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Open Access 01-12-2018 | Research article

Failing to retain a new generation of doctors: qualitative insights from a high-income country

Authors: Niamh Humphries, Sophie Crowe, Ruairí Brugha

Published in: BMC Health Services Research | Issue 1/2018

Abstract

Background

The failure of high-income countries, such as Ireland, to achieve a self-sufficient medical workforce has global implications, particularly for low-income, source countries. In the past decade, Ireland has doubled the number of doctors it trains annually, but because of its failure to retain doctors, it remains heavily reliant on internationally trained doctors to staff its health system. To halve its dependence on internationally trained doctors by 2030, in line with World Health Organisation (WHO) recommendations, Ireland must become more adept at retaining doctors.

Method

This paper presents findings from in-depth interviews conducted with 50 early career doctors between May and July 2015. The paper explores the generational component of Ireland’s failure to retain doctors and makes recommendations for retention policy and practice.

Results

Interviews revealed that a new generation of doctors differ from previous generations in several distinct ways. Their early experiences of training and practice have been in an over-stretched, under-staffed health system and this shapes their decision to remain in Ireland, or to leave. Perhaps as a result of the distinct challenges they have faced in an austerity-constrained health system and their awareness of the working conditions available globally, they challenge the traditional view of medicine as a vocation that should be prioritised before family and other commitments. A new generation of doctors have career options that are also strongly shaped by globalisation and by the opportunities presented by emigration.

Discussion

Understanding the medical workforce from a generational perspective requires that the health system address the issues of concern to a new generation of doctors, in terms of working conditions and training structures and also in terms of their desire for a more acceptable balance between work and life. This will be an important step towards future-proofing the medical workforce and is essential to achieving medical workforce self-sufficiency.

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Ireland trains Irish and EU students as well as a large number of non-EU medical students. The fees paid by these non-EU students are a valuable income source for Ireland’s medical schools, but these students are not intended for the Irish medical workforce and so are excluded from these figures.

NCHD or non-consultant hospital doctor is a junior doctor in the Irish health system. All respondents were on recognised training schemes at the time of the first survey in 2014.

The EWTD seeks to limit the working hours of hospital doctors to a maximum of 48 h per week.

Curson JA, Dell ME, Wilson RA, Bosworth DL, Baldauf B. Who does workforce planning well? Team rapid review summary. International Journal Health Care Quality Assurance. 2010;23(10):110–9.

The World Health Organization., World Health Organisation. Working Together for Health. The World Health Report. Geneva: WHO; 2006.

Humphries N, Tyrrell E, McAleese S, Bidwell P, Thomas S, Normand C, et al. A cycle of brain gain, waste and drain - a qualitative study of non-EU migrant doctors in Ireland. BMC Hum Resour Heal. 2013;11:63.CrossRef

World Health Organization. Global strategy on human resources for health: Workforce 2030. Geneva; 2016.

Smith H. Young, gifted and Greek: Generation G – the world’s biggest brain drain. Guardian 19.01.15 [Internet]. London; 2015; Available from: https://www.theguardian.com/world/2015/jan/19/young-talented-greek-generation-g-worlds-biggest-brain-drain. Accessed 19 Jan 2016.

Kozina D, Panic K. Germany drains bosnia of doctors. Balk Insight [Internet]. 2016; Available from: http://www.balkaninsight.com/en/article/germany-drains-bosnia-of-doctors-and-nurses-12-21-2016. Accessed 19 Jan 2016.

Campbell T. Medical workforce analysis Ireland and the European Union compared (staff paper 2015) [internet]. Department of Public Expenditure and Reform. Dublin; 2015. Available from: http://igees.gov.ie/wp-content/uploads/2014/11/Medical-Workforce-Analysis.pdf. Accessed 20 Jan 2017.

HSE NDTP. Sixth annual Asessment of NCHD posts 2015–2016. 2016. HSE NDTP, Dublin. Available from: https://www.hse.ie/eng/staff/leadership-education-development/met/ed/rep/sixth-annual-assessment-of-nchd-posts-2015-2016-v3.pdf.

