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1.  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
2.  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
3.  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
4.  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
5.  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
6.  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
7.  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
8.  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
9.  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
10.  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
11.  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
12.  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
13.  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
14.  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
15.  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
16.  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
17.  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
18.  Doctors who considered but did not pursue specific clinical specialties as careers: questionnaire surveys 
Objectives
To report doctors' rejection of specialties as long-term careers and reasons for rejection.
Design
Postal questionnaires.
Setting
United Kingdom.
Participants
Graduates of 2002, 2005 and 2008 from all UK medical schools, surveyed one year after qualification.
Main outcome measures
Current specialty choice; any choice that had been seriously considered but not pursued (termed ‘rejected’ choices) with reasons for rejection.
Results
2573 of 9155 respondents (28%) had seriously considered but then not pursued a specialty choice. By comparison with positive choices, general practice was under-represented among rejected choices: it was the actual choice of 27% of respondents and the rejected choice of only 6% of those who had rejected a specialty. Consideration of ‘job content’ was important in not pursuing general practice (cited by 78% of those who considered but rejected a career in general practice), psychiatry (72%), radiology (69%) and pathology (68%). The surgical specialties were the current choice of 20% of respondents and had been considered but rejected by 32% of doctors who rejected a specialty. Issues of work-life balance were the single most common factor, particularly for women, in not pursuing the surgical specialties, emergency medicine, the medical hospital specialties, paediatrics, and obstetrics and gynaecology. Competition for posts, difficult examinations, stressful working conditions, and poor training were mentioned but were mainly minority concerns.
Conclusions
There is considerable diversity between doctors in their reasons for finding specialties attractive or unattractive. This underlines the importance of recruitment strategies to medical school that recognize diversity of students' interests and aptitudes.
doi:10.1258/jrsm.2012.110173
PMCID: PMC3343714  PMID: 22532656
19.  Contribution of Climate and Air Pollution to Variation in Coronary Heart Disease Mortality Rates in England 
PLoS ONE  2012;7(3):e32787.
There are substantial geographic variations in coronary heart disease (CHD) mortality rates in England that may in part be due to differences in climate and air pollution. An ecological cross-sectional multi-level analysis of male and female CHD mortality rates in all wards in England (1999–2004) was conducted to estimate the relative strength of the association between CHD mortality rates and three aspects of the physical environment - temperature, hours of sunshine and air quality. Models were adjusted for deprivation, an index measuring the healthiness of the lifestyle of populations, and urbanicity. In the fully adjusted model, air quality was not significantly associated with CHD mortality rates, but temperature and sunshine were both significantly negatively associated (p<0.05), suggesting that CHD mortality rates were higher in areas with lower average temperature and hours of sunshine. After adjustment for the unhealthy lifestyle of populations and deprivation, the climate variables explained at least 15% of large scale variation in CHD mortality rates. The results suggest that the climate has a small but significant independent association with CHD mortality rates in England.
doi:10.1371/journal.pone.0032787
PMCID: PMC3299689  PMID: 22427884
20.  Incidence and 30-day case fatality for acute myocardial infarction in England in 2010: national-linked database study 
Background: There are limited national population-based epidemiological data on acute myocardial infarction (AMI) in England, making the current burden of disease, and clinical prognosis, difficult to quantify. The aim of this study was to provide national estimates of incidence and 30-day case fatality rate (CFR) for first and recurrent AMI in England. Methods: Population-based study using person-linked routine hospital and mortality data on 79 896 individuals of any age, who were admitted to hospital for AMI or who died suddenly from AMI in 2010. Results: Of 82 252 AMI events in 2010, 83% were first. Age-standardized incidence of first AMI per 100 000 population was 130 (95% CI 129–131) in men and 55.9 (95% CI 55.3–56.6) in women. Age-standardized 30-day overall CFRs including sudden AMI deaths for men and women, respectively, were 32.4% (95% CI 32.0–32.9) and 30.3% (95% CI 29.8–30.9) for first AMI and 29.7% (95% CI 28.7–30.7) and 26.7% (95% CI 25.5–27.9) for recurrent AMI. Age-standardized hospitalized 30-day CFR was 12.0% (95% CI 11.6–12.3) for men and 12.3% (95% CI 11.9–12.7) for women. Conclusions: While the majority of AMIs are not fatal, of those that are, two-thirds occur as sudden AMI deaths. About one in six of all AMIs are recurrent events. These findings reinforce the importance of primary and secondary prevention in reducing AMI morbidity and mortality.
doi:10.1093/eurpub/ckr196
PMCID: PMC3505446  PMID: 22241758
21.  Why UK-trained doctors leave the UK: cross-sectional survey of doctors in New Zealand 
Objectives
To investigate factors which influenced UK-trained doctors to emigrate to New Zealand and factors which might encourage them to return.
