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1.  Doctors’ views about training and future careers expressed one year after graduation by UK-trained doctors: questionnaire surveys undertaken in 2009 and 2010 
BMC Medical Education  2014;14(1):270.
Background
The UK medical graduates of 2008 and 2009 were among the first to experience a fully implemented, new, UK training programme, called the Foundation Training Programme, for junior doctors. We report doctors’ views of the first Foundation year, based on comments made as part of a questionnaire survey covering career choices, plans, and experiences.
Methods
Postal and email based questionnaires about career intentions, destinations and views were sent in 2009 and 2010 to all UK medical graduates of 2008 and 2009. This paper is a qualitative study of ‘free-text’ comments made by first-year doctors when invited to comment, if they wished, on any aspect of their work, education, training, and future.
Results
The response rate to the surveys was 48% (6220/12952); and 1616 doctors volunteered comments. Of these, 61% wrote about their first year of training, 35% about the working conditions they had experienced, 33% about how well their medical school had prepared them for work, 29% about their future career, 25% about support from peers and colleagues, 22% about working in medicine, and 15% about lifestyle issues. When concerns were expressed, they were commonly about the balance between service provision, administrative work, and training and education, with the latter often suffering when it conflicted with the needs of medical service provision. They also wrote that the quality of a training post often depended on the commitment of an individual senior doctor. Service support from seniors was variable and some respondents complained of a lack of team work and team ethic. Excessive hours and the lack of time for reflection and career planning before choices about the future had to be made were also mentioned. Some doctors wrote that their views were not sought by their hospital and that NHS management structures did not lend themselves to efficiency. UK graduates from non-UK homes felt insecure about their future career prospects in the UK. There were positive comments about opportunities to train flexibly.
Conclusions
Although reported problems should be considered in the wider context, in which the majority held favourable overall views, many who commented had been disappointed by aspects of their first year of work. We hope that the concerns raised by our respondents will prompt trainers, locally, to determine, by interaction with junior staff, whether or not these are concerns in their own training programme.
Electronic supplementary material
The online version of this article (doi:10.1186/s12909-014-0270-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s12909-014-0270-5
PMCID: PMC4302441  PMID: 25528260
Medical careers; Junior doctors; Medical education; Foundation training
2.  Views of senior UK doctors about working in medicine: questionnaire survey 
JRSM Open  2014;5(11):2054270414554049.
Summary
Objectives
We surveyed the UK medical qualifiers of 1993. We asked closed questions about their careers; and invited them to give us comments, if they wished, about any aspect of their work. Our aim in this paper is to report on the topics that this senior cohort of UK-trained doctors who work in UK medicine raised with us.
Design
Questionnaire survey
Participants
3479 contactable UK-trained medical graduates of 1993.
Setting
UK.
Main outcome measures
Comments made by doctors about their work, and their views about medical careers and training in the UK.
Method
Postal and email questionnaires.
Results
Response rate was 72% (2507); 2252 were working in UK medicine, 816 (36%) of whom provided comments. Positive comments outweighed negative in the areas of their own job satisfaction and satisfaction with their training. However, 23% of doctors who commented expressed dissatisfaction with aspects of junior doctors’ training, the impact of working time regulations, and with the requirement for doctors to make earlier career decisions than in the past about their choice of specialty. Some doctors were concerned about government health service policy; others were dissatisfied with the availability of family-friendly/part-time work, and we are concerned about attitudes to gender and work-life balance.
Conclusions
Though satisfied with their own training and their current position, many senior doctors felt that changes to working hours and postgraduate training had reduced the level of experience gained by newer graduates. They were also concerned about government policy interventions.
doi:10.1177/2054270414554049
PMCID: PMC4228924  PMID: 25408920
physicians; career choice; medical staff; attitude of health personnel
3.  Career progression of men and women doctors in the UK NHS: a questionnaire study of the UK medical qualifiers of 1993 in 2010/2011 
JRSM Open  2014;5(11):2054270414554050.
Summary
Objectives
To report the career progression of a cohort of UK medical graduates in mid-career, comparing men and women.
Design
Postal and questionnaire survey conducted in 2010/2011, with comparisons with earlier surveys.
Setting
UK.
Participants
In total, 2507 responding UK medical graduates of 1993.
Main outcome measures
Doctors’ career specialties, grade, work location and working pattern in 2010/2011 and equivalent data in earlier years.
Results
The respondents represented 72% of the contactable cohort; 90% were working in UK medicine and 7% in medicine outside the UK; 87% were in the UK NHS (87% of men and 86% of women). Of doctors in the NHS, 70.6% of men and 52.0% of women were in the hospital specialties and the great majority of the others were in general practice. Within hospital specialties, a higher percentage of men than women were in surgery, and a higher percentage of women than men were in paediatrics, obstetrics and gynaecology, clinical oncology, pathology and psychiatry. In the NHS, 63% of women and 8% of men were working less-than-full-time (in general practice, 19% of men and 83% of women; and in hospital specialties, 3% of men and 46% of women). Among doctors who had always worked full-time, 94% of men and 87% of women GPs were GP principals; in hospital practice, 96% of men and 93% of women had reached consultant level.