OECD. International Migration Outlook 2015 [Internet]. OECD, Paris. 2015. Available from: http://www.oecd-ilibrary.org/social-issues-migration-health/international-migration-outlook-2015_migr_outlook-2015-en.

10.

Bidwell P, Humphries N, Dicker P, Thomas S, Normand C, Brugha R. The national and international implications of a decade of doctor migration in the Irish context. Health Policy (New York). 2013;110:29–38.CrossRef

11.

Medical Council of Ireland. Medical Workforce Intelligence Report. Medical Council of Ireland, Dublin; 2016. Available from: https://www.medicalcouncil.ie/News-and-Publications/Reports/Medical-Workforce-Intelligence-Report-2016-.html. Accessed 2 Mar 2017.

12.

HSE NDTP. HSE NDTP strategic plan 2016–2020. HSE NDTP Dublin; 2017. Available from: https://www.hse.ie/eng/staff/leadership-education-development/met/publications/strategy-2016-20.pdf. Accessed 1 May 2017.

13.

Maier C, Buchan J, Wismar M, Ognyanova D, Girasek E, Kovacs E, et al. Monitoring health professional mobility in Europe. In: Buchan J, Wismar M, Glinos I, Bremner J, editors. Health Professional Mobility a Changing Europe. New Dynamics, Mobile Individuals, Diverse Responses. WHO/European Observatory on Health Systems and Policies, Copenhagen, 2014.

14.

Humphries, N, Crowe, S, McDermott, C, McAleese, S, Brugha, R. The consequences of Ireland’s culture of medical migration. BMC Human Resources for Health. 2017;15:87. Available from: https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-017-0263-7.

15.

Humphries N, McAleese S, Matthews A, Brugha R. “Emigration is a matter of self-preservation. The working conditions. .. Are killing us slowly”. Qualitative insights into health professional emigration from Ireland. BMC Hum Resour Heal. 2015;13:35.CrossRef

16.

Humphries N, Brugha R, McGee H. Nurse migration and health workforce planning: Ireland as illustrative of international challenges. Health Policy (New York) [Internet]. 2012;107:44–53. Available from: https://doi.org/10.1016/j.healthpol.2012.06.007.CrossRef

17.

World Health Organisation. WHO Code of Practice on International Recruitment of Health Personnel. 2010.

18.

Williams D, Thomas S. The impact of austerity on the health workforce and the achievement of human resources for health policies in Ireland. Hum Resour health [internet]. Hum Resour Health. 2017;15:1–8. Available from: https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-017-0230-3.

19.

HSE. Towards successful Consultant Recruitment, Appointment and Retention. Recommendations of a Committee appointed by the HSE regarding reform of the processes for creation, approval recruitment and appointment to Consultant posts [Internet]. HSE, Dublin; 2016. Available from: https://www.hse.ie/eng/staff/resources/hr-publications/consultantrecruitment-dec16.pdf. Accessed 1 May 2017.

20.

Mullan F. Doctors and soccer players - African professionals on the move. N Engl J Med. 2007;356:440–3.CrossRefPubMed

21.

Smith LG. Educating the professional physician. In: Humphrey HJ, editor. Mentor Acad Med. Philadelphia: American College of Physicians; 2010.

22.

Lyons ST, Schweitzer L, Ng ESW. How have careers changed? An investigation of changing career patterns across four generations. J Manag Psychol [internet]. Emerald. 2015;30:8–21. Available from: https://doi.org/10.1108/JMP-07-2014-0210.

23.

Carr SC, Inkson K, Thorn K. From global careers to talent flow: Reinterpreting “brain drain.”. J World Bus [Internet]. 2005;40:386–98.

24.

Sinclair S. Disease Narratives Constituting Doctors. Anthropol Med. 2000;7:115–34.CrossRef

25.

Montrouxe LV. Identity, identification and medical education why should we care? Med Educ. 2010;44:40–9.CrossRef

26.