Design
Cross-sectional postal and Internet questionnaire survey.
Setting
Participants in New Zealand; investigators in UK.
Participants
UK-trained doctors from 10 graduation-year cohorts who were registered with the New Zealand Medical Council in 2009.
Main outcome measures
Reasons for emigration; job satisfaction; satisfaction with leisure time; intentions to stay in New Zealand; changes to the UK NHS which might increase the likelihood of return.
Results
Of 38,821 UK-trained doctors in the cohorts, 535 (1.4%) were registered to practise in New Zealand. We traced 419, of whom 282 (67%) replied to our questionnaire. Only 30% had originally intended to emigrate permanently, but 89% now intended to stay. Sixty-nine percent had moved to take up a medical job. Seventy percent gave additional reasons for relocating to New Zealand including better lifestyle, to be with family, travel/working holiday, or disillusionment with the NHS. Respondents' mean job satisfaction score was 8.1 (95% CI 7.9–8.2) on a scale from 1 (lowest satisfaction) to 10 (highest), compared with 7.1 (7.1–7.2) for contemporaries in the UK NHS. Scored similarly, mean satisfaction with the time available for leisure was 7.8 (7.6–8.0) for the doctors in New Zealand, compared with 5.7 (5.6–5.7) for the NHS doctors. Although few respondents wanted to return to the UK, some stated that the likelihood of doctors' returning would be increased by changes to NHS working conditions and by administrative changes to ease the process.
Conclusions
Emigrant doctors in New Zealand had higher job satisfaction than their UK-based contemporaries, and few wanted to return. The predominant reason for staying in New Zealand was a preference for the lifestyle there.
doi:10.1258/jrsm.2011.110146
PMCID: PMC3265234  PMID: 22275495
22.  Maternal and perinatal factors associated with hospitalised infectious mononucleosis in children, adolescents and young adults: record linkage study 
Background
There is current interest in the role of perinatal factors in the aetiology of diseases that occur later in life. Infectious mononucleosis (IM) can follow late primary infection with Epstein-Barr virus (EBV), and has been shown to increase the risk of multiple sclerosis and Hodgkin's disease. Little is known about maternal or perinatal factors associated with IM or its sequelae.
Methods
We investigated perinatal risk factors for hospitalised IM using a prospective record-linkage study in a population in the south of England. The dataset used, the Oxford record linkage study (ORLS), includes abstracts of birth registrations, maternities and in-patient hospital records, including day case care, for all subjects in a defined geographical area. From these sources, we identified cases of hospitalised IM up to the age of 30 years in people for whom the ORLS had a maternity record; and we compared perinatal factors in their pregnancy with those in the pregnancy of children who had no hospital record of IM.
Results
Our data showed a significant association between hospitalised IM and lower social class (p = 0.02), a higher risk of hospitalised IM in children of married rather than single mothers (p < 0.001), and, of marginal statistical significance, an association with singleton birth (p = 0.06). The ratio of observed to expected cases of hospitalised IM in each season was 0.95 in winter, 1.02 in spring, 1.02 in summer and 1.00 in autumn. The chi-square test for seasonality, with a value of 0.8, was not significant.
Other factors studied, including low birth weight, short gestational age, maternal smoking, late age at motherhood, did not increase the risk of subsequent hospitalised IM.
Conclusions
Because of the increasing tendency of women to postpone childbearing, it is useful to know that older age at motherhood is not associated with an increased risk of hospitalised IM in their children. We have no explanation for the finding that children of married women had a higher risk of IM than those of single mothers. Though highly significant, it may nonetheless be a chance finding. We found no evidence that such perinatal factors as birth weight and gestational age, or season of birth, were associated with the risk of hospitalised IM.
doi:10.1186/1471-2334-11-51
PMCID: PMC3056792  PMID: 21356092
23.  Perinatal and early life risk factors for inflammatory bowel disease 
AIM: To investigate associations between perinatal risk factors and subsequent inflammatory bowel disease (IBD) in children and young adults.
METHODS: Record linked abstracts of birth registrations, maternity, day case and inpatient admissions in a defined population of southern England. Investigation of 20 perinatal factors relating to the maternity or the birth: maternal age, Crohn’s disease (CD) or ulcerative colitis (UC) in the mother, maternal social class, marital status, smoking in pregnancy, ABO blood group and rhesus status, pre-eclampsia, parity, the infant’s presentation at birth, caesarean delivery, forceps delivery, sex, number of babies delivered, gestational age, birthweight, head circumference, breastfeeding and Apgar scores at one and five minutes.