Conclusions
The 1993 graduates show a continuing high level of commitment to the NHS. Gender differences in seniority lessened considerably when comparing doctors who had always worked full-time.
doi:10.1177/2054270414554050
PMCID: PMC4228926  PMID: 25408921
medical careers; career choices; career progression; gender differences
4.  GPs’ job satisfaction: doctors who chose general practice early or late 
The British Journal of General Practice  2013;63(616):e726-e733.
Background
In the UK many practising GPs did not choose general practice as their first choice of career when they originally graduated as doctors.
Aim
To compare job satisfaction of GPs who chose general practice early or later in their career.
Design and setting
Questionnaires were sent to all UK-trained doctors who graduated in selected years between 1993 and 2000.
Method
Questionnaires were sent to the doctors 1, 3, 7 and 10 years after graduation.
Results
Of all 3082 responders working in general practice in years 7 and 10, 38% had first specified general practice as their preferred career when responding 1 year after graduation, 19% by year 3, 21% by year 5, and 22% after year 5. Job satisfaction was high and, generally, there was little difference between the first three groups (although, when different, the most positive responses were from the earliest choosers); but there were slightly lower levels of job satisfaction in the ‘more than 5 years’ group. For example, in response to the statement ‘I find enjoyment in my current post’, the percentages agreeing in the four groups, respectively, were 91.5%, 91.1%, 91.0% and 88.2%. In response to ‘I am doing interesting and challenging work’ the respective percentages were 90.2%, 88.0%, 86.6% and 82.6%.
Conclusions
Job satisfaction levels were generally high among the late choosers as well as the early choosers. On this evidence, most doctors who turn to general practice, after preferring another specialty in their early career, are likely to have a satisfying career.
doi:10.3399/bjgp13X674404
PMCID: PMC3809425  PMID: 24267855
career choice; general practice; medical education; workforce, medical
5.  UK doctors and equal opportunities in the NHS: national questionnaire surveys of views on gender, ethnicity and disability 
Objectives
To seek doctors’ views about the NHS as an employer, our surveys about doctors’ career intentions and progression, undertaken between 1999 and 2013, also asked whether the NHS was, in their view, a good ‘equal opportunities’ employer for women doctors, doctors from ethnic minority groups and doctors with disabilities.
Design and Setting
Surveys undertaken in the UK by mail and Internet.
Participants
UK medical graduates in selected graduation years between 1993 and 2012.
Main outcome measures
Respondents were asked to rate their level of agreement with three statements starting ‘The NHS is a good equal opportunities employer for…’ and ending ‘women doctors’, ‘doctors from ethnic minorities’ and ‘doctors with disabilities’.
Results
Of first-year doctors surveyed in 2013, 3.6% (78/2158) disagreed that the NHS is a good equal opportunities employer for women doctors (1.7% of the men and 4.7% of the women); 2.2% (44/1968) disagreed for doctors from ethnic minorities (0.9% of white doctors and 5.8% of non-white doctors) and 12.6% (175/1387) disagreed for doctors with disabilities. Favourable perceptions of the NHS in these respects improved substantially between 1999 and 2013; among first-year doctors of 2000–2003, combined, the corresponding percentages of disagreement were 23.5% for women doctors, 23.1% for doctors from ethnic minorities and 50.6% for doctors with disabilities.
Conclusions
Positive views about the NHS as an equal opportunities employer have increased in recent years, but the remaining gap in perception of this between women and men, and between ethnic minority and white doctors, is a concern.
doi:10.1177/0141076814541848
PMCID: PMC4206637  PMID: 25271275
Equal opportunities; survey; doctors; medical careers
6.  Risk of self-harm and suicide in people with specific psychiatric and physical disorders: comparisons between disorders using English national record linkage 
Background
Psychiatric illnesses are known risk factors for self-harm but associations between self-harm and physical illnesses are less well established. We aimed to stratify selected chronic physical and psychiatric illnesses according to their relative risk of self-harm.
Design
Retrospective cohort studies using a linked dataset of Hospital Episode Statistics (HES) for 1999–2011.
Participants
Individuals with selected psychiatric or physical conditions were compared with a reference cohort constructed from patients admitted for a variety of other conditions and procedures.
Setting
All admissions and day cases in National Health Service (NHS) hospitals in England.
Main outcome measures
Hospital episodes of self-harm. Rate ratios (RRs) were derived by comparing admission for self-harm between cohorts.
Results
The psychiatric illnesses studied (depression, bipolar disorder, alcohol abuse, anxiety disorders, eating disorders, schizophrenia and substance abuse) all had very high RRs (> 5) for self-harm. Of the physical illnesses studied, an increased risk of self-harm was associated with epilepsy (RR = 2.9, 95% confidence interval [CI] 2.8–2.9), asthma (1.8, 1.8–1.9), migraine (1.8, 1.7–1.8), psoriasis (1.6, 1.5–1.7), diabetes mellitus (1.6, 1.5–1.6), eczema (1.4, 1.3–1.5) and inflammatory polyarthropathies (1.4, 1.3–1.4). RRs were significantly low for cancers (0.95, 0.93–0.97), congenital heart disease (0.9, 0.8–0.9), ulcerative colitis (0.8, 0.7–0.8), sickle cell anaemia (0.7, 0.6–0.8) and Down's syndrome (0.1, 0.1–0.2).