Hamstra SJ, Woodrow SI, Mangrulkar RS. Feeling pressure to stay late: socialisation and professional identity formation in graduate medical education. Med Educ [internet]. Blackwell Publishing Ltd. 2008;42:7–9. Available from: https://doi.org/10.1111/j.1365-2923.2007.02958.x.

27.

Becker H, Geer B, Hughes E, Strauss AS. Boys in white. Student culture in medical school. 2007 Editi. Chicago: University of Chicago Press; 1977.

28.

Gallardo S. A generation x physician embraces the millennial doctor perspective [Internet]. kevidmd.com. 21.02.16. Available from: http://www.kevinmd.com/blog/2016/02/generation-x-physician-embraces-millennial-doctor-perspective.html. Accessed 31 May 2016.

29.

Bickel J, Brown A. Generation X implications for faculty recruitment and development in academic health centers. Acad Med. 2005;80

30.

Jovic E, Wallace J, Lemaire J. The generation and gender shifts in medicine an exploratory survey of internal medicine physicians. BMC Health Serv Res. 2006;6:55. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-6-55.

31.

Connell J. The two cultures of health worker migration: a Pacific perspective. Soc Sci med [internet]. Elsevier ltd; 2014;116:73–81.

32.

Finlay E, Fawzy M. Becoming a Doctor. J Med ethics Med Humanit. 2001;27:90–2.CrossRef

33.

Kellogg KC, Breen E, Ferzoco SJ, Zinner MJ, Ashley SW. Resistance to Change in Surgical Residency: An Ethnographic Study of Work Hours Reform. J Am Coll Surg [Internet]. 2006;202:630–6.

34.

Smith-Laing G. Survey of core medical trainees in the United Kingdom 2013. Clin Med J R Coll Physicians London. 2014;14:456.

35.

Gouda P, Kitt K, Evans DS, Goggin D, Mcgrath D, Last J, et al. Ireland ’ s medical brain drain : migration intentions of Irish medical students. 2015;12:1–9.

36.

Vaidyanathan B. Professional Socialization in Medicine - American Medical Association Journal of Ethics (formerly Virtual Mentor). AMA J Ethics [Internet]. 2015;17:164. Available from: http://journalofethics.ama-assn.org/2015/02/msoc1-1502.html.

37.

Johansson EE, Hamberg K. From calling to a scheduled vocation: Swedish male and female students’ reflections on being a doctor. Med Teach. 2007;29:e1–8.CrossRefPubMed

38.

Hayes B, Walsh G, Prihodova L. National Study of Wellbeing of Hospital Doctors in Ireland. Royal College of Physicians of Ireland (RCPI), Dublin. Avaialble from: https://rcpi-live-cdn.s3.amazonaws.com/wp-content/uploads/2017/05/Wellbeing-Report-web.pdf. Accessed 30 July 2017.

39.

Buchan J, Aiken L. Solving nursing shortages: a common priority. J Clin Nurs. 2008;17:3262–8.CrossRefPubMedPubMedCentral

40.

Imrie K. Training 21st century clinical leaders [internet]. Royal College of Physicians of Ireland (RCPI) Dublin; 2014. Available from: https://rcpi-live-cdn.s3.amazonaws.com/wp-content/uploads/2016/01/Training-21st-Century-Clinical-Leaders.pdf.

41.

McDermott C, Sheridan M, Moore K, Gosbell, Gosbell A. The Medical Boomerang: Will it come back? BMJ. Emerg Med J. 2014;0:1–3.

42.

McAleese S, Clyne B, Matthews A, Brugha R, Humphries N. Gone for good? An online survey of emigrant health professionals using Facebook as a recruitment tool. Hum Resour health [internet]. Hum Resour Health. 2016;14:34. Available from: http://human-resources-health.biomedcentral.com/articles/10.1186/s12960-016-0130-y.CrossRefPubMedPubMedCentral

43.