RESULTS: Maternity records were present for 180 children who subsequently developed IBD. Univariate analysis showed increased risks of CD among children of mothers with CD (P = 0.011, based on two cases of CD in both mother and child) and children of mothers who smoked during pregnancy. Multivariate analysis confirmed increased risks of CD among children of mothers who smoked (odds ratio = 2.04, 95% CI = 1.06-3.92) and for older mothers aged 35+ years (4.81, 2.32-9.98). Multivariate analysis showed that there were no significant associations between CD and 17 other perinatal risk factors investigated. It also showed that, for UC, there were no significant associations with the perinatal factors studied.
CONCLUSION: This study shows an association between CD in mother and child; and elevated risks of CD in children of older mothers and of mothers who smoked.
doi:10.3748/wjg.v17.i6.743
PMCID: PMC3042652  PMID: 21390144
Crohn’s disease; Ulcerative colitis; Perinatal risk factors; Record linkage
24.  Maternal Age at Birth and Childhood Type 1 Diabetes: A Pooled Analysis of 30 Observational Studies 
Diabetes  2009;59(2):486-494.
OBJECTIVE
The aim if the study was to investigate whether children born to older mothers have an increased risk of type 1 diabetes by performing a pooled analysis of previous studies using individual patient data to adjust for recognized confounders.
RESEARCH DESIGN AND METHODS
Relevant studies published before June 2009 were identified from MEDLINE, Web of Science, and EMBASE. Authors of studies were contacted and asked to provide individual patient data or conduct prespecified analyses. Risk estimates of type 1 diabetes by maternal age were calculated for each study, before and after adjustment for potential confounders. Meta-analysis techniques were used to derive combined odds ratios and to investigate heterogeneity among studies.
RESULTS
Data were available for 5 cohort and 25 case-control studies, including 14,724 cases of type 1 diabetes. Overall, there was, on average, a 5% (95% CI 2–9) increase in childhood type 1 diabetes odds per 5-year increase in maternal age (P = 0.006), but there was heterogeneity among studies (heterogeneity I2 = 70%). In studies with a low risk of bias, there was a more marked increase in diabetes odds of 10% per 5-year increase in maternal age. Adjustments for potential confounders little altered these estimates.
CONCLUSIONS
There was evidence of a weak but significant linear increase in the risk of childhood type 1 diabetes across the range of maternal ages, but the magnitude of association varied between studies. A very small percentage of the increase in the incidence of childhood type 1 diabetes in recent years could be explained by increases in maternal age.
doi:10.2337/db09-1166
PMCID: PMC2809958  PMID: 19875616
25.  Risk of venous thromboembolism in people admitted to hospital with selected immune-mediated diseases: record-linkage study 
BMC Medicine  2011;9:1.
Background
Venous thromboembolism (VTE) is a common complication during and after a hospital admission. Although it is mainly considered a complication of surgery, it often occurs in people who have not undergone surgery, with recent evidence suggesting that immune-mediated diseases may play a role in VTE risk. We, therefore, decided to study the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) in people admitted to hospital with a range of immune-mediated diseases.
Methods
We analysed databases of linked statistical records of hospital admissions and death certificates for the Oxford Record Linkage Study area (ORLS1:1968 to 1998 and ORLS2:1999 to 2008) and the whole of England (1999 to 2008). Rate ratios for VTE were determined, comparing immune-mediated disease cohorts with comparison cohorts.
Results
Significantly elevated risks of VTE were found, in all three populations studied, in people with a hospital record of admission for autoimmune haemolytic anaemia, chronic active hepatitis, dermatomyositis/polymyositis, type 1 diabetes mellitus, multiple sclerosis, myasthenia gravis, myxoedema, pemphigus/pemphigoid, polyarteritis nodosa, psoriasis, rheumatoid arthritis, Sjogren's syndrome, and systemic lupus erythematosus. Rate ratios were considerably higher for some of these diseases than others: for example, for systemic lupus erythematosus the rate ratios were 3.61 (2.36 to 5.31) in the ORLS1 population, 4.60 (3.19 to 6.43) in ORLS2 and 3.71 (3.43 to 4.02) in the England dataset.
Conclusions
People admitted to hospital with immune-mediated diseases may be at an increased risk of subsequent VTE. Our findings need independent confirmation or refutation; but, if confirmed, there may be a role for thromboprophylaxis in some patients with these diseases.
doi:10.1186/1741-7015-9-1
PMCID: PMC3025873  PMID: 21219637

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