Conclusions
Psychiatric illnesses carry a greatly increased risk of self-harm as well as of suicide. Many chronic physical illnesses are also associated with an increased risk of both self-harm and suicide. Identifying those at risk will allow provision of appropriate monitoring and support.
doi:10.1177/0141076814522033
PMCID: PMC4023515  PMID: 24526464
self-harm; suicide; physical illness; psychiatric illness; chronic illness; cohort study; risk; suicidality
7.  Autoimmune disease preceding amyotrophic lateral sclerosis 
Neurology  2013;81(14):1222-1225.
Objective:
To study whether the risk of amyotrophic lateral sclerosis (ALS) is increased in people with prior autoimmune disease.
Methods:
An all-England hospital record-linkage dataset spanning 1999–2011 was used. Cohorts were constructed of people with each of a range of autoimmune diseases; the incidence of ALS in each disease cohort was compared with the incidence of ALS in a cohort of individuals without prior admission for the autoimmune disease.
Results:
There were significantly more cases than expected of ALS associated with a prior diagnosis of asthma, celiac disease, younger-onset diabetes (younger than 30 years), multiple sclerosis, myasthenia gravis, myxedema, polymyositis, Sjögren syndrome, systemic lupus erythematosus, and ulcerative colitis.
Conclusions:
Autoimmune disease associations with ALS raise the possibility of shared genetic or environmental risk factors.
doi:10.1212/WNL.0b013e3182a6cc13
PMCID: PMC3795611  PMID: 23946298
8.  Trends in hospital admission rates for whooping cough in England across five decades: database studies 
Objectives
Our aim was to report on trends in hospitalisation rates for pertussis in England from the 1960s to 2011; and to provide context for the recent unexpected activity of Bordetella pertussis in the UK.
Design
A retrospective analysis of English national Hospital Episode Statistics (HES, 1968–2011) and the Oxford Record Linkage Study (ORLS, 1963–2011) for people admitted to hospital with whooping cough.
Setting
England and the Oxford Record Linkage Study area.
Main outcome measures
Age- and gender-specific hospital admission rates, and summary age- and sex-standardised rates, for people aged under 25 years per 100,000 population in each age group.
Results
Admission rates declined from the 1960s to the early 1970s. For example, the standardised rates were 12.8 (95% confidence interval 11.2–14.5) per 100,000 in England in 1968 and 4.0 (3.0–4.9) per 100,000 in 1973. They then increased to reach 45.0 (41.4–48.6) per 100,000 in 1978 and 47.4 (43.7–51.1) in 1982. From the late 1980s, admission rates continued to decline, falling to between 1 and 4 per 100,000 in each of the years between 2003 and 2011. While the trend in hospital admissions closely followed that in notifications, the annual ratio between these two measures was not consistent ranging from 1.07 (95% confidence interval 1.00–1.14) to 4.03 (3.79–4.27) notifications per admission over the last 10 years.
Conclusions
Epidemics of whooping cough in the late 1970s and early 1980s were associated with a significant rise in hospital admission rates. Current admission rates are low, by historical comparison. Vaccine programmes must continue to be fully implemented in order to improve control of pertussis activity.
doi:10.1177/0141076813519439
PMCID: PMC4109331  PMID: 24526463
whooping cough; Bordetella pertussis; hospital admissions; England
9.  UK doctors’ views on the implementation of the European Working Time Directive as applied to medical practice: a qualitative analysis 
BMJ Open  2014;4(2):e004390.
Objectives
To report on what doctors at very different levels of seniority wrote, in their own words, about their concerns about the European Working Time Directive (EWTD) and its implementation in the National Health Service (NHS).
Design
All medical school graduates from 1993, 2005 and 2009 were surveyed by post and email in 2010.
Setting
The UK.
Methods
Using qualitative methods, we analysed free-text responses made in 2010, towards the end of the first year of full EWTD implementation, of three cohorts of the UK medical graduates (graduates of 1993, 2005 and 2009), surveyed as part of the UK Medical Careers Research Group's schedule of multipurpose longitudinal surveys of doctors.
Results
Of 2459 respondents who gave free-text comments, 279 (11%) made unprompted reference to the EWTD; 270 of the 279 comments were broadly critical. Key themes to emerge included frequent dissociation between rotas and actual hours worked, adverse effects on training opportunities and quality, concerns about patient safety, lowering of morale and job satisfaction, and attempts reportedly made in some hospitals to persuade junior doctors to collude in the inaccurate reporting of compliance.
Conclusions
Further work is needed to determine whether problems perceived with the EWTD, when they occur, are attributable to the EWTD itself, and shortened working hours, or to the way that it has been implemented in some hospitals.
doi:10.1136/bmjopen-2013-004390
PMCID: PMC3918988  PMID: 24503304
10.  UK doctors’ views on the implementation of the European Working Time Directive as applied to medical practice: a quantitative analysis 
BMJ Open  2014;4(2):e004391.
Objectives
To report on doctors’ views, from all specialty backgrounds, about the European Working Time Directive (EWTD) and its impact on the National Health Service (NHS), senior doctors and junior doctors.
Design
All medical school graduates from 1999 to 2000 were surveyed by post and email in 2012.
Setting
The UK.
Methods
Among other questions, in a multipurpose survey on medical careers and career intentions, doctors were asked to respond to three statements about the EWTD on a five-point scale (from strongly agree to strongly disagree): ‘The implementation of the EWTD has benefited the NHS’, ‘The implementation of the EWTD has benefited senior doctors’ and ‘The implementation of the EWTD has benefited junior doctors’.