Sharma A, Lambert T, Goldacre M. Why UK-trained doctors leave the UK: cross sectional survey of doctors in New Zealand. J R Soc Med. 2012;105:25–34.CrossRefPubMedPubMedCentral

44.

Buchan J, Seccombe I, Charlesworth A. Staffing matters; funding counts. Workforce profile and trends in the English NHS [Internet]. The Health Foundation, London; 2016. Available from: http://www.health.org.uk/publication/staffing-matters-funding-counts. Accessed 2 Mar 2017.

45.

OECD. Health Workforce Policies in OECD Countries. Right Jobs, Right Skills, Right Places [Internet]. OECD, Paris; 2016. Available from: http://www.oecd.org/publications/health-workforce-policies-in-oecd-countries-9789264239517-en.htm. Accessed 10 May 2017.

46.

Thomas S, Burke S, Barry S. The Irish health-care system and austerity: sharing the pain. Lancet. 2014;383(9928):1545–6.CrossRefPubMed

47.

Irish Medical Organisation (IMO). 2020 Vision for health [internet]. Irish Medical Organisation, Dublin; 2016. Available from: http://www.imo.ie/news-media/news-press-releases/2015/imo-launches-2020-vision-/IMO-2020-Vision-(FINAL).pdf. Accessed 19 Feb 2017.

48.

McGowan Y, Humphries N, Burke H, Conry M, Morgan K. Through doctors’ eyes: a qualitative study of hospital doctor perspectives on their working conditions. Br J Health Psychol. 2013;18(4):874–91.CrossRefPubMed

49.

Hayes B, Fitzgerald D, Doherty S, Walsh G. Quality care, public perception and quick-fix service management: a Delphi study on stressors of hospital doctors in Ireland. BMJ Open [Internet]. 2015;5:e009564. Available from: http://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2015-009564.CrossRef

50.

Department of Health. Strategic review of Medical Training and Career Structure. Dublin: Third Progress Report July–December 2015 [Internet]; 2016. Available from: http://health.gov.ie/wp-content/uploads/2016/04/Third-IMG-Progress-Report.-250216.pdf.

51.

Irish Hospital Consultants Association. IHCA Submission to the Public Service Pay Commission, 16.12.16. Available from: http://paycommission.gov.ie/wp-content/uploads/IHCA-supplemental-submission.pdf. Accessed 2 Mar 2017.

52.

RCPI. Towards 2026 a future direction for Irish healthcare [internet]. Dublin: Royal College of Physicians of Ireland (RCPI); 2017. Available from: https://www.rcpi.ie/news/releases/towards-2026-future-health-services-must-be-built-around-the-needs-of-patients/. Accessed 10 May 2017.

53.

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Heal Care. 2007;19:349–57.CrossRef

54.

Clarke N, Crowe S, Humphries N, Conroy R, O’Hare S, Kavanagh P, et al. Factors influencing trainee doctor emigration in a high income country: a mixed methods study. Hum Resour health [internet]. Hum Resour Health. 2017;15:66. Available from: https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-017-0239-7.

55.

Crowe S, Clarke N, Brugha R. “You do not cross them”: hierarchy and emotion in doctors’ narratives of power relations in specialist training. Soc Sci med [internet]. Elsevier Ltd; 2017;186:70–7. Available from: https://doi.org/10.1016/j.socscimed.2017.05.048.

56.

Humphries N, Brugha R, McGee H. Sending money home: a mixed-methods study of remittances sent by migrant nurses in Ireland. BMC Hum Resour Heal Resour Heal. 2009;7:66.CrossRef

57.

Richards L. Handling qualitative data. A practical guide. 2nd Edition. London: Sage; 2009.

58.

Greenaway D. The Shape of Training. Securing the future of excellent patient care Final report of the independent review Led by Professor David Greenaway [Internet]. 2013. London, General Medical Council. Available from: http://www.shapeoftraining.co.uk/static/documents/content/Shape_of_training_FINAL_Report.pdf_53977887.pdf. Accessed 10 Jan 2016.

59.

