characteristics of consultants who hold distinction awards in England and Wales: database analysis with particular reference to sex and ethnicity. BMJ 2004;328:1347-9 (http://bmj.com/cgi/doi/10.1136/bmj.38062.639190.44).
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, Turner G. Career choices of United Kingdom medical graduates of 1999 and 2000: questionnaire surveys. BMJ 2003;326: 194-5.
National Statistics. Census 2001. Ethnicity. http://www.statistics.gov.uk/cci/nugget.asp?id=273 (accessed 24 Oct 2003).
Royal Commission on the National Health Service. Report. London: HMSO, 1979: 217-21. (Cmnd 7615.)
Medical Workforce Standing Advisory Committee. Planning the medical workforce. Third report. London: Department of Health, 1997.
General Medical Council. The Medical Register 2003. London: GMC, 2003.
Taylor DH, Esmail A. Retrospective analysis of census data on general practitioners who qualified in South Asia: who will replace them as they retire? BMJ 1999;318: 306-10.
British Medical Association. The demography of medical schools: a discussion paper. London: BMA, 2004.(Michael J Goldacre, profe)
Correspondence to: M J Goldacre michael.goldacre@dphpc.ox.ac.uk
Abstract
Immigration to the United Kingdom in recent decades has changed the ethnic composition of the medical workforce in two major respects. Firstly, the NHS has relied heavily, and increasingly, on the immigration of doctors to make up the shortfall in numbers of "home trained" doctors. Secondly, the ethnic composition of doctors trained in UK medical schools has changed as second and third generation UK educated pupils from ethnic minorities have entered medicine in increasing numbers. We report on these trends.
Methods
Consultants in post in 2001: distribution by ethnic group and specialty
The figure shows the percentages of NHS consultants by ethnic group and place of training grouped by the year of their first consultant appointment. The distribution of consultants by each demographic group has changed over time: the percentage who trained abroad increased most substantially in the last 10 years covered by the 2002 database. Accordingly, we have summarised the results for consultants who were first appointed before 1992, and for those appointed between 1992 and 2001.
Percentage of NHS consultants by ethnic group and place of training grouped by the year of their first consultant appointment
Table 1 shows the percentage of consultants in each specialty from each demographic group. Of all consultants first appointed during 1964-91, 81.5% were UK trained and white, 3.3% were UK trained and non-white, 6.2% were trained abroad and white, and 9.1% were trained abroad and non-white. Of those first appointed during 1992-2001, 68.6% were UK trained white, 7.2% were UK trained non-white, 10.0% were trained abroad white, and 14.1% were trained abroad non-white. Thus, the percentage of newly appointed consultants who were trained abroad increased from 15.3% in 1964-91 to 24.1% in 1992-2001, and the percentage from ethnic minorities increased from 12.4% in 1964-1991 to 21.3% in 1992-2001.
The consultants first appointed during 1964-91 showed significant and substantial differences in the distribution of the four demographic groups between specialties (, P < 0.001) (table 1). Compared with their overall percentages in the consultant workforce, significantly and substantially lower percentages of UK trained white doctors, and higher percentages of non-white doctors trained abroad, were in geriatric medicine, genitourinary medicine, general psychiatry, old age psychiatry, and learning disability (significance assessed by 2 tests with adjusted standardised residuals); and significantly higher percentages of UK trained white doctors, and significantly lower percentages of non-white doctors trained abroad, were in general medicine and general surgery. In addition, in radiology there was a significantly higher percentage of UK trained white doctors than of other demographic groups, in psychiatry a significantly higher percentage of white doctors trained abroad, and in genitourinary medicine a significantly higher percentage of UK trained non-white doctors. We also found significant differences between the demographic groups in the specialties of employment of the consultants who were first appointed in 1992-2001 (, P < 0.001) (table 1).
Among all consultants in post in 2001 who had been appointed from 1964 to 2001, the differences between specialties in the representation of the four demographic groups were significant (, P < 0.001). Non-white consultants who had trained abroad made up 11.9% of the consultant workforce. They were significantly over-represented in geriatric medicine (22.0%), genitourinary medicine (21.4%), paediatrics (17.2%), learning disability (36.2%), and old age psychiatry (18.4%) and were significantly under-represented in general medicine and public health medicine. Consultants who were white and had trained abroad made up 8.4% of the workforce. They were significantly over-represented in general psychiatry (12.9%) and significantly under-represented in general medicine (6.8%) and general surgery (5.4%). UK trained non-white doctors comprised 5.5% of all consultants and were significantly under-represented in psychiatry (3.4%). There were no other significant differences.