Results
The response rate was 54.4% overall (4486/8252), 55.8% (2256/4042) of the 1999 cohort and 53% (2230/4210) of the 2000 cohort. 54.1% (2427) of all respondents were women. Only 12% (498/4136 doctors) agreed that the EWTD has benefited the NHS, 9% (377) that it has benefited senior doctors and 31% (1289) that it has benefited junior doctors. Doctors’ views on EWTD differed significantly by specialty groups: ‘craft’ specialties such as surgery, requiring extensive experience in performing operations, were particularly critical.
Conclusions
These cohorts have experience of working in the NHS before and after the implementation of EWTD. Their lack of support for the EWTD 4 years after its implementation should be a concern. However, it is unclear whether problems rest with the current ceiling on hours worked or with the ways in which EWTD has been implemented.
doi:10.1136/bmjopen-2013-004391
PMCID: PMC3918994  PMID: 24503305
Health Services Administration & Management; Medical Education & Training
11.  Gender, ethnicity and graduate status, and junior doctors’ self-reported preparedness for clinical practice: national questionnaire surveys 
Objectives
Medical schools need to ensure that graduates feel well prepared for their first medical job. Our objective was to report on differences in junior doctors’ self-reported preparedness for work according to gender, ethnicity and graduate status.
Design
Postal and electronic questionnaires.
Setting
UK.
Participants
Medical graduates of 2008 and 2009, from all UK medical schools, one year after graduation.
Main outcome measures
The main outcome measure was the doctors’ level of agreement with the statement that ‘My experience at medical school prepared me well for the jobs I have undertaken so far’, to which respondents were asked to reply on a scale from ‘strongly agree’ to ‘strongly disagree’.
Results
Women were slightly less likely than men to agree that they felt well prepared for work (50% of women agreed or strongly agreed vs. 54% of men), independently of medical school, ethnicity, graduate entry status and intercalated degree status, although they were no more likely than men to regard lack of preparedness as having been a problem for them. Adjusting for the other subgroup differences, non-white respondents were less likely to report feeling well prepared than white (44% vs. 54%), and were more likely to indicate that lack of preparedness was a problem (30% non-white vs. 24% white). There were also some gender and ethnic differences in preparedness for specific areas of work.
Conclusions
The identified gender and ethnic differences need to be further explored to determine whether they are due to differences in self-confidence or in actual preparedness.
doi:10.1177/0141076813502956
PMCID: PMC3914428  PMID: 24108533
medical education; junior doctors; preparedness for work; gender; ethnicity
12.  Association between multiple sclerosis and epilepsy: large population-based record-linkage studies 
BMC Neurology  2013;13:189.
Background
Multiple sclerosis (MS) and epilepsy are both fairly common and it follows that they may sometimes occur together in the same people by chance. We sought to determine whether hospitalisation for MS and hospitalisation for epilepsy occur together more often than expected by chance alone.
Methods
We analysed two datasets of linked statistical hospital admission records covering the Oxford Record Linkage Study area (ORLS, 1963–1998) and all England (1999–2011). In each, we calculated the rate of occurrence of hospital admission for epilepsy in people after admission for MS, compared with equivalent rates in a control cohort, and expressed the results as a relative risk (RR).
Results
The RR for hospital admission for epilepsy following an admission for MS was significantly high at 4.1 (95% confidence interval 3.1–5.3) in the ORLS and 3.3 (95% CI 3.1–3.4) in the all-England cohort. The RR for a first recorded admission for epilepsy 10 years and more after first recorded admission for MS was 4.7 (2.8–7.3) in ORLS and 3.9 (3.1–4.9) in the national cohort. The RR for the converse–MS following hospitalisation for epilepsy–was 2.5 (95% CI 1.7–3.5) in the ORLS and 1.9 (95% CI 1.8–2.1) in the English dataset.
Conclusions
MS and epilepsy occur together more commonly than by chance. One possible explanation is that an MS lesion acts as a focus of an epileptic seizure; but other possibilities are discussed. Clinicians should be aware of the risk of epilepsy in people with MS. The findings may also suggest clues for researchers in developing hypotheses about underlying mechanisms for the two conditions.
doi:10.1186/1471-2377-13-189
PMCID: PMC4235201  PMID: 24304488
Epilepsy; Multiple sclerosis; Risk; Coexistence; Record-linkage; Epidemiology
13.  Reasons why doctors choose or reject careers in general practice: national surveys 
The British Journal of General Practice  2012;62(605):e851-e858.
Background
Less than one-third of newly qualified doctors in the UK want a career in general practice. The English Department of Health expects that half of all newly qualified doctors will become GPs.
Aim
To report on the reasons why doctors choose or reject careers in general practice, comparing intending GPs with doctors who chose hospital careers.
Design and setting
Questionnaire surveys in all UK medical graduates in selected qualification years.
Method
Questions about specialty career intentions and motivations, put to the qualifiers of 1993, 1996, 1999, 2000, 2002, 2005, 2008, and 2009, 1 year after qualification, and at longer time intervals thereafter.