Burke S, Thomas S, Barry S, Keegan C. Indicators of health system coverage and activity in Ireland during the economic crisis 2008–2014 - From “more with less” to “less with less.” Health Policy (New York) [Internet]. Elsevier Ireland Ltd. 2014;117:275–8. Available from: https://doi.org/10.1016/j.healthpol.2014.07.001.

60.

HSE, MRBI. Have your say: the health services employee survey: report of findings [internet]. 2015. Available from: http://www.lenus.ie/hse/handle/10147/550249. Accessed 10 Dec 2017.

61.

Royal College of Physicans. Being a junior doctor Experiences from the frontline of the NHS. London; 2016.

62.

Tasker F, Newbery N, Burr B, Goddard AF. Survey of core medical trainees in the United Kingdom 2013 - inconsistencies in training experience and competing with service demands. Clin Med J R Coll Physicians London. 2014;14:149–56.

63.

Hayes B, Prihodova L, Walsh G, Doyle F, Doherty S. What’s up doc? A national cross-sectional study of psychological wellbeing of hospital doctors in Ireland. BMJ Open. 2017;7

64.

The National Task Force on Medical Staffing. Report of the National Task Force on Medical Staffing. Department of Health and Children; 2003.

65.

Cullen P. Ireland’s health service is close to “total systems failure.” Irish Times 28.03.17 [Internet]. Dublin; 2017; Available from: http://www.irishtimes.com/news/health/ireland-s-health-service-is-close-to-total-systems-failure-1.3028102. Accessed 28 Mar 2017.

66.

Keane T. Lack of accountability a huge barrier to better healthcare. Irish Times 28.03.17 [Internet]. Dublin; 2017; Available from: http://www.irishtimes.com/opinion/lack-of-accountability-a-huge-barrier-to-better-healthcare-1.3027619. Accessed 28 Mar 2017.

67.

Department of Health. Strategic review of medical training and career structure. Final report [Internet]. Dublin: Department of Health; 2014. Available from: http://health.gov.ie/blog/publications/strategic-review-of-medical-training-and-career-structure-final-report/.

68.

Department of Health. Strategic Review of Medical training and career structure: Fifth Progress Report August 2016–January 2017, Dublin; 2017. Available here: http://health.gov.ie/blog/publications/strategic-review-of-medical-training-and-career-structure-fifth-progress-report/.

69.

O'Conor E. Address by Dr Emily O'Conor to Members of the Oireachtas, Leinster House, 17.01.18. 2018. Available from: https://www.iaem.ie/wp-content/uploads/2018/01/Address-by-Dr-Emily-OConor-President-IAEM-to-the-Oireachtas-170118.pdf. Accessed 20 Jan 2018.

70.

Roche B. Call for mandatory emergency work for graduates. Irish Times 25.05.11 [Internet]; Available from: http://www.irishtimes.com/news/health/call-for-mandatory-emergency-work-for-graduates-1.1279314.

71.

Osanlou O, Hull R. The millennial doctor – a blue collar worker? Futur Hosp. Journal. 2017;4 (1):45-8. Available from: http://futurehospital.rcpjournal.org/content/4/1/45.full.

72.

RCPI. Caring for the care-givers. Physician well-being position paper [Internet]. Royal College of Physicians of Ireland (RCPI) Dublin; 2014. Available from: https://www.rcpi.ie/news/publication/caring-for-the-caregivers-physician-wellbeing-position-paper/.

Title: Failing to retain a new generation of doctors: qualitative insights from a high-income country
Authors: Niamh Humphries
Sophie Crowe
Ruairí Brugha
Publication date: 01-12-2018
Publisher: BioMed Central
Published in: BMC Health Services Research / Issue 1/2018
Electronic ISSN: 1472-6963
DOI: https://doi.org/10.1186/s12913-018-2927-y

At a glance: The STEP trials

Springer Medicine

Failing to retain a new generation of doctors: qualitative insights from a high-income country

Abstract

Background

Method

Results

Discussion

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Method

Results

Discussion

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