A higher percentage of white than of non-white consultants were women (24.0% of white consultants (4729/19710) v 18.4% of non-white doctors (763/4150), , P < 0.001). This difference was more pronounced among consultants trained abroad (27.4% of white doctors were women (547/1994) v 17.4% of the non-white doctors (495/2840), , P < 0.001).
Ethnic group of graduates from UK medical schools
Table 2 shows the distribution of white and ethnic minority doctors among responders to surveys undertaken by our Medical Careers Research Group. Of the respondents who graduated in 1974, 96.7% gave their ethnic group as white and 3.3% as non-white. We reanalysed the data excluding those from homes abroad or who were overseas students (as defined by the level of tuition fees paid to their UK medical schools): the percentages in 1974 were then 98.4% white and 1.6% non-white. In contrast, respondents from the cohort who qualified in 2000 comprised 74.4% white doctors and 25.6% from ethnic minority groups (78.5% and 21.5%, respectively, after excluding overseas students).
Table 2 White and non-white doctors who qualified in each year from UK medical schools. Values are numbers (percentages) of those who replied to questionnaires from Medical Careers Research Group unless stated otherwise
We used data from the Universities and Colleges Admissions Service (UCAS) on admissions to medical school to estimate details of ethnicity and sex of future medical graduates (table 3). The percentage of doctors from ethnic minority groups who were admitted to UK medical schools in 1996, and therefore due to graduate in or soon after 2001, was 26.9% (20.7% Asian, 2.1% Chinese, 1.5% black, 2.5% other non-white) (UCAS Data and Analytical Services, private communication, November 2003). The corresponding percentage of ethnic minority doctors graduating from UK medical schools by 2004-7 is projected to be 28-29%. By comparison, in 2001, 9% of the population of England and Wales were from ethnic minority groups, and, among people aged 20-24 years (the typical age range for medical students), 12.8% were from ethnic minority groups. People of Asian ethnic origin (including Chinese) comprised 8.0% of the population in this age range and 20.8% of the accepted medical students in 2002. People of black ethnic origin comprised 2.5% of the population and 2.6% of the medical students. White people comprised 87.2% of the relevant resident population and 72.0% of the medical students.4 White men comprised 43.5% of the UK population aged 20-24 years but only 26.0% of the UK medical students in 2002.
Table 3 Ethnicity and sex of students accepted at UK medical schools between 1996 and 2002 compared with UK population of comparable age. Values are percentages
Career choices of newly qualified doctors by ethnic origin
Table 4 shows the career choices of doctors in their preregistration year who qualified from UK medical schools in 1993, 1996, 1999, and 2000 (based on responses to our surveys) grouped by ethnic origin. We have shown previously that men and women make different choices of specialty.2 In the present analysis, career choices varied significantly with ethnic origin for both men and women (for men, ; for women, ; P < 0.001 in both cases). Analysis of adjusted standardised residuals showed that non-white men were more likely than white men to choose specialist surgery and less likely to choose anaesthetics. Non-white women were less likely than white women to choose general practice and more likely to choose general medicine.
Table 4 Career choices of newly qualified doctors of 1993, 1996, 1999, and 2000 by sex and ethnicity. Values are percentages
There were no significant differences between different ethnic subgroups in men's choices of mainstream specialty, but there was a significant difference for women (, P < 0.001). Chinese women were significantly more likely than women from other ethnic minority groups to choose general medicine, and significantly less likely to choose general practice; women from the Indian subcontinent were significantly more likely than other women from ethnic minorities, though a little less likely than white women, to choose general practice. (See extra table on bmj.com for details of specialty choice by ethnic subgroup.)
Discussion
Lambert TW, Goldacre MJ, Vallance E, Mallick N. Characteristics of consultants who hold distinction awards in England and Wales: database analysis with particular reference to sex and ethnicity. BMJ 2004;328:1347-9 (http://bmj.com/cgi/doi/10.1136/bmj.38062.639190.44).
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, Turner G. Career choices of United Kingdom medical graduates of 1999 and 2000: questionnaire surveys. BMJ 2003;326: 194-5.
National Statistics. Census 2001. Ethnicity. http://www.statistics.gov.uk/cci/nugget.asp?id=273 (accessed 24 Oct 2003).
Royal Commission on the National Health Service. Report. London: HMSO, 1979: 217-21. (Cmnd 7615.)
Medical Workforce Standing Advisory Committee. Planning the medical workforce. Third report. London: Department of Health, 1997.
General Medical Council. The Medical Register 2003. London: GMC, 2003.
Taylor DH, Esmail A. Retrospective analysis of census data on general practitioners who qualified in South Asia: who will replace them as they retire? BMJ 1999;318: 306-10.
British Medical Association. The demography of medical schools: a discussion paper. London: BMA, 2004.(Michael J Goldacre, profe)