Results
‘Enthusiasm for and commitment to the specialty’ was a very important determinant of choice for intending doctors, regardless of chosen specialty. ‘Hours and working conditions’ were a strong influence for intending GPs (cited as having had ‘a great deal’ of influence by 75% of intending GPs in the first year after qualification), much more so than for doctors who wanted a hospital career (cited by 30%). Relatively few doctors had actually considered general practice seriously but then rejected it; 78% of the doctors who rejected general practice gave ‘job content’ as their reason, compared with 32% of doctors who rejected other specialties.
Conclusion
The shortfall of doctors wanting a career in general practice is not accounted for by doctors considering and rejecting it. Many do not consider it at all. There are very distinctive factors that influence choice for, and rejection of, general practice.
doi:10.3399/bjgp12X659330
PMCID: PMC3505419  PMID: 23211266
career choice; general practice; medical education; workforce, medical
14.  Risk of subarachnoid haemorrhage in people admitted to hospital with selected immune-mediated diseases: record-linkage studies 
BMC Neurology  2013;13:176.
Background
Subarachnoid hemorrhage (SAH) is a devastating cause of stroke, occurring in relatively young people. It has been suggested that some immune-mediated diseases may be associated with an increased risk of SAH.
Methods
We analysed a database of linked statistical records of hospital admissions and death certificates for the whole of England (1999–2011). Rate ratios for SAH were determined, comparing immune-mediated disease cohorts with comparison cohorts.
Results
There were significantly elevated risks of SAH after hospital admission for the following individual immune-mediated diseases: Addison’s disease, ankylosing spondylitis, autoimmune haemolytic anaemia, Crohn’s disease, diabetes mellitus, idiopathic thrombocytopenia purpura, myxoedema, pernicious anaemia, primary biliary cirrhosis, psoriasis, rheumatoid arthritis, scleroderma, Sjogren’s syndrome, SLE and thyrotoxicosis. Elevated risks that were greater than 2-fold were found for Addison’s disease (rate ratio (RR) = 2.01, 95% confidence interval 1.3-2.97), idiopathic thrombocytopenia purpura (RR = 2.42, 1.86-3.11), primary biliary cirrhosis (RR = 2.21, 1.43-3.16) and SLE (RR = 3.76, 3.08-4.55).
Conclusions
Our findings strongly support the suggestion that patients with some immune-mediated diseases have an increased risk of SAH. Further studies of the mechanisms behind this association are warranted.
doi:10.1186/1471-2377-13-176
PMCID: PMC3833635  PMID: 24229049
15.  Breast-Feeding and Childhood-Onset Type 1 Diabetes 
Diabetes Care  2012;35(11):2215-2225.
OBJECTIVE
To investigate if there is a reduced risk of type 1 diabetes in children breastfed or exclusively breastfed by performing a pooled analysis with adjustment for recognized confounders.
RESEARCH DESIGN AND METHODS
Relevant studies were identified from literature searches using MEDLINE, Web of Science, and EMBASE. Authors of relevant studies were asked to provide individual participant data or conduct prespecified analyses. Meta-analysis techniques were used to combine odds ratios (ORs) and investigate heterogeneity between studies.
RESULTS
Data were available from 43 studies including 9,874 patients with type 1 diabetes. Overall, there was a reduction in the risk of diabetes after exclusive breast-feeding for >2 weeks (20 studies; OR = 0.75, 95% CI 0.64–0.88), the association after exclusive breast-feeding for >3 months was weaker (30 studies; OR = 0.87, 95% CI 0.75–1.00), and no association was observed after (nonexclusive) breast-feeding for >2 weeks (28 studies; OR = 0.93, 95% CI 0.81–1.07) or >3 months (29 studies; OR = 0.88, 95% CI 0.78–1.00). These associations were all subject to marked heterogeneity (I2 = 58, 76, 54, and 68%, respectively). In studies with lower risk of bias, the reduced risk after exclusive breast-feeding for >2 weeks remained (12 studies; OR = 0.86, 95% CI 0.75–0.99), and heterogeneity was reduced (I2 = 0%). Adjustments for potential confounders altered these estimates very little.
CONCLUSIONS
The pooled analysis suggests weak protective associations between exclusive breast-feeding and type 1 diabetes risk. However, these findings are difficult to interpret because of the marked variation in effect and possible biases (particularly recall bias) inherent in the included studies.
doi:10.2337/dc12-0438
PMCID: PMC3476923  PMID: 22837371
16.  Hospital admissions for vitamin D related conditions and subsequent immune-mediated disease: record-linkage studies 
BMC Medicine  2013;11:171.
Background
Previous studies have suggested that there may be an association between vitamin D deficiency and the risk of developing immune-mediated diseases.
Methods
We analyzed a database of linked statistical records of hospital admissions and death registrations for the whole of England (from 1999 to 2011). Rate ratios for immune-mediated disease were determined, comparing vitamin D deficient cohorts (individuals admitted for vitamin D deficiency or markers of vitamin D deficiency) with comparison cohorts.
Results
After hospital admission for either vitamin D deficiency, osteomalacia or rickets, there were significantly elevated rates of Addison’s disease, ankylosing spondylitis, autoimmune hemolytic anemia, chronic active hepatitis, celiac disease, Crohn’s disease, diabetes mellitus, pemphigoid, pernicious anemia, primary biliary cirrhosis, rheumatoid arthritis, Sjogren’s syndrome, systemic lupus erythematosus, thyrotoxicosis, and significantly reduced risks for asthma and myxoedema.
