The following is a guest post by e-Council member Ellie Hothersall, BSc, MBChB, MPH, MD, FRAI, FFPH – UK
Regarding the following article in the February issue of Medical Education:
When economics and medical education meet – what do trainees value?
I should start this by declaring an interest – I have briefly studied health economics at HERU [https://www.abdn.ac.uk/heru/], one of the two institutions involved in this paper, so perhaps it’s not surprising I thought this was a suitable paper for commentary. That said, surely you have to be very hard hearted not to be interested in a combination of (health) economics and medical education? Perhaps not.
So, having outed myself as a geek, why should anyone else care about this work?
First, perhaps a quick summary of this kind of work, since it’s probably pretty far from most medical educators’ frame of reference: a discrete choice experiment (DCE) is where participants are asked to undertake a sort of thought experiment where they are asked to choose between a series of slightly imperfect options, normally paired like Top Trumps[http://www.toptrumps.com/] and shown in Figure 2 of the paper. Analysis then determines what influences decision-making. A financial element is usually included to allow calculation of “willingness to pay”, allowing a monetary value to be attached to the different factors. This process allows the identification of both “push” factors (which drive people away) and “pull” factors. As the authors point out, very little investigation of these topics has been done, and what there is has been specific to recruitment into a specialty. This work is unique and I would argue vital because it looks at wider and more generic training considerations.
This study asked UK junior doctors whether they would trade income for different characteristics, identified as being likely to be the key determinants:
- Familiarity with hospital or unit
- Geographical location
- Opportunities for partner/spouse
- Potential earnings
- Clinical/academic reputation
- Working conditions
“Good working conditions” had the greatest influence on selection of a training position – trainees would seek nearly 50% increase in salary to accept a move from “good” to “poor” (Note that neither term was defined). Interestingly, this was more important that good opportunities for spouse/partner (38%), and both of these were more influential than location (31%). (Opportunities for spouse/partner were more important for female trainees than male ones, in case there was any illusion that gender parity had been reached in medical education). There were predictable interactions with age, dependents etc, but the overall pattern wasn’t really changed.
In the light of on-going strikes over pay and conditions for junior doctors in England [http://oneprofession.bma.org.uk/?gclid=CMjxtL66z8oCFckaGwodY-0I_A], does this help to reassure the reader that doctors are likely to put working conditions before pay? Or conversely, should it be a warning to policy makers that doctors put a very high value on working conditions?
In discrete choice experiments, there are always respondents who respond inconsistently, or who don’t answer – in the case of this research I find myself wondering if this could translate into people who might leave training rather than accept these unpalatable offers? Even accepting that this is not the case for all of them, I finished the paper wondering about the implications of this for the workforce – in the experiment it’s just a box to tick, but actually this is the choice we offer doctors in training all the time. In real life, is the equivalent action to find a different career?
What other economic techniques could and should we be applying to medical education?
Is this pattern of preferences consistent with your own experience? Is this likely to be a UK-specific phenomenon or world-wide?
Can we use this research to alter the problems seen with recruitment in some apparently less attractive parts of the country? Similarly, can we use it to influence choice of career, to attract more trainees to less popular specialities?
Does this add anything to the work on spouses of doctors (e.g. http://journals.lww.com/academicmedicine/Citation/2015/01000/Understanding_the_Medical_Marriage___Physicians.22.aspx)?