Conclusions
This study shows that patients with vitamin D deficiency may have an increased risk of developing some immune-mediated diseases, although we cannot rule out reverse causality or confounding. Further study of these associations is warranted and these data may aid further public health studies.
doi:10.1186/1741-7015-11-171
PMCID: PMC3729414  PMID: 23885887
Vitamin D; Immune disease; Hospital episode statistics
17.  Breast cancer mortality trends in England and the assessment of the effectiveness of mammography screening: population-based study 
Objective
To investigate whether mortality statistics show an effect of mammographic screening on population-based breast cancer mortality in England.
Design
Joinpoint regression analyses, and other analyses, of population-based mortality data.
Setting
Analysis of mortality rates in the Oxford region, UK (1979–2009) because, unlike the rest of England, all causes of death mentioned on each death certificate for its residents (not just the underlying cause) are available prior to commencement of the English National Breast Screening Programme (NHSBSP). In addition, analysis of English national breast cancer mortality rates (1971–2009).
Participants
Women who died from breast cancer in the Oxford region (1979--2009) and England (1971--2009)
Main outcome measures
Age-specific mortality rates, and age-standardized mortality rates. Joinpoint regression analysis was used to estimate years (‘joinpoints’) in which trends changed, and annual percentage change between joinpoints, with confidence intervals.
Results
In the Oxford region, trends for breast cancer mortality based on underlying cause and on mentions were very similar. For all ages combined, mortality rates peaked for both underlying cause and mentions in 1985 and then started to decline, prior to the introduction of the NHSBSP in 1988. Between 1979 and 2009, for mortality measured as underlying cause, rates declined by −2.1% (95% CI −2.7 to −1.4) per year for women aged 40–49 years (unscreened), and by the same percentage per year (−2.1% [−2.4 to −1.7]) for women aged 50–64 years (screened). In England, the first estimated changes in trend occurred prior to the introduction of screening, or before screening was likely to have had an effect (between 1982 and 1989). Thereafter, the downward trend was greatest in women aged under 40 years: −2.0% per year (−2.8 to −1.2) in 1988–2001 and −5.0% per year (−6.7 to −3.3) in 2001–2009. There was no evidence that declines in mortality rates were consistently greater in women in age groups and cohorts that had been screened at all, or screened several times, than in other (unscreened) women, in the same time periods.
Conclusions
Mortality statistics do not show an effect of mammographic screening on population-based breast cancer mortality in England.
doi:10.1177/0141076813486779
PMCID: PMC3705415  PMID: 23761583
18.  Associations between selected immune-mediated diseases and tuberculosis: record-linkage studies 
BMC Medicine  2013;11:97.
Background
Previous studies have suggested that there may be an association between some immune-mediated diseases and risk of tuberculosis (TB).
Methods
We analyzed a database of linked statistical records of hospital admissions and death certificates for the whole of England (1999 to 2011), and a similar database (the Oxford Record Linkage Study (ORLS)) for a region of southern England in an earlier period. Rate ratios for TB were determined, comparing immune-mediated disease cohorts with comparison cohorts.
Results
In the all-England dataset, there were significantly elevated risks of TB after hospital admission for the following individual immune-mediated diseases: Addison's disease, ankylosing spondylitis, autoimmune hemolytic anemia, chronic active hepatitis, coeliac disease, Crohn's disease, dermatomyositis, Goodpasture's syndrome, Hashimoto's thyroiditis, idiopathic thrombocytopenia purpura (ITP), myasthenia gravis, myxedema, pemphigoid, pernicious anemia, polyarteritis nodosa, polymyositis, primary biliary cirrhosis, psoriasis, rheumatoid arthritis, scleroderma, Sjögren's syndrome, systemic lupus erythematosus (SLE), thyrotoxicosis and ulcerative colitis. Particularly high levels of risk were found for Addison’s disease (rate ratio (RR) = 11.9 (95% CI 9.5 to 14.7)), Goodpasture’s syndrome (RR = 10.8 (95% CI 4.0 to 23.5)), SLE (RR = 9.4 (95% CI 7.9 to 11.1)), polymyositis (RR = 8.0 (95% CI 4.9 to 12.2)), polyarteritis nodosa (RR = 6.7 (95% CI 3.2 to 12.4)), dermatomyositis (RR = 6.6 (95% CI 3.0 to 12.5)), scleroderma (RR = 6.1 (95% CI 4.4 to 8.2)) and autoimmune hemolytic anemia (RR = 5.1 (95% CI 3.4 to 7.4)).
Conclusions
These two databases show that patients with some immune-mediated diseases have an increased risk of TB, although we cannot explicitly state the direction of risk or exclude confounding. Further study of these associations is warranted, and these findings may aid TB screening, control and treatment policies.
doi:10.1186/1741-7015-11-97
PMCID: PMC3616814  PMID: 23557090
Hospital episode statistics; Immune disease; Tuberculosis
19.  Choice and rejection of psychiatry as a career: surveys of UK medical graduates from 1974 to 2009† 
The British Journal of Psychiatry  2013;202(3):228-234.
Background
Recruitment of adequate numbers of doctors to psychiatry is difficult.
Aims
To report on career choice for psychiatry, comparing intending psychiatrists with doctors who chose other clinical careers.
Method
Questionnaire studies of all newly qualified doctors from all UK medical schools in 12 qualification years between 1974 and 2009 (33 974 respondent doctors).
Results
One, three and five years after graduation, 4–5% of doctors specified psychiatry as their first choice of future career. This was largely unchanged across the 35 years. Comparing intending psychiatrists with doctors who chose other careers, factors with a greater influence on psychiatrists’ choice included their experience of the subject at medical school, self-appraisal of their own skills, and inclinations before medical school. In a substudy of doctors who initially considered but then did not pursue specialty choices, 72% of those who did not pursue psychiatry gave ‘job content’ as their reason compared with 33% of doctors who considered but did not pursue other specialties. Historically, more women than men have chosen psychiatry, but the gap has closed over the past decade.
Conclusions
Junior doctors’ views about psychiatry as a possible career range from high levels of enthusiasm to antipathy, and are more polarised than views about other specialties. Shortening of working hours and improvements to working practices in other hospital-based specialties in the UK may have reduced the relative attractiveness of psychiatry to women doctors. The extent to which views of newly qualified doctors about psychiatry can be modified by medical school education, and by greater exposure to psychiatry during student and early postgraduate years, needs investigation.
doi:10.1192/bjp.bp.112.111153
PMCID: PMC3585421  PMID: 23099446
20.  Geographical movement of doctors from education to training and eventual career post: UK cohort studies 
Objective
To investigate the geographical mobility of UK-trained doctors.
Design
Cohort studies conducted by postal questionnaires.
Setting
UK.
Participants
A total 31,353 UK-trained doctors in 11 cohorts defined by year of qualification, from 1974 to 2008.
Main outcome measures
Location of family home prior to medical school, location of medical school, region of first training post, region of first career post. Analysis for the UK divided into 17 standard geographical regions.
Results
The response rate was 81.2% (31,353/45,061; denominators, below, depended on how far the doctors’ careers had progressed). Of all respondents, 36% (11,381/31,353) attended a medical school in their home region and 48% (10,370/21,740) undertook specialty training in the same region as their medical school.
Of respondents who had reached the grade of consultant or principal in general practice in the UK, 34% (4169/12,119) settled in the same region as their home before entering medical school. Of those in the UK, 70% (7643/10,887) held their first career post in the same region as either their home before medical school, or their medical school or their location of training. For 18% (1938/10,887), all four locations – family home, medical school, place of training, place of first career post – were within the same region. A higher percentage of doctors from the more recent than from the older cohorts settled in the region of their family home.
Conclusion
Many doctors do not change geographical region in their successive career moves, and recent cohorts appear less inclined to do so.
doi:10.1177/0141076812472617
PMCID: PMC3595409  PMID: 23481431
21.  Career choices for cardiology: cohort studies of UK medical graduates 
BMC Medical Education  2013;13:10.
Background
Cardiology is one of the most popular of the hospital medical specialties in the UK. It is also a highly competitive specialty in respect of the availability of higher specialty training posts. Our aims are to describe doctors’ early intentions about seeking careers in cardiology, to report on when decisions about seeking a career in cardiology are made, to compare differences between men and women doctors in the choice of cardiology, and to compare early career choices with later specialty destinations.
Methods
Questionnaire surveys were sent to all UK medical graduates in selected qualification years from 1974–2009, at 1, 3, 5, 7 and 10 years after graduation.
Results
One year after graduation, the percentage of doctors specifying cardiology as their first choice of long-term career rose from the mid-1990s from 2.4% (1993 cohort) to 4.2% (2005 cohort) but then fell back to 2.7% (2009 cohort). Men were more likely to give cardiology as their first choice than women (eg 4.1% of men and 1.9% of women in the 2009 cohort). The percentage of doctors who gave cardiology as their first choice of career declined between years one and five after qualification: the fall was more marked for women. 34% of respondents who specified cardiology as their sole first choice of career one year post-graduation were later working in cardiology. 24% of doctors practising as cardiologists several years after qualification had given cardiology as their sole first choice in year one. The doctors’ ‘domestic circumstances’ were a relatively unimportant influence on specialty choice for aspiring cardiologists, while ‘enthusiasm/commitment’, ‘financial prospects’, ‘experiences of the job so far’ and ‘a particular teacher/department’ were important.
Conclusions
Cardiology grew as a first preference one year after graduation to 2005 but is now falling. It consistently attracts a higher percentage of men than women doctors. The correspondence between early choice and later destination was not particularly strong for cardiology, and was less strong than that for several other specialties.
doi:10.1186/1472-6920-13-10
PMCID: PMC3579736  PMID: 23351301
Cardiology; Career choice; Workforce; Medical education; Hospital medical staff
22.  Risk of fractures in patients with multiple sclerosis: record-linkage study 
BMC Neurology  2012;12:135.
Background
Patients with multiple sclerosis (MS) have been reported to be at higher risk of fracture than other people. We sought to test this hypothesis in a large database of hospital admissions in England.
Methods
We analysed a database of linked statistical records of hospital admissions and death certificates for the whole of England (1999–2010). Rate ratios for fractures were determined, comparing fracture rates in a cohort of all people in England admitted with MS and rates in a comparison cohort.
Results
Significantly elevated risk for all fractures was found in patients with MS (rate ratio (RR) = 1.99, 95% confidence interval (CI) = 1.93-2.05)). Risks were particularly high for femoral fractures (femoral neck fracture RR = 2.79 (2.65-2.93); femoral shaft fracture RR 6.69 (6.12-7.29)), and fractures of the tibia or ankle RR = 2.81 (2.66-2.96).
Conclusions
Patients with MS have an increased risk of fractures. Caregivers should aim to optimize bone health in MS patients.
doi:10.1186/1471-2377-12-135
PMCID: PMC3534503  PMID: 23126555
Multiple sclerosis; Fractures; Epidemiology
23.  Quantifying Urbanization as a Risk Factor for Noncommunicable Disease 
The aim of this study was to investigate the poorly understood relationship between the process of urbanization and noncommunicable diseases (NCDs) in Sri Lanka using a multicomponent, quantitative measure of urbanicity. NCD prevalence data were taken from the Sri Lankan Diabetes and Cardiovascular Study, comprising a representative sample of people from seven of the nine provinces in Sri Lanka (n = 4,485/5,000; response rate = 89.7%). We constructed a measure of the urban environment for seven areas using a 7-item scale based on data from study clusters to develop an “urbanicity” scale. The items were population size, population density, and access to markets, transportation, communications/media, economic factors, environment/sanitation, health, education, and housing quality. Linear and logistic regression models were constructed to examine the relationship between urbanicity and chronic disease risk factors. Among men, urbanicity was positively associated with physical inactivity (odds ratio [OR] = 3.22; 2.27–4.57), high body mass index (OR = 2.45; 95% CI, 1.88–3.20) and diabetes mellitus (OR = 2.44; 95% CI, 1.66–3.57). Among women, too, urbanicity was positively associated with physical inactivity (OR = 2.29; 95% CI, 1.64–3.21), high body mass index (OR = 2.92; 95% CI, 2.41–3.55), and diabetes mellitus (OR = 2.10; 95% CI, 1.58 – 2.80). There is a clear relationship between urbanicity and common modifiable risk factors for chronic disease in a representative sample of Sri Lankan adults.
doi:10.1007/s11524-011-9586-1
PMCID: PMC3191205  PMID: 21638117
Urbanization; Noncommunicable disease; Sri Lanka
24.  Doctors' age at domestic partnership and parenthood: cohort studies 
Objective
To report on doctors’ family formation.
Design
Cohort studies using structured questionnaires.
Setting
UK.
Participants
Doctors who qualified in 1988, 1993, 1996, 1999, 2000 and 2002 were followed up.
Main Outcome Measures
Living with spouse or partner; and doctors’ age when first child was born.
Results
The response to surveys including questions about domestic circumstances was 89.8% (20,717/23,077 doctors). The main outcomes – living with spouse or partner, and parenthood – varied according to age at qualification. Using the modal ages of 23–24 years at qualification, by the age of 24–25 (i.e. in their first year of medical work) a much smaller percentage of doctors than the general population was living with spouse or partner. By the age of 33, 75% of both women and men doctors were living with spouse or partner, compared with 68% of women and 61% of men aged 33 in the general population.
By the age of 24–25, 2% of women doctors and 41% of women in the general population had a child; but women doctors caught up with the general population, in this respect, in their 30s. The specialty with the highest percentage of women doctors who, aged 35, had children was general practice (74%); the lowest was surgery (41%).
Conclusions
Doctors are more likely than other people to live with a spouse or partner, and to have children, albeit typically at later ages. Differences between specialties in rates of motherhood may indicate sacrifice by some women of family in favour of career.
doi:10.1258/jrsm.2012.120016
PMCID: PMC3439659  PMID: 22977049
25.  Trends in doctors' early career choices for general practice in the UK: longitudinal questionnaire surveys 
The British Journal of General Practice  2011;61(588):e397-e403.
Background
The percentage of newly qualified doctors in the UK who want a career in general practice declined substantially in the 1990s. The English Department of Health expects that half of all doctors will become GPs.
Aim
To report on choices for general practice made by doctors who qualified in 2000, 2002, 2005, 2008, and 2009.
Design and setting
A structured, closed questionnaire about future career intentions, sent to all UK medical graduates.
Method
Questionnaires sent 1 year after qualification (all cohorts) and 3 years after (all except 2008 and 2009).
Results
Percentages of doctors who expressed an unreserved first choice for general practice in the first year after qualification, in the successive five cohorts, were 22.2%, 20.2%, 23.2%, 21.3%, and 20.4%. Percentages who expressed any choice for general practice — whether first, second or third — were 46.5%, 43.4%, 52.6%, 49.5%, and 49.9%. Three years after qualification, an unreserved first choice was expressed, in successive cohorts, by 27.9%, 26.1%, and 35.1%. Doctors from newly established English medical schools showed the highest levels of choice for general practice.
Conclusion
The percentage of doctors, in their first post-qualification year, whose first choice of eventual career was general practice has not changed much in recent years. By year 3 after qualification, this preference has increased in recent years. At years 1 and 3, the overall first choice for general practice is considerably lower than the required 50%, but varies substantially by medical school. In depth studies of why this is so are needed.
doi:10.3399/bjgp11X583173
PMCID: PMC3123502  PMID: 21722447
career choice; general practice; junior doctors; medical education; workforce planning

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